In 2006 Dr. San Román began developing a series of software tools that uses data from prior outcomes
to improve the way that labor patients are managed. Research reveals that labor is a physical process
and the risk that a woman’s labor will end in a cesarean birth is determined by BOTH a woman’s physical
characteristics AND the effect of her obstetrical care provider’s labor management strategies.
Therefore, it is impossible to measure the effect of the obstetrical care provider without providing risk
adjustment for the physical characteristics of the women who are giving birth.
In 2010 Dr. San Román was the only one who recognized the flaw in the risk adjustment for age being
used to adjust hospital’s NTSV cesarean birth rate. It took multiple phone calls and letters sent over five
years for the expert panel at the Joint Commission to recognize the flaw. That risk adjustment has since
been abandoned by the Joint Commission.
In 2012 Dr. San Román was the only one who recognized the flaws in the risk adjustment being used in
the Cesarean Section Indicator developed by the Canadian Institute for Health Information (CIHI) which
was published on their website. It took several letters and a publication in the Journal of Obstetricians
and Gynaecologists Canada to get the expert panel at the CIHI to recognize the flaw. That risk adjustment
has since been abandoned by the CIHI.
It now seems that Dr. San Román is the only one who recognizes the disaster that is coming by using an
unadjusted NTSV cesarean birth rate as a cesarean birth measure. The justification given by the expert
panels at the LeapFrog Group and the Joint Commission for using an unadjusted NTSV cesarean birth rate
is that “the effect of age is cancelled out by BMI”. To view the comment made by Dr. San Román at the
National Quality Forum click here.
Birthrisk.com supports Healthy People 2020 in trying to reduce the number of cesarean births. However,
their goal of achieving an unadjusted NTSV cesarean birth rate of 23.9% at the national level is very
different from making the claim that every hospital should have a rate of 23.9%. Unfortunately, hospitals
in California may soon be denied participation in Covered California if they have a rate of over 23.9%.
BIRTHRISK CESAREAN BIRTH MEASURE VIDEO PRESENTATIONS:
For a presentation on why an unadjusted Nulliparous Term Singleton Vertex (NTSV)
cesarean birth rate is not a useful cesarean birth measure
click here (9:48).
For a presentation explaining the creation of the Birthrisk Cesarean Birth Measure
including the research behind the measure and its validation
click here (12:15).
For a presentation on how the Birthrisk Cesarean Birth Measure provides information on its
use to compare outcomes in hospitals and for research
click here (7:00)
For a presentation on the robust reporting features for the Birthrisk Cesarean Birth Measure that
can be used by healthcare administrators, hospitals and obstetrical care providers
click here (3:12)
For a presentation on the data collection required for the Birthrisk Cesarean Birth Measure
click here (1:25)
For a presentation that combines the above five presentations into one
click here (33:12)
In the summer of 2015 Dr. San Román was able to successfully make the Joint Commission aware of
the fatal leveraging error that was contained in the direct standardization age risk adjustment being
used in their core measure PC-02. This error was buried deep in the mathematics of the risk adjustment
and this is probably why it was missed by so many people for so long. For a detailed analysis of
the error click here. Dr. San Román assumed that the acknowledgement of this fatal error would
result in a recall of the measure.
In February of 2016 Dr. San Román became concerned that the fatal leveraging error uncovered in the
risk adjustment for measure PC-02 Cesarean Birth was not disclosed by the Joint Commission to the
National Quality Forum during the measure maintenance process. More concerning is that the Joint
Commission has simply removed the risk adjustment from their core measure PC-02 v2016A. Removing
the risk adjustment only makes the measure worse and this is very concerning since this
measure could potentially affect millions of women every year.
To learn more about Dr. San Román’s concerns and to review the documentation behind his concerns
If you are a healthcare professional and would like more information about Birthrisk.com
and/or the scientific method used in the Birthrisk.com tools, please send an e-mail to
with your name, address and obstetrical group or hospital name and we will send you detailed information.
Last modified: 05/21/16