Hospitals Taking Steps to Lower Cesarean Rates

The number of cesarean deliveries is tapering downward thanks to efforts by teaching hospitals and national medical organizations to promote vaginal delivery, unless there are known medical risks.
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Academic medicine is playing a leading role in reducing the number of cesarean deliveries that are not medically indicated. The effort is significant because cesarean procedures increased by 60% between 1996 and 2011, according to the American College of Obstetricians and Gynecologists (ACOG).

“It seems likely that our [national] cesarean rate is too high at 32%,” said Aaron B. Caughey, MD, PhD, professor and chair of the Department of Obstetrics and Gynecology and associate dean for Women’s Health Research and Policy at Oregon Health & Science University. In 2015, the Centers for Disease Control and Prevention (CDC) reported that 32% of babies in the United States were delivered by cesarean.

“When one looks around the globe,” Caughey added, “it appears that countries improve their neonatal and maternal mortality rates up to cesarean rates of about 20%, but no improvement beyond. Thus, we should probably be able to safely reduce our rates.”

But how to do that? Several academic medical institutions and organizations are finding solutions. A recent study by researchers and clinicians at Beth Israel Deaconess Medical Center (BIDMC) in Boston, for example, demonstrated that the number of cesareans for low-risk mothers could be reduced through hospital-led interventions that included focusing on fetal heart tracings, providing tolerance for labor, induction of labor, and midwifery, which BIDMC introduced in 2014. BIDMC’s overall cesarean delivery rate significantly decreased from 40% to 29% over a seven-year period.

“By preventing the first cesarean delivery, we should be able to reduce the nation’s overall cesarean delivery rate.”

Aaron B. Caughey, MD, PhD
Oregon Health & Science University

Stanford University’s Lucile Packard Children’s Hospital has achieved a cesarean rate of 23% through its use of guidelines outlined by ACOG and the Society for Maternal–Fetal Medicine (SMFM), Obstetric Care Consensus: Safe Prevention of the Primary Cesarean Delivery. Among other recommendations, the guidelines support avoiding the first cesarean delivery in order to reduce future unnecessary cesareans. Additionally, the California Maternal Quality Care Collaborative, which is housed at Stanford, released a tool kit of evidence-based recommendations in 2016 to help hospitals reduce first-time cesareans. Approximately 60% of all cesarean births are primary cesareans.

“By preventing the first cesarean delivery, we should be able to reduce the nation’s overall cesarean delivery rate,” said Caughey. As a member of ACOG’s Committee on Obstetric Practice, Caughey helped develop the Obstetric Care Consensus, which ACOG and SMFM jointly issued in 2014. The guidelines stated that the increase in cesarean birth rates “raises significant concern that cesarean delivery is overused” without clear evidence of improved maternal or newborn outcomes. The guidelines are also aimed at encouraging women with low-risk pregnancies to spend more time in the first stage of labor to help avoid nonmedically indicated cesareans.

Monday, August 07, 2017

Perinatal Quality Collaboratives

Through the CDC, perinatal quality collaboratives are state or multistate networks of teams working to improve health outcomes for mothers and babies through evidence-based programs. (Perinatal refers to the time from the 20th week of gestation through the 28th week of the newborn’s life.)

The New York State Perinatal Quality Collaborative (NYSPQC), made up of 17 regional perinatal centers, achieved a 98% decline in scheduled deliveries—specifically those without a medical indication—from September 2010 through December 2013.

Close to 100 birthing hospitals in New York State partnered with the Department of Health and NYSPQC to develop policies and practices for implementing changes and educating staff on best practices and project objectives. Many of these participants recognized for achieving fewer scheduled deliveries were teaching hospitals and their affiliates.

The strategy: key teams were identified at each hospital to develop data, identify valid medical indications for scheduled deliveries from 36 to 39 weeks of gestation, engage hospital teams to apply these tactics, and offer educational sessions, coaching calls, and educational webinars related to reducing scheduled cesareans.

One of the project’s main conclusions was that buy-in from all disciplines (for example, executives, administrators, physicians, midwives, nurses) was critical to success.

In addition to academic medicine’s efforts and the ACOG-SMFM guidelines, consumer awareness campaigns have been making an impact. The March of Dimes’ Healthy Babies Are Worth the Wait campaign, for instance, asks women to wait until 39 weeks for a full-term baby rather than schedule an earlier cesarean delivery.

Cesareans pose risks

The World Health Organization advocates an “ideal rate” of 10% to 15% for cesareans. But reaching that goal may be challenging because “baseline risks of needing cesarean deliveries are increasing—risks like increasing obesity and diabetes, as well as abnormal labor and women having babies later in life,” said Kristen Sharp, MD, FACOG, clinical assistant professor and medical director of the Centering Pregnancy Program at the University of Wisconsin School of Medicine and Public Health.

Cesarean procedures can be lifesaving when babies or mothers are at risk, but they pose risks, noted Wanda D. Barfield, MD, MPH, director of the CDC’s Division of Reproductive Health and a neonatologist. As an example, she said, cesarean deliveries “without a medical indication” may result in some infants needing care in neonatal intensive care units. Babies who “don’t have the benefit of vaginal delivery” are at risk for retained fetal lung fluid and respiratory distress, Barfield added.

Cesareans are also more costly than vaginal deliveries, noted Serdar Bulun, MD, professor and chief of OB/GYN at Northwestern University Feinberg School of Medicine. But, he added, “It’s not only cost, but the use and availability of [hospitals’] resources. The OB/GYN community has advocated for vaginal delivery as the way to go. Cesareans are performed only if there’s a valid medical reason.” Bulun called Northwestern’s current cesarean rate of 26% for 12,000 deliveries a year “a very respectable rate.”

The CDC, with which AAMC hospitals partner on collaboratives, has supported efforts to reduce elective cesarean deliveries through its perinatal quality collaboratives. These state or multistate networks of teams are working to improve health outcomes for mothers and babies through evidence-based programs. The CDC’s division of reproductive health also offers webinars that address reducing the cesarean delivery rates.