Five Steps Hospitals Can Take to Safely Lower Their Cesarean Rate
Five Steps Hospitals Can Take to Safely Lower Their Cesarean Rate
By Jill Arnold
July 1, 2017
Centers for Disease Control and Prevention (CDC) data show that the low-risk C-section rate in the U.S. remains plateaued. With the nation’s top women’s health organizations recommending a safe reduction of this rate, I asked several experts in perinatal patient safety what steps hospitals can take to safely lower high C-section rates.
1. Learn why reducing C-section rates is important
According to Barbara Levy, M.D., Vice President of Health Policy of the American College of Obstetricians and Gynecologists (ACOG), the push for more and more C-sections is harming women. “If it were just one C-section for the most part, maybe that would be okay,” said Levy, “but we have more and more evidence now that multiple C-sections are really scary and can result in severe consequences for women and their babies.”
The Council on Patient Safety in Women’s Health Care, a consortium of 21 professional organizations and patient advocates, created the Safe Reduction of Primary Cesarean Birth safety bundle to aid hospitals in implementing their own quality improvement (QI) projects.
2. Pull together a team
Experts agree that forming a team to improve quality is essential. “You need to find a champion among your nurses, among your physicians, a champion among your midwives if you have midwives,” said Levy, “and those folks need to sit down around a table and ask, ‘what’s driving this and how do we fix this?’”
Debra Bingham, DrPH, RN, FAAN, Executive Director of the Institute for Perinatal Quality Improvement, emphasized the importance of engaging nurses in the process. “How nurses take care of women in labor affects outcomes,” said Bingham.
3. Be clear on what you’re measuring
There are many types of cesarean birth measures of which hospitals should be aware, said Bingham. Breaking down primary C-section rates into “nulliparous, term, singleton, vertex,” or NTSV, further risk-stratifies the primary rates.
The Cesarean Birth measure used by The Joint Commission, also known as PC-02, measures the rates of cesarean births among first-time moms with low-risk deliveries while also minimizing the burden of data collection.
Designed to identify variation between hospitals, PC-02 measures a specific subset of patients (NTSV) whose outcomes are shown to be largely influenced by physician factors, rather than patient characteristics or obstetric diagnoses. Over 60% of hospital variation in NTSV patients can be attributed to first birth labor induction rates and first birth early labor admission rates.
A pilot program which rapidly lowered NTSV C-section rates at several California hospitals also began by establishing two separate baselines for infants and mothers. Coordinated by the California Maternal Quality Care Collaborative, three hospitals seeking to lower their NTSV rates collected data on balancing measures, including the National Quality Forum’s Unexpected Newborn Complications measure and 3rd/4th degree maternal lacerations occurring in vaginal births. The hospitals averaged a 18.6% reduction in their NTSV rate in 2015, while newborn complications fell significantly by 24.5% and 3rd/4th degree lacerations dropped by 4.7%.
4. Define “normal” labor
All of the medical experts I interviewed recommended letting labor start on its own and letting it take its course unless there is a medical need to induce labor.
ACOG President Haywood Brown stated that achieving a healthier cesarean rate will entail re-education of both providers and patients on models of normal labor, such as the updated definition of active labor beginning at six centimeters of dilation instead of four.
“Six is the new four,” said Brown. “We have been working with this ‘four’ being active labor since 1954.” Brown added that this is addressed in ACOG’s new committee opinion, Approaches to Limit Intervention During Labor and Birth, as well as in the Council on Patient Safety’s safety bundle on reducing primary cesareans.
Levy said that the Council was able to get everyone on the same page about an ideal for low-risk patients.
“[L]ow-risk women don’t need continuous monitoring and we want them up and moving during labor,” said Levy. “We don’t want them strapped to a bed. We want them to have support in labor, whether that’s a doula or that’s family or being in an environment that doesn’t stress them out.”
5. Get help from larger hospitals
For rural and very small hospitals, even low-burden data collection and QI might require additional support. According to Dr. Curtis Lowery, Chair of the University of Arkansas for Medical Sciences Division of Maternal Fetal Medicine and founder of the UAMS Center for Distance Health, these hospitals might start by looking to academic medical centers with a maternal-fetal medicine expert available to consult on everything from management of preeclampsia, postpartum hemorrhage and fetal heart rate interpretations via telemedicine.
“Reducing primary cesareans means better definitions of fetal heart rate abnormalities, better definitions of labor abnormalities and dystocia in labor so that we’re all on the same page,” said Lowery. “In Arkansas, we’re thinking of how to build a system of maternity care that goes from tertiary care all the way down to small hospitals and even directly to the patient in many ways using technology.”
Additional support may be available from state perinatal quality collaboratives. PQCs are state networks of perinatal care providers and public health professionals working to improve health outcomes. Centers for Disease Control and Prevention and the March of Dimes co-sponsor the National Network of Perinatal Quality Collaboratives to support state-based PQCs in making measurable improvements in perinatal care.
"State perinatal quality collaboratives (PQCs) are doing tremendous work to improve the care that pregnant women and babies receive," said Stacey D. Stewart, president of the March of Dimes. "The March of Dimes and CDC's new national network is a great opportunity for these states to share their advances and best practices, like the effort by Ohio's PQC to eliminate early elective (medically unnecessary) deliveries before 39 weeks, including cesarean sections.”
Resources for states, hospitals and health systems
ACOG Alliance for Innovation on Maternal Health (AIM)
CPSWHC’s Safe Reduction of Primary Cesarean Birth safety bundle
CMQCC’s Support Vaginal Birth and Reduce Primary Cesareans toolkit
ACNM’s Reducing Primary Cesareans Project
AWHONN’s Go the Full 40 toolkit
IHI’s How to Guide: Prevent Obstetrical Adverse Events
Ariadne Labs’ Safe Childbirth Checklist
Jill Arnold is a founder of the National Accreta Foundation, a non-profit organization working to eliminate preventable maternal mortality and morbidity related to placenta accreta.
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