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The Importance of Lowering the Rate of Cesarean Deliveries

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C-sections are one of the most common procedures performed in hospitals, with rates rising over the past two decades. While Cesarean birth is a relatively safe procedure, it is not without risk to the patient and baby and can come with increased liability for the institution. Click the title above to learn more about the importance of reducing the rate of C-sections and the primary reasons behind the wide variance in rates from hospital to hospital.

C-sections are one of the most common procedures performed in hospitals and have become relatively safe.  However, it is important to the safety of the mother and newborn as well as for liability reduction for the institution to reduce the rate of Cesarean deliveries whenever possible.

The focus on C-section rate reduction has been led by the California Maternal Quality Care Collaborative (CMQCC), a multi-stakeholder organization established in 2006.  The CMQCC has developed a toolkit, endorsed by the American College of Obstetricians and Gynecologists (ACOG) to help institutions bring down their rate of C-sections.

CMQCC’s focus has been on nulliparous term singleton births (first-time labor, full-term, single births).  The reason for this focus is that if a woman has a Cesarean birth in her first labor, over 90% of all subsequent births will also require a C-section.  The opposite is also true.  If a woman has a vaginal birth in her first labor, over 90% of all subsequent births will be vaginal births.  This means that by preventing C-section for a first labor, the overall number of C-sections is reduced over the patient’s lifetime.

Two indications have been identified by CMQCC to have driven the rise in the rate of Cesarean births.  The first is the belief that the labor is not progressing.  The second is the belief that the fetus is not tolerating labor well.  Both of these indications are subjective measures.  Because of this subjectivity, the rate of C-sections varies widely from hospital to hospital, varying as much as 20% between institutions.

Many physicians believe that their rate of Cesarean births is higher due to their patients being at higher risk due to obesity, high blood pressure, diabetes, age, ethnicity, or a number of other factors.  However, formal risk adjustment analysis, using both BMI and age shows that over two-thirds of hospitals realize less than a 2% change based on these factors.  This demonstrates that once nulliparous term singleton vertex (NTSV) C-section rates are risk stratified, age and BMI effects may be more provider dependent and attributed to the practices of the institution rather than the patients that present.

Comparing hospital to hospital with similar proportions of high maternal age and high BMI, there is a wide variation in C-section rates.  Some institutions have low rates (less than 25%) while others have high rates of Cesarean births (over 35%) despite similar patient profiles.

Analyzing these rates is vital because although C-section procedures have been made as safe as possible, they still present a higher risk to both mother and child than an uncomplicated vaginal delivery.  C-sections increase neonatal morbidity, resulting in impaired neonatal respiratory function, increased NICU admissions, and can affect maternal-newborn interactions, including breastfeeding.  There is also no demonstrated benefit to performing a C-section to the rate of Cerebral Palsy or neonatal seizures and these rates have been unchanged since 1980, despite the rise in Cesarean births.

Risks to the mother include acute problems such as longer hospital stays, increased pain and fatigue, postpartum hemorrhage, need for transfusions, slower return to normal activity and productivity, and delayed or difficulty breastfeeding.  There may also be anesthesia complications, wound infection, or deep vein thrombosis.  Long-term risks and risks to subsequent births include abnormal placentation, which may require hysterectomy, uterine rupture, surgical adhesions, bladder injury, bowel injury, and bowel obstruction.

Maternal psychological risks are also a concern.  Acute risks include delayed and/or ineffective bonding with the baby and maternal anxiety.  Longer term risks involve post-traumatic stress disorder (PTSD), especially in the case of emergent procedures, and postpartum anxiety and depression.

Both CMQCC and ACOG have recognized the value in reducing the rate of Cesarean births and multi-hospital quality improvement collaboratives have been introduced.  In our next post, we will take a deeper look at initiative your institution can use to reduce primary Cesarean rates.

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