Reducing the number of cesarean sections performed in the U.S. has been a top priority for maternal health care experts for several years, and successful efforts in California offer a blueprint for other states.
The California Maternal Quality Care Collaborative, a public-private partnership aimed at improving the state’s maternal health care and outcomes, has taken a three-pronged approach to curb how frequently cesareans occur among women giving birth at term, for the first time and to a single infant in the head-first position – what’s generally considered a “low-risk” birth.
These operations are the least likely to be medically necessary, yet the low-risk C-section rate in the U.S. began to surge in the 1990s, and only within the last decade has started to inch slowly back down. In California, the collaborative’s primary efforts to bring the state’s low-risk C-section rate down safely include promoting best practices on the labor and delivery floor, improving hospitals’ data transparency and adjusting payment mechanisms for childbirth.
“Because this is embedded in culture and attitude, there’s not a single answer or a single easy thing to do,” says Dr. Elliott Main, an obstetrics and gynecology professor at the Stanford University School of Medicine and head of the collaborative.
“That’s why we’ve embraced, in California, pushing all the buttons at once: working with patients, working directly with physicians, hospitals, health plans and the state public health department,” he says.
How exactly the low-risk C-section rate is measured and assessed can vary slightly. But in 2012, before efforts to reduce unnecessary cesareans ramped up in the state, data culled from the collaborative shows low-risk C-section rates ranged from 13% to 83.3% in California hospitals, with a statewide average of 27.8%. The federal government’s Healthy People 2020 goals, using a similar definition for low-risk women, say their rate of first-time cesareans should be no more than 23.9% by next year.
Advocates have been working to bring down the rate because research indicates a higher likelihood of severe complications from a C-section – such as blood clots, infections and even death – than from vaginal deliveries. Problems can manifest later, in subsequent pregnancies and births. Yet once a woman has a C-section, there’s about a 90% chance she’ll have one for her next childbirth, creating a continual cycle of risk.
“The biggest risk of a C-section is becoming a prior C-section,” Main says.
The maternal care collaborative was founded in 2006 by Stanford University and state officials to combat rising rates of maternal mortality and morbidity, and the organization rolled out its C-section “toolkit” for providers in 2016. The toolkit addresses hospital culture and ways to support vaginal birth, how to manage abnormalities during labor without defaulting to C-sections, and how to use data to push for a reduction in low-risk C-sections.
Overall, the toolkit aims to ensure processes on the labor and delivery floor don’t vary by which doctor is on duty, and that any progress in lowering a hospital’s low-risk C-section rate is sustainable. The collaborative’s Maternal Data Center also provides nearly real-time information on California hospitals’ maternal care metrics, including how many C-sections they’ve performed.
A toolkit from the California Maternal Quality Care Collaborative addresses hospital culture and ways to support vaginal birth.(Brett Ziegler for USN&WR)
Hospitals that have engaged with the quality-improvement process for low-risk C-sections have “done a really good job at re-educating their providers on what their expectations are, and their numbers show it,” says Dawn Thompson, a doula who leads the San Diego County-based patient advocacy group Improving Birth.
Hospitals elsewhere are often taciturn about their low-risk C-section rates, but in the Golden State, the maternal care collaborative, the California Healthcare Foundation and their partners publish hospital-level data through the website Cal Hospital Compare. The site also includes maternal care measures such as a hospital’s breastfeeding rate and share of deliveries managed by certified nurse-midwives.
Dr. David Lagrew, a maternal-fetal medicine specialist based in Orange County, California, says publicizing hospital-level C-section rates is a good starting point to compel hospitals to curb the procedures. But he says doctors should know their individual rates as well – and so should their patients.
“One of the most powerful tools we have on lowering C-section rates is giving providers their data,” says Lagrew, a member of the collaborative’s executive committee and executive medical director of the Providence St. Joseph Health Women and Children’s Services Institute. “You can pick a hospital with a low rate, but you don’t know if that individual provider is the one contributing to that.”
The Providence St. Joseph Health system – with facilities ranging from Alaska to Texas – also is creating a data repository to follow patients across multiple pregnancies and track their risk of related complications. Lagrew says the repository will draw some of this data from women’s electronic medical records, and hopes that feeding the information back to providers will push them to more carefully consider whether a C-section is medically necessary.
But perhaps the strongest way to change how physicians practice is to change how they’re paid. In 2018, Covered California, the state’s health insurance marketplace under the Affordable Care Act, announced that all in-network hospitals must meet a target of 23.9% for low-risk C-sections by the end of 2019 or risk losing their in-network designation – a major blow as about 1.5 million Californians received health insurance through the marketplace last year.
“There’s no way individual providers are going to make those changes without a significant amount of pressure coming from somewhere else,” says Dr. Emiliano Chavira, an OB-GYN practicing in the Los Angeles area.
Together, these efforts seek to provide that pressure, spurring doctors to think closely about exactly why they’re making certain decisions. The ultimate goal is to change how labor and delivery is managed in hospitals that haven’t closely measured or improved the quality of their maternal care in the past.
“What we’re trying to do is prevent the indications for having a C-section,” Main says. “Let’s work upstream a bit. … Let’s work on giving people a little bit more time in labor, and let’s get the nurses really engaged in labor support. Let’s make it so you don’t have quite as much of a trigger finger.”
Along with the California collaborative’s toolkit, other resources are available for providers seeking to address maternal health care. For example, The Alliance for Innovation on Maternal Health, or AIM – a national initiative to reduce maternal morbidity and mortality – has developed a series of “maternal safety bundles” that detail best practices for improving obstetric hemorrhage outcomes, race-based maternal health disparities, and mental health during and after pregnancy.
Out of 27 states involved in the AIM initiative, though, California and Maryland are the only two to adopt the bundle on reducing low-risk primary C-sections, as has Trinity Health, which operates in 22 states. Colorado also recently enrolled with AIM and plans to implement the C-section bundle, which was first introduced in 2015.
“The data is there – we know what evidence-based care looks like,” Thompson says. “But it’s not what’s being practiced, and there’s no motivation for the system to change – there hasn’t been until just recently.”
Federal health officials estimate that roughly 700 women in the U.S. die each year of a pregnancy-related issue, but where they’re most at risk varies greatly. An analysis from the United Health Foundation shows that from 2013 to 2017, the maternal mortality rate was 29.6 per 100,000 births in the U.S. overall. California, meanwhile, saw a rate of 17.6 – among the lowest in the country.
“I think it all ties in to maternal safety,” Lagrew says. “If you’re going to take the long-run strategy toward lowering maternal mortality, we have to do away with unnecessary C-sections.”
Main likens the increased momentum around reducing low-risk cesareans to the shift away from routine episiotomies – a surgical cut that makes it easier for a baby to emerge during childbirth. Between 2006 and 2012, the episiotomy rate in the U.S. fell from 17.3% to 11.6%. That rate was closer to 61% as recently as 1979.
“That wasn’t a big collaborative like what we’re doing on C-sections,” Main says. “That was women saying, ‘I don’t want to be cut.'”
Advocates say women’s voices should be equally central to the conversation around reducing C-sections. Last year, the maternal care collaborative and the California Health Care Foundation launched a public awareness campaign to educate expectant mothers about the overuse of C-sections, and to encourage them to discuss their delivery options with their doctors.
“We live in a world where shared decision-making is the rule of the day, and rightly so,” Lagrew says. “We should be listening to women and doing what they want.”
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