W. Lawrence Warner, MD, Utah Section vice chair
When I began medical school in 1970, the overall cesarean delivery rate was 5.5%. After 36 years of practice, the rate has risen to the present level of 31.3%. I practice in Utah, where the rate is 22.2%, the lowest in the country. In New Jersey, the rate is 38.3%, the highest in the country. There are some individual hospitals with rates well over 50%. Many factors have led to this rising rate, but interestingly enough, most are not evidence-based. Maternal mortality has actually risen with the cesarean delivery rate—from 10 per 100,000 births in 1998 when the cesarean delivery rate was 21.2% to 14 per 100,000 in 2004 when the rate had reached 29.1%. The consequences of the increased cesarean delivery rate have been increased risk and cost for current delivery and increased risk for future pregnancies.
Is there an ideal cesarean delivery rate? In 1998, the US Public Health Service Commissioned Corps set forth public health goals in Healthy People 2010, including a cesarean delivery rate of 15%. The year 2010 came and went with double that rate. The new goal for 2020 has been set at 23.9%. Some major health care systems have attempted to set what they determine as an acceptable rate, including Intermountain Healthcare in Utah, which set the rate at 15%. The reaction from the physicians in the system was significant criticism and pushback.
How do you arrive at this predetermined rate? The Hospital Corporation of America (HCA) has taken a different approach to this issue. The organization has stated that the cesarean delivery rate functions poorly as an independent metric of quality of obstetric care and that sustainable reduction in the rate cannot be approached directly but will naturally flow from optimization of care processes that lead to cesarean delivery. HCA’s primary cesarean delivery rate has remained stable since 2005, while the national rate has continued to climb. HCA’s rate stability resulted from the implementation of improvements of each individual component of care.
Primary cesarean deliveries account for 50% of the increasing total cesarean delivery rate. Given its effect on subsequent pregnancies, an understanding of the drivers behind the increase in primary cesarean delivery rates and renewed efforts to reduce them may have a substantial effect on maternal health. The top five contributors to the primary cesarean delivery rate are nonreassuring fetal status, arrest of labor, multiple gestation, preeclampsia, and macrosomia. All five contributors are either subjective or depend on management style. Thus, the decision the patient makes as to whom she will see for her prenatal care and which physician will be on call for her delivery may be major determinants as to whether she will end up with a cesarean delivery or a vaginal birth.
Complete placenta previa, vasa previa, and cord prolapse represent absolute indications for cesarean delivery. However, most indications depend on the caregiver’s interpretation, recommendation, or action in response to the developing situation, making them a modifiable and likely target to lower the cesarean delivery rate. The potentially modifiable indications fall into three categories: obstetric, fetal, and maternal. The challenge for us as a specialty is to look at each component of care and each indication individually and collectively (as departments) and then evaluate if we are following established evidence-based protocols, policies, and/or checklists.
Continuing efforts to eliminate elective inductions prior to 39 weeks of gestation and inductions in nulliparous patients with an unfavorable cervix have helped reduce the overall cesarean delivery rate. We also need to reconsider our approach to patients with a previous cesarean delivery and strive to overcome the barriers to vaginal birth after cesarean delivery.
At the two hospitals where I practice, the departments have begun a project to move us in the right direction. At a recent department meeting, I gave an introductory presentation that identified all the potentially modifiable contributors to the decision to perform a cesarean delivery. Now, at each monthly department meeting, a short presentation will be made by a staff physician about one of these contributing factors, reviewing the most current evidence. The physician will then lead a discussion about where improvements could be made. By assigning a different physician each month, we hope involvement and buy-in by the entire staff will be maximized. Whenever a cesarean delivery is being considered, staff members are now encouraged, when possible, to arrive at a decision after discussion with peers.
Care must be taken to not have the unintended consequence of physicians becoming reluctant to proceed with clearly indicated cesarean deliveries because they fear criticism after later review of the care by the quality committee. This same issue occurs with medically indicated inductions of labor prior to 39 weeks of gestation.
In conclusion, this article is focused on arriving at the appropriate cesarean delivery rate rather than just lowering the cesarean delivery rate. The appropriate rate will be realized as we optimize each component of care, more freely seek the opinion of peers, improve our individual knowledge and skills, and educate our patients about the immediate and future consequences of a cesarean delivery.