Reducing C-Sections for First-Time Mothers
Mimi Murphy, a 32-year-old first time mother from Pittsburg, Pa., gave birth to her son Arlo last Friday through a planned cesarean section.
“My delivery was exceptionally more difficult than predicted, and we already anticipated some trouble ahead of time,” said Murphy.
The C-section was scheduled prior to delivery to prevent Murphy from serious hemorrhaging in a natural delivery, as an anatomy scan during her 20th week revealed she had placenta previa, a condition which causes severe bleeding when the placenta covers the mother’s cervix.
“During the C-section there was no choice but to go through my placenta to get the baby out as quickly as possible and to get me stable. The cut in the placenta caused a large amount of blood loss for the baby and myself. The baby became anemic in the process and ended up needing a full unit himself. He had to be treated in the NICU and is currently still there,” said Murphy.
Cesarean section, a major surgery which involves incisions in the abdomen and uterus, is typically performed when deemed medically necessary for the safety of mother and newborn. However, national variation in C-section rates indicate it is performed in cases where it is not always medically necessary.
“The most common reason for getting a C-section is prolonged labor, where progress is slow or stopped, and second most common is a concern about fetal heart rate on the fetal monitor. Both are somewhat subjective, and vary from one obstetrician to another, and the variation even within the same hospital is quite large among different providers in the same population,” said Elliott Main, clinical professor of obstetrics and gynecology at Stanford and medical director of the California Maternal Quality Care Collaborative.
A report published today from Main and Stanford University Researchers, found that a four-year campaign in California to reduce the rate of cesarean sections for low-risk, first-time mothers worked.
Researchers coordinated initiatives from 2015-2019 in 238 hospitals, to reduce C-sections for women whose pregnancy was at, or near due date, the baby was not a twin, and the baby not in breech but positioned head-down before delivery.
“It was really hard to come up with a number… for national standards for C-section rates, there were so many different settings for C-sections, and each hospital had a different mix of kinds,” said Main.
That’s why Main relied on the national standard C-section rate of 23.9% which was provided by the Centers for Disease Control and Prevention in their Healthy People 2020 goals.
Before the start of the study in 2014, 26% of first-time California mothers with low-risk pregnancies underwent C-sections, a rate equal to national average.
But by 2019, that C-section rate decreased to 22.8%, which is below the target goal set by the CDC.
“We had pregnant women going to different hospitals in California and, through one door, the cesarean delivery rate was 15%, while through another it was 60%. That wasn’t right,” said Main.
Hospitals across the U.S. have always varied in C-section rates, and there appears to be “no medical reason for the variation,” said Main.
“The rates vary so much because there are C-sections which are absolutely necessary, and then there is a grey zone. Our approach is not to say you shouldn’t do a C-section if you have good indication, but we are striving hard to prevent the development of an indication,” he added.
Researchers found that particular initiatives reduced the rate of C-sections, including things like messaging all hospitals from state agencies and health plans, providing annual public reporting of C-sections, and quality improvement programs to target hospitals with highest rates.
The study was the first to prove that reducing C-sections is effective at reducing complications in newborns, as the rate of severe unexpected newborn complications decreased from 2.1% to 1.5% between 2015 and 2019, showing that C-section rates can be lowered without posing harm to a newborn.
Hospitals in the study which achieved C-section rates of 23.9% or lower, received an award given to the CEO of the facility from the Health and Human Services Agency of California, which was an “effective incentive for reducing rates,” Main said.
However, hospitals with C-section rates above 23.9% were invited to participate in an intense, 18-month, quality-improvement initiative aimed at lowering their rates.
Those 91 participating hospitals met monthly with peer mentors to discuss strategies for change, such as educating doctors and nurses about the value of lowering C-section rates, giving labor nurses a more active role in encouraging and supporting vaginal delivery, and following national guidelines for identifying when labor is considered stalled.
Main explained, “Some of these hospitals have rates of 40 or 50%, and were either afraid, or did not know how to approach a change in practice patterns. So, the Collaborative coached them through a variety of approaches toward lowering their C-section rates and helped them teach their staff new techniques. We provided monthly data reports to show them where they needed to put their efforts, whether it was C-sections due to labor inductions, or C-sections related to failure to progress, or concern over fetal heart rate to target interventions better.”
In 2018, the Collaborative also engaged the online review platform Yelp, to pull data from government websites which track C-section rates per hospital and make it publicly available for new patients searching online for the best place to undergo labor.
Main found that factors unrelated to patients’ medical needs, including hospital policies, the culture of the labor and delivery unit, and the attitudes and beliefs of individual doctors and nurses have all been shown to influence C-section rates.
For example, greater reduction of C-sections could have occurred if there were more midwives and doulas to coach women through labor, as only a third of hospitals chose to more actively involve doulas, and only 4% added midwives.
“The national rate was around 26%, and nationally we didn’t make much progress. California dropped but the rest of the US stayed exactly the same,” Main said, adding that the study showed the C-section rate can be changed.
California, which accounts for one-eighth of all births in the nation, is now the first state in the country to sustain reduction of C-section rates. Main says between 11,000- 14,000 C-sections were avoided during the study period.
“We are helping other states, like Illinois, Michigan, and Iowa, that already have active programs to reduce C-section rates, and we are encouraging other states to take on these programs,” said Main.
Although currently every third woman who goes to the hospital will have a C-section, by reducing C-sections during the first pregnancy, there is a chance to avoid a C-section during a second birth.
For Murphy, who was released today from the ICU, and will soon be home with Arlo, she is aware of how the C-section will impact future deliveries.
“Due to the T incision… I would have to have C-sections if I were to get pregnant again to reduce the risk of scar tissue issues,” said Murphy.
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