California C-section Reduction Campaign Shows Positive Results

C-section rates varied widely between hospitals in California before the initiative with no particular reason.

A four-year, Stanford-led initiative to reduce C-sections for low-risk, first-time mother in California is paying dividends, a new study finds.

The study, published in the Journal of the American Medical Association, found that the initiative slightly exceeded national goals and led California to become the first state in the nation to reach a sustained reduction in C-sections.

C-section rates varied widely between hospitals in California before the initiative with no particular reason, said study senior author Elliott Main, MD, clinical professor of obstetrics and gynecology at Stanford Medicine.

"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%," Main said. "That wasn't right."

The study examined several coordinated initiatives in California to reduce C-sections between 2015 and 2019, including annual public reporting of hospital C-section rates, messaging to the state's 238 hospitals, as well as state agencies and payers, and quality improvement programs targeting hospitals with the highest C-section rates.

As a result of those efforts, the study found that the initiative reduced the percentage of first-time California mothers with low-risk pregnancies who underwent C-sections from 26% in 2014 -- a rate equal to the current national average – to 22.8% in 2019, putting the Golden State below the 23.9% target put forward by the Centers for Disease Control and Prevention in its Healthy People 202 initiative.

"It's a big change from the U.S. average, and our collective efforts have not only significantly lowered the average rate for the state but also narrowed the variation between hospitals in California," Main said. "This is great news for California women, especially because we have preserved and even improved on babies’ outcomes at the same time."

When appropriate, Main said, C-sections can be lifesavers for babies and their mothers, but they also carry risks. C-sections are considered major surgery and thus create potential complications, longer recovery periods, and endanger future pregnancies than vaginal births.

The study identified several factors that have nothing to do with the health or safety of the patients as factors driving C-section rates, including hospital policies, the culture of the labor delivery unit, and the attitudes of individual doctors and nurses.

"Getting healthcare providers to change their behaviors is difficult, but this was a concerted effort with many layers of support for our hospital teams," said the study lead author, Melissa Rosenstein, MD, associate director for implementation science at the California Maternal Quality Care Collaborative and an assistant professor of obstetrics, gynecology and reproductive sciences at the University of California, San Francisco.

"After we shared multiple strategies and provided every hospital with an analysis of its own data, each hospital chose the approach, or approaches, it wanted to work on," Rosenstein said.