Effort to Limit Unnecessary C-Sections Making Strides

Cesarean section births can have dangerous complications such as hemorrhaging.

The years-long effort to reduce unnecessary Cesarean section births in the United States is coming to fruition, an obstetrics expert says.

Complications from C-sections such as hemorrhaging are widely considered to be a contributing factor to the country's high maternal mortality rate. The federal Centers for Disease Control and Prevention have been monitoring maternal mortality since 1986. The number of pregnancy-related deaths has risen steadily since the monitoring effort began, from 7.2 deaths per 100,000 live births in 1987 to 18.0 deaths per 100,000 live births in 2014.

"We are finally at the point where most hospitals are sharing their data and having conversations on an individual basis about C-section rates. We are having conversations about quality at labor and delivery units as well as about the quality of individual providers. It has taken more than a decade to get to this point," says Amy VanBlaricom, MD, vice president of clinical operations for western states at Greenville, South Carolina-based Ob Hospitalist Group.

VanBlaricom says she is optimistic about the ongoing effort to limit unnecessary C-sections. "I would not say that we are at the finish line, but we are definitely in the home stretch. Reducing C-sections is on everyone's radar screen. Everyone who is in the practice of obstetrics knows that this is a problem, and they understand that there are medical complications that are happening to women that are avoidable because many C-sections have been done historically for less than medically sound reasons."

Roots of the problem

Both clinicians and patients are responsible for unnecessary C-section births, VanBlaricom says.

"From the physician side, there is fear of medical-legal risk. There is an old adage that obstetricians say, 'You never regret the C-section that you do, but you regret the C-section that you did not do.' There are many obstetricians who are fearful of being sued if they delay too long in performing a C-section, so they may call for a C-section sooner than is medically necessary. There are also inconveniences in scheduling—obstetricians need to coordinate their day if they have other issues going on. An obstetrician can become impatient with how long it takes a labor to progress," she says

"On the patient side, there is a segment of the patient population that asks for a C-section when it is not necessarily medically indicated. Some mothers want a C-section because they want to schedule the day of their birth. Some mothers want a C-section because they are fearful of the process of vaginal delivery—they want to preserve the integrity of their pelvic musculature. They read articles in lay journals about how it is going to impact their body to have a vaginal birth, and they decide they want to try to avoid that impact," VanBlaricom says.

Financial incentives can also drive unnecessary C-sections, she says. "There is a concern that insurance companies pay more for a C-section than for a vaginal delivery. The worry is that there is the convenience factor and the medical-legal climate that makes obstetricians fearful, then the payers incentivize financially toward the surgical delivery. That creates an environment that leans many providers toward the surgical mode of delivery."

Avoiding unnecessary C-sections

Peer pressure can be an effective way to encourage clinicians to avoid unnecessary C-sections, VanBlaricom says.

"That means benchmarking C-section rates for all of the hospital providers and making it transparent. You need to champion those who are doing a good job at keeping their C-section rates low. You also want to allow the providers who have higher C-section rates to learn. They should find out the ways that a colleague, who is seeing patients from the same community and has a lower C-section rate, is doing their practice in ways that achieve a lower C-section rate," she says.

Benchmarking should focus on first-time C-sections because once a C-section has been performed on a mother, she is more likely to have a surgical birth in the future, VanBlaricom says.

"Most hospitals look at the rate of first-time C-sections. There are a couple of different ways to look at that. One is the NTSV C-section rate, which stands for Nulliparous, Term, Singleton, Vertex. This measure eliminates twin gestations, breach babies, and those kinds of situations where it can be a no brainer to conduct a C-section. This is all about avoiding the avoidable, first-time C-section and looking at that rate. A good number is somewhere around 23% of births—that is usually where the data has shown that an appropriate number of avoidable C-sections are avoided," she says.

Standardization of care is another approach to limit unnecessary C-sections, VanBlaricom says.

"A good standardization tool is a labor dystocia checklist. Many clinicians think that the most avoidable form of C-section is the one that is done for a slow labor process—what is called labor dystocia. It is a labor that is taking longer than you think it should take. This can be very subjective. It can be based on the clinician's patience level, it can be based on what the clinician is usually willing to tolerate over time, or it can be based on what the mother is willing to accept," she says.

Labor dystocia checklists are based on evidence and a stepwise approach to labor, VanBlaricom says. "The checklists account for the number of steps you have taken, the amount of time that you have let the mother labor in each section of the labor process, and how long it is safe to let the mother labor. For example, the checklists account for how long the amniotic sack has been broken and how long the mother has been on labor augmentation medications without having the appropriate amount of cervical change."

Including mothers in their care teams is another way to limit C-sections, she says.

"When the mother is included in the care team, she will be more informed about the process and ask appropriate questions. We as clinicians will be less likely to call for a C-section out of convenience or call for a C-section based on a nonstandard indication. At hospitals that involve mothers in the process of labor, what we see is each member of the care team is held accountable to each phase of the process. The physicians are less likely to recommend a procedure that is not medically indicated because the patient requires a level of information and being informed. The patient is more likely to feel empowered to say 'no' if there is not a medical reason to perform a C-section," VanBlaricom says.

C-sections by the numbers

Statistics indicate that unnecessary C-sections are becoming less common.

• Ob Hospitalist Group's NTSV C-section rate for the deliveries their clinicians perform is 20.4% of all births.
   
• According to the Centers for Disease Control and Prevention, the overall C-section rate in the U.S. increased 60% from 1996 through 2009, hitting a high of 32.8% of all births from 2010 to 2012. But hospitals are making progress—the CDC reported that 31.9% of all births were by C-section in 2018.
   
• The rate of low-risk C-sections spiked to 28.1% of all births in 2009 but the rate fell to 25.9% in 2018.
   
• Healthy People 2030 set a national target for low-risk, first-birth C-section deliveries at 23.6% of all births and many states are making headway. For example, California reached a statewide average of 24.5% for low-risk, first-time C-section births in 2017.

Related: 2 Approaches to Reduce Maternal Morbidity and Mortality