Researchers identify factors that drive successful reductions in cesarean delivery rates
Researchers are trying to determine what makes hospitals successful at reducing cesarean deliveries, and what obstacles are preventing others from doing so.
Citing an increased risk for infections, blood clots and other adverse events, the CDC and WHO previously issued recommendations to limit the number of medically unnecessary cesarean sections.
Researchers wrote in Annals of Family Medicine that the state of California “exerted substantial pressure” on its hospitals to meet the CDC’s Healthy People 2020 goal of 24% or fewer cesarean deliveries or risk being excluded from the health insurance exchange plans that add to their revenue.
“Cesarean delivery rates are one of the most stubborn maternity quality metrics to move,” Emily C. White VanGompel, MD, MPH, clinical assistant professor at the University of Chicago Pritzker School of Medicine, told Healio Primary Care. “The purpose behind this study, and several that preceded it, was to try to characterize both what is actually behind the success of hospitals that have moved the needle as well as understand the immovable nature at other hospitals.”
The researchers analyzed survey responses from 840 health care professionals — including nurses, obstetricians, family physicians, midwives and anesthesiologists — at 37 demographically similar hospitals that had not met the Healthy People 2020 cesarean goal at the survey’s baseline. Hospitals that experienced a reduction of 5 percentage points or reached the Healthy People goal in nulliparous, term, singleton and vertex cesarean delivery rates during the 2-year study were considered “successful,” according to the researchers.
White VanGompel and colleagues reported that successful hospitals, compared with unsuccessful ones, had greater consensus on offering more midwifery services (45% vs. 24%; P = .017), carrying out programs that support early labor at home (76% vs. 58%; P = .022), offering additional doula services (44% vs. 17%; P = .002) and lowering the number of labor inductions for nonmedical reasons (85% vs. 63%; P = .002). In addition, nurses at successful hospitals were more likely to endorse that the culture of their unit supports vaginal birth (70% vs. 59%; P = .007) and less were likely to state that there were “too many cesareans” conducted in their unit (46% vs. 63%; P < .001).
Among all the health care professionals surveyed at the successful hospitals, there was greater agreement that their patients have “sufficient knowledge to make informed decisions,” although overall consensus for both groups was low (38% vs. 29%; P = .01), and that doulas were welcomed onto the team (54% vs. 46%; P = .03). There was less agreement that clinician workflow considerations affect labor management decisions (55% vs. 63%; P = .02).
White VanGompel and colleagues also interviewed five physicians and seven registered nurses — all in leadership roles — from eight of the participating hospitals. The themes that emerged as facilitators and barriers to changing cesarean delivery rates were:
- ease of access to shared resources on best practices
- fear and resistance to change;
- collaborative practice and communication;
- the role of subcultures and cultural flexibility; and
- physician commitment and leadership.
White VanGompel said the “fear and resistance to change” that was identified in the follow-up interviews was “concerning,” since it is a recurring theme in the obstetrics community that has yet to be sufficiently addressed.
She also said physicians should realize their “attitudes and actions deeply matter — in setting a tone, expectations, norms and values for others will ultimately impact the quality of care a patient receives.”
“For physicians who are leaders of departments, the take home message is how do you send a message to your department that this is an essential and valued part of clinical work?” she said. “How do you empower nurses to take this on when they are pulled in so many different directions? And how do you ensure that patients come prepared to participate as a member of the team?”
References:
Healthy People 2030. Reduce cesarean births among low-risk women with no prior births — MICH06. https://health.gov/healthypeople/objectives-and-data/browse-objectives/pregnancy-and-childbirth/reduce-cesarean-births-among-low-risk-women-no-prior-births-mich-06. Accessed June 23, 2021.
White VanGompel EC, et al. Ann Fam Med. 2021;doi:10.1370/afm.2675.
WHO. New WHO guidance on non-clinical interventions specifically designed to reduce unnecessary caesarean sections. https://www.who.int/reproductivehealth/guidance-to-reduce-unnecessary-caesarean-sections/en/. Accessed June 23, 2021.
Perspective
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Before 2015, cesarean deliveries trended up to 70%, a rate that cannot be exclusively attributed to women’s risk profile or preferences. In that year, the state of California put pressure on hospitals to reduce the cesarean rates to the Healthy People 2020 goal to a rate of 24% or fewer. Following this, many hospitals did see a significant reduction in cesarean births.
The mixed-methods study by VanGompel and colleagues is an interesting and important one that unboxed the barriers in promoting vaginal births in California hospitals. Physicians’ personal beliefs and attitude toward cesarean deliveries, fear of malpractice and poor communication between the providers and nursing staff are some of the reasons that were cited as contributing factors to the high rate of cesarean deliveries.
One of the most important strategies that can improve patient care in any discipline is having effective communication with all the team members. Being open to change, practicing evidence-based medicine and creating a conducive environment for the nursing and ancillary staff are essential to keep our patients safe and provide quality care.
Employing strong leadership that advocates for the best practices, incorporating courses on team building, resolving conflict and providing effective leadership during residency training can create an open mindset among physicians toward changes and overcome their resistance, which in turn will help patients make an informed decision.
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