Cesarean delivery rates decline in California after efforts supporting vaginal birth
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Key takeaways:
- Hospitals participating in collaboratives to support vaginal birth saw a decrease in low-risk, first-time cesarean deliveries.
- The reductions were not associated with specific patient or hospital characteristics.
Cesarean deliveries declined statewide in California from 2015 to 2019 after efforts to support vaginal birth, including a marked reduction in cesarean deliveries before labor and those due to obstructed labor, researchers reported.
In 2015, California had a cesarean delivery rate higher than the Healthy People 2020 target at 26.1%, which led the state to implement a multifaceted intervention with the goal of safely preventing a first cesarean delivery, Melissa G. Rosenstein, MD, MAS, maternal-fetal medicine specialist and associate professor of obstetrics, gynecology and reproductive sciences at the University of California, San Francisco, and colleagues from the California Maternal Quality Care Collaborative (CMQCC) wrote in Obstetrics & Gynecology. The cesarean delivery rate subsequently fell to 22.8% in 2019; however, the researchers still sought to evaluate the rate reductions among different demographic groups.
“What’s so exciting and inspiring about this study is that it confirms that safely preventing the first cesarean is possible everywhere — in all types of hospitals and for all types of patients,” Rosenstein told Healio. “While it is frustrating that we can’t pinpoint exactly why some hospitals were successful at meeting the target while others weren’t, the study shows that if a hospital has the will to make a change, using already available tools and sharing knowledge and strategies with peers can make a difference in reducing cesarean delivery rates without adversely affecting newborn outcomes.”
Rosenstein and colleagues conducted a population-based study evaluating data from 758,268 nulliparous, term, singleton cesarean deliveries at 238 hospitals in California from 2015 to 2019. In 2015, hospitals with cesarean delivery rates higher than the Healthy People 2020 target of 23.9% were invited to join a California Maternal Quality Care Collaborative or a system-level quality collaborative to support vaginal birth.
Researchers assessed cesarean delivery rates overall and by participation or nonparticipation in the collaborative. Researchers also compared patient-level, hospital-level and obstetric management characteristics between hospitals with rates higher than 23.9% or lower than 23.9% in 2019.
Annual mean cesarean delivery rates decreased among all women statewide, regardless of race and ethnicity, payer, maternal age or BMI.
According to the researchers, the decline in cesarean delivery rates in California was driven largely by decreases from 2015 to 2019 in cesarean deliveries performed for labor dystocia (14.9% to 12.8%) and decreases in cesarean deliveries performed before labor onset (4.2% to 3.3%).
Among the 80 California hospitals participating in the collaborative, those with cesarean delivery rates higher than 23.9% had a mean decline of 6.9 percentage points. In addition, researchers observed a mean decline of 5 percentage points for cesarean delivery rates for the 13 hospitals participating in the system-level collaborative. Conversely, hospitals not participating in any collaboratives had a 2.1 percentage point decline in cesarean delivery rates.
Labor induction rates rose for all hospital groups but were not associated with a change in cesarean delivery rates.
Researchers observed no association between meeting the Healthy People 2020 target and any of the hospital-level factors or patient-level characteristics.
“Although we found that the state-level initiative decreased cesarean delivery rates of patients of all racial and ethnic groups, it did not eliminate disparities,” the researchers wrote. “Although some quality-improvement projects have been shown to decrease maternal disparities, further efforts to address disparities in cesarean delivery rates likely will require setting explicit goals to improve birth equity among Black, Asian, and Pacific Islander populations.”
For more information:
Melissa G. Rosenstein, MD, MAS, can be reached at melissa.rosenstein@ucsf.edu.