A US study found that hospital-led interventions over a seven-year period were associated with a significant reduction in the caesarean delivery rate.
Nearly one in three babies born in the US is delivered via caesarean section, or C-section. Compared to vaginal delivery, caesareans are associated with a number of increased health risks for mother and baby – including increased mortality – as well as longer hospital stays and increased health care costs.
The study measured the impact of a series of strategic quality improvement interventions on the hospital's nulliparous, term singleton vertex (NTSV) caesarean rate – or the proportion of single babies carried to at least 37 weeks in the vertex position born to women having their first baby that were delivered via caesarean.
"The rate of caesarean deliveries in low-risk women varies significantly from hospital to hospital across the nation, and such wide disparities suggest that some caesarean deliveries may be performed for reasons other than medical necessity," said first author Dr Mary A Vadnais, a maternal-foetal medicine specialist and vice chair of the Obstetrics Quality Assurance Committee at BIDMC. "Our research shows that quality improvement initiatives can significantly reduce caesarean deliveries in low-risk women, benefiting mothers and reducing health care costs."
Beginning in 2008, BIDMC obstetricians implemented a series of interventions in five areas: interpretation and management of foetal heart rate tracings, provider tolerance for labour, induction of labour, provider awareness of NTSV caesarean delivery rates and environmental stress.
During the intervention period, researchers found that the NTSV caesarean rate decreased from 34.8% to 21.2%, below the US Department of Health and Human Service's recommended target rate of 23.9%. The hospital's overall caesarean rate also declined from 40% to 29.1% over the same period.
"Since implementing these quality improvement measures, our department has seen a steady decline in our caesarean rate," said senior author Dr Toni Golen, medical director of labour and delivery and post-partum at BIDMC. "More important, with that decline we have not seen a clinically significant rise in complications among babies or mothers, which demonstrates the success of the interventions."
Vadnais and colleagues used available published data and assessed environmental factors in the BIDMC labour and delivery unit to design strategic interventions aimed at lowering the NTSV caesarean delivery rate. In some cases, these interventions meant standardising protocols, increasing provider education or revising guidelines. For example, slow progression of labour is a common reason for a caesarean delivery.
However, historical norms for labour progress may not apply to modern obstetrical populations. Reassessing how to manage slower labours allowed physicians to avoid caesarean deliveries based solely on the previously expected rate of cervical changes.
There is a recognised association between a hospital's environmental factors and its caesarean delivery rate. To optimise the environment at BIDMC, the labour and delivery unit conducted emergency caesarean delivery drills to strengthen cohesiveness between the provider and unit staff members to increase the unit's ability to support the physician during an urgent situation. The department also created a more flexible visitor guideline to promote continual emotional support for the patient.
"We designed the improvement interventions so that they can easily be customised to meet the needs of any medical institution," Golen added. "Our hope is that other hospitals will replicate this approach by identifying factors within their practice and implement similar quality improvement initiatives so that they can reduce their caesarean delivery rates as well."
The authors note that because the study used a series of interventions, they reported cumulative effects, and therefore the study could not measure the impact of any single intervention. Certain data such as administrative data and ICD9 codes were available, but other data, such as patient body mass index (BMI) data, were not.
Also, the impact of midwifery care on a reduced caesarean rate could not be measured due to the fact that such care was not available at BIDMC until 2014.
Abstract
Background: The nulliparous term singleton vertex (NTSV) cesarean delivery rate has been recognized as a meaningful benchmark. Variation in the NTSV cesarean delivery rate among hospitals and providers suggests many hospitals may be able to safely improve their rates. The NTSV cesarean delivery rate at the authors' institution was higher than state and national averages. This study was conducted to determine the influence of a set of quality improvement interventions on the NTSV cesarean delivery rate.
Methods: From 2008 through 2015, at a single tertiary care academic medical center, a multi-strategy approach that included provider education, provider feedback, and implementation of new policies was used to target evidence-based and inferred factors that influence the NTSV cesarean delivery rate. Data on mode of delivery, maternal outcomes, and neonatal outcomes were collected from birth certificates and administrative claims data. The Cochran-Armitage test and linear regression were used to calculate the p-trend for categorical and continuous variables, respectively.
Results: More than 20,000 NTSV deliveries were analyzed, including more than 15,000 during the intervention period. The NTSV cesarean delivery rate declined from 35% to 21% over eight years. The total cesarean delivery rate declined as well. Increase in meconium aspiration syndrome and maternal transfusion were observed.
Conclusion: Quality improvement initiatives can decrease the NTSV cesarean delivery rate. Any increased incidence of fetal or maternal complications associated with decreased NTSV cesarean delivery rate should be considered in the context of the risks and benefits of vaginal delivery compared to cesarean delivery.
Authors
Mary A Vadnais, Michele R Hacker, Neel T Shah, JoAnn Jordan, Anna M Modest, Molly Siegel, Toni H Golen
[link url="https://www.eurekalert.org/pub_releases/2017-01/bidm-hia012417.php"]Beth Israel Deaconess Medical Centre material[/link]
[link url="http://www.jointcommissionjournal.com/article/S1553-7250(16)30057-5/abstract"]The Joint Commission Journal on Quality and Patient Safety abstract[/link]