Thursday, December 18, 2014

The Primary Cesarean Reduction Movement

There is good news to report: Health Care Professionals are paying attention!

When we work on our grass roots advocacy we think that our issues are so important, and everyone we talk to cares, that we must be making change. Sometimes, however, we come to the sad realization that people are not paying attention. But we plug along and keep on hoping that because our issue is important, eventually society and culture will catch up and begin listening to what we have to say.

Well, this is starting to happen. Birth advocates who have been fighting for years to get hospitals, obstetricians, departments of health, the federal government, ANYONE to pay attention to the increasingly harmful Cesarean epidemic are finally making a difference.

How do I know?

I work for an organization that works to improve the quality of health care for mothers and babies in the state. We work in collaboration with ACOG, ACNM, AWHONN, March of Dimes, the hospital association, private and public health insurance agencies, hospitals networks, and individuals willing to be part of maternal and neonatal quality improvement. We network with State Perinatal Quality Collaboratives and members of the Council on Patient Safety in Women's Health. We hear what is developing nationally and discuss issues with organization representatives in our state. We hear directly from nurses, midwives, and physicians about what the environment is like in their hospitals. And I can tell you, people are talking about this issue!

Furthermore, the Society for Maternal and Fetal Medicine (SMFM) and the American Congress of Obstetricians and Gynecologists (ACOG) recently released their Consensus Statement Safe Prevention of the Primary Cesarean Delivery.

The movement to reduce unnecessary Cesarean sections is picking up speed.


One reason folks are starting to pay attention is the cost. Insurance companies generally pay quite a bit for a cesarean delivery, which is more costly than a vaginal delivery. In 2013, on average, the total cost for maternal and newborn care associated with a cesarean was $51,125, compared to $32,093 for a vaginal birth.

Additionally, because cesareans are associated with increased risk of blood clots, bleeding, infection, complications in future pregnancies, hysterectomies, and even death, it would save the health care system a great deal of money to reduce these primary cesarean deliveries. 

Researchers from the California Maternal Quality Care Collaborative make the suggestion that financial incentives be put into place, for example, reforming payment for cesarean deliveries: 
Payment reform could create the proverbial “burning platform” that spurs change more quickly than other strategies. The first step is to remove the perverse financial incentives that currently help drive the rising rate.
This move would have to be made by payers (insurance companies) and/or policymakers. Movements like this are slow to occur, but are one direction that we can move toward.

NTSV Cesareans

The emphasis is on reducing Cesareans among low-risk first-time mothers. The rationale for this is that repeat Cesareans would be reduced if we reduced primary C-sections (makes sense, since VBAC rates are so low), and of course comparing a low risk group makes for an easy comparison group and leaves less room for argument for "medical indication." Nationally, the data and the proposed initiatives focus on nulliparous, term, singleton, vertex Cesareans (NTSV). An NTSV is a pregnant woman who has never had a baby before, delivers at term, there is only one baby (no multiples), and the baby is head-down.

Though this removes some indications for a Cesarean, others could still exist: preeclampsia, fetal distress, failure to progress, cord prolapse, elective delivery, and so on.

Epidemiological data analysis has found extremely wide variation in primary cesarean rates in different parts of the country and across hospitals. What this means is that hospital primary cesarean rates range from 2% to 36%. That means that where you give birth determines whether or not you have a cesarean, not necessarily your personal or medical situation. Wide variation in hospital NTSV cesarean rates suggests that clinical practice patterns and patient preferences are affecting these rates.

National research has shown that it is not individual factors (e.g. mother's age, race/ethnicity) nor pre-existing medical conditions (e.g. gestational diabetes) that account for this variation. We know that maternal request for cesareans, while highly visible among celebrities or in Brazil, is actually quite low in the U.S. What this leaves is physician practice patterns.

Changing Practice Patterns

If you've watched Eugene Declerq's Birth by the Numbers videos, you have heard him examine the rising cesarean rates. He shows us that rates and patterns of diagnoses/cesareans for maternal complications such as placenta abruptio, cord prolapse, fetal distress, dysfunctional labor, and so on all decreased until 1996, and then all have increased since then. His data shows that it is not mothers changing, it is a change in medical practice. He notes an article that came out decades ago called "The rise in the cesarean rate: same indications but a lower threshold."

Even the ACOG/SMFM Statement notes
Variation in the rates of nulliparous, term, singleton, vertex cesarean births also indicates that clinical practice patterns affect the number of cesarean births performed.

Quality Improvement Initiative

I envision the creation of a quality improvement (QI) initiative for hospitals to work to reduce primary cesarean sections through a focus on. A few fantastic places to start are the recommendations that ACOG and SMFM came up with themselves. I will also go beyond their recommendations to offer some of my own.

Here are some changes that need to be made:
  1. Labor Curve. Physicians need to alter the "definition of labor dystocia because recent data show that contemporary labor progresses at a rate substantially slower than what was historically taught." This also goes for the pushing phase (second stage).
    • "A prolonged latent phase (eg, greater than 20 hours in nulliparous women and greater than 14 hours in multiparous women) should not be an indication for cesarean delivery.
    • Slow but progressive labor in the first stage of labor should not be an indication for cesarean delivery.
    • Cervical dilation of 6 cm should be considered the threshold for the active phase of most women in labor. Thus, before 6 cm of dilation is achieved, standards of active phase progress should not be applied.
    • Cesarean delivery for active phase arrest in the first stage of labor should be reserved for women at or beyond 6 cm of dilation with ruptured membranes who fail to progress despite 4 hours of adequate uterine activity, or at least 6 hours of oxytocin administration with inadequate uterine activity and no cervical change.
    • A specific absolute maximum length of time spent in the second stage of labor beyond which all women should undergo operative delivery has not been identified.
    • Before diagnosing arrest of labor in the second stage, if the maternal and fetal conditions permit, allow for the following: At least 2 hours of pushing in multiparous women, and At least 3 hours of pushing in nulliparous women (1B) Longer durations may be appropriate on an individualized basis (eg, with the use of epidural analgesia or with fetal malposition) as long as progress is being documented."
  2. Fetal Monitoring. "Improved and standardized fetal heart rate interpretation and management" are certainly needed. Because providers differ so greatly on how they read the electronic fetal monitoring output, there needs to be some increased training on this. More importantly, however, I would suggest following the evidence, which concludes that the continuous EFM is completely worthless at reducing infant morbidity and mortality. I don't think low risk women should be on it at all. However, I don't think that in our highly litigious society it will ever go away. 
    • "Intermittent monitoring has been shown by the research to be just as good at identifying possible fetal distress as continuous EFM. It has a quite a few benefits, too: Does not increase cesarean deliveries like continuous EFM does, and does not limit women's movement in labor."
  3. Doulas. "Increasing women’s access to nonmedical interventions during labor, such as continuous labor and delivery support, also has been shown to reduce cesarean birth rates". It should be no surprise to anyone reading this blog that the evidence supports the use of doulas to reduce cesareans.
    • "Given that there are no associated measurable harms, this resource is probably underutilized."
  4. Deliveries for Medical Reasons. Stop inducing for non-medical reasons, at any gestation, but particularly before 41 weeks. Stop inducing with a non-favorable cervix. Stop scheduling cesareans for non-medically indicated reasons, particularly suspected macrosomia (big baby).
    • "Cesarean delivery to avoid potential birth trauma should be limited to estimated fetal weights of at least 5,000 g in women without diabetes and at least 4,500 g in women with diabetes. The prevalence of birth weight of 5,000 g or more is rare, and patients should be counseled that estimates of fetal weight, particularly late in gestation, are imprecise."
  5. Operative Vaginal Delivery. Many obstetricians are quick to jump to a cesarean section rather than deliver with forceps or a vacuum. This is most likely because they are not well-trained to use these methods, while they get plenty of experience doing cesarean sections. While these procedures have pros and cons, cesareans certainly do as well, and comparably, these have much fewer associated injuries and morbidities. 
    • "Operative vaginal delivery in the second stage of labor by experienced and well trained physicians should be considered a safe, acceptable alternative to cesarean delivery. Training in, and ongoing maintenance of, practical skills related to operative vaginal delivery should be encouraged."
    • Manual rotation of the fetal occiput in the setting of fetal malposition in the second stage of labor is a reasonable intervention to consider before moving to operative vaginal delivery or cesarean delivery. In order to safely prevent cesarean deliveries in the setting of malposition, it is important to assess the fetal position in the second stage of labor, particularly in the setting of abnormal fetal descent."
  6. Variations. Many obstetricians are not taught how to attend a vaginal breech birth or a twin birth, and go straight to delivering by surgery. Increasing the availability of care providers trained in safely delivering these variations vaginally would greatly reduce the primary cesarean rate. "External cephalic version for breech presentation and a trial of labor for women with twin gestations when the first twin is in cephalic presentation are other of several examples of interventions that can contribute to the safe lowering of the primary cesarean delivery rate."
    • "Fetal presentation should be assessed and documented beginning at 36 0/7 weeks of gestation to allow for external cephalic version to be offered."


No one is quite sure how to remove fears of malpractice litigation, which "leads many physicians to have a lower tolerance for any perceived labor abnormality."

Another issue is time efficiency. Greater patience is needed on the part of the care providers. One possible solution to this might be increasing the use of midwives to handle low-risk labors and births in hospitals. This has yet to be supported by research.

Out-of-hospital births should also be promoted for women with low-risk pregnancies, as cesarean rates are much lower for planned home and birth center births. More states need to legally recognize and license out-of-hospital midwives.

As Main et al of the California paper write,
The most promising mix includes clinical quality improvement strategies with careful examination of labor management practices to reduce those that lead to the development of indications for cesarean deliveries; payment reform to eliminate negative or perverse incentives; health care provider and consumer education to recognize the value of normal vaginal birth; and full transparency through public reporting and continued public engagement.
I agree with the authors of the California paper that we can't focus on just the clinical aspect of this issue (as outline in my QI Initiative recommendations, above), but it is an excellent place to start.

What do you think? Do you have additional ideas?

Click here to read Part 2.

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