An almost 25% reduction in cesarean deliveries for low-risk pregnancies in a California hospital quality improvement initiative did not result in worse maternal or neonatal outcomes, according to a new study published online March 11 in Obstetrics & Gynecology.
In fact, the drop in C-section rates actually occurred alongside an improvement in neonatal outcomes in those hospitals with the greatest reductions.
“Some obstetricians harbor apprehensions about reducing their current high cesarean delivery rates,” say Elliott K. Main, MD, and colleagues, from the California Maternal Quality Care Collaborative (CMQCC) at Stanford University School of Medicine in California.
“Our findings that large reductions in cesarean delivery rates need not lead to worse neonatal or maternal outcomes is important for other hospitals and health systems embarking on this journey.”
“First, that a lower frequency of cesarean delivery needn’t be accompanied by a higher frequency of maternal or neonatal complications and, indeed, may even be associated with fewer adverse outcomes; and second, that the success associated with implementation of the ACOG–SMFM guidelines for labor management achieved by single centers may, with a well-coordinated collaborative effort, be writ large.”
Rates Drop by Almost 50% in a Third of Hospitals With Highest Rates
The study‘s 56 participating hospitals, which included mostly community facilities (87.5%), all had nulliparous, term, singleton, vertex (NTSV) cesarean delivery rates greater than 23.9%, the designated target rate for low-risk cesarean deliveries in the federal 2020 Healthy People goals. Their combined delivery volume over the period studied was 119,000 births, “a higher delivery volume than in all but nine US states,” the authors note.
Under the guidance of the CMQCC, in groups of six to eight hospitals, a physician and nurse mentor offered clinical expertise and quality improvement coaching for implementing labor management and strengthening nursing labor support as per the American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine (ACOG–SMFM) guidelines.
Data analyzed for the study included birth certificates, routinely collected safety measures, and maternal and neonatal medical records for discharge, diagnosis, procedures, and relevant clinical data.
From 2015 to 2017, rates of NTSV cesarean deliveries among participating hospitals dropped from 29.3% to 25%, resulting in a 24% lower odds of a cesarean delivery with these typically low-risk pregnancies (adjusted odds ratio [aOR], 0.76).
There were no changes during the study period in rates of maternal chorioamnionitis, maternal blood transfusions, third- or fourth-degree lacerations, or operative vaginal deliveries. Among newborns, rates also remained stable for a composite of severe unexpected newborn complications and for 5-minute Apgar scores less than 5.
The researchers then looked specifically at safety outcomes in the tercile of hospitals where NTSV cesarean rates dropped the most — almost in half — from 31.2% to 20.6% (aOR, 0.54).
Not only did maternal outcomes remain similar during this period, but neonatal outcomes actually improved in these institutions: rates of the severe unexpected newborn complications composite dropped from 3.2% to 2.2% (aOR, 0.71).
Baseline C-Section Rates Varied Greatly Between Hospitals
In a podcast discussion with the editors of Obstetrics & Gynecology, Main noted that the baseline cesarean rates among the hospitals varied greatly, “from 15% to as high as 65% or 70%” and that interventions at the hospitals correspondingly varied depending on that hospital‘s existing practices and challenges.
“In quality improvement, it’s always an insight when you have such variation that there are opportunities to improve,” he said.
The quality improvement initiative “really focuses on labor support techniques [and] on training staff — physicians and nurses. In short, it was trying to change the culture of the unit so people had more patience.”
Some of the hospitals brought down their rates by 15-16 percentage points, he said, which “underscores the flexibility of a C-section rate, that if you put your mind to it, you can change it quite a bit.”
And even hospitals where cesarean rates dropped below 20% did not show worse maternal or neonatal outcomes, or even an increase in operative vaginal deliveries, Main said.
There were some limitations, the authors acknowledge, including the fact that before-and-after studies must take into account potential confounding factors. Rouse agrees, writing that this limitation precludes an ability to determine “whether the lower frequency of cesarean delivery observed after the collaborative effort was the result of the effort itself or some other factor(s), especially because adherence to the ACOG–SMFM guidelines was not assessed, nor the level of nursing support actually measured.”
And both the authors and Rouse say the question remains as to whether the participating institutions will sustain the lower cesarean delivery rates, although Main said in the podcast discussion that the hospitals‘ rates have remained at the lower rates so far.
Adding to the Evidence: Having Cake and Eating it…
Rouse notes this isn’t the only study to suggest lower C-section rates can be accompanied by better neonatal outcomes.
“The French study by Schmitz et al demonstrates that it is possible on a national level to achieve a high proportion of twin vaginal delivery and that twins delivered vaginally have better neonatal outcomes than those delivered by cesarean,” he writes. That story was covered by Medscape Medical News.
Rouse also mentioned the ARRIVE trial, which was much discussed at the ACOG annual conference last year, which randomly assigned 6000 low-risk nulliparous women at term to expectant management or induction at 39 weeks.
“Not only did induction result in a significantly lower frequency of cesarean delivery (18.6% vs 22.2%), but it came within a whisker of significantly lowering the composite outcome of perinatal death or severe neonatal outcomes (4.3% vs 5.4%; relative risk 0.80; 95% CI, 0.64 – 1.00),” he observes.
“Taken together, the three studies provide reason to believe that, just maybe, we can have our cake and eat it too.”
The research was funded by the California Health Care Foundation. The authors have reported no relevant financial relationships. Rouse also has reported no relevant financial relationships and no external funding for the study.