Hospital Quality Improvement Interventions, Statewide Policy Initiatives, and Rates of Cesarean Delivery for Nulliparous, Term, Singleton, Vertex Births in California

Abstract

IMPORTANCE Safe reduction of the cesarean delivery rate is a national priority.OBJECTIVE To evaluate the rates of cesarean delivery for nulliparous, term, singleton, vertex (NTSV) births in California in the context of a statewide multifaceted intervention designed to reduce the rates of cesarean delivery. DESIGN, SETTING, AND PARTICIPANTSObservational study of cesarean delivery rates from 2014 to 2019 among 7 574 889 NTSV births in the US and at 238 nonmilitary hospitals providing maternity services in California. From 2016 to 2019, California Maternal Quality Care Collaborative partnered with Smart Care California to implement multiple approaches to decrease the rates of cesarean delivery. Hospitals with rates of cesarean delivery greater than 23.9% for NTSV births were invited to join 1 of 3 cohorts for an 18-month quality improvement collaborative between July 2016 and June 2019.EXPOSURES Within the collaborative, multidisciplinary teams implemented multiple strategies supported by mentorship, shared learning, and rapid-cycle data feedback. Partnerships among nonprofit organizations, state governmental agencies, purchasers, and health plans addressed the external environment through transparency, award programs, and incentives. MAIN OUTCOMES AND MEASURESThe primary outcome was the change in cesarean delivery rates for NTSV births in California and a difference-in-differences analysis was performed to compare cesarean delivery rates for NTSV births in California vs the rates in the rest of the US. A mixed multivariable logistic regression model that adjusted for patient-level and hospital-level confounders also was used to assess the collaborative and the external statewide actions. The cesarean delivery rates for NTSV births at hospitals participating in the collaborative were compared with the rates from the nonparticipating hospitals and the rates in the participating hospitals prior to participation in the collaborative.RESULTS A total of 7 574 889 NTSV births occurred in the US from 2014 to 2019, of which 914 283 were at 238 hospitals in California. All California hospitals were exposed to the statewide actions to reduce the rates of cesarean delivery, including the 149 hospitals that had baseline rates of cesarean delivery greater than 23.9% for NTSV births, of which 91 (61%) participated in the quality improvement collaborative. The rate of cesarean delivery for NTSV births in California decreased from 26.0% (95% CI, 25.8%-26.2%) in 2014 to 22.8% (95% CI, 22.6%-23.1%) in 2019 (relative risk, 0.88; 95% CI, 0.87-0.89). The rate of cesarean delivery for NTSV births in the US (excluding California births) was 26.0% in both 2014 and 2019 (relative risk, 1.00; 95% CI, 0.996-1.005). The difference-in-differences analysis revealed that the reduction in the rate of cesarean delivery for NTSV births in California was 3.2% (95% CI, 1.7%-3.5%) higher than in the US (excluding California). Compared with the hospitals and the periods not exposed to the collaborative activities, and after adjusting for patient charact...

Birth Satisfaction During the Early Months of the COVID-19 Pandemic in the United States

“…Evidence-based initiatives to reduce cesarean birth, such as the Supporting Vaginal Birth Collaborative, should be implemented in hospitals and continue to be promoted throughout a pandemic ( Rosenstein et al, 2021 ). Overall, best practices in maternal and infant care should continue during a pandemic with only minor modifications to reduce infection transmission.…”

922 Reduction in cesarean delivery rates following a state collaborative in Maryland

“…As a result, the statewide NTSV cesarean delivery rate decreased by 1.6 percentage points in Maryland, a significant but smaller change than the corresponding 3.2 percentage point reduction reported by California's collaborative. 14 Maryland's collaborative also led to a larger 4.8 percentage point reduction in the cesarean delivery rate for NTSV births following induction.…”

“…The limited progress in the Response domain during the collaborative may help explain why the reduction in cesarean rates was smaller than that observed in California. 14 California hospitals were also required to reduce NTSV cesarean rates to the Healthy People 2020 goal of 24% in order to participate in health insurance exchange plans, 14,27 an additional external incentive not present in Maryland. It should also be noted that the results of the ARRIVE trial, which concluded that labor induction at 39 completed weeks resulted in lower cesarean delivery rates, were published in late 2018, 28 towards the end of both Maryland and California's collaboratives.…”

“…Through three cohorts between 2016 and 2018, California's collaborative successfully reduced NTSV cesarean delivery rates by 3.2 percentage points. 14 A corresponding assessment of the safety of the collaborate reported no adverse effects on maternal or neonatal outcomes. 15 It…”

Rural Hospital Administrators’ Beliefs About Safety, Financial Viability, and Community Need for Offering Obstetric Care

“… 12 , 13 , 14 These include the Alliance for Innovation on Maternal Health (AIM) program, which has created a set of patient safety care bundles to address preventable severe maternal morbidity and mortality, 15 , 16 , 17 and the California Maternal Quality Care Collaborative (CMQCC), which uses research, quality improvement toolkits, and state-wide outreach collaboratives to improve maternal and infant health. 18 , 19 Current clinical and policy initiatives aimed at improving rural maternity care access are hampered by a lack of comprehensive evidence from rural settings about the particular challenges and trade-offs in their communities and health care systems. 20 , 21 To address this, we conducted a national survey of a sample of rural hospitals to describe their perspectives on criteria for safe provision of obstetric care in rural US settings.…”