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.
Method… Show more
“…In the present study, CS rates of nulliparas were originally higher than those of all births at baseline but were 5.9% lower in Stage 2. Thus, we speculate that nulliparous women may be more likely to benefit from the quality improvement initiatives [35,36]. Also, given the high repeated CS rate for multiparous women, we believe that future interventions should target nulliparas primarily.…”
Background
The cesarean section (CS) rate has risen globally during the last two decades. Effective and feasible strategies are needed to reduce it. The aim of this study was to assess the CS rate change after a two-stage intervention package that was designed to reduce the overall CS rate in Guangzhou, China.
Methods and findings
This intervention package was implemented by the Health Commission of Guangzhou Municipality in 2 stages (October 2010–September 2014 and October 2014–December 2016) and included programs for population health education, skills training for healthcare professionals, equipment and technical support for local healthcare facilities, and capacity building for the maternal near-miss care system. A retrospective repeated cross-sectional study was conducted to evaluate influences of the intervention on CS rates. A pre-intervention period from January 2008 to September 2010 served as the baseline. The primary outcome was the CS rate, and the secondary outcomes included maternal mortality ratio (MMR) and perinatal mortality rate (PMR), all obtained from the Guangzhou Perinatal Health Care and Delivery Surveillance System (GPHCDSS). The Cochran-Armitage test was used to examine the trends of the overall CS rate, MMR, and PMR across different stages. Segmented linear regression analysis was used to assess the change of the CS rate over the intervention period.
A total of 1,921,932 records of births and 108 monthly CS rates from 2008 to 2016 were analyzed. The monthly CS rate declined across the intervention stages (Z = 75.067,
p
< 0.001), with an average rate of 42.4% at baseline, 39.8% at Stage 1, and 35.0% at Stage 2. The CS rate declined substantially among nulliparous women who delivered term singletons, with an accelerating decreasing trend observed across Stage 1 and Stage 2 (the difference in slopes: −0.09 [95% CI −0.16 to −0.02] between Stage 1 and baseline,
p
= 0.014; −0.11 [95% CI −0.20 to −0.02] between Stage 1 and Stage 2,
p
= 0.017). The CS rate in the remaining population increased during baseline and Stage 1 and subsequently decreased during Stage 2. The sensitivity analysis suggested no immediate impact of the universal two-child policy on the trend of the CS rate. The MMR (
Z
= −4.368,
p
< 0.001) and PMR (
Z
= −13.142,
p
< 0.001) declined by stage over the intervention period.
One of the main limitations of the study is the lack of a parallel control group. Moreover, the influence of temporal changes in the study population on the CS rate was unknown. Given the observational nature of the present study, causality cannot be confirmed.
Conclusions
Apparent decline in the overall CS rate was observed in Guangzhou, China, after the implementation of a two-stage intervention package. The decline was...
“…In the present study, CS rates of nulliparas were originally higher than those of all births at baseline but were 5.9% lower in Stage 2. Thus, we speculate that nulliparous women may be more likely to benefit from the quality improvement initiatives [35,36]. Also, given the high repeated CS rate for multiparous women, we believe that future interventions should target nulliparas primarily.…”
Background
The cesarean section (CS) rate has risen globally during the last two decades. Effective and feasible strategies are needed to reduce it. The aim of this study was to assess the CS rate change after a two-stage intervention package that was designed to reduce the overall CS rate in Guangzhou, China.
Methods and findings
This intervention package was implemented by the Health Commission of Guangzhou Municipality in 2 stages (October 2010–September 2014 and October 2014–December 2016) and included programs for population health education, skills training for healthcare professionals, equipment and technical support for local healthcare facilities, and capacity building for the maternal near-miss care system. A retrospective repeated cross-sectional study was conducted to evaluate influences of the intervention on CS rates. A pre-intervention period from January 2008 to September 2010 served as the baseline. The primary outcome was the CS rate, and the secondary outcomes included maternal mortality ratio (MMR) and perinatal mortality rate (PMR), all obtained from the Guangzhou Perinatal Health Care and Delivery Surveillance System (GPHCDSS). The Cochran-Armitage test was used to examine the trends of the overall CS rate, MMR, and PMR across different stages. Segmented linear regression analysis was used to assess the change of the CS rate over the intervention period.
A total of 1,921,932 records of births and 108 monthly CS rates from 2008 to 2016 were analyzed. The monthly CS rate declined across the intervention stages (Z = 75.067,
p
< 0.001), with an average rate of 42.4% at baseline, 39.8% at Stage 1, and 35.0% at Stage 2. The CS rate declined substantially among nulliparous women who delivered term singletons, with an accelerating decreasing trend observed across Stage 1 and Stage 2 (the difference in slopes: −0.09 [95% CI −0.16 to −0.02] between Stage 1 and baseline,
p
= 0.014; −0.11 [95% CI −0.20 to −0.02] between Stage 1 and Stage 2,
p
= 0.017). The CS rate in the remaining population increased during baseline and Stage 1 and subsequently decreased during Stage 2. The sensitivity analysis suggested no immediate impact of the universal two-child policy on the trend of the CS rate. The MMR (
Z
= −4.368,
p
< 0.001) and PMR (
Z
= −13.142,
p
< 0.001) declined by stage over the intervention period.
One of the main limitations of the study is the lack of a parallel control group. Moreover, the influence of temporal changes in the study population on the CS rate was unknown. Given the observational nature of the present study, causality cannot be confirmed.
Conclusions
Apparent decline in the overall CS rate was observed in Guangzhou, China, after the implementation of a two-stage intervention package. The decline was...
“…For example, the hospital where a woman chooses to birth is predictive of her risk of having a cesarean birth, even after adjusting for the influence of maternal risk factors. 22,23 Midwifery-led care may also be associated with a lower risk of cesarean birth; in comparisons of midwife-led with physician-led care for women of ✦ Women laboring at medical centers that included midwives were less likely than women at centers without midwives to have a cesarean birth.…”
Section: Introductionmentioning
confidence: 99%
“…There is a growing body of literature exploring the role of the hospital environment in perinatal decision making. For example, the hospital where a woman chooses to birth is predictive of her risk of having a cesarean birth, even after adjusting for the influence of maternal risk factors . Midwifery‐led care may also be associated with a lower risk of cesarean birth; in comparisons of midwife‐led with physician‐led care for women of similar risk factors, midwives waited longer prior to using medical interventions, and their patients had lower rates of labor interventions and cesarean birth .…”
Introduction: Maternal obesity is associated with slow labor progression and unplanned cesarean birth. Midwives use fewer medical interventions during labor, and the women they care for have lower cesarean birth rates, compared with low-risk, matched groups of women cared for by physicians. The primary aim of this study was to examine associations between midwifery unit-level presence and unplanned cesarean birth in women with different body mass index (BMI) ranges. Unit-level presence of midwives was analyzed as a representation of a unique set of care practices that exist in settings where midwives work. Methods: A retrospective cohort study was conducted using Consortium on Safe Labor data from low-risk, healthy women who labored and gave birth in medical centers with (n = 9795) or without (n = 13,398) the unit-level presence of midwives. Regression models were used to evaluate for associations between unit-level midwifery presence and 1) the incidence of unplanned cesarean birth and 2) in-hospital labor durations with stratification by maternal BMI and adjustment for maternal demographic and pregnancy factors. Results: The odds of unplanned cesarean birth among women who gave birth in centers with midwives were 16% lower than the odds of cesarean birth among similar women at who gave birth at centers without midwives (adjusted odds ratio, 0.84; 95% CI, 0.77-0.93). However, women whose BMI was above 35.00 kg/m 2 at labor admission had similar odds of cesarean birth, regardless of unit-level midwifery presence. In-hospital labor duration prior to unplanned cesarean was no different by unit-level midwifery presence in nulliparous women whose BMI was above 35.00 kg/m 2. Discussion: Although integration of midwives into the caregiving environment of medical centers in the United States was associated with overall decrease in the incidence of cesarean birth, increased maternal BMI nevertheless remained positively associated with these outcomes.
“…9 As a result, several initiatives to reduce the incidence of primary cesarean birth and support intended vaginal birth have been proposed and are the subject of current evaluation. [10][11][12][13] The American College of Nurse-Midwives (ACNM) began one such endeavor in 2015 as part of its Healthy Birth Initiative: the Reducing Primary Cesareans (RPC) Learning Collaborative, which focuses on reducing the incidence of NTSV cesareans through the use of a midwife-led interprofessional team and implementation of research-based care bundles. 14 These bundles include promoting progress in labor, promoting comfort in labor, and assessing fetal wellbeing through intermittent auscultation of the fetal heart in labor.…”
Section: Introductionmentioning
confidence: 99%
“…The combination of variation in rates, lack of outcome improvements, and increases in morbidity are hallmarks of procedure overuse and suggest there is opportunity for improvement . As a result, several initiatives to reduce the incidence of primary cesarean birth and support intended vaginal birth have been proposed and are the subject of current evaluation . The American College of Nurse‐Midwives (ACNM) began one such endeavor in 2015 as part of its Healthy Birth Initiative: the Reducing Primary Cesareans (RPC) Learning Collaborative, which focuses on reducing the incidence of NTSV cesareans through the use of a midwife‐led interprofessional team and implementation of research‐based care bundles .…”
Introduction: Preventing a primary cesarean birth in nulliparous women with term, singleton, vertex pregnancies (NTSV) is recognized as an important strategy to reduce maternal morbidities and risks to the newborn. Multiple professional organizations are supporting approaches to safely reduce NTSV cesarean rates, including the American College of Obstetricians and Gynecologists; the Society for Maternal-Fetal Medicine; and the Association of Women's Health, Obstetric and Neonatal Nurses. The American College of Nurse-Midwives (ACNM) is leading one such effort as part of its Healthy Birth Initiative: the Reducing Primary Cesareans (RPC) Learning Collaborative. The objective of this study is to estimate the cost savings of a decrease in NTSV cesareans at one hospital participating in the RPC Learning Collaborative. Methods: All women giving birth at Baystate Medical Center from October 1, 2016, to March 31, 2017, and their newborns were identified by Medicare Severity Diagnosis Related Group (N = 1747). Total hospital costs were calculated using a resource consumption profile for each of 6 groups: women who had vaginal birth, primary cesarean, and repeat cesarean and their linked newborns. A model was developed to estimate cost differences for the first and second births and overall cost savings. Results: For the NTSV birth, total costs for primary cesarean and newborn care were $5989 higher compared with vaginal birth and newborn care. For the subsequent birth, repeat cesareans and newborn care were $4250 higher compared with vaginal birth. In 2016, 69 primary cesareans were prevented, for an actual cost savings of $413,241. Projecting the prevention of 66 subsequent repeat cesareans would result in additional savings of $280,500, for a total savings of $693,741. Apgar score at 5 minutes and length of stay remained unchanged. Discussion: Participation in ACNM's RPC Learning Collaborative led to significant savings in hospital costs during the first year without affecting quality metrics. This cost comparison model could be replicated by other hospitals involved in cesarean reduction endeavors.
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