Efforts to reduce cesarean delivery rates in the United States seem to be gaining ground. But nearly a year after two medical societies released a national consensus statement on the safe prevention of certain C-sections, the strategies, as well as procedure rates, vary considerably among managed care organizations, other insurers and front-line providers. Some are focusing on educational initiatives for stakeholders, including mothers-to-be, while others are throwing payment reforms into the mix.
Broad consensus seems to boil down to this: Steps must be taken to lower C-section rates in the U.S., and strong outreach to ob/gyns is critical for success.
Some managed care organizations, while continuing to evolve C-section strategies, are encouraged by their progress to date on the complex issue. Kaiser Permanente, which handles about 90,000 deliveries annually across its regions, is working to achieve maternal health excellence and trying to identify opportunities for improvement, says Tracy Flanagan, M.D., director of women’s health and chair of the ob/gyn chiefs group for Kaiser Permanente Northern California.
“Our integrated care model is ideal for improving quality, safety and patient satisfaction in all areas of care delivery, including the reduction of unnecessary C-sections,” Flanagan says. “Once we establish a best practice, we can spread it throughout the organization quickly. We can also track progress on an individual, facility, regional and national level, which helps us identify areas of opportunity.”
In its hospitals, Kaiser Permanente’s average C-section rate is 24% for low-risk, first-time mothers (with a term, singleton baby in a headfirst position), Flanagan says. This primary C-section rate ranges from 10% to 29% among its hospitals, but almost all fall below 25%, she says.
Kaiser Permanente’s overall rate, including repeat C-sections, is only slightly higher, around 27%, “partly because we offer VBAC [vaginal birth after cesarean] more aggressively than almost any health system,” Flanagan says. Its VBAC rate is 22%, well above rates in California and nationally, she says.
By comparison, the national cesarean delivery rate increased by 60% from 1996 through 2009, up from 20.7% to 32.9%, according to federal data released in November, 2014. While the overall rate fell slightly by 2013, nearly one-third of U.S. births continue to be delivered
by cesarean section.
Low-risk, primary cesarean delivery reached a low of 18.4% in 1997, federal data show. The rate climbed steadily to a high of 28.1% in 2009 before dropping slightly to 26.9% by 2013.
Citing strategies undertaken by Kaiser Permanente “that set us up for success,” Flanagan says almost all of the managed care organization hospitals have 24-hour-a-day, seven-day-a-week staffing in labor and delivery units, using nurses and, in many hospitals, certified nurse-midwives, to work with ob/gyns.
Thirteen of its 15 northern California hospitals now have midwives, Flanagan says, explaining that the idea is to set up a labor and delivery system that facilitates providing the right care at the right time.
Another strategy involves electronic fetal heartrate monitoring, which researchers say historically has been interpreted with wide variation by obstetric care teams, leading to inconsistent decision-making. In response to tracing interpretation. Kaiser Permanente launched a multidisciplinary electronic fetal monitoring training program for clinicians, using the best available evidence in an effort to help standardize interpretation, Flanagan says.
With category-II fetal heart rate trackings, for example, which are in the gray zone, Flanagan says it is “important to react correctly, and not overreact [by rushing into a C-section] or underreact” by waiting on a C-section if it is medically necessary.
Flanagan says Kaiser Permanente’s initiatives, including more use of midwives, help to meet patients’ needs and expectations.