Interventions aimed at lowering the rate of cesarean deliveries have resulted in a significant reduction in such deliveries over a seven-year study period at Beth Israel Deaconess Medical Center, according to HMS clinician-researchers at the hospital. The study appeared in the February issue of The Joint Commission Journal on Quality and Patient Safety.

Nearly one in three babies born in the United States is delivered via cesarean section, or C-section. Compared to vaginal delivery, cesareans are associated with a number of increased health risks for mother and baby including increased mortality and longer hospital stays, and increased health care costs. The study measured the impact of a series of strategic quality improvement interventions on the hospital’s nulliparous term singleton vertex (NTSV) cesarean rate, or the proportion of single babies carried to at least 37 weeks in the vertex position born to women having their first baby that was delivered via cesarean.

“The rate of cesarean deliveries in low-risk women varies significantly from hospital to hospital across the nation, and such wide disparities suggest that some cesarean deliveries may be performed for reasons other than medical necessity,” says Mary Vadnais, an HMS instructor in obstetrics, gynecology and reproductive biology, part-time, a maternal-fetal medicine specialist, and vice chair of the Quality Assurance Committee/Obstetrics at Beth Israel Deaconess, and first author on the study.

Beginning in 2008, Beth Israel Deaconess obstetricians implemented a series of interventions in five areas: interpretation and management of fetal heart-rate tracings, provider tolerance for labor, induction of labor, provider awareness of NTSV cesarean delivery rates, and environmental stress. During the intervention period, researchers found that the NTSV cesarean rate decreased from nearly 35 percent to a fraction over 21 percent, which is below the U.S. Department of Health and Human Services’ recommended target rate of 23.9 percent. The hospital’s overall cesarean rate also declined from 40 percent to 29 percent over the same period.

Vadnais and colleagues used published data and assessed environmental factors in the Beth Israel Deaconess labor and delivery unit to design strategic interventions aimed at lowering the NTSV cesarean delivery rate. In some cases, these interventions meant standardizing protocols, increasing provider education, or revising guidelines. For example, slow progression of labor is a common reason for cesarean delivery. Historical norms for labor progress, however, may not apply to modern obstetrical populations. Reassessing how to manage slower labors allowed physicians to avoid cesarean deliveries based solely on the previously expected rate of cervical changes.

A recognized association exists between a hospital’s environmental factors and its cesarean delivery rate. To optimize the environment at the hospital, the labor and delivery unit conducted emergency cesarean delivery drills to strengthen cohesiveness between the provider and unit staff members, increasing the unit’s ability to support the physician during an urgent situation. The department also created more flexible visitor guidelines to promote continual emotional support for the patient.       

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