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U.S. Hospitals Held Accountable for C-Section Rates

By Rebecca Dekker, PhD, RN, APRN of www.evidencebasedbirth.com

Back in December, we shared some big news! We found out that starting in January 2014, the Joint Commission will require U.S. hospitals with more than 1,100 births per year to work towards reducing the C-section rate in first-time moms. Our hope is that this article will help you understand the importance of this news for the health of moms and babies all over the U.S.

What are the basics of the new requirement?

Starting in 2014, hospitals who are accredited by the Joint Commission will be required to publicly report on 5 outcomes, known as the “perinatal core measure” set. These outcomes include:

1. Decreasing the early elective birth rate (before 39 weeks)
2. Decreasing the C-section rate in low risk women (first-time moms with a single baby who is head-down at term)
3. Increasing the use of prenatal steroids for babies who are born pre-term
4. Reducing bloodstream infections in newborns
5. Increasing exclusive breastfeeding rates during hospitalization

In this blog article, we are going to be focusing on the 2nd core measure, which is lowering the C-section rate in first-time moms. To find out more about the perinatal core measure set, we talked with Celeste G. Milton MPH, BSN, RN, the project lead for perinatal core measures at the Joint Commission.

What is the Joint Commission?

The Joint Commission (formerly known as JCAHO) is an independent, non-profit organization that accredits and certifies more than 20,000 health care organizations and programs in the United States, including 4,500 hospitals. The mission of the Joint Commission is to continuously improve health care for the public by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.

The Joint Commission carries out periodic, unannounced site visits at all hospitals that they accredit. During these visits, the Joint Commission makes sure that hospitals are complying with evidence-based standards and improving the quality of care that they are delivering. On-site evaluations typically occur every 1.5-3 years and many of the findings are publicly available on the internet.

Joint Commission accreditation is important because hospitals that have been accredited by the Joint Commission are eligible for reimbursement from Medicare and Medicaid. In other words, if hospitals don’t get accredited, they don’t get paid.

How was the new requirement developed?

In 2007, the Joint Commission decided to replace the old perinatal requirements with a new set of evidence-based measures. At the same time, the National Quality Forum launched a perinatal care project, which resulted in the endorsement of 17 perinatal measures.

After reading the 17 new measures, the Joint Commission put together an advisory panel made up of experts. The panel included neonatologists, obstetricians, certified nurse midwives, and labor and delivery nurses. The experts reviewed the 17 perinatal measures, and out of those 17 they selected 5 to make up the Joint Commission’s new perinatal core measures: early elective delivery rates, first-time mom C-section rates, prenatal steroids given for preterm birth, bloodstream infections in newborns, and breastfeeding.

The new perinatal core measures were ready for hospitals to use in the fall of 2009, and data collection began in April 2010. However, very few hospitals chose to adopt the measures because, the measures were optional. In fact only 160 hospitals—out of thousands—voluntarily adopted the perinatal core measures.

Why did they decide to make the perinatal core measures mandatory?

In the past 2 years, the U.S.’s C-section rates began to get serious national attention. The Joint Commission was encouraged by several different stakeholder groups to make the perinatal core measures mandatory. These groups included the American Congress of Obstetricians and Gynecologists, the Association of Women’s Health, Obstetric, and Neonatal Nurses, the American College of Nurse Midwives, the American Academy of Pediatricians, and the Society for Maternal-Fetal Medicine.

In November 2012, the board of commissioners of the Joint Commission announced that the perinatal core measure set would now be mandatory for hospitals with more than 1,100 births per year, starting January 1st, 2014. This is the first time in history that the Joint Commission has required a core measure set to be mandatory for a specific type of situation—in this case, any kind of a hospital with more than 1,100 births per year.

To read the full description and rationale for the perinatal core measures, click here (Click PC-01, 02, 03, 04, or 05 to see each of the 5 measures). To specifically view the C-section measure, click here.

Why did the Joint Commission decide it is important to lower C-section rates?

In their rationale, the Joint Commission wrote, “The removal of any pressure to not perform a cesarean birth has led to a skyrocketing of hospital, state and national cesarean section rates… There are no data that higher rates improve any outcomes, yet C-section rates continue to rise. Some hospitals now have C-section rates over 50%.”

Why did the Joint Commission decide hospitals should lower the C-section rate in first-time moms?

The thing about first-time moms is that there are clear-cut quality improvement activities that can prevent preventable C-sections in these women. For example, a large number of preventable C-sections occur because more than 40% of all first-time moms have their labor induced. When medications are used to force labor, a first-time mom doubles her chance of having an unplanned C-section. Another common practice that contributes to high rates of preventable C-sections is admitting women to the hospital when they are still in very early labor. Finally, a substantial number of unplanned C-sections are due to physicians mislabeling a woman’s labor as “failure to progress”—a term that research says is more aptly named “failure to wait.”

Basically, it boils down to the fact that physician and hospital practice patterns—not pregnant women’s conditions or their diagnoses—are the major reason for differences in C-section rates among hospitals. According to the Joint Commission, it’s time for hospitals and care providers to look at their practice, and see what they can do to prevent preventable Cesareans.

What does the Joint Commission mean when they say the desired outcome is “a decrease” in the C-section rate?

According to Ms. Milton at the Joint Commission, there is no specific C-section rate that hospitals need to attain. The Joint Commission does not set benchmarks or quotas.

Instead, each hospital will receive a quarterly performance report with their hospital’s C-section rate compared to a desired target range. The target range will vary from quarter to quarter, depending on the national performance of all the hospitals reporting the perinatal measures. The Joint Commission anticipates that the target range for the C-section will lower (lower = better) over time.

If hospitals do not decrease in their C-section rate, would they lose their accreditation?

The Joint Commission is not requiring any kind of specific rate that the hospitals need to reach—there is no “one-size-fits-all” rate. So hospitals will not necessarily lose their accreditation if they don’t see a specific decrease in their C-section rates.

However, the new perinatal core measure requirement puts pressure on hospitals—for the first time—to monitor, publicly report, and evaluate their C-section rates. As Ms. Milton said, “The goal here is to get hospitals to look at their practice and get an idea of where their rates are, and to figure out if they do need to make changes.”

Will this put women who legitimately need first-time C-sections at risk?

When asked about this concern, Ms. Milton said there are no set rates for any of the perinatal measures. There are no quotas. Thus the new perinatal core measure requirement should not put women at risk for not receiving a necessary C-section.

“People are not quite grasping what we are doing here,” she said. “We are trying to get people to look at their practice. If your Cesarean rate is 50%, I would say that this is probably something you want to look at. You can at least be aware of what your rate is, and see if there are performance improvement measures you can put into place to make a difference.”

If someone continues to have concerns about this issue, Ms. Milton recommends reading the white paper from the California Maternal Quality Care Collaborative.

When will we be able to view hospitals’ performance on the perinatal measure?

Moms and families will be able to see and compare hospitals’ early elective delivery and breastfeeding rates at www.qualitycheck.org starting in 2013. During the first year, the publicly reported rates will come from the 160 hospitals that are already using the perinatal core measure. In 2014, the website will include the hospitals with more than 1,100 births that are required to take part in the perinatal core measures.

C-section rates may take a little bit longer than the other measures to become publicly available—this is because the C-section rates will be risk-adjusted. Risk adjustment means that the Joint Commission will use a statistical method to control for the fact that some hospitals have a higher percentage of high-risk women. This will allow the public to compare C-section rates between hospitals in a more equal fashion.

Will smaller hospitals eventually be held to the same standard?

In their press release, the Joint Commission suggested that smaller hospitals may eventually have to comply with the perinatal core measures. However, Ms. Milton said that although there is talk about doing this, this is not something that has been officially decided.

So what’s the bottom line for women and their families?

Sometime in 2014, women and their families will be able to see risk-adjusted C-section rates for all hospitals with more than 1,100 births per year. There are no quotas or limits on C-sections, so this new requirement will not hurt women who require C-sections. For the first time, hospitals in the U.S. will be motivated to look at their practice and see what they can do to prevent preventable C-sections in first-time moms.


39 Comments

  1. This is really exciting news for sure. I had a c/s with my first due to breech and was told there was no other option (lied to). This makes me very happy for mothers in the future!

    Also, that is my baby and my boots there on your contribute money button :D I didn’t know that was on here!

    • Its a fantastic shot of both your baby and boots. We couldn’t help but want to share it. :)

  2. This is AWESOME news! Finally some accountability in terms of our ridiculously high C-Section rates. Thanks for posting this. :)

  3. Passionate Mother

    I do NOT agree with this! Some basically random group decides they need to butt in, and now it affects women everywhere!!! There are MEDICALLY sound reasons some babies need to be delivered before 39 weeks. This act will force the doctors’ hands into waiting. I am livid that some of it has already come into play-and not just with first babies. This will be put into effect for all babies. What about the mothers that have issues that will only be able to be remedied upon delivery? How many mothers will be lost or have permanent issues because the hospital couldn’t or wouldn’t deliver them before 39 weeks or wait too long to see if, say their BP will drop on its own? I pray that it does not happen, but if Heaven forbid it does, I hope the family sues this group along with the hospitals and doctors!!! (And, I am not a sue happy person.)

    What about the babies with high birth weights? This forcing the mothers to wait until at least 39 weeks, the average birth weight WILL go up, and there are some mothers out there that just cannot deliver a 9-10 pound baby! Speaking of that, let’s say mom is trying to deliver her 9 1/2 pound baby….she pushes for hours, her body is just not able to do it, even with vacuums, forceps, and episiotimies -baby is already too far down, what then? This “act” is putting that baby in risk of broken shoulders, necks, and death! Stay out of the delivery rooms, stay away from women’s bodies!!!

    All this is going to do is see an increase of injuries (to both baby and mother), if not deaths – HEAVEN FORBID- , and home births-which will open up a whole other world of issues! Shame on you!!!

    Now, I do feel I should clarify, I am not talking about mothers that want to schedule a C-Section because of selfish reasons. (They have vacation plans in a few weeks, or “Oh, I’m just bored of being pregnant.”.) These women are the reasons there are people/acts like you and yours. Now that you are butting into ALL women’s rights to listening to their own bodies, I am even angrier at the selfish women! I have never supported selfish selective C-Sections, never will.

    You can claim all this is about first time mothers, but as it always is when bullied-it will effect everyone!

    Breastfeeding…..another topic I have MAJOR issues with you butting your noses into! I think breastfeeding is a magical and beautiful thing. It is so beneficial to both mother and baby, and yes, I think it should be discussed. Having said that, not all mothers are able to breastfeed, no matter how much help is given, how much research done, how much people try to help them. I was not able with any of my 5. I was devastated, heartbroken, I felt like I was horrible mother. If your act pushes it on people, the ones that know they are not able to, you are going to add more stress (which we all knows goes against breast feeding) on the mothers. How will the nurses look at and treat the mothers that say no? I literally could not make the words come out of my mouth at a certain point, it was a knife to my heart every time I had to say it. Again, shame on you!

    You do not know a person’s reasons, you should have NO right to judge and no right to bully mothers, doctors, nurses, and hospitals into doing things your way. It looks like number 6 we will have to look into midwives and home birth. I have beautiful, happy, healthy children, all born vaginally between 37 and 40+ weeks. My main one I had problems with, was my “full term” babe, that was only one to make it that many weeks. I was moments from a C-Section, after hours of pushing, (I personally had more problems than I shall list, because I am not what was important to me, but many linger-and I will fight to not have other women go through that) when God gave me that last little nudge and let me deliver. I did not have gestational diabetes, that babe weighed the most, had to endure many tests to make sure there were no issues. That babe had the lowest of all Apgars-by a good bit, was purple and not breathing until worked with, cord around the neck-more than once-, had the hardest time eating, had the longest hospital stay, and was not able to be handed straight to me upon being born, the list goes on. You may try to say I feel the way I do because of my experience, and while that is part of it, I am not alone. I know many women that benefited from 37-38 week delivery, that had they had to wait, those babies may not be here now.

    My body, if my doctor and I can agree it is best for the baby and me, then you need to butt out! As for the breast feeding, see above. You don’t know how badly I wish I could! If this is something else you have bullied so many into, how long until Department of Family and Children Services are called for not doing so? Yes, that sounds extreme, but so does everything else on here!

    • DowhatIwant

      I completely agree with you. Besides, no one actually address what the problem is with a C-section. I guess this organization just doesn’t like them? What I want to know is why it is okay to kill my baby preterm but now public organizations want to control how I give birth or feed my child. Ridiculous.

    • Nikki

      The new standard refers to ELECTIVE inductions prior to 39 weeks, not those which have medical reasons. This is a practice the hospital I work at already follows. If a woman needs to be induced at at least 37 weeks for medical reasons we will do it, or send her to a hospital with a NICU if she is prior to 37 weeks.

      Also, with breastfeeding, they are saying they want everyone to try. It is what is best for baby, and while I am so sad to hear you had a bad experience, you were part of a very small percentage of women who were not able to breastfeed. Most women are able, but may struggle and need encouragement and help from a lactation consultant. Many women give up too fast (not saying you, speaking generally) and just need more of a push and to understand that it is natural.

    • Totally agree. This is affecting legit reasons to induce ahead of 39w. I had preeclampsia with my first two pregnancies. With my third, I had high bp starting at 36w and was given meds. Still high. I had to push my ob to please induce at 38w because I didn’t want my bp to get out of control or develop preeclampsia. She was really reluctant, in fear of this political thing.

      There are studies and recommendations from the ACOG and march of dimes that says in my situation, induction prior to 39w is indicated.

      Happily, my induction went well. No c section, and a healthy baby and mom.

    • 1. The guideline is decrease ELECTIVE birth rate before 39 weeks. If there is a medical reason to induce before then it is not elective. The elective ones are the moms that have a vacation coming up, are just bored of being pregnant, just don’t want to risk going into labor before it is on the schedule, etc. I’d say your arguement here is moot.

      2. There are a ridiculous number of things done in hospitals to undermine breastfeeding before it can even get started. The first thing a hospital that wants to increase the breastfeeding rate should do is provide a LOT more training about breastfeeding their staff. The second thing us to change policies so that the baby is given to the mother the first second it is safe to do so. The baby doesn’t need a bath and medicine and weight a hearing test, passed around to all the family before the mother gets a chance to start trying to nurse, and whatever all else excuses they can find where it is more convenient for the staff to keep mom and baby separate. I had to be induced and then have a c-section at 37 weeks 3days with my son due to maternal complications. Supposedly hospital policy is that the baby should be given to the mother once she is in the recovery room. The nursery called to bring him and the nurse with me told them to wait until she checked my vitals again in 15 minutes. After a half hour I asked where the baby was and when she called down the nursery said my brother had just arrived and they had to let him hold the baby before they could bring him to me. I was in recovery almost the full hour before I got to hold my baby and attempt breastfeeding. The nurse that tried to assist me with BFing insisted I do things completely different from what I learned in breastfeeding class. My info was newer info that helps trigger the babies natural instincts for breastfeeding. (Google the breast crawl and laid back nusing for more info.)
      Less than 24 hours after delivery I had to have a CT scan. I was told that I had to pump and dump for 3 days because of the contrast. The lactation consultant checked the next morning and the medicine was in fact safe for the baby, so there was formula he got unneeded instead of suckling and bringing in my milk. It also caused nipple confusion which made nursing harder later. I had several other roadblocks in my 6 days in the hospital that made nursing very difficult and were largely the result of ignorance of the needs of breastfeeding and NOT medical necessities. We’ll make things eaay for the doctors and nurses and who cares what problems it causes the mom and baby. Everytime we had to send him to the nursery we had to label his bassinet with sharpie on a piece of paper for them to NOT give him a bottle of formula and hope they actually listened to it. They had no other way to keep track of which babies got bottles and which went back to mom when they were hungry.

      There are lots of ways of improving breastfeeding rates without pressuring moms who don’t want or can’t.

    • First it says “Decreasing the early elective birth rate (before 39 weeks)” Key word: ELECTIVE, If there is a reason to induce earlier, this doesn’t prevent that.
      Second, you act like 9-10 pounds is dangerously large, and that’s ridiculous.
      Third, this article does not talk about breastfeeding.
      And to your last point. This doesn’t say anything about going into labor at 38 weeks. That’s not even close to the same things as an elective C-section at the same time.

  4. Passionate Mother

    I’m sorry it was all bolded, I messed up with the “HTML tags and attributes”. I do feel quite strongly about what I said though.

  5. This is so exciting! I am glad to see that we are making this move towards holding hospitals accountable for first time mother’s c-sections. Forty-six percent of c-sections performed in this country are repeat c-sections. This is going to do amazing things for our overall c-section rate and thus the maternal death rate!

  6. Hi Passionate Mother, I am glad to see that you are interested in this topic. I understand your concerns, and I hope I can alleviate at least a few of your fears. As far as the elective deliveries, the Joint Commission is only going to ask hospitals to take a look at their practice and see if they can reduce elective deliveries before 39 weeks. This will NOT effect medically necessary deliveries– only the elective ones where there is no medical reason. This is because study after study shows that when you induce labor before 39 weeks, more babies die and more babies are admitted to the NICU for breathing problems. I hope you can understand that this is a safety issue. Elective deliveries will not become “illegal” but hopefully they will become more rare. Physicians will be motivated to be more careful and deliberate when discussing the pros and cons of this course of action. You may be interested to find out that a large number of hospitals have already enacted this measure and put “hard stops” on early elective deliveries when there is no medical reason. For more information, you can go to the LeapFrog Group’s website, a group that has spearheaded this effort: http://www.leapfroggroup.org/media/file/FactSheetElectiveDeliveries011712.pdf

    As far as the breastfeeding measure– you may be happy to find out that this measure only applies to mothers who want to and are able to breastfeed. As for mothers who can’t breastfeed or don’t want to for whatever reason– they will not be counted in this measure. The purpose of the breastfeeding measure is to prevent hospitals from giving unnecessary doses of formula to babies whose moms WANT to exclusively breastfeed. If there is a medical reason or if the moms don’t want to breastfeed, then that won’t count against the hospital.

    You called the Joint Commission a random group– but I would urge you to do your research. This is an important non-profit that has had a major impact on improving the quality of care provided by hospitals all over the U.S. They measure the quality of everything from care of people with pneumonia, to heart failure, to women who are giving birth. It is an extremely important organization, and I don’t think they took this decision lightly. In fact, if you read the article I wrote above, you will see that they were encouraged to make these measures mandatory by a host of professional organizations, including the American Congress of Obstetricians and Gynecologists. This new “perinatal core measure” was a joint effort from all the different organizations and stakeholder groups, and they put a lot of time and effort into these decisions.

    Finally, I am sorry that you feel I should be ashamed for posting this article. I was only reporting what is going on at the national level and efforts to improve the quality of care in hospitals. I am not “butting my nose” into what goes on in people’s lives. I am simply reporting what the Joint Commission decided and trying to make sense of it so that people understand what the new decision means for moms and families. I had many of the same concerns as you, which is why I picked up the phone and had a conversation with the Joint Commission. I shared what they told me here in this article, so that others could benefit from hearing my conversation.

    You seem to be a very passionate and dedicated consumer advocate. If you would like to educate yourself more on this matter, I strongly encourage you to read the article that the Joint Commission told me about when I said that people like you will be concerned. You can download it here: http://www.cmqcc.org/resources/2079

    In the end, we are all about bringing evidence-based care to childbirth which means that women are able to make informed decisions about their births. We agree with you, women should not have limited options. These new perinatal measure is not about limiting options, but about asking hospitals to take a look at their overall practice patterns so that they can improve outcomes.

    Sincerely,

    Rebecca Dekker, PhD, RN, APRN

  7. I am happy to see the new core measures. As a L&D RN I am forced to stand by and watch as primary c-sections get done for all of the wrong reasons. I am forced to not speak the facts and advocate for the patient or I will not have a job. It is sad that patients put their trust in doctors that don’t deserve it. Hospitals need to protect patients and make sure the care givers they hire are current on the standards and they practice that way.

    • Alicia– thank you SO much for what you do for moms and babies! Yours is not an easy profession and we are so thankful that you are out there on the front line of maternity care. I do hope that the new core measures promote change… it will be interesting to hear about how hospitals prepare for the new requirements.
      Sincerly,
      Rebecca

  8. I live in Australia and we already have these measures in place in many of our hospitals. I would like to reassure you Passionate Mother that the things you are worried about are not happening. Our c-sections are not done before 39 weeks unless there is a medical indication. Our rates are down around 23 – 27% in many of the major hospitals and even lower in the low risk units. We also have a maternal/neonatal mortality rate that is one of the lowest in the world so this is not impacting on and causing more deaths. What this is doing is helping to stop unnecessary caesarians. We still have a long way to go with getting birth to be seen as natural and something that does not always (in fact most of the time) need medical intervention but yes when medical intervention is needed I agree it is important.

  9. Rebecca, thank you for sharing this valuable article. I so appreciate what you do to keep us informed. Many blessings to you!

  10. I wished I could of receieved a c-section earlier instead of laying there for 17 hours with my water broke and getting fevers and bpd. My water broke and I dilated to about 3 and then stopped. The next baby I will have a scheduled c-section, happily… Sorry I am just not made for child birth glad Iam born is this century and not left to die trying to make my body have a child naturally…

    • Hi Misty, I don’t believe that I said anything in this article about natural birth being best or right for every woman. Evidence-based, humane care means that you receive care based on medical evidence, tailored to your individual situation, and respecting your decisions. From your brief statement, it sounds like you received good care. I am so sorry to hear about your negative experience, though. Research shows that having your water break before labor starts is just so much more difficult for mom and baby in every respect. I would love to see some research someday on ways we can prevent premature ruptured membranes from happening, since it raises all kinds of risks for first-time moms. Best wishes in your future endeavours!
      Sincerely,
      Rebecca

  11. This is a great step in the right direction, and I am thrilled to hear it!

  12. @ Passionate Mother… take a deep breath and then another one. Step outside of you and think rationally. At no point was the suggestion made that ALL pregnancies would be made to hit 40 weeks. Obviously needs must, but what is being suggested is ceasing to induce and section babies early without due cause. And, breastfeeding is generally physically and emotionally better for babies, women, families and societies – that’s a fact, not a threat to women’s self worth. Please reflect on the beautiful job I’m sure you do for your own children, and not let other’s inroads to achieving better outcomes generally, wound you any further. All the best.

  13. Theresa H

    Thank you Rebecca for this wonderful article. This is something I am VERY passionate about, I guess you would call me, the other side of Passionate Moms argument. I have five children, one of which was a set of twins. My first delivery, the twins, was a necessary c-section, I was young, uninformed and both babies were transverse. I then went on to have a failed VBAC, due to “failure to progress” or “failure to wait” as you aptly put it. Following this I had one planned c-sections, still being very uninformed to my choices and the risks. Finally in 2010 I became pregnant again and just because I really hated surgery and all it’s risks I looked into other options, thinking that there weren’t any. I was wrong, I found a great Dr. who truly, not just in theory, believed in a trial of labor and that the risk or rupture, which increases minimally after multiple c-sections, is less then the possible complications of major surgery. I was successful and I waited out the misery of being “overdue” without induction. I was 41.5 weeks when I delivered. Another misconception is that anything over 40 weeks is overdue, when in reality it’s anything over 42 weeks, some of us just cook slower.

    This being said there are many women who need c-section and there are cases where induction is needed as well. I support health of mother and baby wholeheartedly. The problem is both are overdone, women are not told the truth, and “passionate” if you look into the practices of other countries and their maternal/ fetal death rates, ours is much higher and so is our c-section/ induction rate. Something is not right. To get a clear picture we need to look at facts, not just people we know. I, also, have so many friends and acquaintances that were induced because they just couldn’t take being pregnant any more and even more where the Dr. suggested induction so that they would be the one on call to deliver. It’s absurd and sad. So many are being misinformed.

    As far as breastfeeding goes. Some can’t, most can and some don’t want to, this is ok! I think every large hospital would benefit greatly from a breastfeeding clinic. They are wonderful and are a great help to women who struggle. I have an acquaintance who has pumped for her infant for the last 9 months. Her reason was that baby wasn’t getting enough when he nursed. The bottom line is, if she is able to use a pump and get enough to feed her little one, he would get all he needed if allowed to nurse (unless he had a latch problem or needed his tongue clipped, both fixable). Again, lack of support and information led to this when if someone had just allowed her to weigh baby, nurse, and then weigh again so she could see that indeed he was getting his fill, she could have nursed instead of all the pumping hassle. Not down playing the great sacrifice and love it has taken to do what she has done but support could have made the issue disappear.

    That is my two cents and I am glad that someone is starting to take notice of what is going on and what a disservice is being done to all those new mom’s out there.

  14. Thanks Rebecca for sharing the information about CMQCC’s white paper. I also wanted to point out we published a shorter version of the white paper in the November 2012 issue of Obstetrics and Gynecology (Green Journal) and it is freely available as well: http://www.cmqcc.org/white_paper

    Thank you for your work in sharing information about the quality measures in maternity care.

  15. Passionate Mother

    @Rebecca, thank you for your reply. I have MANY* thoughts on what you said and I will respond, but when I have a little more time. As you can imagine, with 5 babes- my time on the computer is very limited. A stolen minute here and there. I do not want you to think I left my comment, never to return. I will also reply to those that responded to me. For now, tummy time, tea parties, Hot Wheel races, and giggles, take priority. Saturday happiness to all.

    *After messing up last time with the bold lettering, I’m not going to try again. I use caps not as a means of shouting, but as emphasis.

  16. Let me explain the spirit of what an elective pre-term c-Section is about. One example? Doctors delivering a baby early because they re about to go on vacation or delivering during the day becayse they don’t want to be called in at 2 am or something similar. One may also argue they could be pushing them to increase their reimbursement rate. Celebrity moms like Kate Hudson are having them because they don’t want pictures taken of them pushing. Its that kind of frivolous thinking that happens all-too-often and jeopardizes the baby for the convinience of the doctor or patient and not for any medical reason. But, C-sections are serious surgeries with serious pain and risks and should not be taken as lightly as they sometimes are.

  17. Valerie Tyler

    I think that this is absolutely wonderful. As someone who was talked into an unnecessary induction at 39 weeks with my first child that ended in a c-section, I LOVE this! Of course inductions and c-sections have their place, it is FACT that they are widely overused. As for breastfeeding, it is also FACT that it is better for baby. Same as inductions and c-sections, formula also has its place. But again, it is overused. I hope that this really helps!

  18. As always, thank you Rebecca for your wonderful, professional, insightful and kind work, which helps all expectant, birthing and postpartum mothers, even when they don’t realize it. : )

  19. I feel like we are looking at a reading of the “Emperor’s Clothes” story. Suddenly just about everyone seems to believe that ALL “non-indicated” inductions prior to 39 weeks 0 days are bad, that THE MOST common reason for pre-39 week “non-indicated” labor induction is for either doctor convience or mild maternal discomfort. Furthermore, everyone seems to “know” that “non-indicated” labor induction CAUSES major problems for both mother (cesarean delivery, shoulder dystocia, excessive bleeding) and baby (NICU admission, low APGAR scores, slow development). There is even a web-site that calls itself “evidence-based” and prominently supports restrictions on pre-39 week “non-indicated” induction. Furthermore, its pretty clear that if someone thinks otherwise – i.e., that pre-39 week labor induction without an established-accepted indication might actually be good – well then that person is just going to be judged foolish, stupid, uninformed,or misguided…..just like in the Emperor’s clothing story. But what if a significant number of the labor inductions done over the past decades in the 38th week of gestation were in response to increased risk states (obesity, mild hypertension, short stature, suspected large-for-gestational-age fetus? Does everyone know that the rates of these significant risk factors are increasing in the USA? And is anyone considering that delaying delivery a week or two will increase the chances that these risk factors will become actual disease states that will negatively affect both maternal health and infant birth health. Babies do keep growing larger as the term period unfolds, and placentas do begin to age starting in the 39th week of gestation (and even sooner in moms with chronic hypertension, cigarette smoke exposure, nutritional problems, etc). Is it well known that there are studies – including several recent ones – that suggest that non-indicated labor induction may actually be beneficial to both mother and baby?

    I am not saying that I know that the current campaign to restrict the use of pre-39 week non-indicated labor induction “does not have any clothes on” – but I will say that I am not sure whether or not the campaign is wearing clothes (because we do not really know) – and if it is wearing clothes then I am not sure just how good those clothes actually are. ALL – and I do mean all – of the evidence that is used to make us think that labor induction is bad – both labor induction in general, and pre-39 week non-indicated labor induction in particular – is retrospective research (meaning it looks back in time). It is highly likely that such research is significantly confounded by indication (i.e., was it the induction that caused problems….or was it the reason the induction was started in the first place?). It is also highly likely that studies of pre-39 week birth outcomes contained confounding by situation (i.e., were higher rates of neonatal problems seen following 37th or 38th week births due to the gestational age per se, or were they due to the higher rates of adverse neonatal outcomes that are directly linked to the reason that the delivery occurred in the early term period (like early term “indicated” labor inductions, pre-labor “at-home” rupture of membranes, pre-eclampsia, placental abruption, spontaneous chorioamnionitis, etc)? Retrospective research has a very hard time sorting out these kind of confounding issues. In addition to confounding issues, it is important to know that evidence-based guidelines state that the results of retrospective studies should be interpreted cautiously if the relative risk of the rates of adverse events found following an intervention (like labor induction) – as compared the rates of adverse events following the lack of an intervention (like spontaneous labor) – are either less than the value “3″ or more than the value “0.33″. Almost all of the actual retrospective studies used to support the current campaign limiting pre-39 week labor induction have relative risk values well below 3 or well above 0.33. Prospective randomized clinical trials (research looking ahead in time, and where patients would have been randomly assigned to either induction now or to expectant management with delivery later) have not been done in the past 20 years. Two such studies done in the 1980′s showed that induction LOWERS the rate of C/S. One prospective randomized clinical trial that I did several years ago showed improvement in several important birth outcomes following the regular use of risk-based “non-indicated” term labor induction (the HUP-POP AMOR-IPAT Trial – try googling amor-ipat). The bottom line is that we should know better in 2010-2013 than to base changes in medical guidelines on a combination of relatively weak retrospective research (with relatively weak relative risk levels) and expert/public opinion. We should demand that several prospective randomized clinical trials be done before practice guidelines are changed and inforced.

    Finally, there is an serious inherent danger in the current campaign to limit non-indicated labor induction in general and pre-39 week non-indicated labor induction in particular. This danger does not seem to be talked about very much. Because the risk of term stillbirth increases with increasing gestational age, probably anything that increases the average gestational age of any given population (like what the induction restriction campaign is doing to the US pregnant population right now) will increase the incidence of term stillbirth – meaning babies dying in utero in the days or weeks before labor starts. This extremely tragic situation may already be happening. Several published studies have reported this trend – including a study out of Boston presented last week at the Society of Maternal Fetal medicine Conference in San Francisco. So… when the Joint Commission and ACOG and the March of Dimes and the AAFP all say the pre-39 week “non-indicated” labor induction is “bad” and should be restricted – they are saying so without the type of evidence that is usually required to justify a change in clinical guidelines, and without having studied the impact of this change on term stillbirth rates. So the change in clinical practice resulting from this campaign – that everyone seems so happy about – may result in hundreds (and possibly thousands) of additional cases of term stillbirth over the next few years. As noted above, prospective randomized clinical trials need to be done ASAP to determine if pre-39 week non-indicated labor induction is good or bad. In the meantime, as the risk-benefit ratio for early-term non-elective labor induction has not really been determined – meaning that we do not know if non-indicated labor induction increases or decreases rates of adverse outcomes – AND as we have some evidence that restrictions on early-term non-indicated labor induction might increase the risk of term stillbirth – it seems unreasonable that pregnant women and their providers are currently unable to make private joint decisions about early-term pregnancy management.

    Anyone want to join me is seriously questioning the clothing status of the growing restictions on pre-39 week non-indicated labor induction?

    • Rebecca

      Hello Dr. Nicholson,

      Thank you for your comments!

      From reading your work, I believe that you share several goals with the moms of ImprovingBirth.org—including decreasing the number of preventable Cesareans, improving mother/baby outcomes, and providing respectful, compassionate care that is based on best evidence and tailored to each woman’s unique circumstances. We are grateful to you for your research and for doing ground-breaking work that can impact the health of moms and babies!

      I am honored that you left a comment, because I am familiar with your publications and with the very innovative AMOR-IPAT trial. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2855849/

      When I first read your publications, I remember wishing that you had published a more detailed description of your labor induction protocol. I did find a separate critique of your study that included a personal communication with a member of your study team. This is how I learned that the AMOR-IPAT trial used a woman-centered, gentle induction technique for women in the treatment group. http://www.ncbi.nlm.nih.gov/pubmed/19278388

      As a co-author on the AMOR-IPAT trial stated: “The goal of the induction is achieving a vaginal birth (with a healthy mom and baby), and time is not a factor. The induction uses a woman-centered approach that pays attention to circadian rhythms and quality-of-life factors such as eating, ambulation, and hygiene.” The induction protocol included:

      • No time restrictions
      • Encouraging eating and drinking
      • Cervical ripening began at 7 PM and mom was allowed to sleep overnight
      • Induction agents removed/stopped at appropriate times so that women can eat/sleep/rest/shower
      • Moms were encouraged to wait until 4 cm for an epidural
      • Moms were given as much time as they needed to reach active labor (for example, the induction could take 3 days, with breaks during the induction for sleep/eating/showering)
      • Alternative methods of cervical ripening such as using a Foley catheter were used if needed
      • Providers actively practiced “patience” and worked in teams so that provider exhaustion would not become a reason for C-section

      The labor induction approach that you and your investigators used in the AMOR-IPAT trial was very innovative! There were no time restrictions, doctors used extensive cervical ripening before oxytocin, and women were encouraged to take breaks from induction medications so that they could eat, drink, shower, and sleep! This labor induction technique likely would result in a decreased C-section rate compared to the “routine” induction protocol—and in your study, it did!

      When we look at only those moms in the AMOR-IPAT study who were induced, women in the treatment group had a C-section rate of 11% versus 24% in the usual care group. Importantly, more women in the treatment group who were induced had cervical ripening first. This is a very important finding, because it tells us if women undergo “prelabor” cervical ripening, then they are more likely to have a successful induction. But, when we look only at the moms who went into spontaneous labor—there was no difference in C-section rates between the treatment and control groups. They had similar C-section rates of 6.7% and 8.2%.

      I wish that care providers today were all using the AMOR-IPAT protocol of induction that you perfected. Unfortunately, due to the fact that time = money in labor and delivery units, it is unlikely that most hospitals would support or encourage a similar “no time restrictions” type of induction protocol. In fact, one of the largest studies to date on induction practices has shown that most women who are diagnosed as “failure to progress” haven’t even reached active labor yet! So provider impatience is a huge problem with inductions. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2947574/

      With respect to the concern about still births with policies limiting inductions prior to 39 weeks, I defer to this reasoned response from Dr. Steve Clark of the Hospital Corporation of America. I know it is retrospective data, but it does give us a huge sample size (a quarter million births): http://www.ncbi.nlm.nih.gov/pubmed/20619388

      “Concern has been raised regarding the potential effects on stillbirths of delaying elective delivery until 39 weeks of gestation. In light of such concerns, our finding of no statistical increase in the rate of stillbirth that is associated with implementation of this policy is important and merits further discussion. Delivery at any gestational age for any reason whatsoever absolutely eliminates the possibility of subsequent stillbirth; the earlier the delivery, the greater will be the observed effect. Thus, it is certain that, with a sufficiently large denominator, reduction of elective deliveries at <39 weeks of gestation would be associated with an increased rate of stillbirth compared, for example, with a cohort of infants who were delivered at 38 weeks of gestation. Uniform delivery at 28 weeks of gestation would yield an even more impressive reduction in stillbirths.”

      Dr. Clark goes on to make 3 points:

      1. “Our inability to demonstrate any statistically significant increase in stillbirths in a population of almost one-quarter million births suggests that the number of actual stillbirths that potentially are associated with this policy is very small.”

      2. “Any objection to the implementation of such a policy based on concern for stillbirths is only logically consistent if accompanied by advocacy of uniform delivery at <39 weeks of gestation. Otherwise, the benefit of such objections would accrue only to those women whose physicians violate current practice guidelines.”

      3. “An appropriately conducted randomized clinical trial in a very large population potentially could define the cost, in terms of both dollars and morbidity of each stillbirth avoided by uniform delivery at <39 weeks of gestation. However, such a trial is not only logistically unrealistic, but also the data would be of no value in the absence of universal agreement on the relative value of large amounts of iatrogenic morbidity vs the prevention of a small number of deaths.”

      Thank you again for taking the time to comment and we appreciate your concern for the well-being of moms and babies!

      Sincerely,

      Rebecca Dekker

  20. I really wish the focus on quality care would shift away from demonizing cesareans and towards the things that really matter – healthy moms and healthy babies. By focusing on reducing the cesarean section rate in low risk women you may be making birth considerably worse for a small but significant minority (between one and three percent of women) – those who would choose to undergo a cesarean for the delivery of their child. These are women who have considered the risks of planned vaginal delivery and planned cesarean delivery and prefer the risks and benefits associated with planned cesarean delivery. Women who choose cesarean do so for a wide variety of reasons including a fear of the more rare but more severe risks of vaginal delivery (HIE, brachial plexus injuries, etc.), a fear of a lack of epidural anesthesia, a fear of damage to their pelvic floors and consequent urinary/fecal incontinence, some are tokophobics for whom a lack of a cesarean makes the thought of continuing with a pregnancy intolerable. For most women who choose cesarean – they are not doing so to choose a birthday or have a tummy tuck at the same time – they are doing so because they feel that the procedure best meets their needs. Forcing women into vaginal deliveries they do not want puts these women at risk of experiencing birth trauma and developing PTSD. For those planning small families (less than 3 children), planned cesarean has comparable risks to planned vaginal delivery and may reduce the risk of pelvic organ prolapse, urinary and fecal incontinance. From a cost perspective, some studies have shown that planned cesarean may be cost comparable to planned vaginal birth with an epidural. I would encourage you to read “Choosing Cesarean: A Natural Birth Plan” by Pauline McDonough Hull and Magnus Murphy and to reconsider jeopardizing the medical autonomy of thousands of women who would choose cesarean. Forcing women to have vaginal deliveries they do not want should be considered a form of medical battery. Why not measure the rates of women who experience birth trauma and post-natal PTSD and work to reduce that instead – surely it is a far better measure of quality care.

  21. I am not in favour of these restricting regulations.

    I do understand that they are well-meaning, but I am concerned that there is no exception in these guidelines for mothers who choose cesareans themselves for medical or psychological reasons.

    While most women want a normal, uncomplicated birth, some women might prefer a c-section in certain circumstances. For example, a woman carrying twins might not feel entirely comfortable with the risks of a vaginal birth and may prefer to deliver her twins via planned c-section. A woman might suffer from a serious psychological disorder called ‘tokophobia’ which is a pthological fear of childbirth. This can often be triggered by a history of sexual abuse, rape and/or anxiety. There are women who don’t want to have a VBAC and would prefer a repeat c-section. However, with hospitals under such severe pressure to reduce c-section rates at all costs, they will start by targeting the women who are attempting to make these informed choices. This is what concerns me.

    This is already happening in baby friendly hospitals. The idea was to support women who wanted to breastfeed, but in an ambitious attempt to increase breastfeeding rates at all costs, hospitals are putting in place policies that are more and more restrictive and women who don’t want to breastfeed and being put in a corner.

    Whether naturally or surgically, that baby has to come out somehow and I don’t think it is unreasonable to expect that the woman be given a say in what happens to her body and baby.

    I think that the Joint commission needs to make it explicitly clear that they want to focus on women who WANT to have a vaginal birth and women who WANT to breastfeed.

    I completely agree with the above comment that we should focus on reducing the rates of perinatal and maternal mortality. The rate of vaginal births is irrelevant as long as mom and baby are healthy.

    • Rebecca

      Hi Lara, I totally understand your concerns. We at ImprovingBirth.org do not wish women to be restricted from choosing elective C-sections. Serious psychological disorders such as the one you described are a real medical reason for choosing a Cesarean. I think you are reading too much into this. These are not RESTRICTIONS. The Joint Commission is not restricting anyone from performing a C-section. They are simply asking that hospitals take a look at their rates, and do what they can to bring the rates down of the preventable Cesareans. This means encouraging women to stay home until they are in active labor (admission before 4 cm drastically increases the risk of an unplanned C-section in a mom who doesn’t want one), and discouraging medical inductions unless there is a medical reason or unless the mom’s cervix is ripe. But there are no restrictions. Hospitals won’t be restricted from doing anything, unless they choose to implement certain restrictions themselves (like putting hard stops on elective deliveries before 39 weeks, and requiring physicians to get special approval before performing one of these early elective deliveries).

      Also, the Joint Commission recommendations specifically refer to first time moms who are low risk (single baby, head down), so this should not have any bearing on the choice of VBAC versus elective repeat C-section, or twin vaginal birth vs. twin C-section. So I think your fears can be relieved on those matters.

      As far as the breastfeeding guidelines, they only refer to women who CHOOSE or WANT to breastfeed, as you said. So again, I don’t think this prohibits maternal choice.

      Before you draw any more conclusions about what the Joint Commission is or is not saying, I would encourage you to read their new guidelines here. I think that should hopefully answer some of your questions. https://manual.jointcommission.org/releases/TJC2013B/MIF0167.html

      I disagree with your comment that we should soley focus on reducing rates of perinatal and maternal mortality. There are many, many other outcomes that are important for researchers and care providers to go after– things like maternal well-being, lower rates of post-partum depression, fewer maternal complications, fewer newborn complications and NICU admissions. Why would we limit ourselves to only improving mortality? We can do so much better than that! http://www.improvingbirth.org/2013/02/a-healthy-baby-isnt-enough/

      Sincerely,
      Rebecca

  22. I was wondering, since I haven’t been able to find any statics on hospitals in the Michigan area. How would I go about getting statistics for my local hospital? Who am I supposed to call? I think it is very important that the c-section/intervention and mortality rates be public knowledge and yet I am having so much trouble getting in touch with the right people. It wasn’t until after I had my first child that I was informed that the c-section rate was 80% at the time. Fortunately, I was stubborn and refused to have one when they pressured me. That’s not to say that my labor was a good one. What I really want to know is the intervention rate considering the fact that I refused to have pitocin and they put me on a drip without my knowing (they told me it was Saline when I asked). I didn’t find out until I got my medical records a year later. If I’d known they do that I never would have gone there. All woman should know the numbers and common practice of a hospital before being admitted or choosing an OB/midwife. It is especially difficult to find the numbers behind a specific doctor, this is something I think most people don’t even think about when selecting a practitioner. More awareness and more common knowledge!!

    • Hi CiCi,

      Cesarean section rate information per hospital and per obstetrician is indeed difficult data to obtain. I am a researcher involved with compiling state health indicator data in the state of Michigan, and one of those indicators is birth. The C/S rates (2011 data) range from a low of 16% to over 43% (Dickenson, Marquette, Petoskey). The large hospitals with lowest C/S rates seem to have several things in common: Certified Nurse Midwives, neonatal intensive care units, and are within academic institutions. The trend with small hospitals (<1000 births/year) with the lowest rates have is the use of Certified Nurse Midwives.

  23. Alison Snyder

    Hallelujah! Any improvement is better than what we have now. But, I am a bit dubious. My experience (as a CNM and working with many OB’s) is that if it is in their best interest to perform a CS or other interventions, they will make the paperwork (diagnosis etc) fit that agenda. It’s not as difficult to get around these things as it may sound. I am due in 13 weeks, and I shall be getting the job done in the comfort of my home.

  24. Katherine

    The doctors should have to put there stats out there too

  25. I am another passionate mother and birth keeper . There are consequences w c sections. Esp the ones that are done for reasons other than medical necessity We all. Want healthy moms and babies yes ofcourse. Having accointibility is crucial Esp when csection rates are over 40% that’s my opinion. We could look to the farm
    In Tennessee but woman who choose to birth at the farm are not the norm I would safely say. Where I live there is one hospital and it’s csection rate is very high. I am doing all I can to inform share educate in my community. Babies are my passion. Every baby deserves to be loved wanted and welcomed from the beginning. I acknowledge APPPAH. For all their work and dedication.

  26. This news makes me both happy and sad. I think it’s good in that, if the doctor and hospital are simply pushing to get the most money out of the patient by encouraging un-needed C-sections, then something like this is absolutely essential in curbing their reckless greed.

    However, it makes me sad because it brings me back to my C-section. I didn’t induce, I labored for 12 hours without medication and was having transition level contractions with no dilation. The hospital wouldn’t admit me even though I was collapsing in their hallways; ultimately, the doctor gave me a shot of morphine and I started dilating immediately. The contractions continued to be so intense that, even though I had been resolved for months beforehand not to request an epidural, I remember thinking I would throw myself out the window or smash my head in if the pain continued at that level. I was also sick with pnemonia I had gotten just that week.

    I feel like a failure, and this article exacerbates it. But I am still pro-natural delivery.

    I dialated all the way after the epidural, but the baby, who had an enormous head, wouldn’t descend.

  27. Madison

    It is our right to have a c-section if we want one. Not yours. We understand the risks, the abdominal surgery issue, the hospital stay and bills. It is our choice to have a c-section. Not yours, or anybody’s. And some woman have to have a p csection due to complications and possible death to mother and child if they proceed with vaginal birth.you cant tell us we cant have one.

Trackbacks/Pingbacks

  1. Latest Research on Cesareans & Related News | Center for the Childbearing Year, LLC - [...] Hospitals held accountable for c-section rates [...]
  2. very good direction | Between The Gates - […] Slowly the US birthing practices are coming closer aligned to actual birthing reality.  As indicated here […]
  3. Because We Can: A Year of Inspiration - Improving Birth | Improving Birth - […] like Kitty Ernst, Jennie Joseph, Coalition for Improving Maternity Services (CIMS), and the Joint Commission.   Watch our page, sign …
  4. Evidence Based Birth The Joint Commission Requires Evidence-Based Perinatal Measures - […] wrote about my findings at ImprovingBirth.org. Click here to read what I found out! The answers may surprise […]

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