Pam Harrison

May 11, 2017

SAN DIEGO — Rates of primary cesarean delivery can be reduced when physicians are made aware of the relation between their own rates and hospital-wide averages, a single hospital experience suggests.

"Our intervention was designed to decrease individual and hospital-wide C-section rates to below the national average of approximately 25%," said Zishan Hirani, MD, a resident in obstetrics and gynecology at the University of Texas Rio Grande Valley in Harlingen.

"Just by letting physicians know we were watching them, we went from a baseline C-section rate of 35.3% to 27.3% in the first month after announcing that we were launching this project," he reported here at the American College of Obstetricians and Gynecologists (ACOG) 2017 Annual Meeting.

"But we did not have the resources to control a 9000-a-year delivery hospital and, in the absence of any active intervention, the C-section rate climbed back up to almost where we started," Dr Hirani explained. It seems that "old behaviors come back when the pressure is off."

When a residency program in obstetrics and gynecology was initiated in 2015 at Doctors Hospital at Renaissance, in Edinburg, Texas, residents and faculty members decided they wanted to try to reduce the rate of primary cesarean delivery.

The team defined primary rate as nulliparous women who deliver a single term baby in the vertex position by cesarean. The intervention was focused on first-time deliveries to give physicians the best chance to reduce rates, Dr Hirani told Medscape Medical News.

It's not necessarily that the doctors or nurses were trained differently; it's just the culture that exists in that hospital.

"Everyone was required to complete a fetal heart-monitoring course," he said. In addition, individual physicians were given their own cesarean rates and average hospital-wide rates, "so physicians had an idea of where they were relative to everyone else."

Physicians were educated about the evidence-based practices for cesarean delivery specified by societies such as the ACOG, and terminology was standardized.

The project was launched in January 2016 and, as participants — attending physicians, residents, and nurses — completed the fetal heart-monitoring course, cesarean rates continued to decline until June, when the lowest rate — just under 24% — was reached.

After this, the two residents and two part-time faculty members in charge of the project became overwhelmed by the time involved in the collection of data, and their efforts to continue the intervention stopped.

Soon thereafter, cesarean rates started to rise and, by the end of the year, rates were again over 30%.

"Around the United States, some hospitals have very low C-section rates and others have a very high C-section rates," said Anthony Ogburn, MD, chair of obstetrics and gynecology at the University of Texas Rio Grande Valley.

"It's not necessarily that the doctors or nurses were trained differently; it's just the culture that exists in that hospital," he told Medscape Medical News.

"In some places, if a woman is not delivered after a few hours, people will say, 'it's time to get that baby delivered'," he explained. "Others will say, 'it's time to put her in a tub and let her relax or sleep'."

In obstetrics, practice is not always evidence-based, Dr Ogburn added. It often comes down to, "this is what works for us."

Until the resident program was established at Doctors Hospital at Renaissance, the facility was staffed by private practitioners. But as private practitioners, attending physicians all had conflicting obligations, Dr Ogburn pointed out. This meant they were often making delivery decisions because they had to get back to the office or to another hospital.

But now "we are starting a laborist service," he reported. "We'll have a faculty member who is on labor and delivery around the clock who can assist with emergent, and even nonemergent, situations."

"I think we will see some impact from this effort over the next year or two, so we won't have to make a decision to do a C-section because a physician has to run over to another hospital or get back to their office," he explained.

The biggest lesson learned from this intervention is that two residents and two part-time faculty members cannot reduce cesarean rates on their own, Dr Hirani said.

"We need to recruit a bigger team and get additional funding" to sift through the data to determine what qualifies as a primary cesarean delivery, he explained. "Once we do have more manpower and more resources, we will be able to continue this project, and make it more comprehensive."

Culture Change Needed

A change in the culture of hospitals — so that there is greater resistance to cesarean delivery, especially in low-risk patients — might mitigate rates, Neel Shah, MD, from the Beth Israel Deaconess Medical Center in Boston, said during his President's Program presentation.

"About half the C-sections we do in the United States today are probably avoidable," he noted.

Rates in American hospitals range from 7.1% to 69.9%. And for low-risk patients only, rates range from 2.4% to 36.5% (Health Aff [Millwood]. 2013;32:527-535).

Abandoning the use of continuous fetal monitoring in low-risk women, which many hospitals have done, might be one way to reduce cesarean rates, Dr Shah suggested.

"According to our own guidelines, we shouldn't be doing any C-sections on labor progress alone before 6 centimeters," he pointed out. "If we just did that, it's worth tens of thousands of C-sections per year."

Dr Hirani, Dr Ogburn, and Dr Shah have disclosed no relevant financial relationships.

American College of Obstetricians and Gynecologists (ACOG) 2017 Annual Meeting: Abstract 244877. Presented May 7, 2017.

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