When leaders at Virginia Hospital Center in Arlington realized the nulliparous, term, singleton, vertex (NTSV) cesarean delivery rate was too high, they decided to act. Today, the Virginia Hospital Center rate is below the national average and lower than what professional organizations prescribe.

The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine both recognize cesarean deliveries can save lives, but they advise vaginal deliveries for most pregnancies because the risk is lower than that of cesarean deliveries.1,2 A hospital’s NTSV cesarean rate is considered a key indicator of quality and patient safety. Leapfrog reported the average cesarean rate nationwide in 2018 was 26.1%, although the organization set a target of 23.9%.3

At 33%, the Virginia Hospital Center board recognized the cesarean rate was far too high and set a goal to reduce it significantly, says Marian Savage, MSN, RN, NEA-BC, CPHQ, PMP, associate vice president of quality and patient safety.

“I think the most important part was the transparency, which was different from other organizations I’ve worked with,” Savage says. “First, we cleaned the data and made sure it was correct. The OB department put on display in the physicians’ lounge all of the physicians’ C-section rates. I’ve seen that done with groups or with aggregate numbers for a department, but I’ve never seen it done with individual physicians.”

That did not please some physicians, but it did produce the desired effect. Every physician with a high cesarean delivery rate wanted to lower it, and fast.

“It changed the culture on that unit. It was kind of a shock at first, but the rates began dropping,” Savage says. “Everyone wanted to be better than the person next to them.”

Physicians started looking at why they were performing cesarean deliveries and eliminated procedures that were performed out of convenience, says Jeff DiLisi, MD, senior vice president and chief medical officer.

“Generally, the physicians took it well, but there are always a couple who don’t see the value right away,” DiLisi says. “We had a lot of highly educated business professionals coming into our practices and saying they want to go on maternity leave on Sept. 30. That’s when they want to have the baby. Part of the physicians’ concern was that they would have to learn to communicate in a different way with their patients to show them that is not in the best interest of their baby.”

One tactic was communicating to expectant mothers that another name for a cesarean delivery is “surgery,” with all the concomitant risks and downsides, DiLisi says.

The hospital also appointed one of its OB/GYNs to be the medical director of labor and delivery. In that position, the person held a monthly quality meeting during which a group of obstetricians reviewed every cesarean delivery performed at the hospital. Making one person accountable for that was helpful in gaining traction on the issue, DiLisi says. He also notes the decline in cesarean deliveries has been accompanied by a drop in admissions to the neonatal ICU.

“Hospitals get paid more for a C-section than a vaginal delivery, but we did this anyway because felt strongly it was the right thing for our patients,” DiLisi adds.

Nurses Play Major Role

Credit also goes to the interdisciplinary team that worked on the problem, Savage says. Nurses and other clinicians worked with physicians to identify ways to reduce the cesarean delivery rate. Nurses took the lead in working closely with patients, particularly first-time mothers, keeping them calm and progressing well to a vaginal delivery.

Physicians changed the ways they decided to order a cesarean delivery. Previously, that decision might be made rather quickly if the mother had been in labor for many hours — or if the physician’s shift was ending.

“Now, we’re giving much more time. That came from a review of literature that showed a mother can labor longer than we thought,” Savage says. “Safety is always a priority. We will take a mother for a C-section when it is warranted, but we allow the mother to labor longer than before. It might take two or three days, but we allow the mother to go through that natural process.”

Safety Huddles Help

Another obstacle to adoption was everyone sincerely believed they were doing the best they could. Savage and the rest of the team had to overcome that initial resistance to criticism.

The breakthrough was posting the individual physician cesarean delivery rates. The numbers were a shock to some physicians, especially when they could see their patient populations were similar to those with better scores.

“People think they are doing their best and that they’re on par with their peers, so the numbers can jolt them,” Savage says. “But that’s where you get the change. They see those numbers and don’t like them.”

Another component of the success was the use of safety huddles, one in the morning throughout the entire hospital, and another department safety huddle.

Every day in the OB, all clinicians gather to discuss high-risk mothers and other safety issues. Clinicians are encouraged to speak up and offer advice on how to handle a particular patient, based on their experience.

The team addressing the cesarean delivery rates initially hoped they might lower their rate to below 30%. Eventually, the rate declined 12 points to 20.9%. Some physicians have lowered their rates to as low as 15%. “The big lesson is that it’s doable. We’re still seeing hospitals in our area with rates in the 30% and 40% range,” but achieving lower rates is possible, Savage says.


  1. [No authors listed]. ACOG Committee Opinion No. 761: Cesarean delivery on maternal request. Obstet Gynecol 2019;133:e73-e77.
  2. Society for Maternal-Fetal Medicine. Safe prevention of the primary cesarean delivery.
  3. The Leapfrog Group. Report from The Leapfrog Group finds only 1 in 5 U.S. hospitals fully meet payor standards for maternity care. May 29, 2019. https://bit.ly/3jwqlCv


  • Jeff DiLisi, MD, MBA, Senior Vice President, Chief Medical Officer, Virginia Hospital Center, Arlington. Phone: (703) 558-5000.
  • Marian Savage, MSN, RN, NEA-BC, CPHQ, PMP, Associate Vice President, Quality and Patient Safety, Virginia Hospital Center, Arlington. Phone: (703) 558-5000.