Hospitals deliver reduced cesarean rates

9-month study provides some answers

About 22% of all babies are delivered by cesarean in the United States, making C- section the most common major surgery in the country. The cesarean rate, while down from a peak of 25% of births 10 years ago, remains four times higher than it was in 1970. The U.S. Public Health Service and the World Health Organization say that rate should be reduced to 15%.

Twenty-eight hospitals and a faculty of nine physicians and nurses who participated in The Institute for Healthcare Improvement's (IHI) Breakthrough Series on reducing cesarean rates agree the rates can be reduced without harming fetal and maternal outcomes. For nine months, they attended meetings and swapped ideas to help them meet the series' goal of reducing rates by 25%. In the end, they delivered: Half of the hospitals met their goals, and the other half made significant strides, says Andrea Kabcenell, RN, MPH, director of the collaborative series for the Boston-based IHI. (See p. 126 for data collected.)

"The model for change is 18 months in health care. We use an approach that encourages people to test out new ideas next week," Kabcenell says. "The collaborative process overcomes inertia. If you can see that something has already been proven to work at another hospital, you don't spend so much upfront time thinking about whether to try it."

Key issues the hospitals addressed to reduce their cesarean rates include the following:

· preventing admission for false labor;

· avoiding unnecessary induction of labor, especially for social reasons such as the arrival date of the new grandparents;

· educating women more extensively during their pregnancy to expect a trial of labor if they've had a prior cesarean and to be sent home if they're in false labor;

· changing the physiologic model for labor to include walking, changing positions, and drinking;

· managing pain well, including using walking epidurals so women aren't confined to the bed.

"Most of the things we looked at were not rocket science. They have been in the medical literature for many, many years. It's putting them into action that's difficult," says Bruce Flamm, MD, chairman of the collaborative group and area research chairman in obstetrics and gynecology for Kaiser Permanente in Riverside, CA.

To help with implementation, the hospitals were advised to work on creating a will for change in their organization. "It's a prerequisite that you have to get buy-in from at least a certain segment of nurses and physicians," Flamm says. Suggestions include identifying external pressures for safely reducing cesarean rates, bringing in experts in the field, and identifying best practices. Some hospitals post individual cesarean rates with the physician identities blinded and give physicians monthly reports on their rates compared to the rest of the staff. Another idea is keeping a log book that tracks dilatation and effacement of women when they are admitted and their subsequent outcomes. As a general guideline, a woman having her first baby should not be admitted until she's 100% effaced and at least 2 cm dilated, Flamm says.