Reverse high cesarean rates with hard-and-fast data and new policies

Recruit a physician leader to cinch your success

The cesarean rate has long been the bane of quality management professionals, and until recently, many have hesitated to act in what is perceived as a physician's sacred domain. But with the advent of managed care and the pressure to lower costs, quality professionals are no longer shy about developing programs to help their hospitals lower cesarean rates -- with the cooperation of physicians, say quality professionals and medical experts.

Quality professionals are performing tasks such as collecting and distributing data on each physician's cesarean rate, conducting community outreach to educate expectant mothers on the risks of cesareans, and educating labor and delivery nurses on how to handle women in labor who demand cesareans, experts note.

The incidence of cesareans leveled off at around 22% in 1993, statistics from the U.S. Department of Health and Human Services in Hyattsville, MD, show. But quality professionals are faced with helping hospitals recuperate from a trend that saw a 500% increase in cesareans over 25 years and is still deeply rooted in the practice of some physicians, says Bruce Flamm, MD, FACOG, area research chairman for Kaiser Foundation Hospitals in San Bernardino, CA, and co-author of the book Cesarean Section Guidelines for Appropriate Utilization. (See editor's note at end of story.)

The quality manager's role

Quality improvement professionals can help reduce cesareans at their hospitals by performing tasks such as:

* tracking physician cesarean rates in the organization and showing physicians where they stand compared with their peers;

* collaborating with labor and delivery personnel to develop policies that discourage staff from admitting women in false labor;

* conducting community education programs to encourage vaginal births after cesareans (VBACs);

* providing physicians with accurate data that show lowered cesarean rates improve patient outcomes;

* assuring physicians that the project's emphasis is on patient health, not on the hospital's bottom line;

* making changes on a small scale so physicians can test the waters before making big changes.

Quality management departments can also join collaborative efforts that teach cesarean reduction, experts agree. For example, Anita Dorf, PhD, assistant to the president for continuous improvement at Wesley Medical Center in Wichita, KS, joined with 28 other hospitals in a cesarean reduction series sponsored by the Institute for Healthcare Improvement (IHI) in Boston.

The cesarean reduction series is part of IHI's Breakthrough Series aimed at improving quality and reducing costs in health care. Over 18 months, teams meet at IHI to learn techniques for lowering cesarean rates.

Trustworthy data an ally

One of the biggest challenges quality management professionals face in obtaining physician buy-in for a quality management-sponsored cesarean reduction program is trust from labor and delivery staff, say Dorf and other quality experts. Begin by communicating to physicians that the patient's health is top priority. "The motivation from the start should be improved quality of health care for women," emphasizes Bob DeMott, MD, chairman of the department of obstetrics and gynecology at Bellin Hospital in Green Bay, WI, where cesarean rates have dropped from 16% in 1988 to 10.3% in 1994. "It's just secondarily recognized that lower cesarean rates will save money."

In addition, hospital administrators and staff leaders must commit to any cesarean reduction program, says DeMott, who with Herbert Sandmire, MD, has co-authored a four-part series of articles on how Bellin lowered its cesarean rates.1-4

Once physician trust is established, find a physician to champion your quality improvement efforts, DeMott says. "I believe each institution should identify a cesarean monitor or champion," he says. The monitor obtains data and shares the information with other departments.

Choose a physician who is interested in reducing cesareans and willing to do the work, DeMott says. The monitor should have one of the lower cesarean rates in the community along with good success and outcomes, he advises.

A physician champion can make the difference between success and failure, DeMott adds.

When cesarean rates crept up from 12.2% in 1993 to 14.8% in 1994 at Community Memorial Hospital in Menomonee Falls, WI, a physician champion ensured staff buy-in for cesarean reduction efforts says Pat Landenberger, the hospital community outreach coordinator. The hospital joined IHI's cesarean series and found a physician who agreed to attend one IHI meeting. He came back convinced that a quality improvement project could help keep cesarean rates down, Landenberger recalls.

Each month during the obstetrics/gynecology department meeting, the physician champion conducts a half-hour presentation of the results of continuous quality improvement's (CQI's) ongoing chart research, she says.

He presents spreadsheets with cesarean infection rates, VBAC rates, trial of labor rates, and epidural rates. The results are based on the data obtained from the physicians' practices, Landenberger says. "With physicians, you have to prove it to them [with data and results]," she says.

Gaining team, community support

Landenberger also posts articles on cesarean reduction, including proven techniques, in the birthing center. She also posts the results of surveys conducted with nurses concerning their role in cesarean rates, such as whether they believe they have an impact on those rates, she adds.

Teamwork is a very important CQI tool, DeMott says. He suggests holding ongoing information programs with the nursing staff, labor and delivery nurses, Lamaze instructors, and prenatal educators.

An outside expert can spark enthusiasm for cesarean reduction programs because he or she reinforces the idea that goals are achievable, DeMott says. Landenberger invited DeMott to talk on cesarean reduction, which he did via conference call.

Community education is also important to cesarean reduction efforts, Dorf says. "Our next step is to influence the community and let them know the cesarean is a surgical procedure with risks, and we would like to help moms have a normal delivery," she says, adding that the program is not off the ground yet.

Patient education is ongoing at Community Memorial, Landenberger says. In addition to ongoing prenatal case management, Community Memorial has purchased more than 100 copies of Flamm's book, which are given to potential VBAC patients. Patients are encouraged to borrow videos on VBACs and cesareans from the hospital's resource center, she says.

Let nurses go into labor

Role-playing can raise awareness and change behavior among labor and delivery nurses who might be quick to call in a physician when an expectant mother asks for a cesarean, Flamm says.

A quality improvement project can facilitate nurses' role-play by using some of the following techniques, he says:

* Have one nurse play the patient in labor, while the others play the physician, labor and delivery nurses, and husband or boyfriend.

* Set up a scenario, such as this is the first child, the cervix is dilated five centimeters, and the patient is in severe pain and wants a cesarean.

"We start the role-play and see what happens. Each time it's different," Flamm says. This process helps teach nurses how to better handle patients who want a cesarean.

"The nurse can do many things, such as pick up a phone and call the doctor, who may tell the operating room to do a cesarean; or another nurse might not call the doctor and just reassure the patient everything is going well," he says.

Role-playing with nurses, physicians, and childbirth educators made everyone more aware of how important a role nurses play in reducing cesarean rates, Landenberger says.

Changing behavior among physicians may take a little finesse. Physicians will change, but only if you prove your suggestions for change, so don't try to make too many big changes at once, Dorf says. For example, Wesley Medical Center is a 763-bed facility that delivers about 4,000 babies each year. Before joining the IHI project in May 1995, the cesarean rate stood at an average 24.5%. Now, it's 20%, the result of convincing physicians to accept changes slowly.

Wesley Medical Center started experimenting with a policy to not admit a woman until she is in active labor, Dorf says. The policy was adopted slowly until physicians saw it worked.

The quality management department used a Partogram to facilitate this change, Dorf says. The Partogram helps physicians track cervical dilation over time, so it helped reduce the number of women admitted in false labor, she adds. (See Partogram, above.)

Admitting women only when they're in active labor helps reduce cesareans because when a woman is sitting around waiting for active labor, staff tend to feel they must take some sort of action, such as inducing labor or performing a cesarean, notes Andrea Kabcenell, RN, MPH, senior research associate at Cornell University in Ithaca, NY.

Best practice hospitals will not admit a woman unless her cervix is dilated 4 cm for a first baby or the woman is at-risk, she says.

Dorf has also found that clinical pathways with proven outcomes help physicians buy into change, she says.

Use good data wisely

Data are also important CQI tools. Quality managers should strive to provide physicians and labor and delivery staff with simple, accurate cesarean data, Kabcenell says. Extrapolate your data from labor and delivery logs rather than charts, suggests Kabcenell. Help the physicians understand the role of measurement and process improvement. "Show them data, post the data, explain the data, and make sure they don't get lost in it," she says. "Put it on the unit for people to see."

The clinical staff should be encouraged to do some of the data gathering, DeMott says. Collect information on labor management techniques, amount of oxytocin used, the number of centimeters the cervix was dilated, whether the physician used forceps or vacuums, and whether an epidural was done.

In addition, quarterly reports and progress updates are important in keeping physicians informed, DeMott notes. The compiled cesarean data should be readily available and organized in a way the monitor, or physician champion, can utilize, DeMott says.

Be patient because results take time, DeMott notes. "There's a lot of fear in obstetrics and litigation concerns that need to be eased over," he says.

[Editor's note: For more information on the Institute for Healthcare Improvement program on reducing cesareans, write to 135 Francis St., Boston, MA 02215; or call (617) 754-4800.

Cesarean Section Guidelines for Appropriate Utilization, edited by Bruce Flamm and Edward J. Quilligan, is available from Springer-Verlag New York. Call (800) 777-4643.]


1. DeMott R, Sandmire H. Green Bay cesarean section study, the physician factor as a determinant of cesarean birth rates. Am J Obstet Gynecol 1990; 162:1,593-1,602.

2. DeMott R, Sandmire H. Green Bay cesarean section study, the physician factor as a determinant of cesarean birth rates for failed labor. Am J Obstet Gynecol 1992; 166:1,799-1,810.

3. DeMott R, Sandmire H. Green Bay cesarean section study, falling cesarean birth rates without a formal curtailment program. Am J Obstet Gynecol 1994; 170:1,790-1,802.

4. DeMott R, Sandmire H. Green Bay cesarean section study, the physician factor as a determinant of cesarean birth rates for the large fetus. Am J Obstet Gynecol 1996; 180(article pending.) *

The Partogram, which is attached to the patient's chart, tracks cervical dilation over time. It is a visual tool to help staff identify whether labor has been diagnosed correctly or a woman has been admitted in false labor.

Source: Wesley Medical Center, Wichita, KS. Used with permission.