Reducing Low-Risk, First-Birth C-Sections

Posted on Apr 2, 2019 in Announcements | 0 comments

One of the advantages of practicing medicine within a large integrated healthcare delivery network like Sutter is that we benefit from studying the experience and practice patterns of our fellow clinicians. A great example of this is the work happening around supporting vaginal delivery by reducing the rate of cesarean sections for low-risk, first-time births (nulliparous term singleton vertex, commonly referred to as NTSV).

Sutter’s integrated network enables sharing of best practices and real-time data for continual process and quality improvement, which allows Sutter to outperform state and national averages in many quality measures and improve outcomes for the communities it serves. Sutter hospitals have been leaders in the state in lowering C-section rates—notably NTSV C-section rates.

A recent news story on C-section rates highlights the excellent work led by The Sutter Health Women’s Affiliated Group (SHWAG) and demonstrates what is possible when 18 Sutter-affiliated OB groups work together toward a common goal.

The Sutter Health network is a member of the California Maternity Quality Care Collaborative (CMQCC), a multi-stakeholder organization committed to ending preventable morbidity, mortality and racial health disparities in California. Partnering with CMQCC and the California Health Care Foundation, Sutter Health is leading a labor culture campaign to proactively educate first-time mothers about C-sections and encourage them to engage with their care teams to support vaginal birth and avoid C-sections for low-risk pregnancies.

Sutter Health’s NTSV C-section rate is among the lowest in California, with nine hospitals receiving recognition in 2017. Sutter’s average rate (21.2 percent) is lower than the state’s Healthy People 2020 target (23.9 percent) and the 2016 CMQCC P75 target (22.2 percent).
Studies show that a strong predictor of a woman’s chance of having a C-section is the hospital where she delivers, including the practice pattern of the physician/midwife and clinical team. As of January 2019, there is still considerable variation in affiliate performance across Sutter Health, ranging from 12.3 percent to 28.1 percent. In an effort to reduce this variation, we partnered with CMQCC to analyze our 2017 labor culture survey findings and identify qualities of hospitals with lower C-section rates versus those with higher rates. Our OB leaders are developing tools to provide insight into the foundational beliefs of physicians and staff relative to C-sections and how those beliefs impact vaginal birth rates.

There are several key drivers that have been instrumental to achieve real progress in decreasing C-section rates among Sutter Health affiliates.
• The first and most important driver is effective communication and teamwork—a joint commitment by the clinical team (nurses, midwife and physician) to create a great supportive environment for our patients.
• The second driver is alignment on best practices for labor support, including collaborative labor management and education. We adopted a labor dystocia checklist in labor and delivery that establishes parameters clinicians need to complete before deciding on a C-section. The teams work collaboratively using the checklist to ensure that all best practices for supporting a vaginal birth have been implemented. We have implemented the labor dystocia checklist at 13 sites, with a planned roll out to the remaining five OB sites in 2019. Additionally, we have developed labor support education for nurses, midwives and physicians. The next step, which we are now working on, is to include the patient as part of the team as we work through the checklist.
• The third driver is maternal agency—we have created a birth preference sheet to educate new mothers about choices they make that may increase their likelihood of a vaginal delivery and give them the opportunity to talk with their physician or midwife about these choices before birth.
• Finally, a large component of lowering NTSV C-Section rates is the open sharing of physician-level rates among our peers. This transparency creates the opportunity for dialogue and shared learning among clinicians. Each group is encouraged to discuss these rates internally and come up with a plan to address any issues uncovered by the data.

Our goal is that every patient receives the same high quality OB care regardless of which Sutter Health affiliated hospital she delivers at.
We will introduce a suite of resources over the coming months to support this initiative, including a labor and delivery web page, a series of videos and resources for patients and clinicians.

For more information, please reach out to the women’s medical director or OB/GYN chair at your affiliate.

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