A Proven Method for Lowering the Cesarean Rate

Another article in my local newspaper last week bemoaned the fact that the cesarean rate keeps rising and physicians are concerned not only about the high rate of surgery but also the future complications that increase after cesarean surgery.  It’s a well-documented fact that a cesarean can adversely affect a woman’s health for the rest of her life and can lead to catastrophic complications in future births.  That’s one reason why, 40 years ago, doctors did everything in their power to prevent that first cesarean from being done.

What if there was a tried method of reducing the cesarean rate within hospitals?  What if it involved some truly innovative thinking?  What if it had a proven track record and had resulted in a significant drop in the rate of surgeries for first-time mothers?  What if it saved money, recovery time for the patient, and better health for the babies?  Would you think that method would be adopted all over North America right away?  Yes, that would be a reasonable assumption.  Unfortunately, this project was undertaken at B.C. Women’s Hospital, it was a success, and it was dropped once the project was complete with a resulting re-increase of the cesarean rate.  No reason for discontinuing the project has ever been given but i will speculate at the end of this post.

A cesarean is major abdominal surgery

A cesarean is major abdominal surgery


The results were published: Grzybowski S, Harris S, Buchinski B, Pope S, Swenerton J, Peter E, et al. First Births Project manual: a continuous quality improvement project. Vol 1. Vancouver: British Columbia’s Women’s Hospital and Health Centre; 1998.

It was the first phase of a Continuous Quality Improvement project with the aim of “Lowering the Caesarean Section Rate“. Start date was January of 1996. The target objective was to lower the caesarean section rate by 25% for nulliparous women, while maintaining maternal and infant outcomes, within 6 months of implementing solutions. 

Staff from all departments of the hospital were brought together in a brainstorming session to share hypotheses on what was causing the high rate of cesareans.  Many of the ideas thrown out were not under the control of the hospital but, in the end, four practices were identified as possibly contributing to the high rate of surgical births.

1. Women were being admitted to hospital too early (before reaching 4 cms dilation, active labour).

2. fetal surveillance by electronic fetal monitoring (continuous electronic fetal monitoring has been proven to increase the cesarean rate with no improvement to the health of the baby)

3. too early use of epidurals (women who get an epidural before 8 cms dilation are at increased risk of surgery)

4. inappropriate induction (inducing birth before 41 weeks gestational age with no medical indication).

Teams of nurses were assigned to do an audit of hospital records to see if these hypothetical practices were, in fact, as widespread as some of the staff thought.  The audit confirmed that these 4 areas were ones that needed attention.  Task forces were created in each area to use the best evidence and existing guidelines, as well as solutions from other hospitals to improve care at BC Women’s Hospital. Guidelines and other strategies in all four target areas were implemented in the spring of 1997.
 

WHAT HAPPENED?
 
According to published results from the hospital:
After six periods, BC Women’s had admitted and delivered 1369 nulliparous women (first time mothers) with singleton, cephalic, term presentations. The Cesarean section
rate was reduced by 21% compared to the 12 periods prior to implementation. The number of epidurals initiated at 3 3 cms was 64% lower, continuous fetal monitoring was used 14% less, the induction rate had dropped 22% and admission at less than 3 cms cervical dilation had dropped 21%. All changes were statistically significant. Newborn outcomes were unchanged post implementation.”

WHAT’S HAPPENING TODAY (2009)?

It’s back to business as usual at this hospital.  Women are induced, monitored, epidural’ed, and admitted early.  The cesarean rate is 30% and the head of obstetrics is concerned but has no action plan.  Why on earth would this be?  I assert that it is because it is an “up at dawn” battle with the physicians to change their ways.  The gossip that I hear from nurses is that the doctors did everything they could to undermine this project.  For example, a doctor would examine his patient and state “She’s 8 cms dilated, get the anaesthetist.”  Then, later, when the woman had her epidural, someone else would examine the same woman and find her to be only 6 cms.  The doctor would smile and shrug his shoulders, “whoops”.  The same thing happened around the issue of monitoring, induction and admitting. . . trickery to subvert the project and return to their old ways of doing things.

It’s a low tech, novel, innovative approach that had excellent results.  I’d love to see it copied everywhere in North America but it’s a bit like dieting. . . everyone knows how to lose weight (eat less, exercise more) but only a few get into action.  We DO know how to lower the cesarean rate, committed action is needed.

UPDATE: July 2017

A hospital in the USA brings their cesarean rate way down: http://www.stltoday.com/lifestyles/health-med-fit/health/st-mary-s-hospital-has-second-lowest-c-section-rate/article_38258dbb-a906-5e38-9c61-e321c16d6369.html

37 thoughts on “A Proven Method for Lowering the Cesarean Rate

  1. I must have missed this when you first posted it. It really is fascinating. Thanks for including a link in your recent post. I’m bookmarking this for friends!

  2. Nowadays almost everyone is opting for caesarean section. Some years ago, it was said that ‘Once a caesarean, always a caesarean’. Later on, it was found that Vaginal Birth After Caesarean was proven to be safe and effective. Also all post-caesarean pregnancies do not need repeat CS and most of them could have an unfussy vaginal delivery.

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  4. Dear Gloria, thank you so much for posting this. I recently had what I deem is a textbook unecessary cesarean at BC Women’s after being transfered from home for suspicion of foetal distress (which happened to be non-inexistent).
    What would it take to reinstate this experiment at BC women’s? Why are doctors still in such a hurry to deliver babies in the OR when the outcomes are so more likely to be worse? Will it take patients that file complaints? I am more than willing to do so myself.

    As a facilitator, I would love to help facilitate a dialogue within the birthing community on best practices to lower the cesarean rate. I really think doctors, midwives, nurses, doulas and most of all women need to have a serious talk about this. Unecessary cesareans will end up costing a lot more to our healthcare system, so I really cannot wrap my head around why the rate is still rising…

    • The health care system gets paid more. They make more money by cutting the woman. And if she has complications….they get money for that too.

      This is NEVER going to get better until the women themselves (and their lawyers) demand vaginal births.

      • I think the key consumers are the men … to become engaged in the movement to create safer birth, to actually lead the charge. Men can not protect their partner, baby, or self IN the hospital during birth but they can rise up and address the systems that allow it … BEFORE they are having babies, or after they’ve had babies. Men can do the research, confront the medical personnel, take it to legislators, and support midwifery models with meetings, rallies, and legislative changes. This is how and when women need to be protected — when men get it and say no more. This is how it will be, how you will treat birth, women, and babies. My baby or any baby.

  5. Thank you for this fascinating post, Gloria. I am very interested in why no real progress is being made. You mention at the end of your post that you suspect that the doctors essentially sabotage the common-sense approach to lowering caesarean. Elodie points out that high caesarean rates probably cost our healthcare system lots of money. So, do you think the reasons doctors are uncooperative has to do with the money *they* make from births that involve tons of intervention? Or perhaps the reason is more personal, in that doctors have less control when women have more. I think it is probably a combination of factors, but I cannot help but note–from my own experience–that doctors and obstetricians generally seem to suffer from arrogance/paternalism/control issues as a culture. Too bad that mothers and babies suffer.

  6. Is it only me who is outraged at the unethical and malicious attitude of these doctors. If this is normal practice then somethings missing in the hippocratic oath!

    We just published a story on our blog about another way c-sections can be reduced – by having dedicated labor support from doulas – 28% less likelihood! Doulas Reduce Cesareans

    It seems a combination of all these strategies would have significant impact.

    • No….You are NOT the only one who is outraged. Having just witnessed the birth of my grandson at home in a simply beautiful birth, my heart aches for the women who are “operated on” to get their babies out.

      It is such a sick system. I am dedicated to changing it. My site http://www.childbirthsolutions.com has been revamped and from now on I am going to devote all of it to changing women’s minds. It must be the women who demand a different standard of care. The doctors are NOT going to do it.

  7. This isn’t the first time this has happened. In 1847, Semmelweis demonstrated his theory of hand-washing to reduce cases of puerperal fever, and managed to reduce the maternal mortality rate to less than 1% within months. Some notice was taken, but he was largely ignored and the method ridiculed. It wasn’t until 20 years later, when Pasteur proved the existence of germs, that anyone even *began* to entertain Semmelweis’ treatment. Even then, while aseptic routine was introduced, the majority of doctors still refused to wash their hands, out of pride. The maternal mortality really only began to sharply decline in hospitals in the 1940s, when antibiotics were discovered and able to be used to treat the fever, not because they had started to wash their hands! That’s a full 100 years after it was demonstrated that hand-washing reduced maternal mortality. So yeah, I don’t think doctors are any more inclined to change their ways than they were 150 years ago.

  8. Why was it undermined at every opportunity?? .. because it meant a loss of income for the doctors and anesthesiologists… If drs were paid PER BIRTH no matter how much/little they did they would certainly be found to do much LESS in the unnecessary intervention department. Why are the drs concerned about the anesthesiologist and helping THEM out? To help themselves out. Epidurals often lead to purple pushing and other pushing difficulties.. which lead to more c/sections.. not to mention.. you grease my palm, I’ll grease your palm mentality.. 🙁 So sad that the almighty dollar is more important then the health and safety of moms and children 🙁

  9. I have also had what I consider an unnecessary cesarean, in a Calgary hospital. I was induced early (39 weeks). I do have pre-existing diabetes, so the induction was probably warranted, but I was also kept on my back for my entire 24 hours of labour, had my water broken ‘accidentally’ right when I got to the hospital and had my blood sugar ‘controlled’ around 4 for the whole time. I was all too happy to have a c-section by the time the 24 hour mark came around – I was passing out in the washroom since I had no blood sugars left to give me energy. It makes me angry that so much of what led to my c-section could have been avoided if I’d just had ‘care’ givers who cared more about my welfare than their own bottom lines. My husband once suggested that we should try paying OBs the same for a c-section that they get for a vaginal delivery and see what happens to the cesarean rate – I’m guessing it would go down a little at least. But we’d also have to come up with some way to counteract the arrogance that is so prevalent in the OB culture. I’m always treated like I’m incapable of understanding the details required to make my own care decisions. They’d like nothing better than to cut me open again, but I’m having a VBAC (almost just to spite them).

    • You speculated that if doctors received the same payment for Cesareans as they do for vaginal deliveries, then they wouldn’t section as often because it won’t be as lucrative. Nay. In California, the state-based health care pays the same for both: around $565.00. No extra for cesareans. I wondered why section then? Convenience: stack ’em up, move ’em out. Volume.

  10. What do you suppose would happen if doctors were paid by the hour?
    Do you think we’d see slow, relaxed deliveries? Hearing “Take your time” instead of “PUSH! 1-2-3-4-5-6…”

    Nah.. we’d be given labour-stalling drugs upon admission to the hospital…

    • Sheila Stubbs – LOVE it hun!! So very true…

      I’m from Australia, and had a wonderful, unmedicated first birth (2 day labour, posterior baby who got distressed, but only 5 hours in hospital! Midwife only attended besides the anaesthetist who was called in when bub got distressed and was losing meconium, maintained heartrate over 200, etc) It was just beautiful! And to go home right after was lovely, could not have asked for a better experience. I was able to shower, walk, move however I needed… My second birth was not so great, I delivered at 25 weeks after losing our fraternal twin (lots of complications, severe haemorrhaging from subchorionic hematomas, PPROM at 18+5 weeks, chorioamnionitis and placental abruption sending me into labour). So I had an emergency classical (vertical) caesarean performed. I believe this was warrented, as the statistical outcome is slightly higher for breech babies at this gestation when they are surgically delivered. I am pregnant again, and they want to operate to deliver… I am going to VBAC. I have NO hospital support, and have to sign a waiver when in labour. There is only one hospital in this state that cannot refuse my care while in labour (if I presented to any other, I would be transferred there) They also cannot force a caesarean, although I’m sure they will do their best to push one on us! So by default, I get my VBAC. The risks are not what the hospital states either. I have been researching for months and the Obs are quite happy to lie directly and be very misleading – until you present them with the facts! Then they are much more open to discussion. So sad that a woman has to know beforehand what she needs to demand and request…

      • I am so sorry for the loss of your baby in your last pregnancy, and sorry you are dealing with this heavy-handed treatment. I wish you all the best of luck in your upcoming delivery (if you don’t already have the sweet baby in your arms!)

  11. Good stuff.

    The only precaution I question is epidurals *only* at 8cm+. If a woman is screaming for pain management, she should not be ignored with “not yet, honey.” That is also disrespectful of a woman’s wishes. She needs to have the risks very clearly explained to her, and have other options of pain relief provided, but to blatantly ignore her requests is borderline abusive. You would not ignore someone with a broken leg asking for pain medication (and don’t tell me this pain is different, lol, I remember!).

    Frankly, if a woman makes it to 8cm unmedicated, they’ve sometimes made it through the hard part and the anesthesiologist might not make it in time for the birth. In other circumstances, a woman can be “stuck” at another point (6cm, 7cm) for days and an epidural may provide the rest necessary to complete the birthing process. Forcing someone to have a natural birth who wouldn’t otherwise choose one is as archaic as twilight sleep.

    • Yes, yes, yes. If you want to improve care by examining the effect of practice policies, great, but not at the expense of safety, personal autonomy, compassion, and respect. Many women WANT pain relief. There is no justification for instituting a systematic policy that bypasses their rights and human dignity.

      There are also plenty of women who would prefer to have the reassurance of EFM, and situations in which the right decision is induction before 41 weeks or admission before 3cm. Blanket policies designed to promote an agenda other than safe, respectful, individualized care that results in a healthy mother and baby has no place in this debate.

  12. The almightly dollar has eclipsed humanity. Like you said, Gloria….Step one: get her out of the hospital! The hospital system is set up by insurance companies to be big business. It is no longer in the realm of health care. Women complain that it is the OBGYNs, but even a midwife practicing in a hospital (and under their insurance) will do interventions based on fear of litigation rather than letting things naturally progress. The environment is just as much of a factor as the ‘care providers’ themselves. Personally, experiencing a ‘natural hospital birth’ with my first child with a midwife was not at all what I had envisioned. I might as well have had an MD there. Second time around, I chose to avoid the hospital altogether and planned and executed an amazing home waterbirth with a doula that was shorter, calmer, gentler and left me amazingly energized, intact and with a beautiful healthy baby as well. Getting over the decades of fearmongering our society has pushed on childbearing women is what it will take to reclaim our right to be awesome birth warriors!

  13. In South Africa, in the private hospital sector the caesarian rate is 90% in some hospitals. The women who can afford to go to these hospitals are on medical aid and are well- educated women, with access to information if they are curious enough. What bothers me about all this is that women (and their husbands) submit to this treatment and allow it. They behave like sheep going to the slaughter house. N0-one questions the system.

  14. So straight forward. What is it going to take to get people aware of this issue!? What is it going to take for women to realize what danger they are putting themselves in with mainstream medical care? Thanks for sharing this! And thanks for all your help.

  15. As a doula in South Africa, I see a lot of what has been expressed here. I strive to inform my clients about the risks of going in to the hospitals too early and about unnecessary FM etc.
    Sadly these people are ruled by fear. The fear that their own doctors have instilled into them and that our society has continued to feed.
    We need to remove the fear first so that this information can then be heard. Change comes about in an environment of safety and acceptance.
    WE cannot fight the fear with more fear, we need to clear it with support, understanding and respect for women who are pregnant. It makes a difference when a women is informed and makes her own decision. This affects her whole life. Let’s empower through support and love instead.
    thank you gloria for your special way with clearly outlining these issues.

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  17. Hi, the link to the Australian midwife’s website does not work. Please repost?
    “It’s interesting that, when I went to find the references for this post, the most comprehensive archiving of this material is on the website of an Australian midwife.”
    I have tried all the Birthwise sites but can’t tell which one you mean.
    Great article. Thank you.

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  19. Dear Gloria,
    thank you for this article. As you said yourself – it’s all about the money. Only we, who went through c section, know how we felt. Emotionally and physically. But there are hospitals, there are insurance companies, there are many other companies that only care for the money.
    I thank God for my child, but I wish I had a normal birth…
    Thank you.
    Martha

  20. Wow, amazing article:) I had no idea i should have tried to stick it out a lil and not get my epidural so soon. i got it at 4cm! With in five minutes my sons heart rate dropped and everything went wrong. i was rushed for an emergency c section. i feel like i missed everything:(

  21. would you please post more information about the original research regarding the “first births project” at BCW’s that ran in 1996?
    i can’t find it anywhere on the web and the links don’t work.

  22. Tina, thanks for asking. If I hadn’t save the information (above) it would have disappeared. It was on the internet (that’s how I snagged it) but is no longer. I have tried the same Google searches. Gloria

    • Gloria, I found some information that might be useful. Please let me know if it turns out so. The contact info (which could be for a person who has long since replaced this gentleman, but the data should still be there) for the First Births Project is:

      “First Births: Lowering the Caesarean Section Rate”
      Dr. Stefan Grzybowski
      Room F412
      Children’s & Women’s Health Centre of British Columbia
      4500 Oak Street
      Vancouver, British Columbia
      V6H 3N1
      Telephone: (604) 875-3281
      Fax: (604) 875-3435

      I found this at: http://www.hc-sc.gc.ca/hcs-sss/pubs/qual/2000-qual/index-eng.php

      Prepared by MaryLou Harrigan, MCED
      Harrigan Consulting
      For Health Canada
      2000 (2nd Edition)
      ISBN 0-662-28608-1 (print publication)
      Cat. No H39-288/2000E (print publication)

      This discussion is in Section Five
      First Births: Lowering the Caesarean Section Rate

      Children’s & Women’s Health Centre
      of British Columbia
      Vancouver, British Columbia

      The First Births Project evolved as the first phase of a Continuous Quality Improvement project aimed at “Lowering the Caesarean Section Rate at British Columbia Women’s Hospital and Health Centre,” began in January of 1996. The target objective was to lower the caesarean section rate by 25% for nulliparous women, while maintaining maternal and infant outcomes, within 6 months of implementing solutions.

      After mapping the process of care and brainstorming hypotheses that might contribute to the high caesarean section rate, the group selected four areas as the vital few. These were too early admission; fetal surveillance by electronic fetal monitoring; too early use of epidurals; and inappropriate induction. A chart audit supported the group’s choices. Task forces were created in each area to use the best evidence and existing guidelines, as well as solutions from other hospitals to improve care at BC Women’s Hospital. Guidelines and other strategies in all four target areas were implemented in the spring of 1997.

      The project has been about working together to accomplish change in an environment of mutual respect. The process has been data driven as, without measurement, the effectiveness of any change is left to opinion. Hospital policies were created which were consistent with these changes. The project has also been about maintaining and consolidating the gains. This has been achieved through:

      an open and public evaluative process
      enrolment on a voluntary basis of nulliparous low-risk patients
      Nursing Team Leader confidential feedback
      monitoring newborn outcomes

      The spirit of this initiative is Continuous Quality Improvement. It is about making gains in the quality of care and then holding them. In the first six months of implementation the process of continuous quality improvement has worked to create statistically significant change in all the target areas addressed. In this six-month period there were 50-60 nulliparous women who did not have a Caesarean Section, as compared with the previous year. This number is projected to 100 nulliparous women for the entire year. If these women choose to have another pregnancy, their chances of having a caesarean section in the next pregnancy will have been reduced from about 60% to about 5%.

      The teams are continuing to meet and deal with other issues identified as potential opportunities for improvement. We expect that the First Births strategy will serve as an ongoing vehicle for introducing change concepts into the process of care at BC Women’s and might be a template for the province.

      See Appendix C for contact information.

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  24. I’m not sure if this has been addressed in the comments, but what I see as the main problem is that there is no one watching the hospital to make sure that the women are not being exploited for $$$$. I have no idea how to fight this (besides talking about it) but i think it’s really key.

  25. back in the 1990’s in the US, the Institute for Health Care Improvements engaged community hospitals to help them lower C/S rates. I remember attending a childbirth conference where this program got presented. they educated the hospitals, doctors, nurses to keep women up and active, introduce the birth ball. not admit women in early labor, etc. It was so exciting and yet, is seems to have come to naught.

    http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CCMQFjAA&url=http%3A%2F%2Fwww.managedcaremag.com%2Farchives%2F9612%2F9612.employer.html&ei=jXNnVODWGMqbigLnxoEI&usg=AFQjCNEQA-so2Kv9U82_ZzqkMJLQx7CMmQ&sig2=EKj91RdJHpowL8RJOKl-ng&bvm=bv.79142246,d.cGE&cad=rja

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