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
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: Oct 2023
A hospital in the USA brings their cesarean rate way down: Link to St Mary’s Medical Center
https://www.stmarysmc.com/news/newsroom/st-mary-s-medical-center-achieves-healthgrades-5-star-rating-for-vaginal-delivery-and-c-section-delivery-for-the-8th-consecutive-year
UPDATE: MAY 2024
This information is on a Canadian Government Website.
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 Source: https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/quality-care/quest-quality-canadian-health-care-continuous-quality-improvement.html