“We are trying to identify hospitals that have high cesarean section rates as they work to improve,” said Dr. David Baker, executive vice president for Healthcare Quality Evaluation at TJC. “We want to encourage organizations to reduce their C-sections and encourage leaders to do that in a safe way.”
The news comes a few weeks after the Department of Health and Human Services unveiled an action plan to improve maternal health, which included reducing low-risk C-section delivery rate by 25%.
Since 1985, the World Health Organization has considered the ideal rate for C-section births to be between 10% to 15%.
However, the Centers for Disease Control and Prevention reports more than 31% of all deliveries in the U.S. were by C-section in 2018. Tricia Elliott, director of Quality Measurement at TJC, says some U.S. hospitals report C-section rates as high as 60%.
“C-sections are necessary a significant proportion of the time, but not at 30%,” Baker said.
High C-section rates are not the problem, said Dr. William Grobman, professor of obstetrics and gynecology at Northwestern University's Feinberg School of Medicine. The problem is variation between hospitals – low C-section rates in some and high rates in others – with no improved outcome for mother and baby.
“When you see huge variation without differences in outcome, that points to a more meta-issue of quality (of care),” he said. “What people want is the lowest possible rate that gets the best possible outcome.”
According to the Mayo Clinic, C-sections may be performed if labor isn’t progressing, the baby is in distress or in an abnormal position, the mother is carrying more than one baby, there’s a problem with the placenta, or other health concerns.
As with any surgery, there are natural risks associated with C-section delivery. This includes infection, postpartum hemorrhage, a reaction to anesthesia, blood clot, or surgical injury. The Mayo Clinic also says mothers face a higher risk of potentially serious complications in a subsequent pregnancy after a C-section.
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An observational study published in the peer-reviewed journal CMAJ in 2019 found women who had C-sections were 80% more likely to have complications than those who delivered vaginally. Women over the age of 35 who had C-sections were almost three times more likely to have severe complications.
Grobman says this data indicates unnecessary C-sections are an issue in the U.S. because a C-section delivery would logically carry less risk to mother and baby than a vaginal birth if the procedure was truly necessary.
In a statement to USA TODAY, the American College of Obstetricians and Gynecologists (ACOG) said national target C-section rates should be based on clinical data that has been risk-adjusted specifically to the hospital's patient population, and that target rates are meant to be calculated across all births, not across hospitals.
"That being said, health care teams and providers should be working to address the safe reduction of unnecessary cesareans using expert developed and quality improvement, science-based resources such as patient safety bundles and toolkits," ACOG said.
The organization adds that while national and regional organizations can take the lead in setting an agenda regarding prevention, it will need to be prioritized at the level of practices, hospitals, and health care systems, and it will require "culture change."
ACOG and the Society for Maternal-Fetal Medicine says increasing women’s access to nonmedical interventions during labor, such as continuous labor support, can reduce the need for C-sections.
“If we just adhere to guidelines consistently, all in the context of patient-centered care, what you would see is that hospitals would begin to look a lot more like each other than different,” Grobman said.
The Joint Commission echoes this emphasis on patient-centered care, saying lower C-section rates is not always better in some cases and the organization does not want to encourage inappropriately low rates that may be unsafe to patients.
“We don’t want to race to the bottom,” Baker said. “The whole idea is if you follow these best practices, you will have less times when a woman will need a C-section."