Recently, California State Senator Nancy Skinner introduced California’s version of the national “Momnibus,” remarking that “we must do more to protect Californians during childbirth.” With COVID-19 vaccine appointments now widely available, it may be easy to overlook other critical public health battles currently raging across the state. However, unnecessary C-sections have long been an issue in the U.S. and are a critical component of an overall battle plan against high maternal mortality rates.
While the World Health Organization recommends a C-section rate of 10-15%, the Centers for Disease Control and Prevention estimates the U.S. average to be approximately 31%. These rates matter in the larger public health conversation on maternal health in that surgery can pose a serious risk for both infants (e.g., respiratory issues, ICU stays, infection) and their mothers (e.g., blood clots, hemorrhage). Though it’s a life-saving procedure in some circumstances, studies have found that C-sections are often a result of factors outside of necessity, such as misaligned payer incentives and even scheduling conflicts. Disparities also exist in the rates of unnecessary C-sections among Black and Asian women.
California is doing fairly well compared to others in taking bold steps to reduce C-section rates. However, sustaining momentum requires a team-based approach, which includes lawmakers. Hospital leaders and policymakers in California must engage in efforts to help improve the lives of California’s moms, including:
Publicizing (and benchmarking!) timely data. The Joint Commission is now publicly reporting hospital performance on C-section birth rates. This comes on the heels of the U.S. Department of Health and Human Services’ recent action plan to improve maternal health, including reducing C-section rates by 25% in five years. By taking advantage of increasing data transparency requirements, hospitals can establish benchmarks to address high rates within their own settings. Many hospitals and hospital systems are currently working towards unblinding C-section rates among their departments, allowing site-specific quality improvement teams to champion lower rates and guide those with higher rates towards successful care models. Discussing individual C-section rates at a department level can help create peer pressure and friendly competition to move the needle. Quality improvement programs for C-section reduction can differ dramatically between hospitals, so solutions will need to be tailored and tracked according to the unique needs of each setting.
Rethinking care teams. Physician shortages continue to be an issue across the country, and OB/GYN is no exception. When it comes to reducing C-section rates, the provider is highly impactful in the final decision. Ensuring that care teams include providers trained in C-section reduction best practices can make a huge difference in outcomes. For example, physicians at the Ob Hospitalist Group (OBHG) team up with hospitals throughout the country to ensure all patients have an OB physician during their labor and delivery, and work closely to implement quality measures in line with American College of Obstetricians and Gynecologists (ACOG) best practices within the hospital. Because of these efforts, nearly half of OBHG’s current California hospital partners were among those recently recognized by the California Maternal Quality Care Collaborative (CMQCC) for their maternal quality and engagement efforts, including achieving an average C-section rate for deliveries of 20.9% (well below the target for CMQCC). Additionally, reimagining the patient as a key component of the care team can be a game changer when it comes to improving maternal health.
Encouraging financial incentives that align with better maternal health. Policymakers and payers can create incentives for evidence-based interventions that can effectively reduce unnecessary C-sections. This includes continuing to invest in and expand existing review committees that collect and analyze data on maternal mortality rates, such as CMQCC, and exploring financial rewards for better outcomes, such as adopting value-based payment models for maternity care. Integrating incentives to encourage National Quality Forum-endorsed quality measures on C-sections into insurance requirements could also discourage high rates.
The success we’ve achieved thus far in California is encouraging, but there’s plenty more to be done. By encouraging more hospitals to take advantage of evidence-based resources and educating policymakers on investments that support value-based, high-quality care, California can reduce unnecessary C-section rates and foster a culture of patient-centered and equitable maternal care.
Dr. Amy VanBlaricom is the Ob Hospitalist Group Vice President, Clinical Operations for the West Coast, including California.