Strategies for lowering C-section rates

Efforts to reduce cesarean delivery rates in the United States seem to be gaining ground. But nearly a year after two medical societies released a national consensus statement on the safe prevention of certain C-sections, the strategies, as well as procedure rates, vary considerably among managed care organizations, other insurers and front-line providers. Some are focusing on educational initiatives for stakeholders, including mothers-to-be, while others are throwing payment reforms into the mix.

Broad consensus seems to boil down to this: Steps must be taken to lower C-section rates in the U.S., and strong outreach to ob/gyns is critical for success.

Some managed care organizations, while continuing to evolve C-section strategies, are encouraged by their progress to date on the complex issue. Kaiser Permanente, which handles about 90,000 deliveries annually across its regions, is working to achieve maternal health excellence and trying to identify opportunities for improvement, says Tracy Flanagan, M.D., director of women’s health and chair of the ob/gyn chiefs group for Kaiser Permanente Northern California.

“Our integrated care model is ideal for improving quality, safety and patient satisfaction in all areas of care delivery, including the reduction of unnecessary C-sections,” Flanagan says. “Once we establish a best practice, we can spread it throughout the organization quickly. We can also track progress on an individual, facility, regional and national level, which helps us identify areas of opportunity.”

In its hospitals, Kaiser Permanente’s average C-section rate is 24% for low-risk, first-time mothers (with a term, singleton baby in a headfirst position), Flanagan says. This primary C-section rate ranges from 10% to 29% among its hospitals, but almost all fall below 25%, she says.

Kaiser Permanente’s overall rate, including repeat C-sections, is only slightly higher, around 27%, “partly because we offer VBAC [vaginal birth after cesarean] more aggressively than almost any health system,” Flanagan says. Its VBAC rate is 22%, well above rates in California and nationally, she says.

By comparison, the national cesarean delivery rate increased by 60% from 1996 through 2009, up from 20.7% to 32.9%, according to federal data released in November, 2014. While the overall rate fell slightly by 2013, nearly one-third of U.S. births continue to be delivered 

by cesarean section.

Low-risk, primary cesarean delivery reached a low of 18.4% in 1997, federal data show. The rate climbed steadily to a high of 28.1% in 2009 before dropping slightly to 26.9% by 2013.

Citing strategies undertaken by Kaiser Permanente “that set us up for success,” Flanagan says almost all of the managed care organization hospitals have 24-hour-a-day, seven-day-a-week staffing in labor and delivery units, using nurses and, in many hospitals, certified nurse-midwives, to work with ob/gyns.

Thirteen of its 15 northern California hospitals now have midwives, Flanagan says, explaining that the idea is to set up a labor and delivery system that facilitates providing the right care at the right time.

Another strategy involves electronic fetal heartrate monitoring, which researchers say historically has been interpreted with wide variation by obstetric care teams, leading to inconsistent decision-making. In response to tracing interpretation. Kaiser Permanente launched a multidisciplinary electronic fetal monitoring training program for clinicians, using the best available evidence in an effort to help standardize interpretation, Flanagan says.

With category-II fetal heart rate trackings, for example, which are in the gray zone, Flanagan says it is “important to react correctly, and not overreact [by rushing into a C-section] or underreact” by waiting on a C-section if it is medically necessary.

Flanagan says Kaiser Permanente’s initiatives, including more use of midwives, help to meet patients’ needs and expectations.

NEXT: Focusing on C-sections in South Carolina

Focusing on C-sections in South Carolina

BlueCross BlueShield of South Carolina also is focusing on education, re-emphasizing practice guidelines and safe ways to manage births, says Laura Long, M.D., the South Carolina Blues’ chief medical officer and vice president of clinical innovation. The insurer is supporting a mobile lab that trains clinicians on how best to interpret fetal heart rates and a woman’s failure to progress during labor, and it is generating patient education materials on the pros and cons of C-sections.

Meanwhile, South Carolina Medicaid-which, together with the South Carolina Blues, delivers 84% of babies in the state-continues to lead a Birth Outcomes Initiative (BOI) aimed at reducing preterm births, neonatal intensive care unit (NICU) days and racial disparities. The state’s Medicaid program and Blues plan stopped paying for early, elective deliveries as of January 1, 2013, following months of outreach to providers.

As a result, the South Carolina Deptartment of Health and Human Services reports a 70% reduction in early elective deliveries statewide. That is expected to translate to a cost savings of $11.2 million from 2012 through 2018 to the state’s Medicaid program, which handles about 30,000 births annually.

The BOI’s second phase, aimed at reducing C-section rates, began in 2013. Each of the state’s 45 birthing hospitals signed a commitment letter and named two clinical champions for the effort, and the state began educational outreach to providers and patients. The state also began distributing quarterly reports to hospitals on their C-section rates.

“Just like with early elective deliveries, this has been a very collaborative effort with all stakeholders in the state, and that includes managed care....It’s not just about saving the state money. It’s about better health outcomes for moms and babies,” says Melanie Giese, director of the BOI for the South Carolina Department of Health and Human Services.

According to a study published in the December 2014 issue of Health Affairs, reducing early elective deliveries (non-medically indicated labor inductions or C-sections prior to 39 weeks’ gestation) has become a priority for Medicaid programs across the U.S. Noting that Medicaid pays for nearly half of U.S. births, researchers said that in the 22 states participating in the study, nearly 9% of births were early elective deliveries.

By contrast, only 3.8% of South Carolina Medicaid births were early elective deliveries (between 37 weeks and 39 weeks of gestation) by fourth-quarter 2013, according to the latest available state data.

South Carolina Medicaid has wanted to pay hospitals the same rate for C-sections that it pays for vaginal deliveries, and intends to implement a C-section payment change for hospitals by March 2015, Giese says. “We’re still trying to decide how to do it without penalizing hospitals with sicker moms and babies,” she says. “We’re waiting now for actuaries to give us the rate that we’ll apply to each individual hospital.

“Our Medicaid [C-section] rate is 34%, and we have a goal to reduce that to 32% in the coming year, with or without the payment change,” Giese says. She notes that 90% of Medicaid births in South Carolina are covered under one of six capitated managed care plans, and that plans generally follow suit when Medicaid makes a fee-for-service payment change.

“At some point I’m sure we’ll look at whether there are financial incentives we can align...but we’re not ready yet,” Long says. She explains that the insurer has a different arrangement with providers than does Medicaid, using global delivery payment rates regardless of whether babies are born by C-section or vaginally. “We feel for us the more important piece is education and sharing best practices” before evaluating payment changes, she says.

NEXT: Involving providers in the effort

Involving providers in the effort

Citing “skyrocketing” U.S. C-section rates, the Joint Commission began requiring mandatory reporting for its perinatal care measure set effective January 1, 2014 for hospitals with 1,100 or more births annually. Included is a measure defining improvement as a decrease in low-risk primary C-sections.

The com

mission cites a lack of data supporting the idea that higher C-section rates improve outcomes, and asserts that hospitals can employ “clear-cut quality improvement activities” to address wide variability in rates, such as focusing on first-birth labor induction rates and early-labor admission rates.

In March 2014, an obstetric-care statement issued jointly by the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) said the rapid increase in cesarean birth rates from 1996 to 2011, without clear evidence of corresponding decreases in maternal or neonatal morbidity or mortality, raises significant concern that cesarean delivery is being overused.

“If anything, we’ve only seen a rise in maternal death rates,” says Aaron B. Caughey, M.D., Ph.D., a co-author of the consensus statement. He says the document focused on first-time mothers because there is a greater than 90% chance of subsequent C-sections if a woman has a first one.

According to the ACOG/SMFM statement, data show that contemporary labor progresses at a much slower rate than what was historically taught, indicating clinicians might need to exercise more patience. Improved, standardized fetal heart-rate monitoring and continuous labor-and-delivery support may help reduce primary C-section rates, it says, along with tort reform and systemic approaches by organizations to effect culture change. Conceding there is too much practice variation, the authors assert some variation may be warranted due to such factors as patients’ needs and resource limitations.

According to Caughey, who is professor and chair of the department of obstetrics and gynecology for Oregon Health & Science University, hospitals would like C-section rates a bit lower because even though they result in longer hospital stays than vaginal births, payment isn’t much higher. In fact, he describes vaginal births as “a long haul...so you probably should get paid two times to three times more for a [vaginal] first delivery.” But even though the hospital and payers would benefit, he says, “clinicians are being pressured to practice in a certain way.”

Caughey stresses the need for strong clinician involvement. “You’ve got to start with a conversation,” he says. “We reviewed every C-section done, [and used physicians to champion the reduction effort]...and we saw our C-section rate go down from about 34% to 26% in about 18 months” from 2010-2011, and the rate is holding steady, he says. He notes that OHSU, as the only academic medical center in its region, “gets the sickest of the sick and the most fetal anomalies.”

“I think patients need to push clinicians, and clinicians need to talk among themselves to get culture change going,” Caughey says.

NEXT: Exploring financial approaches

Exploring financial approaches

Sometimes it is tough to get physicians to go along, says Stephen Barlow, M.D., an internist and chief medical officer for SelectHealth, a 720,000-member HMO in Utah and Idaho that is a wholly-owned subsidiary of Intermountain Healthcare. He says the organization saw early elective inductions as a main driver of increased C-section rates and worse outcomes, including more NICU admissions.

First Intermountain-by sharing data on best practices with its physicians, reporting peer procedure rates and relying on peer pressure -- reduced early elective inductions from about 30% of its 33,000 deliveries annually to about 5% across its 23 hospitals and several hundred ob/gyns, Barlow says. As a result, its C-section rates have been in the 20% to 21% range, he says.

Barlow describes less success with other strategies. From 2001 to 2004, SelectHealth decided to pay the same amount for C-sections as for vaginal deliveries, he says. “But after about three years,” he says, “I no longer had the support of ob/gyns in the community,” who felt it was more work to do C-sections, resulting in lower payments than doctors doing vaginal births by the luck of the draw.

In 2012 SelectHealth decided to focus on primary cesarean deliveries. Barlow worked with service-line directors, telling ob/gyns they would get pay-for-performance, with no downside risk, if their C-section rates for low-risk, first-time mothers fell below 17%. “We did it just one year, but the obstetricians said, ‘If we get sued and they say I had financial incentive not to do a C-section, I’m in trouble,’” he explains.

Currently, Intermountain uses pay-for-performance with its ob/gyns on patient satisfaction, mamography, chlamydia screening, and if they have no early elective inductions in the calendar year, Barlow says. “It’s my sense that reporting individually on C-section rates and early elective inductions to physicians over the last 10 to 12 years, and comparing them to their peers, has made a difference,” he says.

Judy Packer-Tursman is a journalist based in Washington, D.C. who has covered healthcare issues for nearly 30 years.