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High Primary Cesarean Section Rates: Strategies for Improvement

Published:August 05, 2022DOI:https://doi.org/10.1016/j.jcjq.2022.07.005
      Approximately one in three women giving birth in the United States will undergo cesarean delivery.
      • Gregory KD
      • et al.
      Cesarean versus vaginal delivery: whose risks? Whose benefits?.
      Certain high-risk pregnancy conditions, such as placenta previa, may warrant a cesarean delivery, but most low-risk pregnancies are candidates for a vaginal birth. Low risk can be defined as nulliparous, term, singleton, and vertex (NTSV).
      As of 2020, the Centers for Disease Control and Prevention (CDC) ranked Florida, Mississippi, and Louisiana as the three states with the highest overall cesarean delivery rate, at 35.9%, 38.2%, and 36.8%, respectively.

      Centers for Disease Control and Prevention, National Center for Health Statistics. Cesarean Delivery Rate by State, 2022. Updated: Feb 25, 2022. Accessed Aug 21, 2022. https://www.cdc.gov/nchs/pressroom/sosmap/cesarean_births/cesareans.htm.

      (See Figure 1.) According to the Maternal Safety Foundation, Florida's 2017 NTSV cesarean section rate was 31%, the highest in the nation.

      Maternal Safety Foundation, CesareanRates.org. State Dashboards: Florida. 2020. Accessed Aug 10, 2021. https://www.cesareanrates.org/florida.

      Figure 1
      Figure 1This map shows the percentage of live births by cesarean delivery across the United States in 2020.
      Rising health care costs, increasing placenta accreta spectrum cases, factors affecting breastfeeding and bonding, and the current opioid use crisis all indicate a need to address these high rates. Compared to a vaginal delivery, cesarean delivery poses greater maternal and neonatal risks. These include a higher risk of maternal mortality, hemorrhage, infection, thromboembolism, amniotic fluid embolism, neonatal respiratory distress syndrome, and other long-term sequalae such as chronic pelvic pain and abnormal placentation.
      American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine. Safe prevention of the primary cesarean delivery.
      This commentary will provide an update on evidence-based approaches to lowering cesarean rates among NTSV births. It will also discuss the influence of provider and hospital unit culture, as well as the potential application of perinatal collaborative best practices across state lines. The goal is to provide recommendations to help lower NTSV cesarean births.

      Quality Analysis

      We conducted a quality analysis of NTSV cesarean births using a process map and fishbone diagram. Successful state interventions to lower cesarean births were also reviewed. Figure 2 is a process map showing the pathway a patient may take from preconception to primary cesarean section. This process map allows for identification of potential target areas to decrease unnecessary cesarean sections in low-risk women; it highlights the many pathways that may lead to a primary cesarean section.
      American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine. Safe prevention of the primary cesarean delivery.
      ,
      External cephalic version: ACOG Practice Bulletin, Number 221.
      Figure 2
      Figure 2This process map shows the pathway a patient may take from preconception to primary cesarean section (CS). An oval represents a start or end point. A rectangle represents a process. A diamond shape represents a decision point. Arrows show the flow and connection between shapes. IUPC, intrauterine pressure catheter.
      Figure 3 is a fishbone diagram indicating possible causes of a primary cesarean section. Certain overlapping themes prevail, including a lack of accountability for quality outcomes and a highly litigious specialty that has led to a fear of malpractice. A cultural shift toward improved patient outcomes, including incentives for low NTSV cesarean section rates, are necessary steps to achieve value-based care.
      • Rouse W
      • Cortese D
      Engineering the System of Healthcare Delivery.
      Figure 3
      Figure 3This fishbone diagram shows contributors to high primary cesarean section (CS) rates. L&D, labor and delivery; OB, obstetrics.

      Results

      From this analysis, several internal and external factors were identified as contributors to NTSV cesarean births. See Figure 4.
      Figure 4
      Figure 4This graph shows internal and external factors influencing cesarean section rates among NTSV (nulliparous, term, singleton, and vertex) births.

      External Factors

      External contributors to NTSV births include payers, the medical-legal domain, and government institutions. The payer and regulatory body contributing factors include higher payment for cesarean section, a lack of focus on quality of care, and poor tracking and reporting of NTSV cesarean rates. These higher payments for cesarean delivery may have an influence on provider decisions.
      • DeJoy SA
      • et al.
      Estimating the financial impact of reducing primary cesareans.
      External pressures from the medical-legal domain also need to be considered. When faced with a nonreassuring fetal heart tracing, obstetricians may choose cesarean delivery over intrauterine resuscitation due to fear of potential litigation. In fact, malpractice premiums have been positively correlated with cesarean delivery rates.
      • Yang YT
      • et al.
      Relationship between malpractice litigation pressure and rates of cesarean section and vaginal birth after cesarean section.
      Studies have also shown that providers involved in litigation are less likely to have clinical patience and practice defensive obstetrics when it comes to labor dystocia and fetal heart tracing abnormalities.

      Internal Factors

      Internal contributors to NTSV births include providers, patients, and hospital unit culture.

      Providers

      Providers play a substantial role in primary cesarean sections among low-risk women, as evidenced by the process map (Figure 2) and fishbone diagram (Figure 3). Choosing a provider with a high vaginal delivery rate could ultimately lower a patient's chance of having a primary cesarean delivery. The 15-fold variation in primary cesarean sections among low-risk women indicates provider management is a contributing factor.
      American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine. Safe prevention of the primary cesarean delivery.
      There are various decision points (see Figure 2) where the provider ultimately decides whether labor should be continued, one of the most significant being the management of nonreassuring fetal heart rate tracing. The patient is also counseled at these points; however, shared decision-making, particularly among uninsured, vulnerable, and less educated patients, may be unlikely.
      • Attanasio LB
      • Kozhimannil KB
      • Kjerulff KH.
      Factors influencing women's perceptions of shared decision making during labor and delivery: results from a large-scale cohort study of first childbirth.
      The most common indications for primary cesarean section are also depicted in Figure 2, including abnormal progress of labor, nonreassuring fetal heart rate tracing, and malpresentation.
      American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine. Safe prevention of the primary cesarean delivery.
      Each of these conditions is managed by the provider and is subject to variation. Universal application of active management of labor principles has yet to be implemented. Obstetricians may see labor management recommendations as a strike to physician autonomy and may be resistant to change.
      Health Catalyst
      Using Clinical Metrics the Right Way: 5 Considerations Every Hospital Should Know.
      Other factors to consider include fear of malpractice, poor communication with staff, lack of shared decision-making, convenience, financial gain, and lack of accountability.

      Patients

      Patient preference for cesarean delivery is another cultural factor that needs to be addressed, although it accounts for only a small percentage of NTSV births.
      ACOG Committee Opinion No. 761: Cesarean delivery on maternal request.
      Patients ultimately want to give birth to a healthy child, so their decision-making and preferences at the time of delivery are easily influenced by medical paternalism. Other patient considerations include inadequate prenatal care, anxiety for vaginal birth, misconceptions, and individual risk factors.

      Hospital Unit Culture

      The hospital culture and labor unit also contribute to NTSV cesarean births. Among hospitals, a difference in caesarean rates as great as 10-fold has been observed, with a 15-fold variation among low-risk women.
      American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine. Safe prevention of the primary cesarean delivery.
      Contributing factors include staffing models, culture, lack of quality focus, and inadequate nursing support. Poor hospital tracking and recording of provider cesarean section rates also contributes to the problem, as it fails to give insight into adherence to obstetric guidelines.
      • Kozhimannil KB
      • Law MR
      • Virnig BA.
      Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues.
      Providers may not report the appropriate Current Procedural Terminology (CPT) or ICD-10 code. As a result, this may lead to underreporting of NTSV cesarean births.
      • Sebastião YV
      • et al.
      Hospital variation in cesarean delivery rates: contribution of individual and hospital factors in Florida.
      Research on implementation of labor management guidelines by hospital administration is also lacking. Such research could help us better understand the preferences, practice patterns, and cultural differences of hospitals with high NTSV cesarean births.
      • Sebastião YV
      • et al.
      Hospital variation in cesarean delivery rates: contribution of individual and hospital factors in Florida.

      Proposed Recommendations

      To decrease provider variation, a multifaceted systems approach is needed to address the following areas: standardization of labor management, improvement of accountability, encouraging shared decision-making, and advocating for incentives for quality outcomes (Table 1). The following sections will focus on improvement strategies as well as evidence-based strategies.
      Table 1Proposed Recommendations to Lower NTSV Cesarean Section Rates and Associated Level of Evidence
      Target AreasRecommendationsResponsible PartiesLevel of Evidence
      Level II-2 recommendations are from cohort or case-control studies from more than one center, level II-3 is evidence from time series or uncontrolled studies, and level III evidence is based on expert opinion. NTSV, nulliparous, term, singleton, and vertex; ACOG, American College of Obstetricians and Gynecologists.
      Provider AccountabilityIncrease transparency, public reporting of cesarean section rates.
      Florida Department of Health
      AHCA and FDOH Recognize 19 Hospitals in Florida for Achieving the Healthy People 2020 Low-Risk, Primary C-Section Goal.


      Notify physician of individual cesarean section rates.

      Track outcomes for comparison among providers.

      Harvard Business Review. The Strategy That Will Fix Health Care. Porter ME, Lee TH. Oct 2013. Accessed Aug 10, 2022. https://hbr.org/2013/10/the-strategy-that-will-fix-health-care.



      Create an action plan to address high rates.
      Public health department, regulatory health sector, policy makers, hospitals, providers, payers, information technologyIII
      Patient-Centered CareAddress patient concerns and fears.
      ACOG Committee Opinion No. 761: Cesarean delivery on maternal request.


      Provide labor support, doulas.
      • Kozhimannil KB
      • et al.
      Modeling the cost-effectiveness of doula care associated with reductions in preterm birth and cesarean delivery.


      Dispel any misconceptions.

      Improve shared decision-making at time of labor.
      • Attanasio LB
      • Kozhimannil KB
      • Kjerulff KH.
      Factors influencing women's perceptions of shared decision making during labor and delivery: results from a large-scale cohort study of first childbirth.
      Physicians, nurses, allied health professionals, midwives, social workers, care managers, doulas, hospitals, patients, mediaII-3
      Health System CollaborationCollaborate with peers to improve outcomes.

      Implement peer review process.

      Provide feedback based on performance.
      • Kozhimannil KB
      • Law MR
      • Virnig BA.
      Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues.


      Require mandatory second opinion prior to cesarean.
      • Chaillet N
      • Dumont A.
      Evidence-based strategies for reducing cesarean section rates: a meta-analysis.


      Acquire nursing support.
      Interdisciplinary health care team (providers, quality improvement task force, nurses), hospitals, payers, regulatory health sectorII-3
      Incentives for Quality CareProvide incentives for reaching target cesarean section rates.

      Use blended or bundled payments.
      • Main EK
      • et al.
      Creating a public agenda for maternity safety and quality in cesarean delivery.


      Implement value-based payment for quality outcomes.
      • McClellan M
      • et al.
      Accountable care around the world: a framework to guide reform strategies.


      Promote a culture of patient safety.
      Payers, regulatory health sector, policy makers, hospitalsIII
      Education and StandardizationEnroll in continuing medical education on labor management.

      Reinforce ACOG guidelines on how to reduce primary cesarean sections.
      American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine. Safe prevention of the primary cesarean delivery.


      Enroll in state and hospital quality initiatives to promote vaginal delivery.
      USF Health, University of South Florida Health
      Florida Perinatal Quality Collaborative: Promoting Primary Vaginal Deliveries.
      ,

      California Maternal Quality Care Collaborative. Supporting Vaginal Birth. Accessed Aug 10, 2022. https://www.cmqcc.org/content/supporting-vaginal-birth.

      ,
      • Callaghan-Koru JA
      • et al.
      Implementation of the Safe Reduction of Primary Cesarean Births safety bundle during the first year of a statewide collaborative in Maryland.
      ,

      Alliance for Innovation on Maternal Health. Safe Reduction of Primary Cesarean Birth. 2021. Accessed Aug 10, 2022. https://saferbirth.org/psbs/safe-reduction-of-primary-cesarean-birth/.

      Quality improvement task force, public health department, medical board, hospitals, media, providersII-2
      low asterisk Level II-2 recommendations are from cohort or case-control studies from more than one center, level II-3 is evidence from time series or uncontrolled studies, and level III evidence is based on expert opinion.NTSV, nulliparous, term, singleton, and vertex; ACOG, American College of Obstetricians and Gynecologists.

      External Factors

      One proposed recommendation for payers and regulatory agencies is for providers to receive an incentive for having low NTSV cesarean section rates. For example, providers meeting the Healthy People 2030 primary cesarean section goal of 23.6% could receive a financial bonus from payers. Provider reimbursement can also be based on reaching target outcomes.
      • McClellan M
      • et al.
      Accountable care around the world: a framework to guide reform strategies.
      To address the higher financial rewards for performing a cesarean section, a blended or bundled payment could also be implemented. Here, providers would receive a standard blended payment for either vaginal or cesarean delivery.
      • Main EK
      • et al.
      Creating a public agenda for maternity safety and quality in cesarean delivery.
      With this system, providers can focus on providing efficient and high-quality care. A focus on value-based payment will motivate providers to decrease unnecessary cesarean sections.
      Increasing the visibility of provider and hospital cesarean section rates will improve accountability.
      • DeJoy SA
      • et al.
      Estimating the financial impact of reducing primary cesareans.
      With these data, patients will be able to make informed choices. Several data sources are available, including the Leapfrog Group, which publishes hospital maternal primary cesarean section rates online. Using this data source, one can compare hospitals and detect geographic variation. For example, in Florida the cesarean section rate among hospitals ranges from 26% to 56%.
      Leapfrog Group
      Search Leapfrog's Hospital and Surgical Center Ratings.
      Regulatory agencies and local health departments such as the Agency for Health Care Administration (AHCA) and the Florida Department of Health have also used data to promote and recognize high-performing hospitals. As of 2019, AHCA reported that only 19 of 114 Florida delivery hospitals were at or below the Healthy People 2020 primary cesarean section goal of 23.9%.
      Florida Department of Health
      AHCA and FDOH Recognize 19 Hospitals in Florida for Achieving the Healthy People 2020 Low-Risk, Primary C-Section Goal.
      Greater transparency and public reporting of provider primary cesarean section rates may pressure providers to improve outcomes. It has been shown that tracking quality outcomes and comparing performance to that of peers leads to improvement.

      Harvard Business Review. The Strategy That Will Fix Health Care. Porter ME, Lee TH. Oct 2013. Accessed Aug 10, 2022. https://hbr.org/2013/10/the-strategy-that-will-fix-health-care.

      For that reason, increased access and public reporting of provider NTSV cesarean section rates by local health departments and regulatory bodies will be needed.
      Florida Department of Health
      AHCA and FDOH Recognize 19 Hospitals in Florida for Achieving the Healthy People 2020 Low-Risk, Primary C-Section Goal.
      Additional important external considerations are medical-legal reform and greater liability coverage.

      Internal Factors

      Internally, several strategies are needed to address provider, patient, and hospital culture.

      Providers

      With the rise in primary cesarean sections, greater provider accountability is needed. To achieve this, providers with the highest NTSV cesarean section rates can be identified and enrolled in tracking and reporting databases with comparison to similar peers. The goal would be to increase accountability and to motivate providers to improve quality outcomes. Providers would be encouraged to develop action plans to lower their high NTSV section rates. Although resistance may be encountered by these providers, a shift away from complete physician autonomy is needed.
      Health Catalyst
      Using Clinical Metrics the Right Way: 5 Considerations Every Hospital Should Know.
      ,
      National Academy of Engineering; Institute of Medicine
      Building a Better Delivery System: A New Engineering/Health Care Partnership.
      Another strategy to decrease NTSV cesarean sections is to provide education on labor management. Providers with the highest rates could enroll in continuing medical education (CME) on active management of labor and fetal monitoring. Figure 5 includes American College of Obstetricians and Gynecologists (ACOG) labor management recommendations that can be given to providers for the safe prevention of a primary cesarean section.
      American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine. Safe prevention of the primary cesarean delivery.
      Providers can also enroll in state initiatives, such as the Florida Perinatal Quality Collaborative
      USF Health, University of South Florida Health
      Florida Perinatal Quality Collaborative: Promoting Primary Vaginal Deliveries.
      and the California Maternal Quality Care Collaborative (CMQCC),

      California Maternal Quality Care Collaborative. Supporting Vaginal Birth. Accessed Aug 10, 2022. https://www.cmqcc.org/content/supporting-vaginal-birth.

      where they can receive periodic education and support on how to promote vaginal delivery.
      Figure 5
      Figure 5If maternal and fetal status permit, these labor management strategies are suggested. (Recommendations from American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol. 2014;210:179–193.)

      Patients

      Interventions to decrease unnecessary cesarean sections may be implemented as early as the preconception period (see Figure 2). Patients can be counseled that, in the absence of maternal or fetal indications, vaginal delivery is a safe option.
      ACOG Committee Opinion No. 761: Cesarean delivery on maternal request.
      Providers should specifically address any patient concerns and fears early on; misconceptions should be dispelled and emotional support should be provided throughout antenatal care.
      ACOG Committee Opinion No. 761: Cesarean delivery on maternal request.
      Improving shared decision-making, particularly while the patient is in labor, is also likely to lower primary cesarean section rates.
      • Attanasio LB
      • Kozhimannil KB
      • Kjerulff KH.
      Factors influencing women's perceptions of shared decision making during labor and delivery: results from a large-scale cohort study of first childbirth.
      All too often, patients are left out of the decision-making process. In fact, 27% of patients have reported not receiving their test results, and 47% have reported issues with care coordination.
      • Stremikis K
      • Schoen C
      • Fryer AK.
      A call for change: the 2011 Commonwealth Fund Survey of Public Views of the U.S. Health System.

      Hospital System

      Integrated health systems, with a shared vision of improved maternal outcomes and decreased unnecessary cesarean births, is another potential solution. Within these integrated teams, evidence-based obstetric principles and the active management of labor will likely lead to decreased provider variation.
      • Rouse W
      • Cortese D
      Engineering the System of Healthcare Delivery.
      Toolkits and nursing education on labor management may help improve vaginal delivery rates.
      • Amis D.
      The role of the childbirth educator in supporting vaginal birth and reducing primary cesareans: highlights from the California Maternal Quality Care Collaborative Toolkit.
      Rather than working independently, providers with the highest NTSV cesarean section rates should be encouraged to work with their colleagues—including team huddles, conferences, and peer-to-peer discussions—to improve outcomes. Working collaboratively with peers is likely to lead to higher-quality care and lower costs. Another effective strategy to lower cesarean section rates is to provide obstetricians with feedback based on their performance and practice,
      • Kozhimannil KB
      • Law MR
      • Virnig BA.
      Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues.
      which may also include a mandatory second opinion before cesarean section, if feasible.
      • Chaillet N
      • Dumont A.
      Evidence-based strategies for reducing cesarean section rates: a meta-analysis.
      This strategy will hold providers accountable to ACOG labor management guidelines and likely decrease variation.
      Providers may be accustomed to physician autonomy and may be resistant to change. To address this barrier, trust and rapport must be gained.

      Commonwealth Fund. Hill Physicians Medical Group: Independent Physicians Working to Improve Quality and Reduce Costs. Emswiler T, Nichols LM. Case Study. Mar 2009. Accessed Aug 10, 2022. https://collections.nlm.nih.gov/pdfdownload/nlm:nlmuid-101547641-pdf.

      This could involve meetings to understand providers’ practice patterns and concerns.

      Other Evidence-Based Strategies

      Several evidence-based state interventions have successfully lowered primary cesarean rates among low-risk women. Although no randomized controlled trials have been published to assess the effectiveness of these programs, several observational studies have shown promising results. Statewide approaches have been successful in California, Maryland, and Colorado.
      In California, hospital and statewide policy initiatives have managed to lower cesarean section delivery rates among NTSV births. The CMQCC used tailored educational mentorship, real-time performance metrics for comparison, and monthly team education as improvement strategies; 149 hospitals with cesarean section rates higher than 23.9% were enrolled.
      • Rosenstein MG
      • et al.
      Hospital quality improvement interventions, statewide policy initiatives, and rates of cesarean delivery for nulliparous, term, singleton, vertex births in California.
      Through the use of provider education, labor support, and labor management standardization, as supported by the CMQCC's Toolkit to Support Vaginal Birth and Reduce Primary Cesareans, cesarean section rates decreased from 26.0% to 22.8% between 2014 and 2019. This multifaced program also focused on external stakeholders, achieving buy-in from payers and government agencies. This support was evidenced through the state agency publishing data on high-performing hospitals and health plans incentivizing participation in the collaborative.
      The CMQCC toolkit is one feature unique to this program. Clinical recommendations within the toolkit include bedside emotional labor support from nurses, assistance from doulas, shared patient decision-making, and intermittent fetal monitoring for low-risk women.

      California Maternal Quality Care Collaborative. Toolkit to Support Vaginal Birth and Reduce Primary Cesareans: A Quality Improvement Toolkit. Smith H, et al., editors. 2016. Accessed Aug 10, 2022. https://www.cmqcc.org/VBirthToolkit.

      The use of labor support and coping as well as doulas has been shown to decrease cesarean rates and shorten the duration of labor. In fact, women who receive doula care are less likely to have preterm birth and cesarean sections.
      • Kozhimannil KB
      • et al.
      Modeling the cost-effectiveness of doula care associated with reductions in preterm birth and cesarean delivery.
      The toolkit also promotes the standardization of labor management to decrease variation and encourages clinical patience when medically appropriate. This includes having standard policies for induction of labor, hospital admission, and responses to abnormal fetal heart tracings and labor dystocia.

      California Maternal Quality Care Collaborative. Toolkit to Support Vaginal Birth and Reduce Primary Cesareans: A Quality Improvement Toolkit. Smith H, et al., editors. 2016. Accessed Aug 10, 2022. https://www.cmqcc.org/VBirthToolkit.

      The CMQCC toolkit was also aligned with the Alliance for Innovation on Maternal Health's (AIM) bundle—a model that was also implemented by the state of Maryland. Some key features of this bundle are provider education, a culture that supports vaginal delivery, having obstetricians readily accessible through a laborist model, standardization of care, and data reporting of cesarean section rates for comparison among similar hospitals.
      • Callaghan-Koru JA
      • et al.
      Implementation of the Safe Reduction of Primary Cesarean Births safety bundle during the first year of a statewide collaborative in Maryland.
      ,

      Alliance for Innovation on Maternal Health. Safe Reduction of Primary Cesarean Birth. 2021. Accessed Aug 10, 2022. https://saferbirth.org/psbs/safe-reduction-of-primary-cesarean-birth/.

      Using the tenets of the AIM bundle, hospitals from several states (including Colorado, California, Florida, and Maryland) were able to lower their NTSV cesarean section rates. The NTSV cesarean birth rate decreased by 5.3% in 31 Maryland hospitals that used this bundle.

      Alliance for Innovation on Maternal Health. Safe Reduction of Primary Cesarean Birth. 2021. Accessed Aug 10, 2022. https://saferbirth.org/psbs/safe-reduction-of-primary-cesarean-birth/.

      These proven evidence-based approaches may serve as a guide for other institutions. Futures studies will be needed to show the generalizability of these toolkits. As noted in the CMQCC toolkit and AIM bundle, a labor floor culture that promotes vaginal delivery is a key feature of lowering primary cesarean sections among low-risk women. Hospital and provider attitudes toward cesarean section play a significant role in variability and cesarean section rates. Providers with low NTSV cesarean section rates tend to have more positive attitudes toward vaginal birth, while those with more favorable cesarean section views tend to have higher NTSV cesarean section rates.
      • White VanGompel E
      • et al.
      Do provider birth attitudes influence cesarean delivery rate: a cross-sectional study.
      For this reason, addressing perceived barriers to vaginal delivery within each provider's unique hospital environment, including malpractice concerns and providing labor management education, will be key to achieving quality improvement in the future.
      Finally, these improvement strategies will need to be monitored using Plan-Do-Study-Act (PDSA) cycles and statistical process control methods.
      • Rouse W
      • Cortese D
      Engineering the System of Healthcare Delivery.
      Postimplementation review will also be needed to ensure sustainability.

      Conclusion

      The high primary cesarean section rates across the nation indicate a dire need for quality improvement. Stakeholders from all health care sectors must engage in initiatives to lower unnecessary cesarean sections and improve maternal outcomes. Implementing statewide programs to decrease provider and hospital variation will be valuable in achieving this goal. Strategies may include CME on active management of labor, creating more obstetric hospitalist programs, peer review and feedback, and value-based reimbursement for quality outcomes. Findings of the ARRIVE trial also indicate a potential benefit of prophylactic induction of labor at 39 weeks to lower cesarean delivery rates.
      • Grobman WA
      • et al.
      Labor induction versus expectant management in low-risk nulliparous women.
      It will be essential to acquire nursing support for these initiatives, as well as to address hospital culture and malpractice fears. Finally, improving shared decision-making with patients and enhancing labor support will help lower the high primary cesarean section rates and place patients back at the center of care.

      Conflicts of Interest

      All authors report no conflicts of interest.

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