Wednesday, August 12, 2009

Reducing C-Sections: Incentives and Precedents

The Washington State Legislature has just passed what I hope will be a landmark measure to reduce their state's cesarean section rate. Beginning this month, Medicaid will reimburse Washington hospitals the same amount for uncomplicated c-sections as for complicated vaginal births. Just as in Florida, about half of all births in Washington are paid by Medicaid. The impetus of this measure is to effectively remove the financial incentive to perform a c-section. The theory is that this will impact the economics of birth so drastically that there will be a directly correlated reduction in c-section rates.

Should Washington set a precedent for tremendous cost savings through a return to normal birth, I would certainly expect Florida to follow suit, and will be urging our representatives to take a close look at this initiative in the coming months.

Sarasota can reduce our c-section rates effectively, quickly, and without compromising outcomes. It has been done in hospitals elsewhere with dramatic results.

In January 1996, The 'First Births Project' began at the Children's and Women's Health Centre in Vancouver, British Columbia, as part of the hospital's Continuous Quality Improvement Program. The project's objective was to lower the c-section rate by 25% within six months of implementation, without sacrificing outcomes to mother or baby. To begin the project, the staff of the hospital agreed upon four factors that contributed to high c-section rates:

1: Early admittance to hospital (defined as prior to 4 cms dilation);
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: 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).

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 the British Columbia hospital. Guidelines and other strategies in all four target areas were implemented in the spring of 1997.

The results, published here, show that the cesarean section rate was reduced by 21%. The number of epidurals initiated before active labor was 64% lower, continuous fetal monitoring was used 14% less, the induction rate had dropped 22%, and admission at 'early' cervical dilation had dropped 21%. 'All changes were statistically significant. Newborn outcomes were unchanged post implementation.'

Other cases which I've sited on this blog show results of emergency c-section rates and NICU admissions being literally cut in half in a matter of months. The common thread in all of these initiatives is will, leadership, and commitment of the entire obstetric community.


  1. I totally agree. The cesarean rate is an important quality and safety measure, and it can be decreased signficantly without compromising newborn health. All that is needed is, like you said, the will of all involved in delivering maternity care, strong leadership, and vocal consumers.

    The cesarean rate in low-risk first-time mothers is a measure now adopted by the Joint Commission, the National Quality Forum, and Healthy People 2010.

    I'll be giving my webinar, Why Transparency Matters: Bringing Birth Out of the Dark to Improve Quality, next month for Lamaze. I'll let you know the registration information - it would be great if you could get some folks who are involved in your upcoming forum to sign up. These are the exact issues I'll be covering.

  2. Thank you so much Amy. I'd love to sign up and will spread the word.