CMQCC’s New Vaginal Birth Toolkit

Interview with Christine Morton, PhD, on Strategies and Solutions for Lowering Hospital C-section Rates

A major part of the conversation surrounding rising maternal mortality rates in the United States focuses on cesarean sections. C-sections can be absolute lifesavers when vaginal birth isn’t a safe option, but obstetricians in American hospitals do too many of them and C-sections can contribute to serious health complications and even death for mothers and babies.

Pregnant women receive lots of advice for navigating the healthcare system and avoiding overused medical interventions that often accompany birth in America. But who’s advising their healthcare providers? Who’s helping doctors, midwives and labor nurses understand that changing their practices and decreasing C-section rates are essential for reducing maternal and newborn mortality (death) and morbidity (injury) in the U.S.? Who’s helping them navigate a healthcare system dominated by malpractice insurance and strict hospital mandates that demand they do everything possible for their patients, even if “everything” is way too much?

In California, the answer is the California Maternal Quality Care Coalition (CMQCC) a partnership of more than 40 public and private agencies, programs, professional groups, health systems, and universities whose mission is to end preventable morbidity, mortality and racial disparities in California maternity care. Christine Morton, PhD is a medical sociologist and researcher at CMQCC. She shared how CMQCC’s newest toolkit to support vaginal birth and reduce primary cesareans is helping hospitals and healthcare workers dial C-section rates down.

Every Mother Counts: Why does California need these tools?

Morton: We all know there’s been a tremendous rise in C-sections over the past couple of decades, but what many don’t know is that there’s a huge variation in C-section rates among different parts of the state, different hospitals and individual practices. Between 1998 and 2008 we went from doing 22% to 33% of births by C-section. That makes C-section the nation’s most common surgery. This toolkit helps California and other states achieve Healthy People 2020’s (a national health promotion, disease prevention initiative) goal to reduce C-sections among low-risk, first time pregnant women to 24% (known as NTSV CS). California has the largest population and most births of any state and we know that what’s happening here is happening all over the country.

Every Mother Counts: Who is this toolkit for?

Morton: It’s a free resource that anyone can download, but our target audience is healthcare professionals who work in hospitals and maternity settings including obstetricians, midwives, labor and delivery nurses and hospital managers. It specifically targets hospitals with NTSV C-section rates above 24%. We designed the toolkit, including the tools, strategies and information, to apply to any hospital, in any state.

Every Mother Counts: What do you hope the toolkit will do?

Morton: Our primary focus is to prevent first C-sections in the lowest risk group of women. We refer to these women with the acronym NTSV for Nullip (never given birth before), Term (37 weeks gestation or more), Singleton (having only one baby) and Vertex (baby is head down). Most of this target population of women should be able to give birth vaginally and our goal is to prevent them from having that first C-section. That will help them avoid subsequent C-sections with other pregnancies and complications associated with major surgery.

Every Mother Counts: Why focus on these mothers?

Morton: By focusing on the same low-risk population of women who are optimized to have a vaginal birth, we can standardize comparisons. If we only look at the TOTAL C-section rate, many hospitals say, “Yes our C-section rate is high but, we take care of sicker women and our patients are at higher risk, or older, or heavier than everybody else.” Some hospitals have rates as low as 10% and others are well over 70% but currently about 60% of California’s 250 hospitals are above 24%, the NTSV CS rate recommended by Healthy People 2020 (The Office of Disease Prevention and Health Promotion’s 10-year agenda for improving the Nation’s health). When you see that much variation in a medical specialty that includes a lot of technology and surgery, like obstetrics, you know the difference isn’t in the patients, but in the hospital or doctor’s practices and culture of care.

Every Mother Counts: What’s in the toolkit?

Morton: There’s so much information in there. We begin with strategies for improving the culture of care in maternity settings because currently there’s this casual acceptance among many providers and pregnant women that C-sections are safe and easy and there’s no pressing reason to do fewer. There’s also information about how to improve access to and quality of childbirth education for mothers and strategies for improving communication between doctors, nurses and other providers at critical points in patient care. We talk about ways to improve provider skills and ways for hospital leadership to provide more support. We also discuss tools for helping hospitals and providers shift away from payment models that reward using a high volume of healthcare interventions and provide incentives for doctors to perform C-sections and towards payment models that reward quality outcomes.

Every Mother Counts: Is this toolkit useful for pregnant women too?

Morton: Absolutely. The toolkit provides a great way for women and their support people to start conversations with their doctors and hospital, especially now that it’s being implemented across California, as well as available to any hospital in the country. Childbirth educators, doulas and local advocates can ask their hospitals if they know about the toolkit and if they’re making efforts to reduce their primary C-section rates. The more people who access these tools the better, though I worry that we put too much responsibility on mothers, doulas and other labor support people to implement the changes we need to see put in place. The problem is overwhelmingly caused by hospital and physician practices, as well as systemic issues like malpractice and payment policies. These tools offer real solutions to reduce first cesareans among low risk women.

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