Preventing the First Cesarean Robyn Lamar, MD, MPH Assistant - PowerPoint PPT Presentation

10/18/2018 Disclosures: none, but a debt of gratitude . . . Preventing the First Cesarean Robyn Lamar, MD, MPH Assistant Professor of OB GYN, UCSF Outline Why It Matters ● Why it matters ● Cesareans can be lifesaving ● Epidemiology interventions for women and ● Drivers of primary cesarean rate neonates ● Strategies for improvement ● Data strongly suggest they are ○ Intrapartum management: NICHD paper currently overused in the US & ○ Structural change: CMQCC toolkits many other middle & high income ● Case Studies--hospital-level interventions countries ○ PBGH southern California case study ● Maternal morbidity & mortality are ○ Beth Israel experience higher with cesarean delivery than ● Conclusions & thoughts for another couple talks vaginal delivery, and these risks diverge further with each subsequent birth 1

10/18/2018 Importance of the First Birth If a woman has a Cesarean birth in the first labor, over 90% of ALL subsequent births will be Cesarean births A classic example of path dependency If a woman has a vaginal birth in the first labor, over 90% of ALL subsequent births will be vaginal births Transforming Maternity Care Transforming Maternity Care 5 A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans What’s the right number? What’s the right number? World Health Organization (WHO): JAMA 2015: ● 1985: “no justification for any region to have a rate higher than 10-15%” ● Cross sectional, ecologic study, 2005-2012, all 194 WHO member states ● 2014: Systematic review, and ecologic (longitudinal) studies: ● Outcome/measures: relationship between population level cesarean rate and ○ “A substantial part of the crude association between caesarean section rate and mortality maternal and neonatal mortality appears to be explained by socioeconomic factors” ● Maternal mortality: steepest drop as cesarean rate increased to 7.2%; ○ “However, below a caesarean section rate of 10%, maternal and neonatal mortality decreased continued but slower drop to 19.1% ; no correlation beyond this point when caesarean section rates increased.” ● Neonatal mortality: drop as cesarean rate increased to 19.4% WHO statement on caesarean section rates, April, 2015. Molina G, et al. Relationship Between Cesarean Delivery Rate and Maternal and Neonatal Mortality. http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/cs-statement/en/ JAMA. 2015 Dec 1;314(21):2263-70. 2

10/18/2018 What’s the right number? Health People 2020 Goal: “ Reduce cesarean births among low-risk* women with no prior cesarean births” ● 2007 Baseline: 26.5% ● Target: 23.9% Target-Setting Method: 10% improvement https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health/objectives What’s a low-risk primary cesarean? Why focus on NTSV? ● Population that is the largest contributor to the rise in cesarean rates Nulliparous ● Is significantly risk-stratified, facilitating comparisons between providers & hospitals Term ● “NTSV is special in that it technically represents the most favorable conditions for vaginal birth, but also the most difficult labor management”--CMQCC ● Key feature in national & regional health campaigns Singleton ○ Healthy People 2020: Goal for NTSV 23.9% Vertex https://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi- topics/Maternal-Infant-and-Child-Health/data 3

10/18/2018 https://www.iha.org/our-work/insights/smart-care-california/focus-area-c-sections Accessed from http://calhospitalcompare.org/ on 10/1/2018 Epidemiology: What’s the trend over time? "Starting in less than two years, if the hospitals haven't met certain designated targets for safety and quality, they'll risk being excluded from the "in-network" designation of health plans sold on the state's insurance exchange. "We're saying 'time's up,' " says Dr. Lance Lang, the chief medical officer for Covered California. "We've told health plans that by the end of 2019, we want networks to only include hospitals that have achieved that target. Osterman MJ, Martin JA. Trends in low-risk cesarean delivery in the United https://www.npr.org/sections/health-shots/2018/05/23/611975420/californias-message-to- States, 1990-2013. Natl Vital Stat Rep. 2014 Nov 5;63(6):1-16. hospitals-shape-up-or-lose-in-network-status 4

10/18/2018 Epidemiology: International Comparisons Epidemiology: US State Comparisons The US is at the upper end for high income countries What Explains the Variation? High-risk hospitals? Patient demographics? IVF-driven multiples? Non-medically indicated cesareans? 5

10/18/2018 Declercq E, MacDorman M, Osterman M, Belanoff C, Iverson R. Prepregnancy Obesity and Primary Cesareans among Otherwise Low-Risk Mothers in 38 U.S. States in 2012. Birth. 2015 Dec;42(4):309-18. What explains the variation? ● Age & BMI both clearly impact individual risk ● However, neither plays much role at all in explaining hospital variation ● Why? At least in California: ○ Hospital populations tend to either be older & thinner OR younger & heavier ○ CMQCC provides adjusted NTSV CS rate at the hospital level, showing: ■ Adjusted rates vary ≦ 2% points in most. ■ Only 6/251 hospitals moved >23.9% to below, and they were all <26% to start. ■ “In addition, both age and BMI effects vary greatly from hospital to hospital (and even physician to physician) suggesting that there is an important part of the risk that is provider driven rather than inherent in the patient factor” Source: https://www.cmqcc.org/VBirthToolkit Data: https://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_06.pdf 6

10/18/2018 What Indications Have Driven the RISE in CS? Percent of the Increase in Primary Cesarean Rate Attributable to this Indication Cesarean Indication Kaiser SoCal (1991 v. 2008) Yale (2003 v. 2009) (Primary: 12.5% to 20%) (Total: 26% to 36.5%) Focus: all primary Focus: all primary Cesareans singleton Cesareans Labor progress complications 28% ~38% 60%! (CPD/FTP) Fetal Intolerance of Labor 32% ~24% Breech/Malpresentation <1% <1% Multiple Gestation 16% Not available 20% Various Obstetric and Medical Conditions (Placenta 6% (Did not separate preeclampsia from other Abnormalities, Hypertension, Herpes, etc.) complications) Preeclampsia 10% 18% “Elective” (variously defined) 8% (Those “without a charted indication”) (Scheduled without “medical Transforming Maternity Care Transforming Maternity Care indication”) 26 A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans Reducing Unnecessary Cesareans What Indications Drive the VARIATION in CS? ● By whatever measure you use, our national cesarean rate is higher than is Proportion of Proportion of CS Rate for this CS Indication Overall CS Rate Primary CS Rate Indication useful for women or neonates ● Within the US, tremendous variation exists Repeat (prior) 30-35% --- 90+% ○ Regionally “Abnormal Labor” 25-30% 35-45% Highly variable ○ By state ○ By hospital (CPD/FTP) 60%! ○ Within hospital, by provider Fetal Intolerance of 10-15% 15-20% Highly variable ● Variation = opportunity labor Breech/Transverse 10% 15-20% 98% Multiple Gestation 5-9% 10-15% 60-80% Other: Placenta Previa, ~5% ~10% 90% Herpes, etc Transforming Maternity Care Transforming Maternity Care 27 A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans 7

10/18/2018 Safe Prevention of the Primary Cesarean Delivery Addresses most common indications for primary cesarean delivery 1. Labor dystocia 2. Abnormal or indeterminate (formerly, nonreassuring) fetal heart rate tracing 3. Fetal malpresentation 4. Multiple gestation 5. Suspected fetal macrosomia Outlines a set of evidence-based guidelines for management of each issue, and creates standard criteria for diagnosis of labor dystocia ACOG, SMFM, Caughey AB, Cahill AG, Guise JM, Rouse DJ. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol. 2014 Mar;210(3):179-93. Safe Prevention: Labor Dystocia 1st stage ● Prolonged latent phase ≠ indication for cesarean ● Slow but progressive labor ≠ indication for cesarean ● “6 is the new 4” for active labor diagnosis ● Standard definition Toolkit is aligned with & draws heavily from: ● Safe Reduction of Primary Cesarean Births Bundle (published in 2015 by the Alliance for Innovation on Maternal Health) ● Obstetric Care Consensus on Safe Prevention of the Primary Cesarean Delivery published in 2014 by ACOG & SMFM ACOG, SMFM, Caughey AB, Cahill AG, Guise JM, Rouse DJ. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol. 2014 Mar;210(3):179-93. 8