Vertex Cesarean Delivery Research Articles

Evaluation of Statewide Program to Reduce Cesarean Deliveries Among Nulliparous Individuals With Singleton Pregnancies at Term Gestation in Vertex Presentation.

To evaluate the effect of statewide efforts to reduce nulliparous, term, singleton, vertex (NTSV) cesarean delivery rates in California. This was a population-based study of all NTSV births in California from 2015 to 2019. In 2015, all California hospitals with NTSV cesarean delivery rates above the 23.9% Healthy People 2020 target were invited to join a CMQCC (California Maternal Quality Care Collaborative)-sponsored, 3-year, multifaceted collaborative or a system-level quality collaborative to safely support vaginal birth. We examined the cesarean delivery rate overall and by participation or nonparticipation in a collaborative program. Secondarily, for hospitals that started with an NTSV cesarean delivery rate above 23.9%, we compared patient-level, hospital-level, and obstetric management characteristics between hospitals that met the Healthy People 2020 target (cesarean delivery rate below 23.9%) in 2019 and those that did not. There were 758,268 NTSV births at 238 hospitals. Annual mean NTSV cesarean delivery rates decreased among all racial and ethnic groups statewide and among all patients, regardless of payer, maternal age, or body mass index (BMI). The decrease in cesarean delivery was driven largely by a decrease in the frequency of cesarean delivery performed for labor dystocia (14.9% in 2015 to 12.8% in 2019) and from cesarean delivery before the onset of labor (4.2% in 2015 to 3.3% in 2019). For hospitals that started with an NTSV cesarean delivery rate above 23.9%, NTSV cesarean delivery rates among 80 hospitals participating in the CMQCC had a mean±SD decline of 6.9±5.9%, 13 hospitals participating in the system-level collaborative had a 5.0±4.5% decline, and those not participating in any collaborative had a 2.1±6.0% decline. In multivariable analysis, there was no association between meeting the Healthy People target and any of the hospital-level factors or aggregated patient-level characteristics. Rates of induction of labor increased in both groups and were not associated with a change in cesarean delivery rates. Hospitals in California between 2015 and 2019 with a wide variation in institutional and patient characteristics successfully reduced their NTSV cesarean delivery rates. Reduction in the NTSV cesarean delivery rate at hospitals that started above the Healthy People target was not associated with differences in patient characteristics but rather a reduction in cesarean deliveries for labor dystocia and cesarean deliveries performed before the onset of labor.

The Relationship of Patient/Provider Racial Concordance to Nulliparous, Term, Singleton, Vertex Cesarean Delivery Rates [ID 2683595

INTRODUCTION: Prior studies have explored factors affecting nulliparous, term, singleton, vertex cesarean (NTSV-C) delivery rates, such as induction, provider type, and racial disparities. Some studies have shown higher NTSV-C rates among non-White patients compared to their White counterparts. Our aim was to study the influence of racial concordance between patient and provider on NTSV outcomes. METHODS: A retrospective analysis of 315 NTSV pregnancies at an urban hospital from January to March 2023 was performed. The NTSV outcomes by racial concordance were examined using χ2 and Fisher exact tests with alpha <.05. Logistic regression analysis was used to adjust for high-risk maternal comorbidities. The race of patients and delivering providers was based on self-identification. RESULTS: A majority of patient–provider dyads were concordant for race (199/315 [63.2%]). Racial concordance was associated with a lower NTSV-C rates (23.1 versus 33.6%; P=.04). This association persisted after adjusting for maternal comorbidities (P=.003). When NTSV outcomes were stratified by patient race, significant differences in cesarean delivery rates by patient race were observed for White providers (P=.02). No significant differences between races were observed for Asian (P=.93) or Black providers (P=.82). CONCLUSION: These results emphasize the significant effect of racial concordance between patients and providers on cesarean delivery rates, highlighting the need for further examination of health care disparities and tailored interventions to promote equitable maternal care.

Racial Disparities in Cesarean Delivery Rates: Do Hospital-Level Factors Matter?

This study aimed to assess whether racial disparities in nulliparous, term, singleton, vertex cesarean delivery rates vary among hospitals of different type (academic vs. nonacademic), setting (urban vs. rural), delivery volume, and patient population. This is a retrospective cohort study including singleton term vertex live births in nulliparous Black and non-Hispanic White birthing people in California between 2011 and 2017. Cesarean delivery rates were obtained using birth certificate data and International Classification of Diseases, 9th/10th Revision codes. Risk of cesarean delivery was compared among Black versus White birthing people by hospital type (academic, nonacademic), setting (rural, suburban, urban), volume (< 1,200, 1,200-2,300, 2,400-3,599, ≥3,600 deliveries annually), and patient population (proportion Black-serving). Federal Information Processing codes were used to designate hospital setting. Risks were calculated using univariable and multivariable logistic regression and adjusted for birthing person age, body mass index, medical comorbidities, gestational age, labor type (spontaneous vs. induction), and infant birthweight. The sample included 59,441 Black (cesarean delivery rate: 30.2%) and 363,624 White birthing people (cesarean delivery rate: 26.1%). Black birthing people were significantly more likely than White birthing people to have a cesarean delivery across nearly all hospital-level factors considered with adjusted relative risks ranging from 1.1 to 1.3. The only exception was rural settings in which the adjusted relative risk was 1.3 but did not reach statistical significance. Black-White disparities in nulliparous, term, singleton, vertex cesarean delivery rates were persistent across all hospital-level factors we considered: academic status, rurality, delivery volume, and patient population. Furthermore, disparities existed at roughly the same magnitude regardless of hospital characteristics. These global increased risks likely reflect structural inequities in care, which contribute to disparities in pregnancy-related morbidity and mortality. These data should encourage providers, hospital systems, and quality collaboratives to further investigate racial disparities in cesarean delivery rates and develop strategies for eliminating them. · Nulliparous Black birthing people are more likely than White to undergo cesarean delivery.. · This persists across hospitals of all academic status, rurality, delivery volume, and patient population.. · These findings likely reflect structural rather than institutional inequities in obstetric care..

Hospital-level variation in racial disparities in low-risk nulliparous cesarean delivery rates

Nationally, rates of cesarean delivery are highest among Black patients compared with other racial/ethnic groups. These observed inequities are a relatively new phenomenon (in the 1980s, cesarean delivery rates among Black patients were lower than average), indicating an opportunity to narrow the gap. Cesarean delivery rates vary greatly among hospitals, masking racial disparities that are unseen when rates are reported in aggregate. This study aimed to explore reasons for the current large Black-White disparity in first-birth cesarean delivery rates by first examining the hospital-level variation in first-birth cesarean delivery rates among different racial/ethnic groups. We then identified hospitals that had low first-birth cesarean delivery rates among Black patients and compared them with hospitals with high rates. We sought to identify differences in facility or patient characteristics that could explain the racial disparity. A population cross-sectional study was performed on 1,267,493 California live births from 2018 through 2020 using birth certificate data linked with maternal patient discharge records. Annual nulliparous term singleton vertex cesarean delivery (first-birth) rates were calculated for the most common racial/ethnic groups statewide and for each hospital. Self-identified race/ethnicity categories as selected on the birth certificate were used. Relative risk and 95% confidence intervals for first-birth cesarean delivery comparing 2019 with 2015 were estimated using a log-binomial model for each racial/ethnic group. Patient and hospital characteristics were compared between hospitals with first-birth cesarean delivery rates <23.9% for Black patients and hospitals with rates ≥23.9% for Black patients. Hospitals with at least 30 nulliparous term singleton vertex Asian, Black, Hispanic, and White patients each were identified. Black patients had a very different distribution, with a significantly higher rate (28.4%) and wider standard deviation (7.1) and interquartile range (6.5) than other racial groups (P<.01). A total of 29 hospitals with a low first-birth cesarean delivery rate among Black patients were identified using the Healthy People 2020 target of 23.9% and compared with 106 hospitals with higher rates. The low-rate group had a cesarean delivery rate of 19.9%, as opposed to 30.7% in the higher-rate group. There were no significant differences between the groups in hospital characteristics (ownership, delivery volume, neonatal level of care, proportion of midwife deliveries) or patient characteristics (age, education, insurance, onset of prenatal care, body mass index, hypertension, diabetes mellitus). Among the 106 hospitals that did not meet the target for Black patients, 63 met it for White patients with a mean rate of 21.4%. In the same hospitals, the mean rate for Black patients was 29.5%. Among Black patients in the group that did not meet the 23.9% target, there were significantly higher rates of all cesarean delivery indications: labor dystocia, fetal concern (spontaneous labor), and no labor (eg, macrosomia), which are all indications with a high degree of subjectivity. The statewide cesarean delivery rate of Black patients is significantly higher and has substantially greater hospital variation compared with other racial or ethnic groups. The lack of difference in facility or patient characteristics between hospitals with low cesarean delivery rates among Black patients and those with high rates suggests that unconscious bias and structural racism potentially play important roles in creating these racial differences.

Reducing primary cesarean delivery rate through implementation of a smart intrapartum surveillance system

The rapid changes in clinical maternity situations that occur in a labor and delivery unit can lead to unpredictable maternal and newborn morbidities. Cesarean section (CS) rate is a key indicator of the accessibility and quality of a labor and delivery unit. This retrospective cross-sectional study assesses the nulliparous, term, singleton, vertex (NTSV) cesarean delivery rates before and after the implementation of a smart intrapartum surveillance system. Research data were collected from the electronic medical records of a labor and delivery unit. The primary outcome was the CS rate of the NTSV population. The data of 3648 women admitted for delivery were analyzed. Of the studied deliveries, 1760 and 1888 occurred during the preimplementation and postimplementation periods, respectively. The CS rate for the NTSV population was 31.0% and 23.3% during the preimplementation and postimplementation periods, respectively, indicating a significant 24.7% (p = 0.014) reduction in CS rate after the implementation of the smart intrapartum surveillance system (relative risk, 0.75; 95% confidence interval, 0.71–0.80). In the NTSV population, the vaginal and CS birth groups, no significant difference in terms of newborn weight, neonatal Apgar scores, composite neonatal adverse outcome indicator, and the occurrence of the following: neonatal intensive care unit admission, neonatal meconium aspiration, chorioamnionitis, shoulder dystocia, perineal laceration, placental abruption, postpartum hemorrhage, maternal blood transfusion, and hysterectomy before and after the implementation of the smart intrapartum surveillance system. This study reveals that the use of the smart intrapartum surveillance system can effectively reduce the primary CS rate for low-risk NTSV pregnancies without significantly affecting perinatal outcomes.

Applying Automated Machine Learning to Predict Mode of Delivery Using Ongoing Intrapartum Data in Laboring Patients.

This study aimed to develop and validate a machine learning (ML) model to predict the probability of a vaginal delivery (Partometer) using data iteratively obtained during labor from the electronic health record. A retrospective cohort study of deliveries at an academic, tertiary care hospital was conducted from 2013 to 2019 who had at least two cervical examinations. The population was divided into those delivered by physicians with nulliparous term singleton vertex (NTSV) cesarean delivery rates <23.9% (Partometer cohort) and the remainder (control cohort). The cesarean rate among this population of lower risk patients is a standard metric by which to compare provider rates; <23.9% was the Healthy People 2020 goal. A supervised automated ML approach was applied to generate a model for each population. The primary outcome was accuracy of the model developed on the Partometer cohort at 4 hours from admission to labor and delivery. Secondary outcomes included discrimination ability (receiver operating characteristics-area under the curve [ROC-AUC]), precision-recall AUC, and calibration of the Partometer. To assess generalizability, we compared the performance and clinical predictors identified by the Partometer to the control model. There were 37,932 deliveries during the study period; after exclusions, 9,385 deliveries were included in the Partometer cohort and 19,683 in the control cohort. Accuracy of predicting vaginal delivery at 4 hours was 87.1% for the Partometer (ROC-AUC: 0.82). Clinical predictors of greatest importance in the stacked Intrapartum Partometer Model included the Admission Model prediction and ongoing measures of dilatation and station which mirrored those found in the control population. Using automated ML and intrapartum factors improved the accuracy of prediction of probability of a vaginal delivery over both previously published models based on logistic regression. Harnessing real-time data and ML could represent the bridge to generating a truly prescriptive tool to augment clinical decision-making, predict labor outcomes, and reduce maternal and neonatal morbidity. · Our ML-based model yielded accurate predictions of mode of delivery early in labor.. · Predictors for models created on populations with high and low cesarean rates were the same.. · A ML-based model may provide meaningful guidance to clinicians managing labor..

Does Insurance Status Effect the Nulliparous, Term, Singleton, Vertex Cesarean Delivery Rate? [A276

INTRODUCTION: Per the CDC, nulliparous, term, singleton, vertex (NTSV) cesarean delivery (CD) rates are between 21% and 33% in the United States, and the current initiative is to decrease the NTSV CD rate to 24.7% by 2030. At Saint Peters University Hospital in New Brunswick, NJ, the NTSV CD rate was 29.3% in 2020. METHODS: This is a retrospective cohort study of NTSV patients who delivered between 1/1/2020 and 12/31/20. Data were obtained from Paragon Electronic Medical Record. The insurance status of each patient was obtained and codified as private insurance (PI) versus HMO, Medicaid, or no insurance/self-pay (NI) coverage. The mode of delivery and insurance type were recorded. NI patients are delivered by hospital-employed physicians present in the labor and delivery department, which is staffed 24 hours a day. Significance was set at P&lt;.05. RESULTS: A total of 1,421 NTSV patients were delivered in 2020, with 1,004 delivering vaginally and 417 delivering via CD. There were 1,047 patients with private insurance, with an NTSV CD rate of 31% (325 of 1,047). There were 374 patients with NI, with an NTSV CD rate of 24.6% (92 of 374). There was a significant difference between the two CD rates (P&lt;.0196). CONCLUSION: Patients with NI had a statistically lower CD rate (24.6% vs. 31.0%) as compared to those with PI. This may partly be due to the availability of hospital faculty physicians present in the hospital 24/7. The effect of individual practice patterns impacting the private NTSV CD rate cannot be ruled out. The majority of the private physicians are not present in labor and delivery 24 hours a day.

Delivery Outcomes in High-Risk versus Low-Risk NTSV Pregnancies

The nulliparous, term, singleton, vertex (NTSV) cesarean delivery rate is an established quality measure with the national target set below 24%. While NTSV pregnancies are often referred to as low-risk, many NTSV pregnancies are high-risk. We hypothesize that cesarean delivery rates and adverse maternal outcomes are higher in high-risk versus low-risk NTSV pregnancies.

Obesity and nulliparous, term, singleton, vertex cesarean delivery rates on the United States county level

Unadjusted nulliparous, term (≥37 weeks gestation), vertex, singleton (NTSV) cesarean delivery rates are used as a US quality indicator. However, obesity may be an important predictor of cesarean delivery. This analysis determined whether obesity was associated with NTSV cesarean rates across counties in the US.

Reduction in Cesarean Delivery Rates Associated With a State Quality Collaborative in Maryland.

To assess the extent to which hospitals participating in the MDPQC (Maryland Perinatal-Neonatal Quality Care Collaborative) to reduce primary cesarean deliveries adopted policy and practice changes and the association of this adoption with state-level cesarean delivery rates. This prospective evaluation of the MDPQC includes 31 (97%) of the birthing hospitals in the state, which all voluntarily participated in the 30-month collaborative from June 2016 to December 2018. Hospital teams agreed to implement practices from the "Safe Reduction of Primary Cesarean Births" patient safety bundle, developed by the Council on Patient Safety in Women's Health Care. Each hospital's implementation of practices in the bundle was measured through surveys of team leaders at 12 months and 30 months. Half-yearly cesarean delivery rates were calculated from aggregate birth certificate data for each hospital, and differences in rates between the 6 months before the collaborative (baseline) and the 6 months afterward (endline) were tested for statistical significance. Among the 26 bundle practices that were assessed, participating hospitals reported having a median of seven practices (range 0-23) already in place before the collaborative and implementing a median of four (range 0-17) new practices during the collaborative. Across the collaborative, the cesarean delivery rates decreased from 28.5% to 26.9% (P=.011) for all nulliparous term singleton vertex births and from 36.1% to 31.3% (P<.001) for nulliparous, term, singleton, vertex inductions. Five hospitals had a statistically significant decrease in nulliparous, term, singleton, vertex cesarean delivery rates and four had a significant increase. Nulliparous, term, singleton, vertex cesarean delivery rates were significantly lower across hospitals that implemented more practices in the "Response" domain of the bundle. The MDPQC was associated with a statewide reduction in cesarean delivery rates for nulliparous, term, singleton, vertex births.

Culture That Facilitates Change: A Mixed Methods Study of Hospitals Engaged in Reducing Cesarean Deliveries.

Large-scale efforts to reduce cesarean deliveries have shown varied levels of impact; yet understanding factors that contribute to hospitals' success are lacking. We aimed to characterize unit culture differences at hospitals that successfully reduced their cesarean rates compared with those that did not. A mixed methods study of California hospitals participating in a statewide initiative to reduce cesarean delivery. Participants included nurses, obstetricians, family physicians, midwives, and anesthesiologists practicing at participating hospitals. Hospitals' net change in nulliparous, term, singleton, and vertex cesarean delivery rates classified them as successful if they achieved either a minimum 5 percentage point reduction or rate of fewer than 24%. The Labor Culture Survey was used to quantify differences in unit culture. Key informant interviews were used to explore quantitative findings and characterize additional cultural barriers and facilitators. Out of 55 hospitals, 37 (n = 840 clinicians) meeting inclusion criteria participated in the Labor Culture Survey. Physicians' individual attitudes differed by hospital success on 5 scales: best practices (P = .003), fear (P = .001), cesarean safety (P = .014), physician oversight (P <.001), and microculture (P = .044) scales. Patient ability to make informed decisions showed poor agreement across all hospitals, but was higher at successful hospitals (38% vs 29%, P = .01). Important qualitative themes included: ease of access to shared resources on best practices, fear of bad outcomes, personal resistance to change, collaborative practice and effective communication, leadership engagement, and cultural flexibility. Successful hospitals' culture and context was measurably different from nonresponders. Leveraging these contextual factors may facilitate success.

113 Advanced maternal age and its impact on the NTSV cesarean delivery rate

The nulliparous, term, singleton, vertex cesarean delivery (NTSV CD) rate is an established quality measure, with the national target set below 24% based on the Healthy People initiative. While advanced maternal age (AMA) is associated with a higher rate of cesarean delivery in general, its impact on the NTSV CD rate is unclear. Therefore, we sought to determine if AMA is associated with higher NTSV CD rates at our institution. Cohort study of women with NTSV pregnancies undergoing a trial of labor at our institution from August 2016 to August 2017. Those undergoing an elective cesarean delivery were excluded. The primary exposure was maternal age ≥35 years (AMA), and the primary outcome measure was the NTSV CD rate. Secondary outcomes were the NTSV CD rate by age category (<20, 20-24, 25-29, 30-34, 35-39 and ≥40 years). Confounders assessed included gestational age, BMI, race/ethnicity, insurance status and labor induction. We conducted analyses with Chi-squared tests and multivariable logistic regression, with α=0.05. We evaluated 2,862 women with NTSV pregnancies undergoing a trial of labor, of whom 931 (33%) were AMA and 498 (17%) had a cesarean delivery. Compared to the maternal age distribution of NTSV deliveries in the United States, our population was skewed towards more women with AMA (33% vs 10%, P<0.001), Table 1. At our institution, the NTSV CD rate was significantly higher in women ages 35 and over compared to those less than age 35 (24% vs 14%, P<0.001), Table 2. In addition, the NTSV CD rate increased with advancing maternal age category [<20 (0%), 20-24 (9%), 25-29 (13%), 30-34 (16%), 35-39 (22%) and ≥40 (31%), P<0.001]. The odds of NTSV CD was significantly greater in women ages 35 and over, even after adjustment for gestational age, BMI, race/ethnicity, insurance status and labor induction (aOR 1.8, 95% CI 1.5-2.2, P<0.001). The NTSV CD rate was significantly higher among women ages 35 and over undergoing a trial of labor at our institution. Maternal age distribution should be considered when assessing NTSV CD rates at individual institutions.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

272 Patient factors and impact on NTSV cesarean delivery rate among individual physicians

The nulliparous, term, singleton, vertex cesarean delivery (NTSV CD) rate is an established obstetric quality measure. Tracking NTSV CD rates of individual physicians may help identify outliers and drive change. However, patient factors may also contribute to physician NTSV CD rates. Therefore, we sought to determine if patient factors are associated with high versus low NTSV CD rates among individual physicians. Cohort study of women with NTSV pregnancies undergoing a trial of labor at our institution from August 2016 to August 2017. Those undergoing an elective cesarean delivery were excluded. The NTSV CD rates of individual physicians were determined over the 12-month study period. Those with a cumulative NTSV CD rate below the 50th percentile were classified as successful, and those above the 50th percentile unsuccessful. Patient factors were evaluated as predictors of successful NTSV CD rate, and included maternal age, BMI, race/ethnicity, gestational age and insurance status. We conducted analyses with Chi-squared tests and multivariable logistic regression, with α=0.05. We identified 2,862 women with NTSV pregnancies who were cared for by 78 individual physicians. The overall NTSV CD rate was 17.4% (498/2862). The 50th percentile for NTSV CD rate among individual physicians was 20%, and those below this rate were classified as successful (Figure 1). Compared to physicians with successful NTSV CD rates below 20%, those with higher rates had more patients who were Black (10% vs 7%, P=0.004), ≥35 years old (35% vs 31%, P=0.034) and undergoing induction (65% vs 61%, P=0.016). These factors remained significant after multivariable adjustment [aOR (95% CI): Black race, 1.5 (1.1-2.0); Age ≥35, 1.2 (1.0-1.4); and Induction, 1.2 (1.0-1.4)], (Table 1). Successful NTSV CD rates were not associated with BMI, insurance status, diabetes or hypertension. Individual physician NTSV CD rates were impacted by patient factors such as maternal age and Black race. Efforts should be devoted to decreasing NTSV CD rates in these populations.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Rates of Indicated Nulliparous, Term, Singleton, Vertex Cesarean Deliveries Among Practice Models [31P

INTRODUCTION: There has been an increased focus on strategies to reduce the nulliparous, term, singleton, vertex (NTSV) cesarean delivery rate since March 2014 when the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal Fetal Medicine published Obstetric Care Consensus (OCC) guidelines on the safe prevention of the primary cesarean delivery. The purpose of this study was to determine if performance of NTSV cesarean deliveries meeting OCC guidelines differed between provider practice models at Virginia Hospital Center (VHC). METHODS: We conducted an IRB-approved retrospective cohort study of all NTSV cesarean deliveries from January 2014 to December 2017 at VHC. A third-party reviewer determined if the indication for each delivery met OCC guidelines. Adherence was compared according to practice model (in-house providers with resident involvement, in-house providers without resident involvement, and non-in-house providers without resident involvement). Fisher exact test was used to determine whether performance of NTSV cesarean deliveries meeting OCC guidelines differed among practice models. RESULTS: There were 1,833 NTSV cesarean deliveries, of which 743 (40.5%) met OCC guidelines for delivery and 1,090 (59.5%) did not. Performance of NTSV cesarean deliveries meeting OCC guidelines was statistically different among provider practice models. Providers without resident involvement, in-house providers without resident involvement, and in-house providers with resident involvement had 37% (472 out of 1,271), 47% (178 out of 379), and 51% (93 out of 183), respectively, of NTSV cesarean deliveries meeting OCC guidelines (P&lt;.001). CONCLUSION: In-house provider coverage and resident involvement are associated with increased performance of NTSV cesarean deliveries meeting OCC guidelines.

State Based Perinatal Quality Collaborative Pilot-Statewide Reduction of Colorado Primary Cesarean Delivery Rate [04OP

INTRODUCTION: The Colorado Perinatal Care Quality Collaborative performed a pilot quality improvement project to increase adherence to guidelines from the Consensus for the Prevention of the Primary Cesarean Delivery in a statewide cohort of hospitals to safely reduce their nulliparous, term, singleton, vertex (NTSV) cesarean delivery (CD) rate. METHODS: This quality improvement initiative was performed at 6 community hospitals across Colorado. Pre (January 2017 to May 2018) and post intervention (June to Oct 2018) NTSV CD and composite maternal and neonatal morbidity rates were determined for each hospital and the overall cohort using Colorado State Vital Statistics data. Interventions included distributing institution and provider specific NTSV CD rates, education for providers and nurses, implementation of a pre-cesarean labor dystocia checklist, and convening two forums for collaboration between hospitals. NTSV CD and composite maternal and neonatal morbidity rates were compared before and after the interventions for each hospital and the cohort. RESULTS: The 6 participating hospitals perform 19% of live births in Colorado. Pre-intervention hospital NTSV CD rates ranged from 19.3% to 33.8%. The cohort pre-intervention NTSV CD rate was 24.6%, and decreased to 21.9% post-intervention (P=0.04, 95% CI 0.77-0.99). There was no significant increase in composite maternal or neonatal morbidity post-intervention (8.6% vs 7.1% and 7.1% vs 6.8% respectively). CONCLUSION: A quality improvement effort led by a state-based Perinatal Quality Collaborative was effective at safely reducing NTSV CD rates across multiple hospitals. Future efforts will aim at expanding the number of participating hospitals and sustainability.

Safety Assessment of a Large-Scale Improvement Collaborative to Reduce Nulliparous Cesarean Delivery Rates.

To evaluate maternal and neonatal safety measures in a large-scale quality improvement program associated with reductions in nulliparous, term, singleton, vertex cesarean delivery rates. This is a cross-sectional study of the 2015-2017 California Maternal Quality Care Collaborative (CMQCC) statewide collaborative to support vaginal birth and reduce primary cesarean delivery. Hospitals with nulliparous, term, singleton, vertex cesarean delivery rates greater than 23.9% were solicited to join. Fifty-six hospitals with more than 119,000 annual births participated; 87.5% were community facilities. Safety measures were derived using data collected as part of routine care and submitted monthly to CMQCC: birth certificates, maternal and neonatal discharge diagnosis and procedure files, and selected clinical data elements submitted as supplemental data files. Maternal measures included chorioamnionitis, blood transfusions, third- or fourth-degree lacerations, and operative vaginal delivery. Neonatal measures included the severe unexpected newborn complications metric and 5-minute Apgar scores less than 5. Mixed-effect multivariable logistic regression model was used to calculate odds ratios (Ors) and 95% CIs. Among collaborative hospitals, the nulliparous, term, singleton, vertex cesarean delivery rate fell from 29.3% in 2015 to 25.0% in 2017 (2017 vs 2015 adjusted OR [aOR] 0.76, 95% CI 0.73-0.78). None of the six safety measures showed any difference comparing 2017 to 2015. As a sensitivity analysis, we examined the tercile of hospitals with the greatest decline (31.2%-20.6%, 2017 vs 2015 aOR 0.54, 95% CI 0.50-0.58) to evaluate whether they had greater risk of poor maternal and neonatal outcomes. Again, no measure was statistically worse, and the severe unexpected newborn complications composite actually declined (3.2%-2.2%, aOR 0.71, 95% CI 0.55-0.92). Mothers and neonates participating in a large-scale Supporting Vaginal Birth collaborative had no evidence of worsened birth outcomes, even in hospitals with large cesarean delivery rate reductions, supporting the safety of efforts to reduce primary cesarean delivery using American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine guidelines and enhanced labor support.

Effect of Severity of Illness on Cesarean Delivery Rates in Washington State

(Am J Obstet Gynecol 2017;217:474.e1–e5) Perinatal quality initiatives, including proposed national benchmarks for acceptable cesarean delivery rates, have aimed to design best practices to reduce cesarean delivery rates and obtain optimal outcomes for mothers and infants. However, whether all hospitals can be held to the same benchmark for an acceptable cesarean delivery rate regardless of patient acuity is debatable, and the reasons for between-hospital variation in cesarean rates are not clear. The aim of this study was to evaluate the association between the severity of illness at admission and the primary term singleton vertex (TSV) cesarean delivery rates in Washington State. The authors hypothesized that hospitals with higher patient acuity would have higher term TSV cesarean delivery rates and that this relationship would persist despite temporal trends.

Variation in the Nulliparous, Term, Singleton, Vertex Cesarean Delivery Rate.

To estimate the contributions of patient and health care provider-hospital characteristics to the variation in the frequency of nulliparous, term, singleton, vertex cesarean delivery in a multi-institutional U.S. cohort. We performed a secondary analysis of the multicenter Assessment of Perinatal Excellence cohort of 115,502 mother and neonatal pairs who were delivered at 25 hospitals between March 2008 and February 2011. Women met inclusion criteria if they were nulliparous and delivered a singleton in vertex presentation at term. Hospital ranks for nulliparous, term, singleton, vertex cesarean delivery frequency were determined after risk adjustment. The fraction of variation in nulliparous, term, singleton, vertex cesarean delivery frequency attributable to patient and health care provider-hospital characteristics was assessed using hierarchical logistic regression. Of the 115,502 deliveries in the initial cohort, 38,275 nulliparous, term, singleton, vertex deliveries met inclusion criteria. The median hospital nulliparous, term, singleton, vertex cesarean delivery frequency was 25.3% with a range from 15.0% to 35.2%. The majority of hospitals (16/25) changed rank quintiles after risk adjustment; overall the changes in rank were not statistically significant (P=.53). Patient characteristics accounted for 24% of the nulliparous, term, singleton, vertex cesarean delivery variation. The analyzed health care provider-hospital characteristics were not significantly associated with cesarean delivery frequency. Although patient characteristics accounted for some of the variation in nulliparous, term, singleton, vertex cesarean delivery frequency and accounting for case mix had implications for hospital cesarean delivery rankings, the majority of the variation was not explained by the characteristics evaluated. These findings emphasize the importance of continued efforts to understand aspects of obstetric care, including case mix, that contribute to cesarean delivery variation.

Effect of severity of illness on cesarean delivery rates in Washington State

Hospitals and providers are increasingly held accountable for their cesarean delivery rates. In the perinatal quality improvement arena, there is vigorous debate about whether all hospitals can be held to the same benchmark for an acceptable cesarean rate regardless of patient acuity. However, the causes of variation in hospital cesarean delivery rates are not well understood. We sought to evaluate the association and temporal trends between severity of illness at admission and the primary term singleton vertex cesarean delivery rate among hospitals in Washington State. We hypothesized that hospitals with higher patient acuity would have higher cesarean delivery rates and that this pattern would persist over time. In this cross-sectional analysis, we analyzed aggregate hospital-level data for all nonmilitary hospitals in Washington State with ≥100 deliveries/y during federal fiscal years 2010 through 2014 (287,031 deliveries). Data were obtained from the Washington State Comprehensive Hospital Abstract Reporting System, which includes inpatient demographic, diagnosis, procedure, and discharge information derived from hospital billing systems. Age, admission diagnoses and procedure codes were converted to patient-level admission severity-of-illness scores using the All Patient Refined Diagnosis Related Groups classification system. This system is widely used throughout the United States to adjust hospital data for severity of illness. Mean admission hospital-level severity-of-illness scores were calculated for each fiscal year among the term singleton vertex population with no history of cesarean delivery. We used linear regression to evaluate the association between hospital admission severity of illness and the primary term singleton vertex cesarean delivery rate, calculated Pearson correlation coefficients, and compared regression line slopes and 95% confidence intervals for each fiscal year. Hospitals were diverse with respect to delivery volume, level of care, and geographic location within Washington. Hospital aggregate admission severity-of-illness score correlated with primary term singleton vertex cesarean delivery rate in all fiscal years (R2 0.38-0.58, P < .001). For every year in the study interval, as admission severity of illness increased so did the primary term singleton vertex cesarean rate. The slope of the regression line decreased during the study interval, suggesting that statewide decrease in primary term singleton vertex cesarean rate occurred across the range of severity of illness. Admission severity-of-illness score is strongly associated with the primary term singleton vertex cesarean delivery rate among hospitals in Washington State. Approximately 50% of variation in hospital primary term singleton vertex cesarean delivery rates appeared to be related to admission severity of illness. This relationship persisted over time despite a statewide decrease in cesarean delivery, suggesting that patient acuity will likely continue to contribute to hospital variation in cesarean delivery rates despite perinatal quality improvement efforts. The major implication of this study is that patient acuity should be considered when determining optimal cesarean delivery rates. High-acuity hospitals are likely to have high cesarean rates because they provide a specific role in serving regional needs. To hold these centers to an arbitrary benchmark may jeopardize the funding necessary to support regional safety net institutions.

Nulliparous, Term, Singleton, Vertex (NTSV): Can We Predict Cesarean Delivery? [23R

INTRODUCTION: The nulliparous, term, singleton, vertex (NTSV) cesarean delivery rate has become the obstetric quality measure, as it is the most variable portion of the rise in cesarean delivery and represents low risk primary cesarean births. We hypothesize that analysis of previous nulliparous, term, singleton vertex (NTSV) deliveries will yield maternal, fetal, and/or obstetrical characteristics that are associated with increased risk for cesarean delivery. METHODS: Retrospective study of all NTSV births that occurred at St. Joseph Mercy Oakland Hospital during the year 2015, with the purpose of identifying factors contributing to cesarean delivery. We compared demographic, obstetrical, and neonatal data. The data were analyzed using SPSS-19 software, with categorical outcomes using the chi square regression analysis and numerical outcomes using the t test. RESULTS: A total of 475 cases of NTSV were included analysis. The overall NTSV cesarean delivery rate was 27.08%, with a range of 12.9% to 39.1% amongst obstetrical providers. The most common reasons for NTSV cesarean delivery were abnormal FHR tracing, 53.2%, and labor dystocia, 38.7%. The factors that were statistically significant were diabetes (LHR 7.192, P &lt; 0.004), hypertension (LHR 14.9, P &lt; 0.00), maternal race (LHR 5.42, P &lt; 0.02), age in years (P CONCLUSION: The NTSV cesarean delivery rate is influenced by many factors, and a wide variation in incidence can be seen across obstetric providers within the same hospital system. Further research should be performed analyzing variations in obstetrical practices that may contribute to this significant difference.