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Reducing cesarean births at a primarily private university hospital
Reducing cesarean births at a primarily private university hospital Michael L. Socol, MD, Patricia M. Garcia, MD, Alan M. Peaceman, MD, and Sharon L. Dooley, MD Chicago, Illinois OBJECTIVE: The rise in cesarean birth at Northwestern Memorial Hospital in 1986 to 27.3% prompted implementation of three initiatives to reverse the escalating cesarean section rate. STUDY DESIGN: First, vaginal birth after cesarean section was more strongly encouraged. Second, after the 1988 calendar year the cesarean section rate of every obstetrician was circulated annually to each attending physician. Third, on completion of a prospective, randomized trial of the active management of labor in early 1991, this protocol was recommended as the preferred method of labor management for term nulliparous patients. RESULTS: The total, primary, and repeat cesarean section rates declined from 27.3%,18.2%, and 9.1% in 1986 to 16.9%, 10.6%, and 6.4%, respectively, in 1991. At the same time the perinatal mortality dropped from 19.5 to 10.3. Significant reductions in abdominal deliveries occurred for both private patients (30.3% to 19.1%, P < 0.0001) and clinic patients (20.8% to 11.5%, P < 0.0001). A decline in operative deliveries for dystocia and an increase in vaginal birth after prior cesarean section were the principal factors contributing to the lower cesarean section rates. However, in 1991 individual private physicians still had wide variations in primary cesarean section rates (4.6% to 21.1 %) and use of vaginal birth after prior cesarean section (5.3% to 90%). CONCLUSION: The cesarean section rate has been significantly reduced for both private and clinic patients. Differences in population demographics and individual physician practice patterns contributed to a higher incidence of cesarean birth on the private service. (AM J OSSTET GVNECOL 1993;168:1748-58.)
Key words: Cesarean section, vaginal birth after cesarean section, dystocia, active management of labor
The increased use of cesarean delivery, like the institution of electronic fetal heart rate (FHR) monitoring, was anticipated to improve perinatal outcome. This expectation remains unfulfilled. 1. 2 Nevertheless, the cesarean section rate in the United States reached 24.7% in 1988' with an accompanying negative impact on maternal health4 • 5 and obstetric care costs. 6 The major factors accounting for this rise in abdominal delivery are dystocia and prior cesarean section, with malpresentation and FHR abnormalities contributing to a lesser degree.' Strategies proposed for controling the cesarean section rate include physician education and peer evaluation, changes in physician and hospital reimbursement, and medical malpractice reform. s Two university hosFrom the Section of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Medical School and Northwestern Memorial Hospital. Presented at the Sixtieth Annual Meeting of The Central Association of Obstetricians and Gynecologists, Chicago, Illinois, October 15-17, 1992. Reprint requests: Michael L. Socol, MD, 333 E. Superior St., #410, Chicago, lL 60611. Copyright © 1993 by Moslry-Year Book, Inc. 0002-9378/93 $1.00 + .20 6/6/45999
1748
pitals servicing a primarily low-income, inner-city population have demonstrated that it is feasible to reduce the incidence of cesarean birth to approximately 11% by incorporating strict guidelines for abdominal delivery and comprehensive peer review. g • 10 A centralized approach to intrapartum decision making, however, is unlikely to be well received by the obstetric community at large, and effective administrative reforms are not likely to be implemented in the near future. Concern over the escalating cesarean section rate at our institution, a primarily private tertiary university hospital, prompted us to undertake and evaluate the outcome of three initiatives that are the subject of this report.
Methods Northwestern Memorial Hospital is a primarily private tertiary university facility. The medical staff comprises approximately equal numbers of full-time and volunteer faculty. The resident house staff evaluates each patient admitted to labor and delivery, but their primary responsibility is for all clinic patients and complicated private patients. Resident supervision for the medically indigent patients is provided by the full time faculty. Demographic data for the total obstetric popu-
Socol et al.
Volume 168, Number 6, Part 1 Am J Obstet Gynecol
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Table I. Demographic data Total patients Nulliparous Multiparous Payor status Private Clinic Race White Black Other
1986
1987
1988
1989
1990
1991
4240 2009 (47.4) 2231 (52.6)
4219 1969 (46.7) 2250 (53.3)
4271 2037 (47.7) 2234 (52.3)
4391 2081 (47.4) 2310 (52.6)
4829 2327 (48.2) 2502 (51.8)
4669 2243 (48.0) 2426 (52.0)
2910 (68.6) 1330 (31.4)
2950 (69.9) 1269 (30.1)
3036 (71.1) 1235 (28.9)
3035 (69.1) 1356 (30.9)
3383 (70.l) 1446 (29.9)
3364 (72.0) 1305 (28.0)
2718 (64.1) 894 (21.1) 628 (14.8)
2799 (66.3) 850 (20.2) 570 (13.5)
2759 (64.6) 932 (21.8) 580 (13.6)
2849 (64.9) 916 (20.9) 626 (14.2)
3031 (62.8) 1009 (20.9) 789 (16.3)
2942 (63.0) 888 (19.0) 839 (18.0)
lation are listed in Table I. The proportion of private patients, that was nulliparous was 52.5% in 1986 and 52.6% in 1991; for clinic patients the proportions were 35.5% and 35.6%, respectively. The institutional cesarean section rate reached its zenith in 1986 when 27.3% of births were abdominal deliveries. Three initiatives were subsequently undertaken between 1987 and 1991 to reduce the cesarean birth rate. First, vaginal birth after one prior low-transverse cesarean section was more strongly encouraged. Physicians were required to document that eligible patients had been offered a trial of labor and that an elective repeat operation was performed because the patient declined a trial of labor. Patients with an unknown uterine scar were allowed a trial of labor if the prior indication for cesarean section was one for which a low-transverse incision was most likely used. Patients with two prior low-transverse uterine incisions were not strongly encouraged to labor, although this decision was supported for well motivated patients, particularly those who had never attempted vaginal birth after cesarean section. Patients with a prior vertical uterine incision or a myomectomy in which the uterine cavity had been entered were not considered candidates for vaginal delivery. Management oflabor initially included the use of an internal scalp electrode and intrauterine pressure catheter whenever possible, but more recently labor has been managed similarly to that in a patient with an un scarred uterus. Electronic FHR monitoring continues to be routinely used, and both epidural anesthesia and oxytocin augmentation are used as deemed necessary. Second, a quality management initiative was introduced because of suspected significant differences among physicians in cesarean section rates and use of vaginal birth after prior cesarean section. After the 1988 calendar year the cesarean section rate (divided into primary cesarean sections, repeat cesarean sections, and number of patients undergoing a trial of labor after prior cesarean section) for every obstetrician was circulated annually to each attending physician,
with the presumption that this would provide positive reinforcement for achieving a lower rate of abdominal delivery. Third, because dystocia (arrest of labor, failure to progress) is the factor that has contributed most to the rise in primary cesarean sections, a prospective randomized trial to evaluate the efficacy of the active management of labor protocol for term nulliparous patients was undertaken in 1990. II Spontaneous labor was defined as the presence of regular, painful uterine contractions at least once every 5 minutes in association with either complete cervical effacement or spontaneous rupture of membranes. Patients assigned to the active management of labor protocol had amniotomy performed within 1 hour of the diagnosis of labor if membranes were intact. At any time in the first stage of labor that the rate of cervical dilation was found to be < 1 cm/hr, a determination of inadequate progress in labor was made, and oxytocin augmentation was initiated. The initial oxytocin infusion rate was 6 mU/min, which was increased by 6 mU/min every 15 minutes until there were seven contractions in 15 minutes or a maximum of 36 mU/min was reached. After the completion of this study in March 1991 this scheme has been recommended to the medical staff as the preferred method of labor management for term nulliparous patients. Since 1986 there has not been any formal change in the recommended management of FHR abnormalities, breech presentations, or twin gestations. Cesarean section is discouraged for FHR abnormalities unless fetal acidosis is confirmed by scalp pH assessment. Route of delivery and consideration of external version for breech presentations are left to the discretion of the attending physician. Similarly, there is no standrad protocol for multiple gestations, but a trial of labor is encouraged for vertex-nonvertex presentations, particularly if the fetuses are thought to be ;;:: 32 weeks' gestations or ;;:: 1500 gm. The decision to use external version or breech extraction for a second twin is determined by the attending physician. Delivery data were retrieved from the perinatal data
1750 Socci et al.
June 1993 Am J Obstet Gynecol
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o~----~------------~----~----~ 1986 1987 1988 1989 1990 1991 Fig. 1. Although incidence of operative deliveries in Illinois (IL) remained constant from 1986 to 1991, total, primary, and repeat cesarean section rates at Northwestern Memorial Hospital (NMH) declined.
base. Annual proportions of primary and repeat cesarean sections were computed from 1986 to 1991. Primary cesarean sections were further subclassified by indication. The proportion of patients with prior cesarean deliveries undergoing a trial of labor and the number of vaginal births were also tabulated. Perinatal outcome measures included neonatal intensive care unit admissions, neonatal and perinatal mortality rates, Apgar scores, and umbilical cord arterial pH values. Statistical comparisons of data between 1986 and 1991 or between private and clinical services were made by X2 analysis. Statistical significance was assumed at a level of p < 0.05. Results The total, primary, and repeat cesarean section rates at Northwestern Memorial Hospital are compared with data from the State of Illinois in Fig. 1. The statewide figures have remained essentially unchanged over the 6-year period. The total, primary, and repeat cesarean section rates in Illinois were 23.2%, 14.4%, and 8.8% in 1986 compared with 22.9%, 13.7%, and 92.%, respectively, in the first 6 months of 1991. In contrast, at Northwestern Memorial Hospital the rates of total, primary, and repeat cesarean deliveries dropped from 27.3%, 18.2%, and 9.1% in 1986 to 16.9% (p < 0.0001), 10.6% (p < 0.0001), and 6.4% (p < 0.0001), respectively, in 1991. During the sample period there was an increase in the intrapartum use of epidural anesthesia (28.4% vs 47.7%, P < 0.0001), but there was no change in the incidence of operative vaginal delivery (12.6% vs 13.3%, P = 0.38). The annual total, primary, and repeat cesarean section rates for the private and clinic services are enumerated in Fig. 2. There was a significant decline in total cesarean deliveries from 1986 to 1991 for both private
patients (odds ratio 0.54, 95% confidence interval 0.48 to 0.61) and clinic patients (odds ratio 0.49, 95% confidence interval 0.40 to 0.62). In spite of this decline in operative delivery, private patients were more likely to be delivered by cesarean section than were clinic patients in both years. There was also a significant decline in primary cesarean sections from 1986 to 1991 for both private patients (odds ratio 0.54, 95% confidence interval 0.47 to 0.62) and clinic patients (odds ratio 0.45, 95% confidence interval 0.34 to 0.60). In Fig. 3 the annual primary cesarean section rates are categorized by indication for intervention for the private and clinic services. Primary cesarean sections for dystocia, FHR abnormalities, and other indications (e.g., multiple gestation, herpes, third-trimester bleeding) decreased for both groups of patients. Operative intervention for malpresentation also dropped for clinic patients. The decline in operative intervention for dystocia was greater on the private service, whereas the decline in abdominal delivery for FHR abnormalities was greater on the clinic service. For the entire population there was a decline in cesarean births for dystocia from 8.8% to 4.8% (odds ratio 0.53, 95% confidence interval 0.44 to 0.63), for FHR abnormalities from 2.8% to 1.4% (odds ratio 0.49, 95% confidence interval 0.35 to 0.67), for malpresentation from 3.4% to 2.7% (odds ratio 0.80, 95% confidence interval 0.62 to 1.02), and for other indications from 3.3% to 1.7% (odds ratio 0.51, 95% confidence interval 0.38 to 0.67). Vaginal birth after cesarean section increased over time, as shown in Fig. 4. As a result, there was a significant decline in repeat cesarean sections from 1986 to 1991 for private patients (odds ratio 0.67, 95% confidence interval 0.56 to 0.81) and clinic patients (odds ratio 0.66, 95% confidence interval 0.47 to 0.92).
Socol et al.
Volume 168, Number 6, Part 1 Am J Obstet Gynecol
40
~
t:t: a:
30
ll!!!!
Wi
1.65 (1.41 ·1.94) PRIMARY 1.59 (1.32·1.91) Nulliparous 1.47 (1.15-1.88)
TOTAL
[;] REPEAT
(J)
W
Ilil PRIMARY
P
1751
1.81 (1.. . . 2.20) 1.90 (1.48 - 2.43) 2.01 (1.45 - 2.78) 0.88 (0.56·1.39)
Muhiparous
Z
0
t5w
20
en
z «w a: « en w
10
()
0
1986
1987
1989
1988
1990 1
* **
1991
p < .05 p < .0001
>vs
19861
Fig. 2. Total, primary, and repeat cesarean section rates declined for both private (P) and clinic (C) patients. Insert, Odds ratios for abdominal delivery for private patients compared with clinic patients in 1986 and 1991.
25
20
iii DYSTOCIA
EiiI MALPRESENTATION lIII FETAL HEART RATE El OTHER ABNORMALITIES P
1986
1987
1988
Dystoc;.
2.25 (1.70 - 2.99)
ll!!!!
~ 1.78 (1.25·2.56)
FetalHe8It Rate Abnormalities
0.66 (0.48-1.01)
1.39 (0.74·2.64)
Malpresentation
I.SO (1.00 - 2.26)
3.21 (1.79·5.85)
Othe,
1.30 (0.87 • 1.96)
1.21 (0.70.2.11)
1989
1991
1990
* '* '*
P<.05) va
p < .01 ***P < .0001
1986
Fig. 3. Annual primary cesarean section rates are presented by indication for intervention for private (P) and clinic (C) services. Odds ratios for primary cesarean section for private patients compared with
clinic patients in 1986 and 1991 are enumerated.
Clinic patients with a prior cesarean section were more likely to be delivered vaginally, however, because of the greater use of a trial of labor. For the entire population the proportion of patients with prior cesarean deliveries undergoing a trial of labor increased from 27.2% to 58.3%
significantly greater proportion of newborn infants in the private-practice group had a birth weight > 3500 gm
1752 Socol et al.
June 1993 Am J Obstet Gyneco1
70 Cl
Trial of labor
Z
5
60
Successful
Cl
II: W
a Z =>
l
Vaginal Birth
SO
~
.1.!!1
0." (0.30·0.75)
0.50 (0.33·0.76)
Cl VAGINAL BIRTH
0.49
(0.21-1.18)
0.40 (0.24 . 0.66)
II:
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1986
1987
1988
1989
1990 1
*
1991 p < .0001 vs 1986 1
Fig. 4. Proportion of patients with prior cesarean section(s) undergoing trial of labor increased for both private (P) and clinic (C) patients but was consistently higher for latter group. Proportion of those patients undergoing trial of labor who were delivered vaginally was comparable. Odds ratios for undergoing trial of labor, being successful, and achieving vaginal birth after prior cesarean section for private patients compared with clinic patients in 1986 and 1991 are listed.
Table II. Birth weight distribution and birth weight-specific cesarean section rates 1991
1986 Private Birth weight (gm) ~1000
1001-1500 1501-2000 2001-2500 2501-3000 3001-3500 3501-4000 >4000
No.
23 27 34 103 401 1056 896 406
I
Private
Clinic
% Cesarean section
No.
43.4 63.0 50.0 32.0 28.4 26.1 30.6 39.4
53 46 58 108 283 422 279 109
% Cesarean
I
section
No.
28.3 41.3 37.9 25.0 16.6t 15.9t 17.9t 32.1
24 27 49 108 494 1190 1086 442
I
Clinic
% Cesarean section
No.
45.8 44.4 46.9 22.2 16.4 16.9 18.3 25.1
30 23 40 110 298 479 266 88
I
% Cesarean section
26.7 43.4 17.5* 7.2* 6.7t 9.0t 14.3 26.1
*p < 0.01, clinic versus private patients. tp < 0.001, clinic versus private patients. tp < 0.0001, clinic versus private patients.
Table III. Practice patterns for physicians delivering
(N (N (N (N
=
13)
= 13) = 16) = 18)
27.9 22.3 21.8 20.4
± 9.8 ± 8.9 ± 6.4 ± 8.8
(5.2-42.3) (10.6-40.2) (11.3-30.3) (6.5-4Ll)
100 private patients Repeat cesarean section (%)
Primary cesarean section (%)
Total cesarean section (%) 1988 1989 1990 1991
~
17.4 14.4 14.3 11.5
± 6.0 (3.0-26.1)
± 4.8 (6.0-20.6) ± 4.8 (4.5-22.9) ± 4.7 (4.6-2Ll)
10.6 7.8 7.5 9.0
± 5.4 (2.2-21.5)
± 4.7 (1.8-19.6) ± 4.0 (2.1-14.6)
± 5.9 (1.6-20.0)
Attempted vaginal birth after ceserean section (%)
31.6 47.5 55.6 54.2
± 20.1 (lLl-66.7) ± 21.0 (12.8-90.0)
± 20.1 (12.9-87.5) ± 25.9 (5.3-90.0)
Mean (percent) ± SD with accompanying range.
section and encouragement of vaginal birth after a prior cesarean section(s) persisted through 1991. Perinatal outcome data are contained in Table IV. The percentage of in-house newborns admitted to the neonatal intensive care unit was 10.3% in 1986 and
9.7% in 1991
Socol et al.
Volume 168, Number 6, Part 1 Am J Obstet Gynecol
1753
Table IV. Perinatal outcome 1986
Live births Admissions to neonatal intensive care unit Apgar score at I min ,;;3 <7 Apgar score at 5 min ,;;3 <7 Cord arterial pH <7.10(%)* Fetal deaths Neonatal deaths Neonatal mortality rate Perinatal mortality rate
1987
1988
1990
1989
1991
4264 441
4255 373
4329 417
4429 497
4894 454
4723 457
132 547
128 491
112 598
98 535
ll8 697
114 619
20 98 2.9 40 44 10.3 19.5
23 107 3.0 29 29 6.8 13.5
18 93 2.7 23 28 6.5 11.7
21 73 2.5 32 24 5.4 12.6
19 75 3.0 35 16 3.3 10.3
15 84 2.9 31 18 3.8 10.3
*Over the 6-year period umbilical cord arterial pH measurements were obtained in 89.5% of patients.
Apgar scores ::; 3 and 5-minute Apgar scores ::; 3 or < 7, but the differences were not significant. The incidence of umbilical cord arterial pH values <7.10 remained unchanged at 2.9% (p = 0.96). Comment
During a 6-year period in which the cesarean section rate in the State of Illinois remained constant, we were able to decrease the incidence of total, primary, and repeat cesarean deliveries by 38%, 42%, and 30%, respectively. Less operative intervention for dystocia and greater encouragement of vaginal birth after a prior cesarean section were the major contributing factors to the decline in abdominal deliveries. Recognition by the medical staff that curtailment of unnecessary cesarean sections was an institutional priority probably also contributed to the lower incidence of cesarean births for FHR abnormalities and other indications (e.g., herpes, multiple gestations, third-trimester bleeding). There was a slight reduction in abdominal breech deliveries, but the incidence of cesarean section for malpresentation on the private service did not change over the 6 years. There was a 45% reduction in cesarean births on the clinic service and a 37% drop for private patients. Primary operative delivery for dystocia and malpresentation, plus repeat cesarean section, were all more common on the private service. Factors contributing to the higher cesarean section rate for private patients were the greater proportion of nulliparous patients and more infants with birth weights > 3500 gm. However, the birth weight-specific cesarean section rate was equivalent or higher for private patients at each weight category. Further, substantial variation in clinical practice among individual private practitioners was evidenced by the wide spectrum in total, primary, and repeat cesarean section rates and by the extent to which vaginal birth after cesarean section was encouraged.
These observations are consistent with prior reports suggesting that private physicians perform significantly more cesarean sections than house officers and that individual practice style is an important determinant of the wide range in rates of cesarean delivery among obstetricians. 12. 13 Patient education and expectations, concern about professional liability if there is an adverse outcome, convenience, and financial considerations have all been implicated as contributors to the increase in abdominal deliveries. 14. 15 The higher rate of cesarean deliveries for private patients, however, has not been associated with improved perinatal outcome. 12. 13 The decline in cesarean births was not accomplished at the expense of neonatal outcome. To the contrary, the neonatal mortality rate dropped from 10.3 to 3.8, and the perinatal mortality rate was reduced from 19.5 to 10.3. Measures of neonatal morbidity also did not rise. The percentage of admissions to the neonatal intensive care unit remained constant, as did the percentage of neonates with umbilical cord arterial pH values < 7.10. Similarly, there was not an increase in the incidence of low Apgar scores; in fact, the trend was in the opposite direction. Studies from other countries have demonstrated reductions in perinatal mortality independent of an increase in abdominal delivery.16-18 More data now accumulating in the United States strongly suggest that the cesarean section rate can be safely lowered without increasing perinatal morbidity or mortality.9. 10. 19 Successful programs for reducing the cesarean section rate have been previously reported from predominantly indigent populations. Two university hospitals reduced the incidence of cesarean birth from 27.5% and 17.5% to approximately 11%,9. 10 and in a third hospital the cesarean section rate for the clinic service was lowered to 5.7%. I 9 These programs use a centralized approach to intrapartum decision making that
1754 Socol et al.
incorporates strict guidelines for abdominal delivery and comprehensive peer review. Attempts to implement similar programs in the obstetric community at large may be met with significant resistance because private practitioners feel their autonomy threatened. Consequently, reversal of the previously escalating cesarean section rate will depend on alternative strategies that can be adapted to individual institutions. We have successfully reduced our cesarean section rate in a primarily private tertiary university facility by establishing this as an institutional priority, encouraging vaginal birth after prior cesarean section, circulating the cesarean section rate of each obstetrician to the entire attending staff, and implementing an active management of labor protocol for term nulliparous patients. Significant reductions in abdominal deliveries occurred for both private and clinic patients, but differences in population demographics and individual physician practice patterns contributed to a higher incidence of cesarean birth on the private service. We thank Roseann LoSasso for assistance with data collection. REFERENCES 1. Stanley F], Watson L. The cerebral palsies in Western Australia: trends 1968 to 1981. AM ] OBSTET GYNECOL 1988; 158:89-93. 2. Malloy MH, Rhoads GG, Schramm W, Land G. Increasing cesarean section rates in very low-birth weight infants. Effect on outcome. ]AMA 1989;262:1475-8. 3. Taffel SM, Placek P], Moien M, Kosary CL. 1989 U. S. cesarean section rate steadies - VBAC rate rises to nearly one in five. Birth 1991;18:73-7. 4. Rubin GL, Peterson HB, Rochat RW, McCarthy BJ, Terry ]S. Maternal death after cesarean section in Georgia. AM J OBSTET GYNECOL 1981;139:681-5. 5. Evrard JR, Gold EM. Cesarean section and maternal mortality in Rhode Island - incidence and risk factors. Obstet Gynecol 1977;50:594-7. 6. Cesarean childbirth: report of the NICHD Task Force on Cesarean Childbirth. Bethesda, Maryland: National Institutes of Health, 1981; Department of Health and Human Services publication no (NIH) 82-2067. 7. Bottoms SF, Rosen MG, Sokol RJ. The increase in the cesarean birth rate. N Engl J Med 1980;302:559-63. 8. Stafford RS. Alternative strategies for controlling rising cesarean section rates. JAMA 1990;263:683-7. 9. Myers SA, Gleicher N. A successful program to lower cesarean section rates. N Engl J Med 1988;319: 1511-6. 10. Sanchez-Ramos L, Kaunitz AM, Peterson HB, MartinexSchell B, Thompson RJ. Reducing cesarean sections at a teaching hospital. AM J OBSTET GVNECOL 1990;163:1081-8. 11. Lopez-Zeno JA, Peaceman AM, Adashek], Socol ML. A controlled trial of a program for the active management of labor. N Engl J Med 1992;326:450-4. 12. Haynes de Regt R, Minkoff HL, Feldman J, Schwarz RH. Relation of private or clinic care to the cesarean birth rate. N Engl J Med 1986;315:619-24. 13. Goyert GL, Bottoms SF, Treadwell MC, Nehra PC. The physician factor in cesarean birth rates. N Engl J Med 1989;320:706-9. 14. Phillips RN, Thornton J, Gleicher N. Physician bias in cesarean sections. JAMA 1982;248: 1082-4. 15. Anderson GM, Lomas J. Determinants of the increasing
June 1993 Am J Obstet Gynecol
16. 17. 18. 19.
cesarean birth rate: Ontario data 1979 to 1982. N Engl J Med 1984;311:887-92. O'Driscoll K, Foley M. Correlation of decrease in perinatal mortality and increase in cesarean section rates. Obstet GynecoI1983;61:1-5. Bonham DG. Caesarean birth. N Z Med J 1983;96:205-6. Rockenschaub A. Technology-free obstetrics at the Semmelweis Clinic. Lancet 1990;335:977-8. Porreco RP. High cesarean section rate: a new perspective. Obstet Gynecol 1985;65:307-11.
Discussion
DR. HERBERT F. SANDMlRE, Green Bay, Wisconsin. The authors' concern over the escalating cesarean rate at their institution prompted them to introduce three initiatives that might reduce their cesarean rate. Although applauding the reduction enumerated in their report, I would ask if they remain concerned regarding some subset of cesarean rates at their institution. In particular it appears that their 1991 private patient rate of 19.1 is unacceptably high. The 11.5 clinic rate for the same year comes closer to optimal rates proposed or achieved by other authors (Table I). The management of the nulliparous private patient was problematic for Northwestern obstetricians, resulting in a twofold greater risk of cesarean birth compared with comparable clinic patients (insert, Fig. 2). This disparity actually increased after the introduction of the authors' cesarean-reducing initiatives from 1.47 (odds ratio) in 1986 to 2.01 in 1991. Do the authors have an explanation for this difference? Is the difference attributable to higher rates by volunteer faculty compared with full time faculty? Are there differences in epidural use or frequency of induction of labor between the private and clinic services? These differences are important because the proper management of the nulliparous patient with appropriate cesarean birth decisions is the key to achieving an optimal overall cesarean section rate. Meanwhile, multiparous private patients had less chance of cesarean than clinic patients (odds ratio 0.88). I would ask the authors if they know why their faculty achieved more reasonable cesarean birth rates in their private multiparous patients compared with nulliparous. Similarly, private patient physicians demonstrated no change in their cesarean rates for malpresentation from 1986 to 1991, whereas the clinic rate decreased dramatically (Fig. 3). Do the authors have a reason for this discrepancy? Do those faculty physicians (full time) who supervise residents have cesarean rates lower than volunteer faculty and similar to the clinic rates?
Table I. Optimal cesarean rates Porreco' (1985) Myers and Gleicher2 (1988) DeMott and Sandmire' (1990) Green Bay, Wisconsin 4 (1990 and 1991) Quilligan 5 (1985), proposed
6.0% 11.0% 7.8% 11.7% 8.0%
Socol et al.
Volume 168, Number 6, Part I Am J Obstet Gynecol
1755
Table II. Combined Bellin and St. Vincent Hospital Deliveries (Green Bay)
1986 (N 1991 (N
= 3256) = 3292)
Total cesarean section (%)
Primary cesarean section (%)
Repeat cesarean section (%)
Successfol vaginal birth after cesarean
15.8 11.6 (5.3-18.4)
9.5 7.2
6.3 4.4
23.1 (St. Vincent only) 37.5
Table III. Birth weight distribution and birth weight-specific cesarean section rates 1986 Private patients Actual weights Birth weight (gm)
:51000 1001-1500 1501-2000 2001-2500 1501-3000 3001-3500 3501-4000 >4000
No.
23 27 34 103 401 1056 896 406 2910
I
%
0.08]
~:~9 3.5 13.8 36.3 30.8 13.9 100
I%
Cesarean section
43.4 63.0 6.4% 50.0 32.0 28.4 26.1 30.6 39.4
I
Clinical weight distribution * No. of cesarean sections
No.
10 17 17 33 114 276 274 160
116 102 128 236 620 922 611 239
901 (30.3%)
2910
I
% 4.0 3.5 4.4 8.1 21.3 31.7 21.0 8.2 100
I
% Cesarean sectIOn
)19"*
I
No. of cesarean sectIOns
43.4 63.0 50.0 32.0 28.4 26.1 30.6 39.4
50 64 64 76 176 241 187 94 952 (32.7%)
*Weight-specific cesarean rates for private patients if their birth weight distribution was the same as clinic patients.
The authors' Table III depicts alarming variations in cesarean section rates among physicians delivering ;;:: 100 patients. Particularly surprising is the 1991 total and repeat cesarean rates for one physician of 41.1 and 20.0, respectively. These very high cesarean rates and an attempted vaginal birth after cesarean delivery rate of only 5.3% are incomprehensible to Green Bay obstetricians, whose rates are depicted in Table II. Apparently the authors' institution's traditional quality assurance procedures and the three initiatives described in this paper are not influencing cesarean birth decisions made by this physician. The author's conclusion that newborn birth weights > 3500 gm contribute to the higher cesarean rate for private patients is not supported by their data, at least for the 1991 births. Their Table II provides their birth weight distribution and birth weight-specific cesarean rates. The 18.3 1991 private patient cesarean rate for the 350 I to 4000 gm weight group is not significantly higher than their 16.9 rate for the 3001 to 3500 gm weight group. This difference accounts for only 15 of the 662 private cesarean births for that year. Meanwhile, the excess private patient cesarean births resulting from the difference in private and clinic 1991 cesarean rates (19.1 vs 11.5) totals 256. In addition, for the ;;:: 4000 gm weight group the private cesarean rate (25.1) is actually lower than the clinic rate (26.1). Overall, the birth weight distribution for private patients is more favorable for a lower cesarean rate than is the clinic birth weight distribution. Tables III and IV demonstrate the weight-specific cesarean rates after changing the private birth weight distribution to the distribution existing for clinic patients. This change
would have resulted in a higher cesarean rate for private patients in 1986 and 1991 compared with the rates reported with the actual birth weight distribution (32.7 vs 30.3 and 20.5 vs 19.1, respectively). The author's contention that patient population characteristics contribute to the higher cesarean rate for private patients should be rejected. The authors have provided cesarean birth statistics comparing clinic and private patients and rates comparing individual faculty members who have more than 100 deliveries per year. It may be instructive to have cesarean rate comparisons between volunteer and full time faculty and faculty members with < 100 to those with > 100 deliveries per year. In the opinion of Myers and Gleicher6 an individual "cesarean section rate above 15 percent is almost always excessive." In spite of this, the authors claim to "have successfully reduced their cesarean rate at their primarily private tertiary university facility." The correctness of their claim depends on the definition of success. Certainly they have achieved substantially lower cesarean rates in 1991 compared with 1986. However, can a university facility with a private patient cesarean rate of 19.1 - almost twice the clinic rate - be regarded as successful in reaching their goal, which was the "curtailment of unnecessary cesarean sections"? To achieve success the authors need to find ways to raise the quality of labor management for nulliparous private patients to that level currently provided to their clinic patients. Their private patients deserve no less. In addition, reducing the private cesarean rate for malpresentation to the clinic rate would be helpful. The authors' cesarean birth decrease is impressive.
1756 Socol et al.
June 1993 Am J Obstet Gynecol
Table IV. Birth weight distribution and birth weight-specific cesarean section rates 1991 Private patients Actual weights Birth weight (gm)
:-;; 1000 1001-1500 1501-2000 2001-2500 2501-3000 3001-3500 3501-4000 >4000
No.
24 27 49 108 494 1190 1086 442 3364
I
% 0.07 0.08 1.5 3.2 14.7 35.4 32.3 13.1 100
I
% Cesarean sectwn
I No. sectIOns of cesarean
45.8 44.4 6.2% 46.9 22.2 16.4 16.9 18.3 25.1
No.
11 12 23 24 81 201 199 III
77 61 104 283 767 1235 686 225
662 (19.1%)
3364
1
%
2.3 1.8 3.1 8.4 22.8 36.7 20.4 6.7
100
I
Clinical weight distribution *
I
% Cesarean
15.5%
sectwn
45.8 44.4 46.9 22.2 16.4 16.9 18.3 25.1
No. of cesarean sections
35 27 49 63 126 209 126 56 691 (20.5%)
*Weight-specific cesarean rates for private patients if their birth weight distribution was the same as clinic patients.
Their very high initial cesarean rate and persistently high private patient cesarean rates (breech, nulliparous) are not impressive. Having rates only slightly different than statewide rates is not good enough for a university center from which leadership is expected. REFERENCES
1. Porreco RP. High cesarean section rate: a perspective. Obstet Gynecol 1985;65:307-11. 2. Myers SA, Geicher N. A successful program to lower cesarean section rates. N Engl J Med 1988;319: 1511-6. 3. DeMott RK, Sandmire HF. The Green Bay cesarean section study. I. The physician factor as a determinant of cesarean birth rates. AM J OBSrET GVNECOL 1990;162:1593-602. 4. Health Pages 1992 Sept 24. 5. Quilligan EJ. Cesarean section: modem perspective. In: Queenan JT, ed. Management of high-risk pregnancy. 2nd ed. Oradell, New Jersey: Medical Economics, 1985:594600. 6. Myers SA, Gleicher N. The Mount Sinai cesarean section reduction program: automated data collection and peer review. Quality Lett 1991; March. DR. GERALD F. JOSEPH, New Orleans, Louisiana. "Peer review," "quality assurance," "practice guidelines," "continued quality improvement" are part of the medical phraseology of the 1990s recognizable to each of us but ideals that are accepted and used with feelings that range from disgust and resistance to guarded enthusiasm. In spite of how we may feel, the progressive intrusion into the practice of medicine will likely continue and even increase. In the past decade the increased use of cesarean section gained national recognition and attention. The relative appropriateness of this trend has been debated in our medical literature, I. 2 in public forums,' and among each of us in private conversation. In recent years there has emerged a consensus among most obstetricians that the increase in cesarean delivery has done very little to improve delivery outcomes and has greatly increased the cost of delivery services, as cited by
Socol et al. Studies began to focus on suggested causes and potential "cures" for this escalating rate both in the private and public sectors of obstetrics. This paper profoundly demonstrates how one group incorporated the basic principles of "quality assurance," "peer review," and "practice guidelines" to effect a program of "continued quality improvement." The requirement for documentation that vaginal birth after cesarean delivery had been offered and supposedly encouraged exemplifies one aspect of quality assurance initiated in 1987. In this study it is not possible to clearly separate the influence of encouraging vaginal birth after cesarean delivery from the influence of posting individual cesarean section rates. Indeed, if emphasis on vaginal birth after cesarean delivery began in 1987, there was actually an increase in repeat cesarean sections in 1988, and it was at the end of that calender year that cesarean section rates were published. The great variation among physicians with respect to trials of labor points to continued physician resistance. I would also suspect that patient resistance remains a deterrent and explains the inability to further reduce repeat cesarean delivery in the last year or two of the study. Peer review with resulting praise or criticism from one's closest colleagues is an extremely sensitive measure of professional acceptance to the caring physician. Little wonder why publishing cesarean section rates might function as such an effective tool for behavior modification. It is most interesting to note that in spite of any formal change in policy regarding the management of FHR abnormalities, malpresentation, multiple gestations, or third-trimester bleeding, abdominal delivery for these indications also decreased, in certain instances, separate from the indication of dystocia. Further, institution of this quality management initiative in 1988 preceded any protocol for active management of labor. The year with the greatest decrease of any single year was in 1989, the first year after posting
Volume 168, Number 6, Part 1 Am J Obstet Gynecol
cesarean rates and before protocol modifications for conduct of active labor. Suggestive evidence, at least, that the human factor associated with clinical decision making involving peer review is operative and influential. Practice guidelines represent a pattern of thought and action describing how we function as physicians, When we judge outcomes to be bad, we instinctively examine and reexamine what we do and why and seek to formulate new, hopefully better methods to solve problems. This group sought a better way to overcome the clinical diagnosis of dystocia so often cited as the indication for cesarean delivery. Practice guidelines for active management of labor established by others, evaluated and recommended by this group for their own practice, seemed to safely and effectively reduce the need for primary abdominal delivery. It is hoped that other studies will likewise demonstrate similar results so that active management of labor can be more vigorously endorsed by The American College of Obstetricians and Gynecologists in its Technical Bulletin on induction and augmentation of labor. In that way obstetricians, when following these practice guidelines, may feel greater protection from the medicolegal consequences of bad delivery outcomes that have little if anything to do with the conduct of labor. Embracing many of the principles of quality assurance, peer review, and practice guidelines, a significant reduction in the incidence and need for cesarean delivery was accomplished over a 5-year period. The staggered start of these three initiatives makes it difficult to calculate the relative impact of each initiative independently. Increased use of epidural anesthesia without increased need for operative vaginal delivery during the study period suggests that the results were not accomplished by "the use of mirrors." A very favorable comparative review of perinatal parameters points to the safety of the implemented guidelines. This study represents an excellent example of the essence of continued quality improvement, and, to think, it was done by physicians alone! I have several questions: (1) I was unable to determine if the same group of physicians were being followed longitudinally. From the tables it is apparent that the total staff delivering more than 100 babies per year grew by at least five from 1988 to 1991. Are you teaching "old dogs new tricks" or do you have more "new dogs"? (2) Was there any attempt at standardizing the approach to counseling patients about vaginal bi:-th after cesarean delivery? What was considered adequate documentation? and (3) Does the author have any other information or a personal opinion as to the relative importance of each of these initiatives in reducing the cesarean rate? REFERENCES
1. Petitti DB, Cefalo Re, Shapiro S, et al. In hospital maternal mortality in the United States: time trends and relation to method of delivery. Obstet Gynecol 1982;59:6.
Socol et al.
1757
2. Porreco RP. High cesarean section rate: a new perspective. Obstet Gynecol 1985;65:307-11. 3. Cesarean childbirth. Washington: United States Department of Health and Human Services, 1981; publication no 82-2067.
DR. EUGENE W.J. PEARCE, Shawnee Mission, Kansas. Those of us who have been around for a while realize that there was a sea change about 1970, when the obstetric standard of practice changed in the interest of fetal survival, and the panacea became cesarean section for all obstetric problems, best expressed by the following idea: "Ifit doesn't fall out, cut it out." Consequently, what happened is that many of the young people were never taught some of the old-fashioned techniques of getting the baby out safely. In addition, there was a release from corporate control. It used to be the standard of practice that a primary cesarean section required a consultant to agree, and The American College of Obstetricians and Gynecologists decided about that time that that was unnecessary . One of the things that this article emphasizes is the return to corporate control; that is, there are some institutional responsibilities for the cesarean section rate. I was about to retire, a miserable old man in the twilight of a mediocre career, when Youngblood decided that I ought to become a full-time faculty member at Truman Medical Center. I discovered I was in charge of archaic obstetrics, including the use of forceps, vaginal breech delivery, and the management of dystocia, and I'm about to bring out a resident lecture on clinical pelvimetry. The amazing thing about all of these subjects is that there is a modern literature on all of them. There have been three books written on forceps in the last 4 years. There's a modern study on breech delivery. There are two books on the management of labor, which came out within the last 3 years, and in Surgical Obstetrics by Plauche published in 1992 there's an article on clinical pelvimetry. The point is, if we're going to reduce the cesarean section rate, we're going to have to reinstitute some of those old measures about how to get the baby out safely without damaging the mother. DR. ROBERT ZURAWIN, Houston, Texas. The attempts to decrease the cesarean section rate as presented here so far have not sufficiently addressed either the lack of skill in forceps delivery by the younger obstetricians or the abandoning by older obstetricians of non operative delivery because of medical-legal liability . Pressure from law suits resulting from poor outcome is still a great determinant of the mode of delivery. I do not think that it is helpful for a discussant to impose arbitrary limits of, for example, 15% and then declare anything above that as representing an unacceptably high rate of cesarean section. Bragging about one's low percentage is somewhat akin to bragging
1758 Socol et al.
about the size of one's genitals. It may only serve to impress yourself. We must not allow others to impose on us their ideas of what is an "acceptable" rate of cesarean section. Clearly, egregious rates must be critically analyzed, of course, but we would be better served by teaching our residents how to use forceps skillfully and to manage labor with clinical judgement without slavish reliance on monitor strips. Finally, this problem is not going to go away so long as we and our colleagues are so eager and willing to testity as so-called experts for plaintiffs in cases where there are either forceps deliveries or noncesarean deliveries where the baby comes out with anything but a perfect outcome. All of us know of babies delivered by forceps who have learning disabilities. We know of far more who have disabilities where forceps have not been applied or after completely normal pregnancies and deliveries. Anybody here who testifies against one of our colleagues in one of those kind of cases should be held directly responsible for the current crisis on obstetrics. This is where peer review and quality assurance should be concentrated, not against those practitioners whose cesarean rates fall outside arbitrary guidelines. DR. ROBERT K. DEMoTT, Green Bay, Wisconsin. When we started the Green Bay cesarean section study, our total cesarean section rate was 14%. Just by simply performing a study we noted a decrease in our rate to 10%, with a similar drop in primary and repeat sections. We also noted a change in our medical staff with the retirement of some older physicians, who actually had higher rates, and an influx of younger physicians with lower rates. DR. LEE MATTHEWS, Bloomington, Indiana. I feel that the authors will have better results if they start with a lower dosage oxytocin, probably 0.5 to 1 mU, and maybe increasing by 1 to 2 mU every 15 or 20 minutes. I think in most of their cases they would be able to accomplish results at least as good with a 6 mU dose, which is what their starting dose was by using intrauterine pressure catheters. DR. BROOKS RANNEY, Yankton, South Dakota. There is a techical point concerning individual cesarean section rates. It is dangerous to draw conclusions from raw statistics without careful study. For example, between 1948 and 1972 I was delivering between 250 and 300 babies a year, so these were large statistics for each year. However, in one of those years my cesarean section rate was 3.2%, but in the next year it was 13.4%. This was not caused by a difference in indications. Rather, this was caused by a difference in the patients referred with serious complications. So one should take a 5-year average of individual doctors' statistics to draw valid conclusions. Additionally, it helps to place referred patients' statistics in a separate category from those of individual obstetricians' primary-care patients. DR. JOHN CALKINS, Kansas City, Missouri. In our institution we battle back and forth regarding the issue of oxytocin dosage that Dr. Matthews addressed. My question is, was the protocol outlined for active manage-
June 1993 Am J Obstet Gynecol
ment of labor applied to patients with vaginal birth after cesarean delivery as well as for nulliparous patients? If it was not applied to that group of patients who clearly have a high incidence of dystocia as an indication for the previous cesarean section, why was it not applied? DR. SOCOL (Closing). To begin with Dr. Sandmire's comments, I agree that the process is not perfect and I would prefer to view it as an evolving one. It is difficult to pick a specific number as an ideal cesarean section rate. Interestingly, the State of Illinois has targeted 15% as an appropriate incidence of abdominal delivery. I'm not sure what the source of wisdom is to arrive at that figure, but if I were to pick a number that is probably in the right ballpark. We have to realize that the rise in cesarean sections in the 1970s and 1980s did not decrease the incidence of cerebral palsy, which has not changed over the last 30 years. Approximately half our practitioners are full time and the remainder are volunteer faculty. Both the lowest and highest cesarean section rates belong to members of the volunteer faculty. Undoubtedly, there remains considerable variation in the practice patterns of our faculty. Lastly, the intrapartum use of epidural anesthesia rose almost twofold on both the private and clinic services, but the cesarean section rates declined for both groups of patients. As for Dr. Joseph's comments, I believe there has been a positive effect on some of the young faculty who have been influenced by our institutional emphasis, but some of our "old dogs" have also recognized some merit. We do not have a standardized policy for counseling patients about vaginal birth after cesarean section, but we do require that if a patient undergoes an elective repeat abdominal delivery after only one prior low-transverse cesarean section the attending physician must document that the patient declined a trial of labor. The hospital quality management committee audits charts periodically and forwards outliers to the departmental committee. The increase in trials of labor and the decline in repeat operations attest that the process works. It is difficult to determine the effect of each of the three initiatives, but if I were to speculate on the most beneficial one it probably would be the peer pressure generated from distributing the cesarean section rate of every obstetrician to each attending physician. The incidence of operative vaginal delivery remained unchanged at approximately 13%. In spite of similar attitudes towards forceps over the last 6 years, we have been able to successfully reduce our cesarean section rate. The purpose of this presentation is not to allege that we are better than anyone else but rather to assert that a reduction in abdominal deliveries by 40% is an important achievement. I would disagree that we should be using lower doses of oxytocin and our previously published randomized trial of the active management of labor supports this posture. That trial was confined to term nulliparous patients and therefore did not apply to candidates for vaginal birth after cesarean delivery.
Key words: Cesarean section, vaginal birth after cesarean section, dystocia, active management of labor
The increased use of cesarean delivery, like the institution of electronic fetal heart rate (FHR) monitoring, was anticipated to improve perinatal outcome. This expectation remains unfulfilled. 1. 2 Nevertheless, the cesarean section rate in the United States reached 24.7% in 1988' with an accompanying negative impact on maternal health4 • 5 and obstetric care costs. 6 The major factors accounting for this rise in abdominal delivery are dystocia and prior cesarean section, with malpresentation and FHR abnormalities contributing to a lesser degree.' Strategies proposed for controling the cesarean section rate include physician education and peer evaluation, changes in physician and hospital reimbursement, and medical malpractice reform. s Two university hosFrom the Section of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Medical School and Northwestern Memorial Hospital. Presented at the Sixtieth Annual Meeting of The Central Association of Obstetricians and Gynecologists, Chicago, Illinois, October 15-17, 1992. Reprint requests: Michael L. Socol, MD, 333 E. Superior St., #410, Chicago, lL 60611. Copyright © 1993 by Moslry-Year Book, Inc. 0002-9378/93 $1.00 + .20 6/6/45999
1748
pitals servicing a primarily low-income, inner-city population have demonstrated that it is feasible to reduce the incidence of cesarean birth to approximately 11% by incorporating strict guidelines for abdominal delivery and comprehensive peer review. g • 10 A centralized approach to intrapartum decision making, however, is unlikely to be well received by the obstetric community at large, and effective administrative reforms are not likely to be implemented in the near future. Concern over the escalating cesarean section rate at our institution, a primarily private tertiary university hospital, prompted us to undertake and evaluate the outcome of three initiatives that are the subject of this report.
Methods Northwestern Memorial Hospital is a primarily private tertiary university facility. The medical staff comprises approximately equal numbers of full-time and volunteer faculty. The resident house staff evaluates each patient admitted to labor and delivery, but their primary responsibility is for all clinic patients and complicated private patients. Resident supervision for the medically indigent patients is provided by the full time faculty. Demographic data for the total obstetric popu-
Socol et al.
Volume 168, Number 6, Part 1 Am J Obstet Gynecol
1749
Table I. Demographic data Total patients Nulliparous Multiparous Payor status Private Clinic Race White Black Other
1986
1987
1988
1989
1990
1991
4240 2009 (47.4) 2231 (52.6)
4219 1969 (46.7) 2250 (53.3)
4271 2037 (47.7) 2234 (52.3)
4391 2081 (47.4) 2310 (52.6)
4829 2327 (48.2) 2502 (51.8)
4669 2243 (48.0) 2426 (52.0)
2910 (68.6) 1330 (31.4)
2950 (69.9) 1269 (30.1)
3036 (71.1) 1235 (28.9)
3035 (69.1) 1356 (30.9)
3383 (70.l) 1446 (29.9)
3364 (72.0) 1305 (28.0)
2718 (64.1) 894 (21.1) 628 (14.8)
2799 (66.3) 850 (20.2) 570 (13.5)
2759 (64.6) 932 (21.8) 580 (13.6)
2849 (64.9) 916 (20.9) 626 (14.2)
3031 (62.8) 1009 (20.9) 789 (16.3)
2942 (63.0) 888 (19.0) 839 (18.0)
lation are listed in Table I. The proportion of private patients, that was nulliparous was 52.5% in 1986 and 52.6% in 1991; for clinic patients the proportions were 35.5% and 35.6%, respectively. The institutional cesarean section rate reached its zenith in 1986 when 27.3% of births were abdominal deliveries. Three initiatives were subsequently undertaken between 1987 and 1991 to reduce the cesarean birth rate. First, vaginal birth after one prior low-transverse cesarean section was more strongly encouraged. Physicians were required to document that eligible patients had been offered a trial of labor and that an elective repeat operation was performed because the patient declined a trial of labor. Patients with an unknown uterine scar were allowed a trial of labor if the prior indication for cesarean section was one for which a low-transverse incision was most likely used. Patients with two prior low-transverse uterine incisions were not strongly encouraged to labor, although this decision was supported for well motivated patients, particularly those who had never attempted vaginal birth after cesarean section. Patients with a prior vertical uterine incision or a myomectomy in which the uterine cavity had been entered were not considered candidates for vaginal delivery. Management oflabor initially included the use of an internal scalp electrode and intrauterine pressure catheter whenever possible, but more recently labor has been managed similarly to that in a patient with an un scarred uterus. Electronic FHR monitoring continues to be routinely used, and both epidural anesthesia and oxytocin augmentation are used as deemed necessary. Second, a quality management initiative was introduced because of suspected significant differences among physicians in cesarean section rates and use of vaginal birth after prior cesarean section. After the 1988 calendar year the cesarean section rate (divided into primary cesarean sections, repeat cesarean sections, and number of patients undergoing a trial of labor after prior cesarean section) for every obstetrician was circulated annually to each attending physician,
with the presumption that this would provide positive reinforcement for achieving a lower rate of abdominal delivery. Third, because dystocia (arrest of labor, failure to progress) is the factor that has contributed most to the rise in primary cesarean sections, a prospective randomized trial to evaluate the efficacy of the active management of labor protocol for term nulliparous patients was undertaken in 1990. II Spontaneous labor was defined as the presence of regular, painful uterine contractions at least once every 5 minutes in association with either complete cervical effacement or spontaneous rupture of membranes. Patients assigned to the active management of labor protocol had amniotomy performed within 1 hour of the diagnosis of labor if membranes were intact. At any time in the first stage of labor that the rate of cervical dilation was found to be < 1 cm/hr, a determination of inadequate progress in labor was made, and oxytocin augmentation was initiated. The initial oxytocin infusion rate was 6 mU/min, which was increased by 6 mU/min every 15 minutes until there were seven contractions in 15 minutes or a maximum of 36 mU/min was reached. After the completion of this study in March 1991 this scheme has been recommended to the medical staff as the preferred method of labor management for term nulliparous patients. Since 1986 there has not been any formal change in the recommended management of FHR abnormalities, breech presentations, or twin gestations. Cesarean section is discouraged for FHR abnormalities unless fetal acidosis is confirmed by scalp pH assessment. Route of delivery and consideration of external version for breech presentations are left to the discretion of the attending physician. Similarly, there is no standrad protocol for multiple gestations, but a trial of labor is encouraged for vertex-nonvertex presentations, particularly if the fetuses are thought to be ;;:: 32 weeks' gestations or ;;:: 1500 gm. The decision to use external version or breech extraction for a second twin is determined by the attending physician. Delivery data were retrieved from the perinatal data
1750 Socci et al.
June 1993 Am J Obstet Gynecol
30
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o~----~------------~----~----~ 1986 1987 1988 1989 1990 1991 Fig. 1. Although incidence of operative deliveries in Illinois (IL) remained constant from 1986 to 1991, total, primary, and repeat cesarean section rates at Northwestern Memorial Hospital (NMH) declined.
base. Annual proportions of primary and repeat cesarean sections were computed from 1986 to 1991. Primary cesarean sections were further subclassified by indication. The proportion of patients with prior cesarean deliveries undergoing a trial of labor and the number of vaginal births were also tabulated. Perinatal outcome measures included neonatal intensive care unit admissions, neonatal and perinatal mortality rates, Apgar scores, and umbilical cord arterial pH values. Statistical comparisons of data between 1986 and 1991 or between private and clinical services were made by X2 analysis. Statistical significance was assumed at a level of p < 0.05. Results The total, primary, and repeat cesarean section rates at Northwestern Memorial Hospital are compared with data from the State of Illinois in Fig. 1. The statewide figures have remained essentially unchanged over the 6-year period. The total, primary, and repeat cesarean section rates in Illinois were 23.2%, 14.4%, and 8.8% in 1986 compared with 22.9%, 13.7%, and 92.%, respectively, in the first 6 months of 1991. In contrast, at Northwestern Memorial Hospital the rates of total, primary, and repeat cesarean deliveries dropped from 27.3%, 18.2%, and 9.1% in 1986 to 16.9% (p < 0.0001), 10.6% (p < 0.0001), and 6.4% (p < 0.0001), respectively, in 1991. During the sample period there was an increase in the intrapartum use of epidural anesthesia (28.4% vs 47.7%, P < 0.0001), but there was no change in the incidence of operative vaginal delivery (12.6% vs 13.3%, P = 0.38). The annual total, primary, and repeat cesarean section rates for the private and clinic services are enumerated in Fig. 2. There was a significant decline in total cesarean deliveries from 1986 to 1991 for both private
patients (odds ratio 0.54, 95% confidence interval 0.48 to 0.61) and clinic patients (odds ratio 0.49, 95% confidence interval 0.40 to 0.62). In spite of this decline in operative delivery, private patients were more likely to be delivered by cesarean section than were clinic patients in both years. There was also a significant decline in primary cesarean sections from 1986 to 1991 for both private patients (odds ratio 0.54, 95% confidence interval 0.47 to 0.62) and clinic patients (odds ratio 0.45, 95% confidence interval 0.34 to 0.60). In Fig. 3 the annual primary cesarean section rates are categorized by indication for intervention for the private and clinic services. Primary cesarean sections for dystocia, FHR abnormalities, and other indications (e.g., multiple gestation, herpes, third-trimester bleeding) decreased for both groups of patients. Operative intervention for malpresentation also dropped for clinic patients. The decline in operative intervention for dystocia was greater on the private service, whereas the decline in abdominal delivery for FHR abnormalities was greater on the clinic service. For the entire population there was a decline in cesarean births for dystocia from 8.8% to 4.8% (odds ratio 0.53, 95% confidence interval 0.44 to 0.63), for FHR abnormalities from 2.8% to 1.4% (odds ratio 0.49, 95% confidence interval 0.35 to 0.67), for malpresentation from 3.4% to 2.7% (odds ratio 0.80, 95% confidence interval 0.62 to 1.02), and for other indications from 3.3% to 1.7% (odds ratio 0.51, 95% confidence interval 0.38 to 0.67). Vaginal birth after cesarean section increased over time, as shown in Fig. 4. As a result, there was a significant decline in repeat cesarean sections from 1986 to 1991 for private patients (odds ratio 0.67, 95% confidence interval 0.56 to 0.81) and clinic patients (odds ratio 0.66, 95% confidence interval 0.47 to 0.92).
Socol et al.
Volume 168, Number 6, Part 1 Am J Obstet Gynecol
40
~
t:t: a:
30
ll!!!!
Wi
1.65 (1.41 ·1.94) PRIMARY 1.59 (1.32·1.91) Nulliparous 1.47 (1.15-1.88)
TOTAL
[;] REPEAT
(J)
W
Ilil PRIMARY
P
1751
1.81 (1.. . . 2.20) 1.90 (1.48 - 2.43) 2.01 (1.45 - 2.78) 0.88 (0.56·1.39)
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en
z «w a: « en w
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1986
1987
1989
1988
1990 1
* **
1991
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19861
Fig. 2. Total, primary, and repeat cesarean section rates declined for both private (P) and clinic (C) patients. Insert, Odds ratios for abdominal delivery for private patients compared with clinic patients in 1986 and 1991.
25
20
iii DYSTOCIA
EiiI MALPRESENTATION lIII FETAL HEART RATE El OTHER ABNORMALITIES P
1986
1987
1988
Dystoc;.
2.25 (1.70 - 2.99)
ll!!!!
~ 1.78 (1.25·2.56)
FetalHe8It Rate Abnormalities
0.66 (0.48-1.01)
1.39 (0.74·2.64)
Malpresentation
I.SO (1.00 - 2.26)
3.21 (1.79·5.85)
Othe,
1.30 (0.87 • 1.96)
1.21 (0.70.2.11)
1989
1991
1990
* '* '*
P<.05) va
p < .01 ***P < .0001
1986
Fig. 3. Annual primary cesarean section rates are presented by indication for intervention for private (P) and clinic (C) services. Odds ratios for primary cesarean section for private patients compared with
clinic patients in 1986 and 1991 are enumerated.
Clinic patients with a prior cesarean section were more likely to be delivered vaginally, however, because of the greater use of a trial of labor. For the entire population the proportion of patients with prior cesarean deliveries undergoing a trial of labor increased from 27.2% to 58.3%
significantly greater proportion of newborn infants in the private-practice group had a birth weight > 3500 gm
1752 Socol et al.
June 1993 Am J Obstet Gyneco1
70 Cl
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60
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Vaginal Birth
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1987
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1989
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*
1991 p < .0001 vs 1986 1
Fig. 4. Proportion of patients with prior cesarean section(s) undergoing trial of labor increased for both private (P) and clinic (C) patients but was consistently higher for latter group. Proportion of those patients undergoing trial of labor who were delivered vaginally was comparable. Odds ratios for undergoing trial of labor, being successful, and achieving vaginal birth after prior cesarean section for private patients compared with clinic patients in 1986 and 1991 are listed.
Table II. Birth weight distribution and birth weight-specific cesarean section rates 1991
1986 Private Birth weight (gm) ~1000
1001-1500 1501-2000 2001-2500 2501-3000 3001-3500 3501-4000 >4000
No.
23 27 34 103 401 1056 896 406
I
Private
Clinic
% Cesarean section
No.
43.4 63.0 50.0 32.0 28.4 26.1 30.6 39.4
53 46 58 108 283 422 279 109
% Cesarean
I
section
No.
28.3 41.3 37.9 25.0 16.6t 15.9t 17.9t 32.1
24 27 49 108 494 1190 1086 442
I
Clinic
% Cesarean section
No.
45.8 44.4 46.9 22.2 16.4 16.9 18.3 25.1
30 23 40 110 298 479 266 88
I
% Cesarean section
26.7 43.4 17.5* 7.2* 6.7t 9.0t 14.3 26.1
*p < 0.01, clinic versus private patients. tp < 0.001, clinic versus private patients. tp < 0.0001, clinic versus private patients.
Table III. Practice patterns for physicians delivering
(N (N (N (N
=
13)
= 13) = 16) = 18)
27.9 22.3 21.8 20.4
± 9.8 ± 8.9 ± 6.4 ± 8.8
(5.2-42.3) (10.6-40.2) (11.3-30.3) (6.5-4Ll)
100 private patients Repeat cesarean section (%)
Primary cesarean section (%)
Total cesarean section (%) 1988 1989 1990 1991
~
17.4 14.4 14.3 11.5
± 6.0 (3.0-26.1)
± 4.8 (6.0-20.6) ± 4.8 (4.5-22.9) ± 4.7 (4.6-2Ll)
10.6 7.8 7.5 9.0
± 5.4 (2.2-21.5)
± 4.7 (1.8-19.6) ± 4.0 (2.1-14.6)
± 5.9 (1.6-20.0)
Attempted vaginal birth after ceserean section (%)
31.6 47.5 55.6 54.2
± 20.1 (lLl-66.7) ± 21.0 (12.8-90.0)
± 20.1 (12.9-87.5) ± 25.9 (5.3-90.0)
Mean (percent) ± SD with accompanying range.
section and encouragement of vaginal birth after a prior cesarean section(s) persisted through 1991. Perinatal outcome data are contained in Table IV. The percentage of in-house newborns admitted to the neonatal intensive care unit was 10.3% in 1986 and
9.7% in 1991
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Table IV. Perinatal outcome 1986
Live births Admissions to neonatal intensive care unit Apgar score at I min ,;;3 <7 Apgar score at 5 min ,;;3 <7 Cord arterial pH <7.10(%)* Fetal deaths Neonatal deaths Neonatal mortality rate Perinatal mortality rate
1987
1988
1990
1989
1991
4264 441
4255 373
4329 417
4429 497
4894 454
4723 457
132 547
128 491
112 598
98 535
ll8 697
114 619
20 98 2.9 40 44 10.3 19.5
23 107 3.0 29 29 6.8 13.5
18 93 2.7 23 28 6.5 11.7
21 73 2.5 32 24 5.4 12.6
19 75 3.0 35 16 3.3 10.3
15 84 2.9 31 18 3.8 10.3
*Over the 6-year period umbilical cord arterial pH measurements were obtained in 89.5% of patients.
Apgar scores ::; 3 and 5-minute Apgar scores ::; 3 or < 7, but the differences were not significant. The incidence of umbilical cord arterial pH values <7.10 remained unchanged at 2.9% (p = 0.96). Comment
During a 6-year period in which the cesarean section rate in the State of Illinois remained constant, we were able to decrease the incidence of total, primary, and repeat cesarean deliveries by 38%, 42%, and 30%, respectively. Less operative intervention for dystocia and greater encouragement of vaginal birth after a prior cesarean section were the major contributing factors to the decline in abdominal deliveries. Recognition by the medical staff that curtailment of unnecessary cesarean sections was an institutional priority probably also contributed to the lower incidence of cesarean births for FHR abnormalities and other indications (e.g., herpes, multiple gestations, third-trimester bleeding). There was a slight reduction in abdominal breech deliveries, but the incidence of cesarean section for malpresentation on the private service did not change over the 6 years. There was a 45% reduction in cesarean births on the clinic service and a 37% drop for private patients. Primary operative delivery for dystocia and malpresentation, plus repeat cesarean section, were all more common on the private service. Factors contributing to the higher cesarean section rate for private patients were the greater proportion of nulliparous patients and more infants with birth weights > 3500 gm. However, the birth weight-specific cesarean section rate was equivalent or higher for private patients at each weight category. Further, substantial variation in clinical practice among individual private practitioners was evidenced by the wide spectrum in total, primary, and repeat cesarean section rates and by the extent to which vaginal birth after cesarean section was encouraged.
These observations are consistent with prior reports suggesting that private physicians perform significantly more cesarean sections than house officers and that individual practice style is an important determinant of the wide range in rates of cesarean delivery among obstetricians. 12. 13 Patient education and expectations, concern about professional liability if there is an adverse outcome, convenience, and financial considerations have all been implicated as contributors to the increase in abdominal deliveries. 14. 15 The higher rate of cesarean deliveries for private patients, however, has not been associated with improved perinatal outcome. 12. 13 The decline in cesarean births was not accomplished at the expense of neonatal outcome. To the contrary, the neonatal mortality rate dropped from 10.3 to 3.8, and the perinatal mortality rate was reduced from 19.5 to 10.3. Measures of neonatal morbidity also did not rise. The percentage of admissions to the neonatal intensive care unit remained constant, as did the percentage of neonates with umbilical cord arterial pH values < 7.10. Similarly, there was not an increase in the incidence of low Apgar scores; in fact, the trend was in the opposite direction. Studies from other countries have demonstrated reductions in perinatal mortality independent of an increase in abdominal delivery.16-18 More data now accumulating in the United States strongly suggest that the cesarean section rate can be safely lowered without increasing perinatal morbidity or mortality.9. 10. 19 Successful programs for reducing the cesarean section rate have been previously reported from predominantly indigent populations. Two university hospitals reduced the incidence of cesarean birth from 27.5% and 17.5% to approximately 11%,9. 10 and in a third hospital the cesarean section rate for the clinic service was lowered to 5.7%. I 9 These programs use a centralized approach to intrapartum decision making that
1754 Socol et al.
incorporates strict guidelines for abdominal delivery and comprehensive peer review. Attempts to implement similar programs in the obstetric community at large may be met with significant resistance because private practitioners feel their autonomy threatened. Consequently, reversal of the previously escalating cesarean section rate will depend on alternative strategies that can be adapted to individual institutions. We have successfully reduced our cesarean section rate in a primarily private tertiary university facility by establishing this as an institutional priority, encouraging vaginal birth after prior cesarean section, circulating the cesarean section rate of each obstetrician to the entire attending staff, and implementing an active management of labor protocol for term nulliparous patients. Significant reductions in abdominal deliveries occurred for both private and clinic patients, but differences in population demographics and individual physician practice patterns contributed to a higher incidence of cesarean birth on the private service. We thank Roseann LoSasso for assistance with data collection. REFERENCES 1. Stanley F], Watson L. The cerebral palsies in Western Australia: trends 1968 to 1981. AM ] OBSTET GYNECOL 1988; 158:89-93. 2. Malloy MH, Rhoads GG, Schramm W, Land G. Increasing cesarean section rates in very low-birth weight infants. Effect on outcome. ]AMA 1989;262:1475-8. 3. Taffel SM, Placek P], Moien M, Kosary CL. 1989 U. S. cesarean section rate steadies - VBAC rate rises to nearly one in five. Birth 1991;18:73-7. 4. Rubin GL, Peterson HB, Rochat RW, McCarthy BJ, Terry ]S. Maternal death after cesarean section in Georgia. AM J OBSTET GYNECOL 1981;139:681-5. 5. Evrard JR, Gold EM. Cesarean section and maternal mortality in Rhode Island - incidence and risk factors. Obstet Gynecol 1977;50:594-7. 6. Cesarean childbirth: report of the NICHD Task Force on Cesarean Childbirth. Bethesda, Maryland: National Institutes of Health, 1981; Department of Health and Human Services publication no (NIH) 82-2067. 7. Bottoms SF, Rosen MG, Sokol RJ. The increase in the cesarean birth rate. N Engl J Med 1980;302:559-63. 8. Stafford RS. Alternative strategies for controlling rising cesarean section rates. JAMA 1990;263:683-7. 9. Myers SA, Gleicher N. A successful program to lower cesarean section rates. N Engl J Med 1988;319: 1511-6. 10. Sanchez-Ramos L, Kaunitz AM, Peterson HB, MartinexSchell B, Thompson RJ. Reducing cesarean sections at a teaching hospital. AM J OBSTET GVNECOL 1990;163:1081-8. 11. Lopez-Zeno JA, Peaceman AM, Adashek], Socol ML. A controlled trial of a program for the active management of labor. N Engl J Med 1992;326:450-4. 12. Haynes de Regt R, Minkoff HL, Feldman J, Schwarz RH. Relation of private or clinic care to the cesarean birth rate. N Engl J Med 1986;315:619-24. 13. Goyert GL, Bottoms SF, Treadwell MC, Nehra PC. The physician factor in cesarean birth rates. N Engl J Med 1989;320:706-9. 14. Phillips RN, Thornton J, Gleicher N. Physician bias in cesarean sections. JAMA 1982;248: 1082-4. 15. Anderson GM, Lomas J. Determinants of the increasing
June 1993 Am J Obstet Gynecol
16. 17. 18. 19.
cesarean birth rate: Ontario data 1979 to 1982. N Engl J Med 1984;311:887-92. O'Driscoll K, Foley M. Correlation of decrease in perinatal mortality and increase in cesarean section rates. Obstet GynecoI1983;61:1-5. Bonham DG. Caesarean birth. N Z Med J 1983;96:205-6. Rockenschaub A. Technology-free obstetrics at the Semmelweis Clinic. Lancet 1990;335:977-8. Porreco RP. High cesarean section rate: a new perspective. Obstet Gynecol 1985;65:307-11.
Discussion
DR. HERBERT F. SANDMlRE, Green Bay, Wisconsin. The authors' concern over the escalating cesarean rate at their institution prompted them to introduce three initiatives that might reduce their cesarean rate. Although applauding the reduction enumerated in their report, I would ask if they remain concerned regarding some subset of cesarean rates at their institution. In particular it appears that their 1991 private patient rate of 19.1 is unacceptably high. The 11.5 clinic rate for the same year comes closer to optimal rates proposed or achieved by other authors (Table I). The management of the nulliparous private patient was problematic for Northwestern obstetricians, resulting in a twofold greater risk of cesarean birth compared with comparable clinic patients (insert, Fig. 2). This disparity actually increased after the introduction of the authors' cesarean-reducing initiatives from 1.47 (odds ratio) in 1986 to 2.01 in 1991. Do the authors have an explanation for this difference? Is the difference attributable to higher rates by volunteer faculty compared with full time faculty? Are there differences in epidural use or frequency of induction of labor between the private and clinic services? These differences are important because the proper management of the nulliparous patient with appropriate cesarean birth decisions is the key to achieving an optimal overall cesarean section rate. Meanwhile, multiparous private patients had less chance of cesarean than clinic patients (odds ratio 0.88). I would ask the authors if they know why their faculty achieved more reasonable cesarean birth rates in their private multiparous patients compared with nulliparous. Similarly, private patient physicians demonstrated no change in their cesarean rates for malpresentation from 1986 to 1991, whereas the clinic rate decreased dramatically (Fig. 3). Do the authors have a reason for this discrepancy? Do those faculty physicians (full time) who supervise residents have cesarean rates lower than volunteer faculty and similar to the clinic rates?
Table I. Optimal cesarean rates Porreco' (1985) Myers and Gleicher2 (1988) DeMott and Sandmire' (1990) Green Bay, Wisconsin 4 (1990 and 1991) Quilligan 5 (1985), proposed
6.0% 11.0% 7.8% 11.7% 8.0%
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1755
Table II. Combined Bellin and St. Vincent Hospital Deliveries (Green Bay)
1986 (N 1991 (N
= 3256) = 3292)
Total cesarean section (%)
Primary cesarean section (%)
Repeat cesarean section (%)
Successfol vaginal birth after cesarean
15.8 11.6 (5.3-18.4)
9.5 7.2
6.3 4.4
23.1 (St. Vincent only) 37.5
Table III. Birth weight distribution and birth weight-specific cesarean section rates 1986 Private patients Actual weights Birth weight (gm)
:51000 1001-1500 1501-2000 2001-2500 1501-3000 3001-3500 3501-4000 >4000
No.
23 27 34 103 401 1056 896 406 2910
I
%
0.08]
~:~9 3.5 13.8 36.3 30.8 13.9 100
I%
Cesarean section
43.4 63.0 6.4% 50.0 32.0 28.4 26.1 30.6 39.4
I
Clinical weight distribution * No. of cesarean sections
No.
10 17 17 33 114 276 274 160
116 102 128 236 620 922 611 239
901 (30.3%)
2910
I
% 4.0 3.5 4.4 8.1 21.3 31.7 21.0 8.2 100
I
% Cesarean sectIOn
)19"*
I
No. of cesarean sectIOns
43.4 63.0 50.0 32.0 28.4 26.1 30.6 39.4
50 64 64 76 176 241 187 94 952 (32.7%)
*Weight-specific cesarean rates for private patients if their birth weight distribution was the same as clinic patients.
The authors' Table III depicts alarming variations in cesarean section rates among physicians delivering ;;:: 100 patients. Particularly surprising is the 1991 total and repeat cesarean rates for one physician of 41.1 and 20.0, respectively. These very high cesarean rates and an attempted vaginal birth after cesarean delivery rate of only 5.3% are incomprehensible to Green Bay obstetricians, whose rates are depicted in Table II. Apparently the authors' institution's traditional quality assurance procedures and the three initiatives described in this paper are not influencing cesarean birth decisions made by this physician. The author's conclusion that newborn birth weights > 3500 gm contribute to the higher cesarean rate for private patients is not supported by their data, at least for the 1991 births. Their Table II provides their birth weight distribution and birth weight-specific cesarean rates. The 18.3 1991 private patient cesarean rate for the 350 I to 4000 gm weight group is not significantly higher than their 16.9 rate for the 3001 to 3500 gm weight group. This difference accounts for only 15 of the 662 private cesarean births for that year. Meanwhile, the excess private patient cesarean births resulting from the difference in private and clinic 1991 cesarean rates (19.1 vs 11.5) totals 256. In addition, for the ;;:: 4000 gm weight group the private cesarean rate (25.1) is actually lower than the clinic rate (26.1). Overall, the birth weight distribution for private patients is more favorable for a lower cesarean rate than is the clinic birth weight distribution. Tables III and IV demonstrate the weight-specific cesarean rates after changing the private birth weight distribution to the distribution existing for clinic patients. This change
would have resulted in a higher cesarean rate for private patients in 1986 and 1991 compared with the rates reported with the actual birth weight distribution (32.7 vs 30.3 and 20.5 vs 19.1, respectively). The author's contention that patient population characteristics contribute to the higher cesarean rate for private patients should be rejected. The authors have provided cesarean birth statistics comparing clinic and private patients and rates comparing individual faculty members who have more than 100 deliveries per year. It may be instructive to have cesarean rate comparisons between volunteer and full time faculty and faculty members with < 100 to those with > 100 deliveries per year. In the opinion of Myers and Gleicher6 an individual "cesarean section rate above 15 percent is almost always excessive." In spite of this, the authors claim to "have successfully reduced their cesarean rate at their primarily private tertiary university facility." The correctness of their claim depends on the definition of success. Certainly they have achieved substantially lower cesarean rates in 1991 compared with 1986. However, can a university facility with a private patient cesarean rate of 19.1 - almost twice the clinic rate - be regarded as successful in reaching their goal, which was the "curtailment of unnecessary cesarean sections"? To achieve success the authors need to find ways to raise the quality of labor management for nulliparous private patients to that level currently provided to their clinic patients. Their private patients deserve no less. In addition, reducing the private cesarean rate for malpresentation to the clinic rate would be helpful. The authors' cesarean birth decrease is impressive.
1756 Socol et al.
June 1993 Am J Obstet Gynecol
Table IV. Birth weight distribution and birth weight-specific cesarean section rates 1991 Private patients Actual weights Birth weight (gm)
:-;; 1000 1001-1500 1501-2000 2001-2500 2501-3000 3001-3500 3501-4000 >4000
No.
24 27 49 108 494 1190 1086 442 3364
I
% 0.07 0.08 1.5 3.2 14.7 35.4 32.3 13.1 100
I
% Cesarean sectwn
I No. sectIOns of cesarean
45.8 44.4 6.2% 46.9 22.2 16.4 16.9 18.3 25.1
No.
11 12 23 24 81 201 199 III
77 61 104 283 767 1235 686 225
662 (19.1%)
3364
1
%
2.3 1.8 3.1 8.4 22.8 36.7 20.4 6.7
100
I
Clinical weight distribution *
I
% Cesarean
15.5%
sectwn
45.8 44.4 46.9 22.2 16.4 16.9 18.3 25.1
No. of cesarean sections
35 27 49 63 126 209 126 56 691 (20.5%)
*Weight-specific cesarean rates for private patients if their birth weight distribution was the same as clinic patients.
Their very high initial cesarean rate and persistently high private patient cesarean rates (breech, nulliparous) are not impressive. Having rates only slightly different than statewide rates is not good enough for a university center from which leadership is expected. REFERENCES
1. Porreco RP. High cesarean section rate: a perspective. Obstet Gynecol 1985;65:307-11. 2. Myers SA, Geicher N. A successful program to lower cesarean section rates. N Engl J Med 1988;319: 1511-6. 3. DeMott RK, Sandmire HF. The Green Bay cesarean section study. I. The physician factor as a determinant of cesarean birth rates. AM J OBSrET GVNECOL 1990;162:1593-602. 4. Health Pages 1992 Sept 24. 5. Quilligan EJ. Cesarean section: modem perspective. In: Queenan JT, ed. Management of high-risk pregnancy. 2nd ed. Oradell, New Jersey: Medical Economics, 1985:594600. 6. Myers SA, Gleicher N. The Mount Sinai cesarean section reduction program: automated data collection and peer review. Quality Lett 1991; March. DR. GERALD F. JOSEPH, New Orleans, Louisiana. "Peer review," "quality assurance," "practice guidelines," "continued quality improvement" are part of the medical phraseology of the 1990s recognizable to each of us but ideals that are accepted and used with feelings that range from disgust and resistance to guarded enthusiasm. In spite of how we may feel, the progressive intrusion into the practice of medicine will likely continue and even increase. In the past decade the increased use of cesarean section gained national recognition and attention. The relative appropriateness of this trend has been debated in our medical literature, I. 2 in public forums,' and among each of us in private conversation. In recent years there has emerged a consensus among most obstetricians that the increase in cesarean delivery has done very little to improve delivery outcomes and has greatly increased the cost of delivery services, as cited by
Socol et al. Studies began to focus on suggested causes and potential "cures" for this escalating rate both in the private and public sectors of obstetrics. This paper profoundly demonstrates how one group incorporated the basic principles of "quality assurance," "peer review," and "practice guidelines" to effect a program of "continued quality improvement." The requirement for documentation that vaginal birth after cesarean delivery had been offered and supposedly encouraged exemplifies one aspect of quality assurance initiated in 1987. In this study it is not possible to clearly separate the influence of encouraging vaginal birth after cesarean delivery from the influence of posting individual cesarean section rates. Indeed, if emphasis on vaginal birth after cesarean delivery began in 1987, there was actually an increase in repeat cesarean sections in 1988, and it was at the end of that calender year that cesarean section rates were published. The great variation among physicians with respect to trials of labor points to continued physician resistance. I would also suspect that patient resistance remains a deterrent and explains the inability to further reduce repeat cesarean delivery in the last year or two of the study. Peer review with resulting praise or criticism from one's closest colleagues is an extremely sensitive measure of professional acceptance to the caring physician. Little wonder why publishing cesarean section rates might function as such an effective tool for behavior modification. It is most interesting to note that in spite of any formal change in policy regarding the management of FHR abnormalities, malpresentation, multiple gestations, or third-trimester bleeding, abdominal delivery for these indications also decreased, in certain instances, separate from the indication of dystocia. Further, institution of this quality management initiative in 1988 preceded any protocol for active management of labor. The year with the greatest decrease of any single year was in 1989, the first year after posting
Volume 168, Number 6, Part 1 Am J Obstet Gynecol
cesarean rates and before protocol modifications for conduct of active labor. Suggestive evidence, at least, that the human factor associated with clinical decision making involving peer review is operative and influential. Practice guidelines represent a pattern of thought and action describing how we function as physicians, When we judge outcomes to be bad, we instinctively examine and reexamine what we do and why and seek to formulate new, hopefully better methods to solve problems. This group sought a better way to overcome the clinical diagnosis of dystocia so often cited as the indication for cesarean delivery. Practice guidelines for active management of labor established by others, evaluated and recommended by this group for their own practice, seemed to safely and effectively reduce the need for primary abdominal delivery. It is hoped that other studies will likewise demonstrate similar results so that active management of labor can be more vigorously endorsed by The American College of Obstetricians and Gynecologists in its Technical Bulletin on induction and augmentation of labor. In that way obstetricians, when following these practice guidelines, may feel greater protection from the medicolegal consequences of bad delivery outcomes that have little if anything to do with the conduct of labor. Embracing many of the principles of quality assurance, peer review, and practice guidelines, a significant reduction in the incidence and need for cesarean delivery was accomplished over a 5-year period. The staggered start of these three initiatives makes it difficult to calculate the relative impact of each initiative independently. Increased use of epidural anesthesia without increased need for operative vaginal delivery during the study period suggests that the results were not accomplished by "the use of mirrors." A very favorable comparative review of perinatal parameters points to the safety of the implemented guidelines. This study represents an excellent example of the essence of continued quality improvement, and, to think, it was done by physicians alone! I have several questions: (1) I was unable to determine if the same group of physicians were being followed longitudinally. From the tables it is apparent that the total staff delivering more than 100 babies per year grew by at least five from 1988 to 1991. Are you teaching "old dogs new tricks" or do you have more "new dogs"? (2) Was there any attempt at standardizing the approach to counseling patients about vaginal bi:-th after cesarean delivery? What was considered adequate documentation? and (3) Does the author have any other information or a personal opinion as to the relative importance of each of these initiatives in reducing the cesarean rate? REFERENCES
1. Petitti DB, Cefalo Re, Shapiro S, et al. In hospital maternal mortality in the United States: time trends and relation to method of delivery. Obstet Gynecol 1982;59:6.
Socol et al.
1757
2. Porreco RP. High cesarean section rate: a new perspective. Obstet Gynecol 1985;65:307-11. 3. Cesarean childbirth. Washington: United States Department of Health and Human Services, 1981; publication no 82-2067.
DR. EUGENE W.J. PEARCE, Shawnee Mission, Kansas. Those of us who have been around for a while realize that there was a sea change about 1970, when the obstetric standard of practice changed in the interest of fetal survival, and the panacea became cesarean section for all obstetric problems, best expressed by the following idea: "Ifit doesn't fall out, cut it out." Consequently, what happened is that many of the young people were never taught some of the old-fashioned techniques of getting the baby out safely. In addition, there was a release from corporate control. It used to be the standard of practice that a primary cesarean section required a consultant to agree, and The American College of Obstetricians and Gynecologists decided about that time that that was unnecessary . One of the things that this article emphasizes is the return to corporate control; that is, there are some institutional responsibilities for the cesarean section rate. I was about to retire, a miserable old man in the twilight of a mediocre career, when Youngblood decided that I ought to become a full-time faculty member at Truman Medical Center. I discovered I was in charge of archaic obstetrics, including the use of forceps, vaginal breech delivery, and the management of dystocia, and I'm about to bring out a resident lecture on clinical pelvimetry. The amazing thing about all of these subjects is that there is a modern literature on all of them. There have been three books written on forceps in the last 4 years. There's a modern study on breech delivery. There are two books on the management of labor, which came out within the last 3 years, and in Surgical Obstetrics by Plauche published in 1992 there's an article on clinical pelvimetry. The point is, if we're going to reduce the cesarean section rate, we're going to have to reinstitute some of those old measures about how to get the baby out safely without damaging the mother. DR. ROBERT ZURAWIN, Houston, Texas. The attempts to decrease the cesarean section rate as presented here so far have not sufficiently addressed either the lack of skill in forceps delivery by the younger obstetricians or the abandoning by older obstetricians of non operative delivery because of medical-legal liability . Pressure from law suits resulting from poor outcome is still a great determinant of the mode of delivery. I do not think that it is helpful for a discussant to impose arbitrary limits of, for example, 15% and then declare anything above that as representing an unacceptably high rate of cesarean section. Bragging about one's low percentage is somewhat akin to bragging
1758 Socol et al.
about the size of one's genitals. It may only serve to impress yourself. We must not allow others to impose on us their ideas of what is an "acceptable" rate of cesarean section. Clearly, egregious rates must be critically analyzed, of course, but we would be better served by teaching our residents how to use forceps skillfully and to manage labor with clinical judgement without slavish reliance on monitor strips. Finally, this problem is not going to go away so long as we and our colleagues are so eager and willing to testity as so-called experts for plaintiffs in cases where there are either forceps deliveries or noncesarean deliveries where the baby comes out with anything but a perfect outcome. All of us know of babies delivered by forceps who have learning disabilities. We know of far more who have disabilities where forceps have not been applied or after completely normal pregnancies and deliveries. Anybody here who testifies against one of our colleagues in one of those kind of cases should be held directly responsible for the current crisis on obstetrics. This is where peer review and quality assurance should be concentrated, not against those practitioners whose cesarean rates fall outside arbitrary guidelines. DR. ROBERT K. DEMoTT, Green Bay, Wisconsin. When we started the Green Bay cesarean section study, our total cesarean section rate was 14%. Just by simply performing a study we noted a decrease in our rate to 10%, with a similar drop in primary and repeat sections. We also noted a change in our medical staff with the retirement of some older physicians, who actually had higher rates, and an influx of younger physicians with lower rates. DR. LEE MATTHEWS, Bloomington, Indiana. I feel that the authors will have better results if they start with a lower dosage oxytocin, probably 0.5 to 1 mU, and maybe increasing by 1 to 2 mU every 15 or 20 minutes. I think in most of their cases they would be able to accomplish results at least as good with a 6 mU dose, which is what their starting dose was by using intrauterine pressure catheters. DR. BROOKS RANNEY, Yankton, South Dakota. There is a techical point concerning individual cesarean section rates. It is dangerous to draw conclusions from raw statistics without careful study. For example, between 1948 and 1972 I was delivering between 250 and 300 babies a year, so these were large statistics for each year. However, in one of those years my cesarean section rate was 3.2%, but in the next year it was 13.4%. This was not caused by a difference in indications. Rather, this was caused by a difference in the patients referred with serious complications. So one should take a 5-year average of individual doctors' statistics to draw valid conclusions. Additionally, it helps to place referred patients' statistics in a separate category from those of individual obstetricians' primary-care patients. DR. JOHN CALKINS, Kansas City, Missouri. In our institution we battle back and forth regarding the issue of oxytocin dosage that Dr. Matthews addressed. My question is, was the protocol outlined for active manage-
June 1993 Am J Obstet Gynecol
ment of labor applied to patients with vaginal birth after cesarean delivery as well as for nulliparous patients? If it was not applied to that group of patients who clearly have a high incidence of dystocia as an indication for the previous cesarean section, why was it not applied? DR. SOCOL (Closing). To begin with Dr. Sandmire's comments, I agree that the process is not perfect and I would prefer to view it as an evolving one. It is difficult to pick a specific number as an ideal cesarean section rate. Interestingly, the State of Illinois has targeted 15% as an appropriate incidence of abdominal delivery. I'm not sure what the source of wisdom is to arrive at that figure, but if I were to pick a number that is probably in the right ballpark. We have to realize that the rise in cesarean sections in the 1970s and 1980s did not decrease the incidence of cerebral palsy, which has not changed over the last 30 years. Approximately half our practitioners are full time and the remainder are volunteer faculty. Both the lowest and highest cesarean section rates belong to members of the volunteer faculty. Undoubtedly, there remains considerable variation in the practice patterns of our faculty. Lastly, the intrapartum use of epidural anesthesia rose almost twofold on both the private and clinic services, but the cesarean section rates declined for both groups of patients. As for Dr. Joseph's comments, I believe there has been a positive effect on some of the young faculty who have been influenced by our institutional emphasis, but some of our "old dogs" have also recognized some merit. We do not have a standardized policy for counseling patients about vaginal birth after cesarean section, but we do require that if a patient undergoes an elective repeat abdominal delivery after only one prior low-transverse cesarean section the attending physician must document that the patient declined a trial of labor. The hospital quality management committee audits charts periodically and forwards outliers to the departmental committee. The increase in trials of labor and the decline in repeat operations attest that the process works. It is difficult to determine the effect of each of the three initiatives, but if I were to speculate on the most beneficial one it probably would be the peer pressure generated from distributing the cesarean section rate of every obstetrician to each attending physician. The incidence of operative vaginal delivery remained unchanged at approximately 13%. In spite of similar attitudes towards forceps over the last 6 years, we have been able to successfully reduce our cesarean section rate. The purpose of this presentation is not to allege that we are better than anyone else but rather to assert that a reduction in abdominal deliveries by 40% is an important achievement. I would disagree that we should be using lower doses of oxytocin and our previously published randomized trial of the active management of labor supports this posture. That trial was confined to term nulliparous patients and therefore did not apply to candidates for vaginal birth after cesarean delivery.