Reducing the Cesarean Rate: Our Time is Now

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Harmful obstetric interventions often have a long and predictable lifespan. For example, routine episiotomy was introduced in the 1920s, and it wasn't until recently that routine episiotomy was discarded from clinical practice in the face of clear evidence that this procedure is associated with more harm than good.[1, 2] Clinician beliefs about obstetric procedures that turn out to be harmful go through stages. Initial enthusiasm is followed by an assumption the procedure is beneficial. Then, calls for reevaluation, which are often first voiced by consumers and midwives, occur. Calling these practices into question is followed by well-conducted studies that demonstrate harm. A few years after this body of research is published, it becomes obvious that the procedure causes adverse effects without clear positive benefit, and professional associations release clinical practice guidelines that recommended the procedure be discarded.[3] Unfortunately, technological adoption is easy but technological abandonment can take a long time.[4] Even after recommendations are made, accomplishing actual changes to practice can be a slow process.

Right now, I am hopeful that the life course of unnecessary primary cesareans will move through this set of developmental stages much faster. A plethora of studies documenting adverse effects of cesarean have been published,[5] and there is consensus among all maternity care stakeholders that the US cesarean rate of 32.8%[6] is too high.[7] In 2012, the National Institutes of Health and Child Development held a workshop that reviewed reasons for the increased cesarean rate and methods of lowering this rate. Commentaries, editorials, and white papers summarizing the problem and solutions have been published.[8-12] And now, key maternity care professional organizations, the American College of Nurse-Midwives (ACNM),[13] the Association of Women's Health, Obstetrics and Neonatal Nurses (AWHONN),[14] and the American College of Obstetricians and Gynecologists (ACOG),[7] have released guidelines that recommend specific practice changes that will help lower the cesarean rate. All that is left is adoption of these guidelines in clinical practices.

In March of this year, ACOG and the Society for Maternal Fetal Medicine (SMFM) published a white paper titled, “Safe Prevention of the Primary Cesarean Delivery.”[7] This document summarizes the evidence for specific practices that can lower the primary cesarean rate. Chief among these are waiting until a woman's cervix is at least 6 cm dilated before assuming she is in the active phase of labor; using amnioinfusion and scalp stimulation to manage variable fetal heart rate (FHR) decelerations and category II FHR tracings; allowing nulliparous women to push for 3 hours and multiparous women for 2 hours before diagnosing arrest of labor in the second stage; and avoiding induction of labor before 41 0/7 weeks’ gestation unless there is a medical indication.[7]

Interestingly, many of the recommended changes in intrapartum management have been requested by childbearing women for some time,[15] and they are practices long associated with midwifery care.[16, 17] These practices may be part of the reason midwives have excellent outcomes in caring for low-risk women; they are patient-centered and reflective of the biology of labor. But they also require technology abandonment because it can be easier to perform a cesarean than to sit with a woman whose labor is taking longer than Friedman declared was normal in the 1950s.

So now we are at the hard step. How do we change practice? Change of this magnitude requires a multi-strategy approach. Fortunately, I believe we are at the tipping point because there are multiple drivers in the health care system today that will support this sea change, which is going to involve abandoning the Friedman Curve, allowing more time for second stage, and avoiding induction of labor. First, policy-setting agencies, such as The Joint Commission, have issued Perinatal Core Measures that hospitals must address. One of these measures is Perinatal Care Measure PC-02. Hospitals are mandated to report their statistics on the number of cesareans performed on nulliparous women with a single fetus in vertex presentation, and the goal is to reduce the number of cesareans experienced by this population of women.[18] When stakeholders such as hospitals and hospital systems start tracking individual cesarean rates, they join the effort to identify ways to lower those rates. Second, the current interest in decreasing variability in practice has resulted in many hospitals adopting checklists, protocols, and bundles such as criteria for elective induction. These checklists are rapidly being disseminated and adopted in different settings. They will help standardize care so it is evidence-based. Finally, the public and media are paying attention. Articles, Web sites, blogs, and television segments have been produced that call for lowering the cesarean rate such as the one titled, “C-sections May Not Provide the Brain Benefits of Vaginal Birth.”[19]

Right now all the stakeholders, policy-making groups, physicians, midwives, nurses, and consumers are focused on lowering the cesarean rate. This is a critical moment. We need to recognize it and be part of the solution by promoting practices that are inherent to midwifery and that we have long known support physiologic labor. Midwives can be leaders in helping institute intrapartum care practices that prevent cesareans. Let's seize this moment and use our clinical expertise in supporting physiologic labor and birth so that midwifery care practices become the norm for all women.

Ancillary