Cesarean section in the 21st century: A comprehensive model for quality improvement

The cesarean delivery rate in the United States has been increasing for the last 3 decades. Complex factors have influenced this development, including the increased safety of the procedure, demographic changes in the patient population, social expectations, health care and malpractice insurance changes and perceptions and realities of the medico-legal climate. As the rate has approached and surpassed 33% for low risk women, diverse parties are becoming interested in influencing a reduction of the cesarean delivery rate. Public policy and scientific research organizations, like the National Institutes of Health, and credentialing organizations like the Joint Commission have addressed the issue, as has the American College/Congress of Obstetricians & Gynecologists. Additionally, important non-medical parties, like state governments, are attempting to influence cesarean delivery rates through public policy, legislation and hospital reimbursement changes. Popular media depictions as well as peer reviewed research are questioning the necessity and safety of the current cesarean delivery rate as well. Because there are influences outside of medicine that are working to reduce cesarean delivery rates by means of reducing access for patients and reimbursement for hospitals, it is crucial that physicians, hospital administrators, nursing staff and patients participate in the practice change efforts to ensure both a safe environment for patient care and a long lasting impact on cesarean delivery rates. Because cesarean delivery is so prevalent in American society & culture, a multifaceted model is necessary to produce both these outcomes. Clinicians must be supported in engaging in non-paternalistic risk counseling for patients, provided with accurate data regarding their individual practice and the broader context of their performance on identified patient outcomes. In the model presented, medico-legal issues and physician education and support on the topic are also addressed. Nursing staff and hospital administrators can support excellence in patient care with specific research-based norms and development of a professionally supportive culture on the unit and up the clinical ladder. Patient choice is an ever-increasing influence on cesarean delivery rates. As such, patients need clear and accurate education to manage expectations regarding induction and cesarean risk reduction. The presentation will include a concise case statement, lessons learned from past and current efforts at cesarean quality improvement, as presented in literature, and the presentation of an original, evidence-based model for implementing a cesarean quality improvement program in a hospital or health care system.