Reducing the C-section Rate

Wanda D. Barfield, MD, MPH


August 25, 2014

Editorial Collaboration

Medscape &

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Hello. I am Dr. Wanda Barfield, Director of CDC's Division of Reproductive Health. I'm pleased to speak with you as part of the CDC Expert Commentary series on Medscape. Today let's consider what some say is the overuse of cesarean section (C-section) deliveries. In the United States, C-sections declined slightly in 2013 to 32.7%, a decline of only 0.2% since 2009.

Much public and professional attention is being given to deliveries known as "elective C-sections." In some circumstances, these are procedures performed with no medical indication. In other cases, C-sections are performed on a woman's request. We understand that some women request a C-section because it gives them a firm date for childbirth and a schedule for maternity leave.

As a nation, we are seeing a very modest reduction in C-sections. What is behind this decline? We believe that healthcare professionals are adopting the American College of Obstetricians and Gynecologists guidelines.[1] These guidelines discourage the use of elective C-sections prior to the 39th week of gestation. We also believe that consumer awareness campaigns are reaching families with messages promoting full-term deliveries. One example is the March of Dimes' Healthy Babies Are Worth the Wait campaign asking women to "wait until 39 weeks."

Let's be pragmatic. C-sections are surgical procedures that pose risks. There are cases when the risks associated with the procedure will outweigh other potential maternal and perinatal risks and consequences. In the end, we all want a healthy infant to be delivered into the waiting arms of a healthy mother and family.

I know you wonder why we are presenting this commentary. CDC is one of many organizations throughout the country working to improve maternal and infant health. Let me talk for a minute about what CDC is doing that is of interest to providers.

First, there are state-to-state variations in rates of non-medically indicated C-sections. Indeed, there are variations even within states when looking at rates in specific medical facilities. This shows that there is no systematic pattern of decision-making about C-sections. It may even suggest that the differences are based on the decisions of providers and provider groups.

Second, a 2007 article published in the American Journal of Obstetrics and Gynecology[2] further supports this observation. The investigators found that these variations within geographical locations were random. They attributed this to a lack of standardized decision-making and a lack of appropriate tools for making these decisions at the patient's bedside.

Third, our partners in public health and medicine reviewed information about outcomes in both maternal and infant health. After reviewing evidence and examples of best practices, CDC decided to launch an evidence-based program promoting perinatal improvement collaboratives. We believe that collaboration between clinical providers and public health officials is a means to improve decision-making for patient care. It's an excellent example of how clinical practice and public health interact to improve health outcomes.

Our project partners are bringing many things to our attention. For example, they saw that Utah's Intermountain Healthcare System – which represents about half of all hospital beds in the state -- used quality improvement processes that significantly reduced the rate of C-sections. Changes in institutional policies and practices can result in an example of a "best practice." We also know that research by CDC and others found that C-sections without a medical indication resulted in some infants needing care in the neonatal intensive care unit.

Today, please consider how you might bring about changes in your organization or in your own practice. We now offer webinars through our Division's Perinatal Quality Improvement project with the most recent data and suggestions for taking action. You can participate in live webinars during which leaders discuss examples of successful activities and programs. You are also able to view archived webinars, offering you an option that fits with your busy schedule. We believe that working with others in your area or state to reduce the overuse of C-sections will help all meet the needs of patients while providing high-quality care.

We understand public perceptions about so-called "financial incentives" to perform C-sections. Yet, we also know that C-sections, when medically indicated, are a time-honored means of saving lives. But when we can reduce risks, we must do so.

I'm a neonatologist. I work with many fine obstetrical and maternal-fetal medicine specialists who know the consequences of preterm birth. I want women to take home full-term and healthy babies to their families. Infants who do not have the benefit of vaginal delivery are at risk for retained fetal lung fluid and respiratory distress. We can change the number of women who face days and nights sleeping on a recliner in our nation's neonatal intensive care units. I urge you to consider how we, together, can make a difference.

Thank you for your attention to this important area where public health meets clinical practice.