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A Proven Method For Lowering The Caesarean Rate

By Gloria Lemay

Yet another article in my local newspaper last week bemoaned the fact that the caesarean rate keeps rising, reporting that physicians are concerned not only about the high rate of surgery, but also the future complications that increase after caesarean surgery. It’s a well documented fact that a caesarean can adversely affect a woman’s health for the rest of her life and can lead to catastrophic complications in future births. That’s one reason why, 40 years ago, doctors did everything in their power to prevent that first caesarean from being done.

What if there was already a tried method of reducing the caesarean rate within hospitals?

What if it involved some truly innovative thinking?

What if it had a proven track record and had resulted in a significant drop in the rate of surgeries for first-time mothers?

What if it saved money, lowered recovery time, and resulted in healthier babies?

Would you think that method would be adopted all over North America right away? Think again. This project was undertaken at British Columbia Women’s Hospital. It was a success…and it was dropped once the project was complete, resulting in a re-increase of the caesarean rate. No reason for discontinuing the project has ever been given.

The “First Births Project” was undertaken at B.C. Children’s & Women’s Health Centre in Vancouver. It was the first phase of a continuous quality improvement project with the stated aim of “lowering the caesarean section rate.” Its start date was January, 1996. The target objective was to lower the caesarean rate by 25 percent for nulliparous women (those who had never given birth), while maintaining maternal and infant outcomes, within 6 months of implementing solutions.

Staff from all departments of the hospital were brought together to brainstorm what might be causing the high rate of caesareans. Many of the ideas thrown out were not under the control of the hospital but, in the end, four practices were identified as possibly contributing to the high rate of surgical births.

  1. Women were being admitted to the hospital too early (before reaching 4 cm dilation, active labor).

  2. Fetal surveillance by electronic fetal monitoring (continuous electronic fetal monitoring has been proven to increase the cesarean rate with no improvement to the health of the baby).

  3. Too early use of epidurals (women who get an epidural before 8 cm dilation are at increased risk of surgery).

  4. Inappropriate induction (inducing birth before 41 weeks gestational age with no medical indication).

Teams of nurses were assigned to do an audit of hospital records to see if these hypothetical practices were, in fact, as widespread as some of the staff thought. The audit confirmed that these four areas needed attention. The hospital created task forces in each area to use the best evidence and existing guidelines, as well as solutions from other hospitals, to improve care at B.C. Women’s Hospital. Guidelines and other strategies in all four target areas were implemented in the spring of 1997.

What Happened?

This is an excerpt from the hospital’s published results:

After six periods, B.C. Women’s had admitted and delivered 1,369 nulliparous women with singleton (one baby only), cephalic (head enters pelvis first), term presentations. The caesarean section rate was reduced by 21 percent compared to the 12 periods prior to implementation. The number of epidurals initiated at 3 cm was 64 percent lower, continuous fetal monitoring was used 14 percent less, the induction rate had dropped 22 percent and admission at 3 cm cervical dilation had dropped 21 percent. All changes were statistically significant. Newborn outcomes were unchanged post implementation.

What’s Happening Today?

In 2009, it’s back to business as usual at this hospital. Women are induced, monitored, epiduraled, and admitted early. The caesarean rate is 30 percent and the head of obstetrics is concerned but has no action plan.

Why on Earth Would This Be?

I assert that it is because it is an “up at dawn” battle with the physicians to change their ways. I hear from nurses that doctors did everything they could to undermine this project. For example, a doctor would examine his patient and state, “She’s 8 cm dilated, get the anesthetist.” Then, later, when the woman had her epidural, someone else would examine the same woman and find her to be only 6 cm. The doctor would smile and shrug his shoulders: “Whoops.” The same thing happened around the issue of monitoring, induction, and admitting: trickery to subvert the project and return to their old ways of doing things.

Most obstetrics workers have no idea that this project ever existed. It’s a low-tech, innovative approach that had excellent results. I’d love to see it copied everywhere, but it’s a bit like dieting: Everyone knows how to lose weight (eat less, exercise more) but only a few get into action.

We do know how to lower the cesarean rate. But committed action is needed.