Behind the Curtain: The Role, Cost, and Future of C-Sections

The Centers for Disease Control and Prevention (CDC) estimates that 31% of all deliveries in the U.S. were via C-section in 2018. Considering that the World Health Organization’s (WHO) ideal rate is between 10% to 15%, it’s clear the U.S. has significant room for improvement.

Compared to vaginal birth, C-sections result in higher instances of maternal mortality, longer hospital stays, and excessive bleeding. Yet despite these risks, C-sections have continued to increase in popularity among patients — even when the procedure isn’t medically necessary.

The Cost of C-Sections

C-sections are not only associated with higher risks of patient harm but also with higher costs. Healthcare leaders are pressed to understand just how much would the U.S. save by reducing C-sections.

According to the CDC, the percentage of births in 2019 covered by private insurance was 50.2%, followed by Medicaid at 42.1%, with uninsured deliveries making up 4.2% and other insurance (state or local) filling the remaining 3.5%.

An article in the Harvard Business Review estimates that with 1.9 million deliveries in employer sponsored health insurance plans each year, the U.S. would save $1B if the Healthy People 2020 target (decreasing C-sections to 23%) were achieved. This estimate (based on the CDC’s birth statistics for 2019) represents only 50.2% of births, leaving greater room for cost savings when Medicaid and uninsured deliveries are included.

One OB-GYN medical practice is taking a new approach to insurance costs in the future for reducing the number of C-sections performed. Partnering with UnitedHealthcare, the practice tested a new payment model that begins with the insurer setting a budget with the practice to pay doctors one lump sum for prenatal services, delivery, and 60 days of care afterward. If the costs come in below that amount, the medical practice gets to keep some of the savings.

Other insurers and state Medicaid programs are considering similar models, sometimes incorporating hospitals and other health providers as well. Approaches like these aim to cut costs while improving the quality of care for expectant mothers.

National Efforts to Reduce C-Sections

In recent years, efforts to reduce C-sections have gained traction, both on national and international levels. The WHO has called attention to the fact that C-section rates have increased steadily worldwide over the last decade, despite being linked to increased risk for maternal and perinatal harm — or worse, morbidity. To promote improvement, the organization has developed resources that aim to reduce unnecessary C-sections.

Additionally, The Joint Commission (TJC) is leveraging data to foster improvement through the “reduce unnecessary C-sections performance measure” or PC-02. TJC began publicly reporting hospitals with consistently high C-section rates on July 1, 2020, on the PC-02 measure. Specifically, this measures the rates of cesarean births among a subset of the general obstetric population of low-risk women having their first birth with a term, singleton baby in a vertex position (NTSV).

The Department of Health and Human Services (HHS) shared its vision for ensuring that the U.S. is one of the safest countries in the world to give birth in the Healthy Women, Healthy Pregnancies, Healthy Futures: Action Plan to Improve Maternal Health in America. Released in late 2020, the Action Plan calls out three targets — one of which is to reduce the low-risk C-section deliveries by 25% in five years.

How to Reduce C-Sections

The Council on Patient Safety in Women’s Health Care has organized a wealth of resources for both patients and providers looking to better understand how to reduce the amount of C-sections. Often an underutilized approach, educating mothers and the public may help promote progress in reducing C-sections. Patient education is incredibly important for expecting mothers, who often believe C-sections are more advanced, safer, or easier than vaginal births.

From a provider perspective, the California Maternal Quality Care Collaborative (CMQCC) offers an Implementation Guide and Toolkit to Support Vaginal Birth and Reduce Primary C-Sections. In general, the most common high-level goals for improvement include:

• Analyzing the data to inform initial focus areas for improvement and establish a baseline
• Developing a quality improvement team
• Communicating the implementation plan
• Providing education and training
• Promoting a just culture and incorporating high reliability framework into the unit/organization

Reasons for Emergency C-Sections

As providers aim to reduce unnecessary C-sections, it’s important to differentiate between those that are preventable, and those that are performed in the best interest of the mom and baby. Expectant mothers often wonder “why do emergency C-sections happen?” but are perhaps too hesitant to ask their physician before delivery.

While the CDC estimates that 31% of all deliveries in the U.S. were via C-section in 2018, the percentage of emergency C-sections is much lower. The rate of emergency C-sections varies based on patient populations, and one study found only 5.5% of total C-section deliveries were considered emergency procedures. Despite being less common, emergency C-sections have been linked to increased risks to mothers. A recent study and article on outcomes of emergency C-sections found emergent C-sections carried an increased risk of overall maternal complications.

Emergency C-sections are most commonly due to prolonged or delayed labor, complications with the baby’s position or umbilical cord, placental problems, or a uterine rupture. As the U.S. has made strides in reducing planned, unnecessary C-sections, labor and delivery teams must always be prepared for an emergency C-section delivery when a mother’s or baby’s health is in danger.

How Relias Can Help

Every labor and delivery team has a part to play in reducing medically unnecessary C-sections. To minimize variation in care, hospitals must embrace evidence-based obstetrics education that facilitates a uniform approach to treatment.

Relias Obstetrics (Relias OB) is an assessment-driven education and analytics solution designed to help healthcare providers identify and reduce variation in care where it matters most. Relias OB casts a wide net, helping to improve clinical practices and clinical outcomes in every part of the delivery room by providing all members of the obstetrics care team with critical maternal care insights.

Promoting vaginal birth and improving maternal health requires every hospital to take an evidence-based approach to maternal care. The courses offered by Relias OB (including Promoting Vaginal Birth) have been validated by the Association of Women’s Health Obstetric and Neonatal Nurses and accredited by the American Nurses Credentialing Center and the Accreditation Council for Continuing Medical Education.

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John Harrington

Director, Clinical Solutions, Relias

John co-founded APS in 1993 after completing his training as a board certified medical illustrator. He is one of fewer than two hundred board certified medical illustrators worldwide. He has acted as a courtroom expert witness in obstetrics, orthopedics, and neurology, and has been a contributing illustrator to a variety of texts along with publications including the New England Journal of Medicine, Boston Globe, Fortune Magazine, and Lawyer’s Alert. He has also presented at a range of continuing medical and legal education seminars and events throughout the country.

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