Cesarean deliveries are the most frequent hospital surgery in the United States. Although there are many instances when cesarean deliveries are the safest choice, far too many are performed for non-medically indicated reasons.

Statistics on Cesarean Deliveries

According to the CDC, the number of cesarean deliveries in the United States increased by 60 percent between 1996-2009, with no demonstrable improved outcomes for moms, birthing people or babies. The overuse of this major surgical procedure has significant social, economic and health costs, including:

  • higher rates of maternal complications and longer recovery times
  • higher rates of NICU admissions
  • increased barriers to the breastfeeding/chestfeeding relationship between baby and mother/birthing person

One of the major contributors in the overuse of cesarean deliveries is among low-risk, first-time mothers and brithing people. Once a woman/birthing person has the first cesarean delivery, the successful rate of VBAC (vaginal birth after cesarean delivery) is approximately 8 percent.

In order to help clinicians measure the number of low-risk, first-time mothers and birthing people having a cesarean delivery, CMQCC developed the Nulliparous, Term, Singleton, Vertex (NTSV) Cesarean Birth Rate quality metric. Data from CMQCC's Maternal Data Center demonstrates that there are large variations among the NTSV rates across California hospitals—from 11% to as high as 77%—indicating substantial improvement opportunities.

Lowering NTSV Cesarean Delivery Rates

CMQCC is committed to helping hospitals improve labor management and lower their low-risk, first-time cesarean delivery rates.

In 2016, CMQCC published the Toolkit to Support Vaginal Birth and Reduce Primary Cesareans, as well as the Implementation Guide to help hospitals put the recommendations from the evidence-based toolkit into practice. The Toolkit was developed and disseminated by the Supporting Vaginal Birth and Reducing Primary Cesarean Delivery Task Force, a multi-disciplinary task force including physicians, nurses, midwives, public health professionals and childbirth advocates, and with representation from healthcare purchasers. CMQCC also led multiple outreach collaboratives across hospitals in California to help them lower their NTSV rates using the Toolkit's practices. 

The Toolkit is a comprehensive, evidence-based “how-to” guide designed to educate and motivate maternity clinicians to apply best practices for supporting vaginal birth. Cesarean births among low-risk, first-time mothers have been the largest contributor to the recent rise in cesarean rates, and accounts for the greatest variation in cesarean rates between hospitals. The Toolkit contains key strategies and resources to:

  • Improve the Culture of Care, Awareness, and Education for Cesarean Reduction
  • Support Intended Vaginal Birth
  • Manage Labor Abnormalities and Safely Reduce Cesarean Births
  • Use Data to Drive Reduction in Cesareans

 

Toolkit to Support Vaginal Birth and Reduce Primary Cesareans

Download Toolkit to Support Vaginal Birth and Reduce Primary Cesareans (with Addendum Part V), (2022)

Individual sections of the toolkit are also available to download:

 

Key Resources

Download Implementation Guide (2016)

CMQCC also released the Implementation Guide, an addendum to the Toolkit that provides additional evidence-based tools and resources to effectively integrate midwifery care and doula support into the hospital setting, and guidance on how to best support those who transfer to the hospital from a community birth setting. There is an emphasis on health equity and team-based care to improve outcomes for women and birthing people. This supplemental section was developed with a Task Force of hospital and community-based midwives and doulas, along with a patient advocate, nurses, and physicians.

Application of the ARRIVE Trial

Following the publication of “A Randomized Trial of Induction Versus Expectant Management (ARRIVE)” study in the New England Journal of Medicine (2018), CMQCC’s leadership team released a statement about the application of the ARRIVE trial into practice. 

CMQCC cautions that if a hospital’s induction guidelines are changed to allow for elective inductions at 39 weeks, strict guidelines for defining failed induction and guidelines for management of active phase and fetal monitoring abnormalities should be adopted simultaneously. If labor guidelines and definitions for failed induction similar to those in the study hospitals are not adopted, it is very likely cesarean rates will rise significantly. This can be followed in CMQCC's Maternal Data Center.

 

HUDLS: Hands-On Understanding and Demonstration of Labor Support

Thanks to generous funding by the Yellow Chair Foundation, CMQCC has developed HUDLS: Hands-On Understanding and Demonstration of Labor Support. HUDLS is our online education platform for L&D staff who want to refresh or learn new evidence-based labor support skills. HUDLS online didactic lessons all cover current evidence-based labor support skills and are designed to take 15 minutes or less. For hospital trainers, we also have a lesson plan, teaching script, and instructional video demonstrating how to present the lesson concepts in a hands-on bedside huddle to reinforce learnings. Up to five contact hours accepted by the California Board of Registered Nurses are available to CMQCC members through HUDLS. 

HUDLS is available to all CMQCC member hospitals through your CMQCC Accounts login. 

 

Funding Acknowledgement

Funding for the development of the Toolkit to Support Vaginal Birth and Reduce Primary Cesareans and the Collaboratives to Support Vaginal Birth were generously provided by the California Health Care Foundation.