A number of years ago quality improvement staff at a hospital proudly showed me their C-section and VBAC (vaginal birth after previous C-section) rates for the first 6 months of the year which showed dramatically lower rates for both compared to the previous year. I told them “show me the same data in September”. Of course, I knew from previous experience that the rates would likely jump substantially in July and August, mostly due to scheduled vacations for both physicians and families. Sure enough, the September report showed that the C-section and VBAC rates through the end of August were now the same as the prior year.
Cesarean section rates remain at high levels throughout the US. Now a new study (Iriye 2013) has suggested that a full-time laborist model has resulted in reduced cesarean section rates whereas a community laborist model did not. The study was a retrospective before and after study at a tertiary hospital staffed by private practice physicians, broken up into three time periods from 2006 to 2011. The first period was 16 months during which there were no laborists. The second a 14-month period where a community laborist model was used. And the final period 24 months with full-time laborists. C-section rates for the three periods were 39.2%, 38.7%, and 33.2%, respectively.
Because this is a retrospective study, not a controlled trial, one has to be careful that factors other than the full-time laborist program were not contributory. The obvious one would be the recent campaign to reduce non-medically indicated labor inductions and C-sections prior to 39 weeks of pregnancy (see our February 8, 2011 Patient Safety Tip of the Week “Inducing Too Early”). That campaign, originally sponsored by the March of Dimes, Leapfrog Group, California Maternal Quality Care Collaborative and the California Department of Public Health; Maternal, Child and Adolescent Health Divisions, and later adopted by the American College of Obstetricians and Gynecologists (ACOG) highlighted the risks to newborns delivered prior to 39 weeks of gestation and provided tools to help avoid inductions prior to 39 weeks.
In fact, recently released CDC data (Osterman 2013) shows that the C-section rate in the US has leveled off from 2009 to 2011 after 12 years of consecutive increases. Interestingly, C-section delivery rates decreased more than 5% among births at 38 weeks of gestation, but increased 4% among births at 39 weeks. This probably does reflect the campaign noted above.
Nevertheless, we do suspect that much of the success in the Iriye study was due to the full-time laborist model. That model is getting increasing traction at many hospitals and is worth your looking at. And, of course, by now you should all be onboard for the 39-week campaign.
Iriye BK, Huang WH, Condon J, et al. Implementation of a laborist program and evaluation of the effect upon cesarean delivery. American Journal of Obstetrics & Gynecology 2013; published online 30 July 2013
Osterman MJK, Martin JA. Changes in Cesarean Delivery Rates by Gestational Age: United States, 1996–2011. CDC 2013; NCHS Data Brief Number 124, June 2013
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