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How High is Too High?

Cesarean Section and Quality of Care in the Euro-American Context
by

Nick Rubashkin

on 5 February 2017

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Transcript of How High is Too High?

Overview
Cesarean rates globally

Cesarean section in the US

National quality efforts in the US

Maternity surveys and quality efforts
U.S. Perspective
In Conclusion: How High is Too High?
Global and US cesarean rate increases

It is possible to set a CD standard

Myths
What does this mean for Hungary?
Morbidity and Mortality from CD in Hungary
-Is it necessary to replicate?

Quality care systems?
-Hospital level pressures to decrease CD

Women's preferences?
-Studies to understand and interventions to change

Public awareness?
-Availability of data
How high is too high?
Cesarean Sections and Quality of Care in the Euro-American Context
Nicholas Rubashkin, MD MA
Fulbright Scholar, Semmelweis University
Assistant Clinical Professor, University of California San Francisco
Staff Physician, California Pacific Medical Center, St. Luke's Campus

1985: World Health Organization
Recommends CD 10-15%
Somewhat arbitrary
Only developed countries

Lesson: CD should be the lowest
necessary to acheive best outcomes
Global Perspective
Csection
Rate
$$$$$
Legal
Doctors
Hospitals
Fewer Downward Pressures
Greater Upward Pressures
Women
Women
Doctors
Hospitals
$$$$$
Legal
National Priorities
Cycle of Continuous Quality Improvement:
Labor admission at 6cm
System of
Birth Statistics
Regular
Reports
Provider
Feedback
Hospital
Oversight
Clinical
Care
-Internet based survey
-Delivered in Hungary last 5 years
-Preferences and Satisfaction
-Common obstetric Procedures
Preferences
and Satisfaction
Demographic
Clinical
Mental Health
Financial
Payment
Malpractice
Reform
Morbidity and Mortality

Recent quality efforts at reduction of CD

Role of maternity surveys
Medium
Income
Hungary
CD 21%
High
Income U.S. CD 24%
-19 high-income countries
-Quality data systems
-Controlled for economic and
social factors
-30 years of data
-119 Countries--comprehensive
-59 Low (76% <10% CD)
-31 Middle (16% <10% CD)
-29 High income (3% <10% CD)

Challenges to defining CD rate
Countries are different
Women are different
Obstetricians are different
-Inflection Neo 10%, Mat 15%
No significant change CD> 10%
No significant change CD> 10%
-54 Countries CD < 10%
Need: 3.18 million cesareans
-69 Countries CD > 15%
Excess: 6.20 million cesareans
-50% excess in China and Brazil
137 Countries
95% global births
Myth:
Only
Older
Women
Myth:
Only
Premature
Myth:
Only Whites
Many myths existed about why elevated CD rate
Unexplained variation in practice
Increased public awareness
Recognition of increased morbidity from CD
National agenda of professional groups

Prolonged latent phase not an indication for CD
Active labor starts at 6cm, OK to extend 4-6hrs for arrest CD
Three hours of pushing OK for nullip no epid
Instrumental delivery is recommended to decrease CD
Recurrent variable decelerations not pathologic
Chorioamnionitis not an indication for CD
Ultrasounds late in pregnancy can increase CD
Continuous labor support can decrease CD
Vertex first twin not a reason to perform CD
CD rate = under-use in high risk + over-use in low risk
Limitation: Data from low income countries
Optimal Outcomes + Equity
Total Cost of 'Excess' CD: $2.32 Billion
Total Cost of 'Needed' CD: $432 Million
Source: CMQCC
Full transcript