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How High is Too High?
Transcript of How High is Too High?
Cesarean rates globally
Cesarean section in the US
National quality efforts in the US
Maternity surveys and quality efforts
In Conclusion: How High is Too High?
Global and US cesarean rate increases
It is possible to set a CD standard
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
-Studies to understand and interventions to change
-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%
Only developed countries
Lesson: CD should be the lowest
necessary to acheive best outcomes
Fewer Downward Pressures
Greater Upward Pressures
Cycle of Continuous Quality Improvement:
Labor admission at 6cm
-Internet based survey
-Delivered in Hungary last 5 years
-Preferences and Satisfaction
-Common obstetric Procedures
Morbidity and Mortality
Recent quality efforts at reduction of CD
Role of maternity surveys
Income U.S. CD 24%
-19 high-income countries
-Quality data systems
-Controlled for economic and
-30 years of data
-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
95% global births
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