**NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE**

Measure Information Form

Measure Set: Perinatal Care (PC)

Set Measure ID: PC-02

Performance Measure Name: Cesarean Birth

Description: Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean birth

Rationale: The removal of any pressure to not perform a cesarean birth has led to a skyrocketing of hospital, state and national cesarean birth (CB) rates. Some hospitals’ CB rates were over 50%. Hospitals with CB rates at 15-20% have infant outcomes that are just as good and better maternal outcomes (Symum et al., 2021). There is no data that higher rates improve any outcomes, yet the CB rates continue to rise. This measure seeks to focus attention on the most variable portion of the CB epidemic, the term labor CB in nulliparous women. This population segment accounts for the large majority of the variable portion of the CB rate and is the area most affected by subjectivity.

As compared to other CB measures, what is different about NTSV CB rate (Primary CB in first births with term singleton pregnancies in head down position) is that there are clear cut quality improvement activities that can be done to address the differences. Main et al. (2012) found that over 60% of the variation among hospitals can be attributed to first birth labor induction rates and first birth early labor admission rates. The results showed if labor was forced when the cervix was not ready the outcomes were poorer. Rosenstein et al. (2021) also showed that labor and delivery guidelines can make a difference in labor outcomes. Many authors have shown that physician factors, rather than patient characteristics or obstetric diagnoses are the major driver for the difference in rates within a hospital (Berkowitz, et al.,1989; Goyert et al., 1989; Luthy et al., 2003, Symum et al., 2021). The dramatic variation in cesarean rates seen in all populations studied is striking. (Cesarean rates varied tenfold in US hospitals nationwide across hospitals, from 7.1 % to 69.9 % and there was a 15-fold variation among low-risk women, from 2.4% to 36.5% (Kozhimannil et al., 2013).

A reduction in the number of nulliparous patients with live term singleton newborns in vertex position (NTSV) delivering by cesarean birth will result in increased patient safety, a substantial decrease in maternal and neonatal morbidity and substantial savings in health care costs. Successful quality improvement efforts incorporate audit and feedback strategies combined with provider and nurse education, guidelines and peer review.

The measure will assist health care organizations (HCOs) to track nulliparous patients with live term singleton newborns in vertex position delivering by cesarean birth to reduce the occurrence. Nulliparous women have 4-6 times the cesarean birth rate than multiparous women thus the NTSV population is the largest driver of primary cesarean birth rate (Sakala et al., 2020). NTSV has a large variation among facilities, thus identifying an important population on which to focus quality improvement efforts.

In addition, a reduction in primary cesarean births will reduce the number of women having repeat cesarean births (almost 90% of mothers who have a primary cesarean birth will have subsequent cesarean birth (CDC, 2020)). Thus, improvement in the rates of cesarean birth for the first birth will reduce the morbidity of all future births and avoid all the controversies with trial of labor after cesarean/elective repeat cesareans.

Type Of Measure: Outcome

Improvement Noted As: Within Optimal Range

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may require evaluation to ensure consistency.

Measure Analysis Suggestions: The Joint Commission does not want to encourage inappropriately low Cesarean rates that may be unsafe to patients. Acceptable PC-02 rates are 30% or lower, however there is not an established threshold for what rate may be too low. PC-06 serves as a balancing measure for PC-02 to guard against any unanticipated or unintended consequences and to identify unforeseen complications that might arise as a result of quality improvement activities and efforts for this measure. In order to identify areas for improvement, hospitals may want to review results based on specific ICD-10 codes or patient populations. Data could then be analyzed further determine specific patterns or trends to help reduce cesarean births.

Sampling: Yes. For additional information see the Sampling Section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

• Agency for Healthcare Research and Quality. (2002). AHRQ Quality Indicators Guide to Inpatient Quality Indicators: Quality of Care in Hospitals Volume, Mortality, and Utilization. Revision 4 (December 22, 2004). AHRQ Pub. No. 02-RO204.
• American College of Obstetricians and Gynecologists. (2000). Task Force on Cesarean Delivery Rates. Evaluation of Cesarean Delivery. (Developed under the direction of the Task Force on Cesarean Delivery Rates, Roger K. Freeman, MD, Chair, Arnold W. Cohen, MD, Richard Depp III, MD, Fredric D. Frigoletto Jr, MD, Gary D.V. Hankins, MD, Ellice Lieberman, MD, DrPH, M. Kathryn Menard, MD, David A. Nagey, MD, Carol W. Saffold, MD, Lisa Sams, RNC, MSN and ACOG Staff: Stanley Zinberg, MD, MS, Debra A. Hawks, MPH, and Elizabeth Steele)
• Bailit, J.L., Garrett, J.M., Miller, W.C., McMahon, M.J., & Cefalo, R.C. (2002). Hospital primary cesarean delivery rates and the risk of poor neonatal outcomes. Am J Obstet Gynecol. 187(3):721-7.
• Bailit, J. & Garrett, J. (2003). Comparison of risk-adjustment methodologies. Am J Obstet Gynecol.102:45-51.
• Bailit, J.L., Love, T.E., & Dawson, N.V. (2006). Quality of obstetric care and risk-adjusted primary cesarean delivery rates. Am J Obstet Gynecol.194:402.
• Bailit, J.L. (2007). Measuring the quality of inpatient obstetrical care. Ob Gyn Sur. 62:207-213.
• Berkowitz, G.S., Fiarman, G.S., Mojica, M.A., et al. (1989). Effect of physician characteristics on the cesarean birth rate. Am J Obstet Gynecol. 161:146-9.
• Center for Disease Control (2020). Recent trends in vaginal birth after cesarean delivery: United States, 2016-2018. Retrieved from National Center for Health Statistics: https://www.cdc.gov/nchs/products/databriefs/db359.htm
• Cleary, R., Beard, R.W., Chapple, J., Coles, J., Griffin, M., & Joffe, M. (1996). The standard primipara as a basis for inter-unit comparisons of maternity care. Br J Obstet Gynecol. 103:223-9.
• DiGiuseppe, D.L., Aron, D.C., Payne, S.M., Snow, R.J., Dieker, L., & Rosenthal, G.E. (2001). Risk adjusting cesarean delivery rates: a comparison of hospital profiles based on medical record and birth certificate data. Health Serv Res.36:959-77.
• Goyert, G.L., Bottoms, F.S., Treadwell, M.C., et al. (1989). The physician factor in cesarean birth rates. N Engl J Med.320:706-9.
• Kozhimannil, K. B., Law, M. R., & Virnig, B. A. (2013). Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues. Health affairs (Project Hope), 32(3), 527–535. https://doi.org/10.1377/hlthaff.2012.1030
• Le Ray, C., Carayol, M., Zeitlin, J., Berat, G., & Goffinet, F. (2006). Level of perinatal care of the maternity unit and rate of cesarean in low-risk nulliparas. Am J Obstet Gynecol. 107:1269-77.
• Luthy, D.A., Malmgren, J.A., Zingheim, R.W., & Leininger, C.J. (2003). Physician contribution to a cesarean delivery risk model. Am J Obstet Gynecol.188:1579-85.
• Main E.K., Bloomfield, L., & Hunt, G. (2004). Development of a large-scale obstetric quality-improvement program that focused on the nulliparous patient at term. Am J Obstet Gynecol.190:1747-58.
• Main, E. K., Chang, S. C., Cape, V., Sakowski, C., Smith, H., & Vasher, J. (2019). Safety Assessment of a Large-Scale Improvement Collaborative to Reduce Nulliparous Cesarean Delivery Rates. Obstetrics and gynecology, 133(4), 613–623. https://doi.org/10.1097/AOG.0000000000003109
• Main, E.K., Moore, D., Farrell, B., Schimmel, L.D., Altman, R.J., Abrahams, C., et al., (2006). Is there a useful cesarean birth measure? Assessment of the nulliparous term singleton vertex cesarean birth rate as a tool for obstetric quality improvement. Am J Obstet Gynecol. 194:1644-51.
• Main, E. K., Morton, C. H., Melsop, K., Hopkins, D., Giuliani, G., & Gould, J. B. (2012). Creating a public agenda for maternity safety and quality in cesarean delivery. Obstetrics and gynecology, 120(5), 1194–1198. https://doi.org/10.1097/aog.0b013e31826fc13d
• Romano, P.S., Yasmeen, S., Schembri, M.E., Keyzer, J.M., & Gilbert, W.M. (2005). Coding of perineal lacerations and other complications of obstetric care in hospital discharge data. Am J Obstet Gynecol.106:717-25.
• Rosenstein, M. G., Chang, S. C., Sakowski, C., Markow, C., Teleki, S., Lang, L., Logan, J., Cape, V., & Main, E. K. (2021). Hospital Quality Improvement Interventions, Statewide Policy Initiatives, and Rates of Cesarean Delivery for Nulliparous, Term, Singleton, Vertex Births in California. JAMA, 325(16), 1631–1639. https://doi.org/10.1001/jama.2021.3816
• Sakala, C., Belanoff, C., & Declercq, E. R. (2020). Factors Associated with Unplanned Primary Cesarean Birth: Secondary Analysis of the Listening to Mothers in California Survey. BMC pregnancy and childbirth, 20(1), 462. https://doi.org/10.1186/s12884-020-03095-4
• Symum, H., & Zayas-Castro, J. L. (2021). A Multistate Decomposition Analysis of Cesarean Rate Variations, Associated Health Outcomes, and Financial Implications in the United States. American journal of perinatology, 10.1055/s-0041-1736538. Advance online publication. https://doi.org/10.1055/s-0041-1736538
• U.S. Department of Health and Human Services. (n.d.). Reduce cesarean births among low-risk women with no prior births-MICH-06. Retrieved from Healthy People 2030: https://health.gov/healthypeople/objectives-and-data/browse-objectives/pregnancy-and-childbirth/reduce-cesarean-births-among-low-risk-women-no-prior-births-mich-06
• Yasmeen, S., Romano, P.S., Schembri, M.E., Keyzer, J.M., & Gilbert, W.M. (2006). Accuracy of obstetric diagnoses and procedures in hospital discharge data. Am J Obstet Gynecol. 194:992-1001.

Original Performance Measure Source / Developer:
California Maternal Quality Care Collaborative