Reducing Rates of Cesarean Birth and Cesarean-Linked Hemorrhage through Improved Obstetric Care

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Almost 1 in 3 U.S. childbirths are cesarean births, rates varying 10-fold across hospitals, with Black and Asian individuals having the highest prevalence of cesarean birth among low-risk pregnancies. While cesarean birth can be a lifesaving intervention when appropriate, it is associated with significant risks that include postpartum hemorrhage. We propose that enhanced respectful care and reduced variability in obstetric management are important strategies in improving outcomes for cesarean-linked postpartum hemorrhage and reducing postpartum hemorrhage-related severe maternal morbidity.

Aim 1: Identify strategies to reduce rates of cesarean birth and cesarean-associated hemorrhage using mixed methods.

Aim 1B

In Year 2 of the PRIHSM grant, the Aim 1B team interviewed 38 participants from 8 different hospitals in California. Participants included hospital staff (e.g., physicians, midwives, and nurses) in different roles (e.g., leadership, front-line, and in non-leadership roles). This qualitative comparison included hospitals with high disparities in NTSV cesarean rates, low disparities in NTSV cesarean rates, and mid-disparities in NTSV cesarean rates, which are defined as hospitals which showed improvements in disparities over time.

The goal in Year 3 is to complete the coding of all interviews and transfer the transcripts to an analytic software. Four reviewers will then independently analyze themes and conduct a de-identified and blinded qualitative analysis, stratified by hospital. These themes will culminate in analysis specific to each hospital group (high disparity, low disparity and mid-disparity) and finally, in publication of findings.

Aim 2: Center patient voices in the validation and continuous curation of action tools and resources that will be integrated into a Hospital Action Guide to support improvement action.

Aim 2C

In Year 2 of the PRIHSM grant, the Aim 2C team interviewed 20 participants across several different clinical and nonclinical hospital roles through semi-structured interviews. Five independent coders developed a final codebook through 25 iterations.

The goal in Year 3 is to complete five additional interviews, achieve theme saturation, and apply the finalized codebook to all transcripts. After all transcripts have been uploaded to an analytic software, the team plans to analyze themes and complete a qualitative analysis of existing literature on culture of respectful care measurement tools. Following this process, the team will use a delphi process (three rounds) with a panel of culture of respectful care experts to select the most effective survey questions which arise from the literature review. Lastly, the team will conduct a round of ten cognitive debriefing interviews to validate the final survey tool.

Aim 3: Expand implementation of the Hospital Action Guide in state-wide efforts to reduce cesarean birth and cesarean-linked postpartum hemorrhage.

Aim 4: Assess effectiveness of Hospital Action Guide tools, resources, and implementation strategies.

Aims 3 & 4:

In Year 2 of the PRIHSM grant, the Aim 4 team collaborated with the CMQCC team on opportunities to collect and organize data related to implementation outcomes of the “Learning Initiative” (LI). This included qualitative analysis of all LI monthly sessions across multiple cohorts.

The CMQCC/Aim 3 team conducted outreach to all 201 California hospitals which offer birthing services and shared the Hospital Action Guide tools and resources.

In Year 3, the goal is to better understand the strengths and limitations of LI calls data for Aim 4. The Aim 3 team will be working on creative implementation and data collection strategies to measure the impact of the Hospital Action Guide across the state of California.

Main EK, Chang SC, Tucker CM, Sakowski C, Leonard SA, Rosenstein MG. Hospital-level variation in racial disparities in low-risk nulliparous cesarean birth rates. Am J Obstet Gynecol MFM. 2023 Dec;5(12):101145. Doi

Bane S, Mujahid MS, Main EK, Carmichael SL. Socioeconomic disadvantage and racial/ethnic disparities in low-risk cesarean birth in California. Am J Epidemiol. 2024 Jun 26:kwae157.

Rosenstein MC, Chang S-C, Tucker CM, Sakowski C, Leonard SA, Main EK.  Evaluation of Statewide Program to Reduce Cesarean Deliveries Among Nulliparous Individuals With Singleton Pregnancies at Term Gestation in Vertex Presentation. Obstet Gynecol 2024 Oct 144(4):p 507-515,

Leonard SA, Xu X, Davies-Balch S, Main EK, Bateman BT, Rehkopf DH, Lee HC, Illuzzi J, Igbinosa I, Iwekaogwu I, Lyell DJ. Labor and delivery unit practices and racial and ethnic disparities in severe maternal and neonatal morbidity among nulliparous individuals with low-risk pregnancies. Am J Epidemiol. 2024 Dec 16:kwae459. doi: 10.1093/aje/kwae459. Epub ahead of print.

Community advisory boards (CABs) are composed of community members who share an identity, geography, history, language, culture, or other characteristic or experience and convene to contribute community voice to an initiative, program, policy, or project.

PRIHSM Project 2 has assembled a 10 person CAB which includes a mix of members with lived experience of cesarean birth and members with community-based experience.

Please find details about the Health Equity Advisory Council, including objectives, expectations and council members here: https://www.cmqcc.org/committees/health-equity-advisory-council-heac