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Promoting Safer Cesarean Delivery

04/07/2021

By Susan Yendro, MSN, RN, Associate Director 

When a Cesarean is necessary, it can be a lifesaving surgery.

However, unnecessary Cesareans can cause complications for the mother such as: 

  • infections
  • hemorrhage
  • complications related to use of anesthesia or blood transfusion
  • subsequent pregnancy complications including uterine rupture, placental implantation problems and need for hysterectomy

The Joint Commission has worked for many years to help avoid unnecessary C-sections and we are proud to support International Cesarean Awareness Network for April’s Cesarean Awareness Month.

Reporting Hospitals with High Caesarean Rates
Recently, Joint Commission began reporting hospitals on Quality Check, a public facing website, for the following ORYX® Perinatal Care (PC) measures:  

  1. PC-02—Cesarean Birth
  2. PC-06—Unexpected Complications in Term Newborns 

Our goal is to provide meaningful information for the performance of accredited organizations on measures affecting maternal and newborn health. We’re fully aware there is no “magic number” of hospital Cesareans but some hospitals are reporting more than 30% of deliveries via C-section.

With this in mind, The Cesarean Birth measure, PC-02, calculates the rates of cesarean births among a subset of the general obstetric population of low-risk women having their first birth (nulliparous) with a term, single baby in a head down (vertex) position (NTSV). Initially, The Joint Commission is using data reported by hospitals during calendar years 2018 and 2019, along with the following three criteria, to determine a hospital’s PC-02 rating:  

  1. ≥ 30 cases reported in both years  
  2. PC-02 rate > 30% for the current year (2019)
  3. Overall 24-month aggregate PC-02 rate > 30% (see the following note) 

For those hospitals identified as having high rates (-), The Joint Commission shows those hospitals’ actual 2019 PC-02 rates. Hospitals with acceptable rates (+) do not have their actual PC-02 rates reported. The Joint Commission believes hospitals should work to reduce unnecessary cesarean births; however, it does not want to differentiate between groups of hospitals whose rates are in the acceptable range. Lower is not always better in these cases, and The Joint Commission does not want to encourage inappropriately low rates which may be unsafe to patients. 

Balancing Measure
The Joint Commission has also added the Unexpected Complications in Term Newborns measure, PC-06, which became effective January 1, 2019, to measure the number of unexpected newborn complications among full-term newborns with no preexisting conditions.  

Although measures have been developed to assess clinical practices and outcomes in preterm infants, metrics that assess the health outcomes of term infants are lacking. This measure addresses this gap and gauges adverse outcomes resulting in severe or moderate morbidity in otherwise healthy term infants without preexisting conditions.  

Importantly, this metric also serves as a balancing measure for other maternal measures such as PC-02, Cesarean Birth, and PC-01, Early Elective Delivery. 
The purpose of a balancing measure is to guard against any unanticipated or unintended consequences of other performance measures and to identify unforeseen complications that might arise as a result of quality improvement activities and efforts for these measures. For example, if a cesarean delivery is not done when medically appropriate, there could be a negative effect on the health of the newborn. This measure helps hospitals monitor newborn outcomes.  

Feedback from Health Care Organizations
We are pleased to receive positive feedback from many of our accredited organizations.

“Hospitals play a key role in improving maternal and neonatal health and safety. By targeting our performance improvement projects to include processes that lower cesarean rates and focusing on developing and following protocols on hypertensive crisis and obstetrical hemorrhage, we hope to improve maternal outcomes in the future. The public reporting of data specific to our hospital helps consumers make an informed decision when choosing who will provide healthcare for their family,” noted Wendy Bolinger, MBA, BSN, RN - Golden Valley Memorial Healthcare (MO). 

That’s not to say it’s necessarily easy to reduce rates of unnecessary Cesarean delivery.

“The work done to reduce our hospital’s primary C-section rate was challenging, but it finally paid off. As a result, we’ve improved patient safety, and we were recognized by The Joint Commission – whose new perinatal care standards emphasize the importance of addressing the United States’ rising unnecessary Cesarean rates.” 

It’s  wonderful to see organizations  taking important steps in the name of safer deliveries. We invite you to join us in our observation of Cesarean Awareness Month. Feel free to follow us on Twitter and chime into the discussion at #CAM2021.


Susan Yendro, MSN, RN is Associate Director at The Joint Commission.