Cesarean Rate for Low-Risk Birth Women (NQF 0471)

EMeasure Name Cesarean Rate for Low-Risk Birth Women EMeasure Id D7EF019A-130D-46B7-8C7A-276ED535BA84
Version number 1 Set Id 93D57440-A7EA-4861-BE7F-4630C84D6428
Available Date No information Measurement Period January 1, 20xx through December 31, 20xx
Measure Steward California Maternal Quality Care Collaborative
Endorsed by National Quality Forum
Description Cesarean Rate for low-risk first birth women (aka NTSV CS rate: nulliparous, term, singleton, vertex) identifies the portion of cesarean births that has the most variation among practicioners, hospitals, regions and states. Unlike other cesarean measures, it focuses attention on the proportion of cesarean births that is affected by elective medical practices such as induction and early labor admission. Furthermore, the success (or lack thereof) of management of the first labor directly impacts the remainder of the woman's reproductive life especially given the current high rate of repeat cesarean births. This is also the measure used in Healthy Person 2010 (Objective 16.9a, US DHS, 2000) and previously received endorsement from the American College of Obstetricians and Gynecologists (American College of Obstetricians and Gynecologists: Task Force on Cesarean Delivery, 2000). A recent European review of cesarean birth measures also identified that this measure pinpointed the portion of cesarean births that had the greatest variation and contributed the most to the rise in overall rates in every country studied (Brennan, 2009).
Copyright
Measure scoring Proportion
Measure type Outcome
Stratification
None
Risk Adjustment
Maternal age is a significant risk factor for primary cesaren rates with a continuous effect from age 19 through age 45 in both hospital level data and national data sets (Main, 2000; Menacker, 2005; Main, 2006 ).
Data Aggregation
Rationale
The removal of all pressures to not perform a cesarean section (CS) birth has led to a skyrocketing of hospital, state and national CS rates.  Some hospitals now have CS rates over 50%.  While rates have risen overall, there remains great variation on rates at the provider, hospital and even state levels.  Interestingly hospitals with CS rates at 15-20% have just as good infant outcomes and better maternal ones (Gould 2004).  There are no data that demonstate that higher rates improve any neonatal or maternal outcomes yet the CS rates continue to rise.  This measure seeks to focus attention on the most variable portion of the CS epidemic--the term labor CS in nulipaorus women.  This population segment accounts for the large majority of the variable portion of the CS rate and is the area most affected by subjectivity.  It also highlights two key facts--if one manages the first labor well and succeeds in a vaginal delivery the risk of a CS in the second birth is reduced 10-fold, and the whole VBAC/repeat CS debate (and risk) is avoided.

As compared to other CS measures, an important difference about NTSV CS rate (Low-risk Primary CS in first births) is that there are clear cut quality improvement activities that can be done to address the variations.  Main et al (2006) 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 message was clear, if labor is forced when the cervix is not ready the result is higher NTSV CS rates.  Alfirevic (2004) also showed that labor and delivery guidelines can make a big difference in labor outcomes.   Many authors have shown that physcian factors, rather than patient characteristics or obstetric diagnoses are the major driver for the difference in rates within a hospital (Goyert 1989, Berkowitz 1989, Luthy 2003).

The dramatic variation in NTSV rates seen in all populations studied is striking: States (Menacker 2006), hospitals within a state (Koonrod 2008, OSHPD 2007), and physicians within a hospital (Main 1999) have rates that vary by 3-5 fold.
Clinical Recommendation Statement
Improvement notation
Measurement duration
12 month(s)
Reference
AHRQ Quality Indicators-Guide to Inpatient Quality Indicators: Quality of Care in Hospitals-Volume, Mortality, and Utilization. Rockville, MD: Agency for Healthcare Research and Quality, 2002.  Revision 4 (December 22, 2004).  AHRQ Pub. No. .02-RO204. (also available at http://www.qualityindicators.ahrq.gov )
Reference
Alfirevic Z, Edwards G, Platt MJ.  The impact of delivery suite guidelines on intrapartum care in "standard primigravida." Eur J Obstet Gynecol Repod Biol 2004;115:28-31.
Reference
American College of Obstetricians and Gynecologists: Task Force on Cesarean Delivery Rates.  Evaluation of Cesarean Delivery (2000)  (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).
Reference
Bailit JL, Garrett JM, Miller WC, McMahon MJ, Cefalo RC. Hospital primary cesarean delivery rates and the risk of poor neonatal outcomes. Am J Obstet Gynecol. 2002;187(3):721-7.
Reference
Bailit J, Garrett J.  Comparison of risk-adjustment methodologies.  Obstet Gynecol 2003;102:45-51.
Reference
Bailit JL, Love TE, Dawson NV. Quality of obstetric care and risk-adjusted primary cesarean delivery rates. Am J Obstet Gynecol. 2006 Feb;194:402-7.
Reference
Bailit JL. Measuring the quality of inpatient obstetrical care.  Ob Gyn Sur 2007; 62:207-213.
Reference
Berkowitz GS, Fiarman GS, Mojica MA, et al. Effect of physician characteristics on the cesarean birth rate. Am J Obstet Gynecol 1989;161:146-9.
Reference
Brennan DJ, Robson MS, Murphy M, O'Herlihy C.  Comparative analysis of international cesarean delivery rates using 10-group classification identifies significant variation in spontaneous labor.  Am J Obstet Gynecol. 2009 Sep;201(3):308.e1-8.
Reference
California Office of Statewide Hospital Planning and Development (OSHPD).  Utilization Rates for Selected Medical Procedures in California Hospitals, 2006, available at http://www.oshpd.state.ca.us/Charts/VolUtil/2006Util.pdf (accessed November 1, 2007).
Reference
Cleary R, Beard RW, Chapple J, Coles J, Grifin M, Joffe M.  The standard primipara as a basis for inter-unit comparisons of maternity care.  Br J Obstet Gynecol 1996;103:223-9.
Reference
Coonrod DV, Drachman D, Hobson P, Manriquez M.  Nulliparous term singleton vertex cesarean delivery rates: institutional and individual level predictors. Am J Obstet Gynecol 2008; in press (presented at the Pacific Coast Obstetrical and Gynecological Society, October 10-14, 2007).
Reference
DiGiuseppe DL, Aron DC, Payne SM, Snow RJ, Dieker L, Rosenthal GE.  Risk adjusting cesarean delivery rates: a comparison of hospital profiles based on medical record and birth certificate data.  Health Serv Res  2001;36:959-77.
Reference
Goyert GL, Bottoms FS, Treadwell MC, et al. The physician factor in cesarean birth rates.  N Engl J Med 1989;320:706-9.
Reference
Gould J, Danielson B, Korst L, Phibbs R, Chance K, Main EK, Wirtschafter D, Stevenson D. Cesarean Delivery Rate and Neonatal Morbidity in a Low-Risk Population. Obstet Gynecol 2004; 104:11-19.
Reference
Le Ray C, Carayol M, Zeitlin J, Berat G, Goffinet. Level of perinatal care of the maternity unit and rate of cesarean in low-risk nulliparas.  Obstet Gynecol 2006; 107:1269-77.
Reference
Luthy DA, Malmgren JA, Zingheim RW, Leininger CJ.  Physician contribution to a cesarean delivery risk model.  Am J Obstet Gynecol 2003;188:1579-85.
Reference
Main, EK: Reducing cesarean birth rates with data-driven quality improvement activities.  Peds, 1999; 103: 374-383.
Reference
Main DM, Main EK, Moore DH.  The relationship between maternal age and uterine dysfunction: a continuous effect throughout reproductive life.  Am J Obstet Gynecol. 2000 Jun;182(6):1312-20.
Reference
Main EK, Bloomfield L, Hunt G. Development of a large-scale obstetric quality-improvement program that focused on the nulliparous patient at term. Am J Obstet Gynecol  2004; 190:1747-58.
Reference
Main EK, Moore D, Farrell B, Schimmel LD, Altman RJ, Abrahams C, Bliss MC, Polivy L, Sterling J.  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 2006; 194:1644-51.
Reference
Menacker F. Trends in cesarean rates for first births and repeat cesarean rates for low-risk women: United States, 1990-2003.  Nat Vital Stat Rep 2005; 54(4): 1-5.
Reference
Romano PS, Yasmeen S, Schembri ME, Keyzer JM, Gilbert WM. Coding of perineal lacerations and other complications of obstetric care in hospital discharge data.  Obstet Gynecol. 2005 Oct;106:717-25.
Reference
U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: U.S. Government Printing Office, November 2000.  Measure 16-9.
Reference
Yasmeen S, Romano PS, Schembri ME, Keyzer JM, Gilbert WM. Accuracy of obstetric diagnoses and procedures in hospital discharge data. Am J Obstet Gynecol. 2006;194:992-1001
Definition
Guidance

Table of Contents


Population criteria

Data criteria (QDS Data Elements)

Summary Calculation

Calculation is generic to all measures:



Measure set CLINICAL QUALITY MEASURE SET 2011-2012