Evidence Tools
Low-Risk Cesarean Delivery
Introduction
This toolkit summarizes content from the Low-Risk Cesarean Delivery Evidence Accelerator and the MCHbest database. The peer-reviewed literature supporting this work can be found in the Established Evidence database. Use the resources below as you develop effective evidence-based/informed programs and measures.
From the MCH Block Grant Guidance. Cesarean delivery can be a life-saving procedure for certain medical indications. However, for most low-risk pregnancies, cesarean delivery poses avoidable maternal risks of morbidity and mortality, including hemorrhage, infection, and blood clots—risks that compound with subsequent cesarean deliveries.1 Much of the temporal increase in cesarean delivery (over 50% in the past decade), and wide variation across states, hospitals, and practitioners, can be attributed to first-birth cesareans.1 Moreover, cesarean delivery in low-risk first births may be most amenable to intervention through quality improvement efforts.1 This low-risk cesarean measure, also known as nulliparous term singleton vertex (NTSV) cesarean, is endorsed by the National Quality Forum (#0471) and included within The Joint Commission’s National Quality Measures for hospitals (PC-02), and the Core Set of Maternal and Perinatal Health Measures for Medicaid and CHIP. An Alliance for Innovation on Maternal Health (AIM) patient safety bundle for Safe Reduction of Primary Cesarean Births was released in 2018.2
Goal. To reduce the percent of cesarean deliveries among low-risk first births.
Note. Access other related measures in this Population Domain through the Toolkits page.
Detail Sheet: Start with the MCH Block Grant Guidance
GOAL: To reduce the percent of cesarean deliveries among low-risk first births.
DEFINITION:
Numerator: Number of cesarean deliveries among term (37+ weeks), singleton, vertex births to nulliparous women
Denominator: Number of term (37+ weeks), singleton, vertex births to nulliparous women
Units: 100
Text: Percent
HEALTHY PEOPLE 2030 OBJECTIVE Identical to Maternal, Infant, and Child Health (MICH) Objective 06: Reduce cesarean births among low-risk women with no prior births (Baseline: 25.9% of low-risk females with no prior births had a cesarean birth in 2018, Target: 23.6%)
DATA SOURCES National Vital Statistics System (NVSS)
MCH POPULATION DOMAIN Women/Maternal Health
MEASURE DOMAIN Clinical Health Systems
1. Accelerate with Evidence—Start with the Science
The first step to accelerate effective, evidence-based/informed programs is ensuring that the strategies we implement are meaningful and have high potential to affect desired change. Read more about using evidence-based/informed programs and then use this section to find strategies that you can adopt or adapt for your needs.
Evidence-based/Informed Strategies: MCHbest Database
The following strategies have emerged from studies in the scientific literature as being effective in advancing the measure. Use the links below to read more about each strategy or access the MCHbest database to find additional strategies.
| Evidence-Informed |
Evidence-Based |
|||
|---|---|---|---|---|
Mixed Evidence |
Emerging Evidence |
Expert Opinion |
Moderate Evidence |
Scientifically Rigorous |
|
|
|||
Field-Based Strategies: Find promising programs from AMCHP’s Innovation Hub
Cutting-Edge:
Emerging:
- Accurate Self-Monitored Blood Pressure (National; 2020)
- Free Health Messaging (OK; 2016)
- Medical and Nursing Staff Simulation Training (OH; 2015)
- Reproductive Health Education (SC; 2023)
Promising:
- Consumer Education Initiatives (NY; 2019)
Best:
- Community-Based Doula Program (National; 2015)
- Prematurity Prevention Programs and Services (KY; 2014)
2. Think Upstream with Planning Tools—Lead with the Need
The second step in developing effective, evidence-based/informed programs challenges us to plan upstream to ensure that our work addresses issues early and is measurable in “turning the curve” on big issues that face MCH populations. Read more about moving from root causes to responsive programs and then use this section to align your work with the data and needs of your populations.
Move from Need to Strategy
Use Root-Cause Analysis (RCA) and Results-Based Accountability (RBA) tools to build upon the science to determine how to address needs.
Planning Tools: Use these tools to move from data to action
3. Work Together with Implementation Tools—Move from Planning to Practice
The third step in developing effective, evidence-based/informed programs calls us to work together to ensure that programs are implementable and moveable within the realities of Title V programs and lead to improved health outcomes for all people. Read more about implementation tools designed for MCH population change and then use this section to develop responsive strategies to bring about change that is responsive to the needs of your populations.
Additional MCH Evidence Center Resources: Access supplemental materials from the literature
- Find field-based resources focused on low-risk cesarean delivery relevant to Title V programs in the MCH Digital Library.
- Search the Established Evidence database for peer-reviewed research articles related to strategies for low-risk cesarean deliveries.
- Request Technical Assistance from the MCH Evidence Center
- MCH Evidence Center Frameworks and Toolkits:
Implementation Resources: Use these field-generated resources to affect change
Examples of statewide QI collaboratives working to lower primary cesarean section rates include the Illinois Perinatal Quality Collaborative and the California Maternal Quality Care Collaborative.
Other resources include the Safe Reduction of Primary Cesarean Birth (Alliance for Innovation on Maternal Health) and The Practical Playbook III: Working Together to Improve Maternal Health (Maternal Health Learning and Innovation Center).
Practice. The following tools can be used to translate evidence to action to advance this SM:
- Support Vaginal Birth and Reduce Primary Cesareans Toolkit (California Maternal Quality Care Collaborative). This comprehensive, evidence-based “how-to” guide is designed to educate and motivate maternity clinicians to apply best practices for supporting vaginal birth.
- Medicaid Coverage of Doulas (American Institutes for Research). This brief identifies strategies and provides recommendations to improve the implementation of doula coverage.
Partnership. The following organizations focus efforts to reduce cesarean deliveries:
- The Alliance for Innovation on Maternal Health (AIM) Technical Assistance Center. Provides comprehensive, high impact technical assistance to the AIM QI initiative to support best practices that make birth safer, improve maternal health outcomes, and save lives.
- Improving Maternal Health by Reducing Low-Risk Cesarean Delivery (LRCD) Learning Collaborative. Offers technical assistance to states and their partners through (1) a webinar series and (2) an affinity group, as part of the Maternal and Infant Health Initiative.
References
Introductory References: From the MCH Block Grant Guidance
1 American College of Obstetricians and Gynecologists (College); Society for Maternal-Fetal Medicine, Caughey AB, Cahill AG, Guise JM, Rouse DJ. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol. 2014;210(3):179-193. doi:10.1016/j.ajog.2014.01.026
2 Alliance for Innovation on Maternal Health. Safe Reduction of Primary Cesarean Birth. (n.d.)