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Strengthen the Evidence for Maternal and Child Health Programs

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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.

Overview: Read a summary of the issue related to Title V

Evidence suggests that engaging providers in hospital-wide efforts dedicated to cesarean reduction may promote decreases in the percentage of cesarean deliveries among low-risk first births. Additional trends emerged from the evidence that can serve as ideas to expand your ESM in the future.

  • Interventions implemented at the patient only (e.g., childbirth education classes) and hospital only (e.g., chart audit and feedback) levels appear most effective in decreasing the percentage of cesarean deliveries among low-risk first-time mothers (nulliparous women).
  • Labor support, which includes supportive care from trained doulas, also appears to be an effective provider-based intervention to reduce cesarean deliveries among low-risk first births.
  • The evidence of effectiveness for other provider-based interventions (e.g., active management of labor, administration of epidural analgesia) is less clear.
  • Adding population-based components in interventions occurring among hospitals, providers, or patients may support the effectiveness of those interventions, as compared to interventions implemented in those categories alone.
  • Using multicomponent interventions (e.g., combining patient and provider interventions) may have increased effectiveness, but there are insufficient number of published studies to determine effectiveness.

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

Data Sources: Learn more about the issue and access the data directly

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.

Chart of Evidence-Linked Strategies and Tools

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:

Promising:

Best:

 

Key Findings and Emerging Issues: Read more from the literature

KEY FINDINGS

  • Interventions implemented at the patient only (e.g., childbirth education classes) and hospital only (e.g., chart audit and feedback) levels appear most effective in decreasing the percentage of cesarean deliveries among low-risk first-time mothers (nulliparous women).
  • Labor support, which includes supportive care from trained doulas, also appears to be an effective provider-based intervention to reduce cesarean deliveries among low-risk first births.
  • The evidence of effectiveness for other provider-based interventions (e.g., active management of labor, administration of epidural analgesia) is less clear.
  • Adding population-based components to interventions occurring among hospitals, providers, or patients may support the effectiveness of those interventions, as compared to interventions implemented in those categories alone.

IMPLICATIONS

  • Improved monitoring of patient-specific interventions and routine in-hospital reviews of obstetric care practices and outcomes is needed to better understand the current status of strategies to reduce primary cesarean deliveries.
  • Further evaluation is needed to understand how implementation of specific interventions affects the proportion of cesarean deliveries among low-risk first births.

EVIDENCE ANALYSIS REPORTS

Strategy Video: Watch a summary of evidence-based/informed strategies

Watch a short video discussing state-of-the-art, evidence-based/informed strategies that can be used or adapted as ESMs. Experts in the field discuss approaches, the science, and specific ways that Title V agencies can implement and measure these approaches. Presented by Deborah F. Perry, GU Center for Child and Human Development.

 

 

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.

A. 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

B. Align with the Needs of the Population

Consider the following findings related to this performance measure.

The Role of Title V: Get ideas on how to implement strategies

Many of the strategies with the strongest evidence supporting them are those that are more clinical or those based in enabling services rather than those that can be easily implemented by Title V agencies. As we look to “move down the MCH Pyramid” with less emphasis on direct services (disease management) to an increased focus on public health services and systems (primary and secondary prevention and population health management), we are often challenged in identifying evidence-based/informed practices to meet the new focus of the transformed MCH Block Grant.1 

Where possible, we try to align evidence-based strategies (“what works”) to activities that can be adopted by Title V agencies (“what we can do”). However, there is often the need for adaptation and innovation.2 Sometimes it’s difficult to identify the role a Title V agency could take in implementing and/or adopting such evidence-based/informed strategies.

When deciding how best to implement a strategy that seems outside the typical role of Title V, it may be helpful to consider activities that support the strategy while aligning with activities that Title V is charged with,3 such as:

  • Assessing ongoing community needs: Title V can use data collected by programs, evaluations, or more formal needs assessment findings to see if the strategy could address identified service gaps or build equity in access and positive health outcomes.
  • Informing and educating the public: Title V can provide educational/outreach materials to families/consumers to advance the strategy through training and peer support.
  • Engaging community partners and families: Title V can serve as the convener for those groups/organizations that can implement the strategy.
  • Integrating systems of public health. Title V can help ensure access, sharing of resources, and coordination of services to assure maximum impact of the strategy (coordinating the public health approach, health care, and related community services).
  • Educating the MCH workforce (building capacity): Title V can partner with groups actually conducting this strategy in order to train MCH and healthcare professionals in strategy implementation.
  • Developing public health policies and plans: Title V can support adoption of the strategy at a state level.
  • Ensuring quality improvement and promoting applied research: Title V can collect data and evaluate programs in the state/jurisdiction that are implementing this strategy to build the evidence base and promote rapid innovation.

SDOH and Health Equity Considerations: Identify ways to advance health for all

Not all strategies are effective for all population groups, and the evidence is often lacking in terms of using specific strategies to advance health equity.

Once the evidence has been considered for what works generally, it is important to understand if a specific strategy will work for targeted populations, especially those most affected by health disparities. Implementation science helps to translate the science into programs and policies that impact health outcomes in light of multiple social determinants. In finding strategies to meet needs, we have the ability to adopt and/or adapt what works.

ADOPT Strategies to Meet Needs

In choosing to adopt an existing strategy based on existing science and practice, we should consider:2

Is the study sample or population similar to our target audience?

  • ​Geography
  • Demographic characteristics
  • Culture, values, and preference
  • Health status
  • Other characteristics of interest 

Do we have the resources needed to implement?

  • ​Workforce capacity
  • Money
  • Time
  • Leadership 

Does our organization and the broader environment support the strategy? ​

  • Political support
  • Financial and legal support
  • Champions for intervention
  • Community norms and partnerships
  • Title V priority and jurisdiction
  • Favorable environment for change​​

Special Considerations: Tease out ways to zoom in on populations of focus

ADAPT Strategies to Meet Needs

Not all strategies are effective for all populations. To adapt strategies to meet needs, we should consider:5

What about the existing strategy works? If we understand the key ingredients of a strategy, we can replicate and/or adapt the effective components. Looking at a strategy through a health behavior theory identifies key ingredients. Here are several to consider:

How does it work? Being specific about the underlying mechanisms can help us increase the impact. Developing a logic model with program actions, targets, outcomes, and moderators allows you track the process from action to outcome.

For whom does it work, and for whom does it not work? When we know who is and is not responding, we can make targeted adaptations to improve outcomes. Think about the program life cycle:

  • Precision. Understand what a strategy entails so you can go beyond “does it work,” to “what about it works” and “for whom does it work.”
  • Fast-cycle iteration. Incorporate new ideas as you go – what is working and what is not working.
  • Shared learning. Create a mechanism to share learning about success and failures.
  • Co-creation. Bring together multiple parties to create a mutually valued outcome.

In what contexts does it work? By evaluating the context in which a strategy is implemented, we can adapt it for other settings. The best way to ensure that a strategy is effective is to conduct a robust evaluation. The MCH Navigator’s Evaluation Spotlight provides trainings and resources related to the steps and standards for effective program evaluation.

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 movable within the realities of Title V programs and lead to health equity 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

Implementation Resources: Use these field-generated resources to affect change

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.)

Toolkit References: From the Evidence Accelerator

1,3 Brownson RC, Fielding JE, Green LW. Building Capacity for Evidence-Based Public Health: Reconciling the Pulls of Practice and the Push of Research. Annual Review of Public Health 2018 39:1, 27-53.
2 US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, Division of State and Community Health. Title V Maternal and Child Health Services Block Grant to States Program: Guidance and Forms for the Title V Application/Annual Report
4,5 Adapted from IDEAS Impact Framework, Center on the Developing Child, Harvard University.
6 Hayden J. Introduction to Health Behavior Theory, Second Edition. Burlington, MA: Jones & Bartlett Learning. 2014.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.