On February 28, 2017, The Leapfrog Group released their 2017 Maternity Care Report to the public. This report was eye-opening to both significant improvements that have been made in some areas of maternity care and a clear signal that other benchmarks still have a long way to go. The Leapfrog Group is a nonprofit national watchdog group whose mission is to improve the safety, quality and affordability of health care by a) supporting informed health care decisions by those who use and pay for health care; and b) promoting high-value health care through incentives and rewards. The Leapfrog Group was a participant at Lamaze International's 2015 Childbirth Education Roundtable Discussion.
The 2017 Maternity Care Report examines the performance of hospitals based in the United States in three areas of maternity care that have been determined to be key components in improving outcomes in maternal and infant health. The report is derived from the 2016 Leapfrog Hospital Survey. 49% of all hospitals in the U.S. voluntarily participated in the Leapfrog Hospital Survey. The three components of performance measured are:
- NTSV (Nulliparous, Term, Singleton, Vertex) cesarean section rates.
- Early elective deliveries (Scheduled cesarean sections or medical inductions performed prior to 39 completed weeks gestation without medical necessity).
The Successes - Episiotomies and Early Elective Deliveries
One of the great successes revealed in the 2017 Maternity Care Report is in the area of early elective deliveries. In 2010, the rate of deliveries by planned cesarean or medical induction without medical necessity that occurred prior to 39 weeks was 17%. In 2016, this rate had dropped to 1.9%. This is a significant decrease in six years. There has been a coordinated effort by many professional stakeholders (ACOG, ACNM, AWHONN) to share the message about the importance of reducing early elective births. Clearly, the message is effectively out there and great positive change has been made in reducing this unnecessary intervention. Leapfrog's target rate for early elective deliveries is 5.0% or lower.
Episiotomies also declined from previous rates but have still not yet met The Leapfrog Group's target rate of 5%. In 2016, the episiotomy rate of the participating hospitals was 9.6%. This is a drop from 13.0% in 2012 but has still not met the established target rate. More education and outreach still need to be done to meet the appropriate benchmark for this intervention that has long been recognized as often harmful and unnecessary.
Needs Improvement - NTSV Cesarean Rates
Unfortunately, the NTSV cesarean section rate continues to reflect how much work still needs to be done to reduce this number down to a level deemed acceptable to experts in the field. The average rate of NTSV cesareans was 25.8% in 2016. This number indicates that there has been very little improvement and only a very small decrease from the 2015 rate which was 26.4%. 2015 was when Leapfrog first began reporting this data.
When Leapfrog examined this NTSV cesarean delivery rate more closely, it revealed that there is a significant variation across the country. The eastern and southern states continue to show higher rates of NTSV cesarean deliveries compared to western states. Louisiana had the highest rate at 32.1% and New Mexico the lowest with a rate of 17.1%. Leapfrog has established a target rate of 23.0% for this benchmark which aligns with the Healthy People 2020 goals.
Expectant families with a low-risk pregnancy need to understand that they can reduce their odds of receiving an unnecessary cesarean section by choosing their hospital and caregiver wisely. Both The Leapfrog Group and Consumer Reports have published guides to hospital NTSV cesarean rates, a recognized important predictor of what families can expect.
What determines which hospital will have a "good" (low) NTSV cesarean delivery rate is still not widely understood. There are not clear determinates - such as rural vs urban, high-risk facilities versus community hospitals or other factors that easily predict which hospital will have lower rates. What is understood is that rates can vary widely within a geographic location, by facility, and by provider. Parents must be savvy consumers when choosing both a facility to give birth in and a health care provider to take care of them.
Conclusion - Receiving Evidence-Based Maternity Care
There are some things that are clear from this recent Leapfrog Group report. Collaborated efforts amongst professional stakeholders can quickly and significantly reduce unnecessary maternity care interventions. The early elective birth rate is proof of that. Some practices, like episiotomies, which have long been shown to do more harm than good in most cases, still need to see improvement to meet rates that reflect evidence-based care. And in the case of NTSV cesarean rates, many U.S. hospitals have a long way to go. Identifying the factors that influence this rate, and then developing practices that can have an effect on reducing it are being studied, but all the nuances are still not clear.
What is clear is that expectant families must do due diligence in choosing both a provider and a facility. When families make the choice to receive services from hospitals and care providers who have demonstrated evidence-based practices and good outcomes, then change will come to those locations whose numbers fall short of acceptable.
Childbirth educators and other birth professionals that work with families can help educate families about this information and provide them the tools to evaluate where they feel comfortable in giving birth. Sharing The Leapfrog Group report and the Consumer Reports information is a great first step. When everyone, both professionals, and consumers, work together, we can start to see some traction on these statistics and an improvement in maternal infant health outcomes. Lamaze International recognizes the importance of childbirth education in helping to improve outcomes. To further this work, our organization continues to collaborate with The Leapfrog Group and other stakeholders to work as a collective community to improve outcomes for parents and newborns.
What are you doing in your classes to create savvy consumers of maternity care? Please share in the comments below.