May 2019
Maternal Morbidity and Rising C-Section Rates: What’s the connection? What’s the solution?
By: Dr. Derek J. Robinson, M.D., MBA, FACEP, CHCQM, Vice President and Chief Medical Officer, Blue Cross and Blue Shield of Illinois (BCBSIL)
The World Health Organization (WHO) estimates that only 10 to 15% of all births medically require a Caesarean section (C-section).1 So why are an increasing number of C-sections being performed in the U.S.? And, rather than supporting maternal and child health, how does this increase in C-sections put both mothers and babies at risk? Most importantly, what can be done to reverse the trend?
The Centers for Disease Control and Prevention (CDC) noted that severe maternal morbidity, during hospitalized deliveries, rose by nearly 200% from 1993 to 2014 (49.5/10,000 to 144/10,000, respectively).2 A 2015 Lancet study noted that the rise in maternal complications coincides with an increase in the maternal death rate, which rose from 17 deaths for every 100,000 live births in 1990, to 26.4 deaths by 2015.3 This trend also appears to be tied to the elevated need for both post C-section maternal care and Neonatal Intensive Care Unit (NICU) admissions.4
Whether due to causation or correlation, research shows a strong connection between the rise in maternal death rates and the growing number of C-sections performed across the country. This is a problem we can’t afford to ignore as it has the potential to affect the lives of so many of our members, your patients and their families.
To help address these concerns, further analysis of the indications for performing a C-section must be evaluated. WHO notes that C-section rates above 15% may cause more harm than good when compared to vaginal deliveries in low-risk patients.5 The indications and proper documentation for performing C-sections have been addressed by the CDC and multiple national organizations, including the American College of Obstetrics and Gynecology(ACOG). For example, the ACOG website includes a Cesarean Delivery: Resource Overview.6
Provider education concerning the need for, and use of, the C-section procedure needs to be stressed and ongoing, with an emphasis on routine and required prenatal exams and screenings. It’s also important to educate pregnant women about their options when it comes to the type of care they receive during the delivery process, as well as the prenatal and postnatal timeframes. Racial and ethnic disparities in the delivery of pregnancy-related care also must be considered and completion of cultural competency and implicit bias training programs by maternal health providers is critical.
Your role is essential. Some of your patients may not be aware of the importance of prenatal care to help reduce the risk of complications during pregnancy. We encourage you to talk with your patients about lifestyle changes to help improve reproductive health, such as adopting a healthy maternal diet, avoiding alcohol and the cessation of smoking. Also talk with your patients about medical disorders, such as hypertension and diabetes, which, if identified, should be appropriately addressed, and if indicated, adequate treatment provided.
The development of effective clinical strategy protocols must be created and implemented to identify and prevent adverse pregnancy-related outcomes. The key here is prevention, which includes the avoidance of unnecessary C-sections and placing a focus on those modifiable factors that can be addressed to prevent maternal deaths. The health of our nation depends upon the assurance that the health of our children will remain of paramount importance. This begins with an increased focus on maternal health care before, during and after pregnancy.
At Blue Cross and Blue Shield of Illinois (BCBSIL), we are doing our part to help partner with you to educate our members, your patients. Our health equity strategy includes an intentional focus on maternal and child health. We know, based on national, state, local, and our own member-level data that African American women are disproportionately impacted by preterm deliveries and higher C-section and morbidity/mortality rates. We want to partner with organizationsand providers to reach our shared goals around health-based outcomes. We welcome your input and collaboration as we work to lead more innovative and population-specific programs.
How can BCBSIL work with providers to help close gaps in care related to maternal health? Please share your ideas with us by emailing the Blue Review editor. I’d also like to extend a personal invitation for you to join me at our Blue University event on May 15. I’ll be your host for this event, which will spotlight health equity and social determinants of health. Register now if you haven’t done so already and bring your ideas and input with you on May 15!
Learn more about Dr. Derek J. Robinson
The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. References to third party sources or organizations are not a representation, warranty or endorsement of such organizations. Any questions regarding those organizations should be addressed to them directly. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.
1 WHO website, WHO Statement on Caesarean Section. Accessed April 5, 2019, at https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/cs-statement/en/.
2 CDC website, Severe Maternal Morbidity in the United States. Accessed April 5, 2019, at https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html.
3 Lancet, Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group. Accessed April 9, 2019, at https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)00838-7/fulltext.
4 Kamath, BD, et al, Neonatal Outcomes After Elective Cesarean Delivery, Obstet Gynecol. June 2009; 113(6): 1231–1238.
doi: 10.1097/AOG.0b013e3181a66d57. Accessed April 5, 2019, at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3620716/.
5 WHO website, Sexual and Reproductive Health, WHO Statement on Caesarean Section Rates, April 2015. Accessed April 5, 2019, at https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/cs-statement/en/.
6 ACOG website, Cesarean Delivery: Resource Overview. Accessed April 5, 2019, at https://www.acog.org/Womens-Health/Cesarean-Delivery?IsMobileSet=false.