California Maternal Quality Care Collaborative (M.G.R., S.-C.C., C.S., E.K.M.) and the Division of Neonatal and Developmental Medicine, Department of Pediatrics, and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, and the Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California.
Obstet Gynecol. 2024 Oct 1;144(4):507-515. doi: 10.1097/AOG.0000000000005696. Epub 2024 Aug 1.
To evaluate the effect of statewide efforts to reduce nulliparous, term, singleton, vertex (NTSV) cesarean delivery rates in California.
This was a population-based study of all NTSV births in California from 2015 to 2019. In 2015, all California hospitals with NTSV cesarean delivery rates above the 23.9% Healthy People 2020 target were invited to join a CMQCC (California Maternal Quality Care Collaborative)-sponsored, 3-year, multifaceted collaborative or a system-level quality collaborative to safely support vaginal birth. We examined the cesarean delivery rate overall and by participation or nonparticipation in a collaborative program. Secondarily, for hospitals that started with an NTSV cesarean delivery rate above 23.9%, we compared patient-level, hospital-level, and obstetric management characteristics between hospitals that met the Healthy People 2020 target (cesarean delivery rate below 23.9%) in 2019 and those that did not.
There were 758,268 NTSV births at 238 hospitals. Annual mean NTSV cesarean delivery rates decreased among all racial and ethnic groups statewide and among all patients, regardless of payer, maternal age, or body mass index (BMI). The decrease in cesarean delivery was driven largely by a decrease in the frequency of cesarean delivery performed for labor dystocia (14.9% in 2015 to 12.8% in 2019) and from cesarean delivery before the onset of labor (4.2% in 2015 to 3.3% in 2019). For hospitals that started with an NTSV cesarean delivery rate above 23.9%, NTSV cesarean delivery rates among 80 hospitals participating in the CMQCC had a mean±SD decline of 6.9±5.9%, 13 hospitals participating in the system-level collaborative had a 5.0±4.5% decline, and those not participating in any collaborative had a 2.1±6.0% decline. In multivariable analysis, there was no association between meeting the Healthy People target and any of the hospital-level factors or aggregated patient-level characteristics. Rates of induction of labor increased in both groups and were not associated with a change in cesarean delivery rates.
Hospitals in California between 2015 and 2019 with a wide variation in institutional and patient characteristics successfully reduced their NTSV cesarean delivery rates. Reduction in the NTSV cesarean delivery rate at hospitals that started above the Healthy People target was not associated with differences in patient characteristics but rather a reduction in cesarean deliveries for labor dystocia and cesarean deliveries performed before the onset of labor.
评估加利福尼亚州全州范围内降低无指征初产妇、足月、单胎、头位（NTSV）剖宫产率的效果。
这是一项针对 2015 年至 2019 年加利福尼亚州所有 NTSV 分娩的基于人群的研究。2015 年，所有 NTSV 剖宫产率高于 23.9%《健康人民 2020 目标》的加利福尼亚州医院均受邀参加 CMQCC（加利福尼亚州产妇质量护理合作组织）赞助的为期 3 年、多方面的合作或系统级质量合作，以安全支持阴道分娩。我们检查了总体剖宫产率以及参与或不参与合作计划的剖宫产率。其次，对于那些剖宫产率开始高于 23.9%的医院，我们比较了在 2019 年达到《健康人民 2020 目标》（剖宫产率低于 23.9%）的医院和未达到该目标的医院之间的患者水平、医院水平和产科管理特征。
在 238 家医院中，有 758268 名 NTSV 分娩。全州范围内，所有种族和族裔群体以及所有无论支付方式、产妇年龄或体重指数（BMI）如何的患者的年度平均 NTSV 剖宫产率均有所下降。剖宫产率的下降主要是由于分娩困难剖宫产（2015 年为 14.9%，2019 年为 12.8%）和未发动分娩即剖宫产（2015 年为 4.2%，2019 年为 3.3%）的频率下降所致。对于那些剖宫产率开始高于 23.9%的医院，80 家参加 CMQCC 的医院的 NTSV 剖宫产率平均下降了 6.9±5.9%，13 家参加系统级合作的医院下降了 5.0±4.5%，而没有参加任何合作的医院下降了 2.1±6.0%。在多变量分析中，达到健康人目标与任何医院水平因素或汇总患者水平特征之间均无关联。两组诱导分娩的比例均有所增加，与剖宫产率的变化无关。
2015 年至 2019 年期间，加利福尼亚州的医院在机构和患者特征方面存在广泛差异，但都成功降低了 NTSV 剖宫产率。在达到《健康人民 2020 目标》的医院中，NTSV 剖宫产率的降低与患者特征的差异无关，而是与分娩困难剖宫产和未发动分娩即剖宫产的减少有关。
