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Cesarean rate reduction interventions in the United States

Richard, Jessica M (2017) Cesarean rate reduction interventions in the United States. Master's Thesis, University of Pittsburgh. (Unpublished)

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Objective: To identify gaps in current efforts to reduce the US’ cesarean delivery rate and to propose additional interventions.
Background: 32% of all US births are by cesarean section. Health organizations have called for action to reduce the cesarean rate. Cesareans have benefits for mother and baby when medically indicated. However, 10% of cesareans are performed without indication. Cesarean sections expose women and their babies to increased health risks, a matter of public health importance since not all cesareans are medically necessary. Individual, interpersonal, social, and policy level factors influence delivery decisions. In the context of the socioecological model, each level offers an opportunity for intervention.
Methods: A PubMed literature search produced 12 articles meeting inclusion criteria for this review of existing US interventions to reduce cesarean rates. Six articles discussed hospital-based programs. Three articles evaluated different staffing models for labor and delivery units and their impact of cesarean rates. Two articles evaluate the impact of professional recommendations on trial of labor after cesarean (TOLAC) policy. One article assessed the impact of an insurance structure change away from traditional fee-for-service to voluntary managed care.
Results: Four of the hospital-based programs decreased elective early term cesareans prior to 39 weeks gestation through educational activities, standardized protocols, changes to scheduling policies. These programs did not address elective cesareans after 39 weeks. Studies of labor and delivery staffing models found laborists and midwives had lower cesarean rates compared to traditional private practice models. In California and New Mexico, availability and access to TOLAC declined after ACOG issued restrictive recommendations in 1999. Despite changes in the recommendations in 2010, vaginal birth after cesarean (VBAC) rates remained low.
Conclusion: Multifaceted approaches will be necessary to make sustainable reductions in the US cesarean birth rate. Future interventions need to expand existing hospital-based programs, restructure traditional labor and delivery staff models, promote evidence-based professional recommendations, and research the effectiveness of educational interventions targeted to pregnant women. Additional interventions should include campaigns to increase awareness and acceptability of midwives and doulas, improvements to physician education and training, and changes to insurance policies to allow for evidenced-based practices.


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Item Type: University of Pittsburgh ETD
Status: Unpublished
CreatorsEmailPitt UsernameORCID
Richard, Jessica Mjem253@pitt.edujem253
ETD Committee:
TitleMemberEmail AddressPitt UsernameORCID
Thesis AdvisorTerry, Martha
Committee MemberHaggerty, Catherine
Committee MemberDocumet, Patricia
Date: 29 June 2017
Date Type: Publication
Defense Date: 12 April 2017
Approval Date: 29 June 2017
Submission Date: 30 March 2017
Access Restriction: No restriction; Release the ETD for access worldwide immediately.
Number of Pages: 69
Institution: University of Pittsburgh
Schools and Programs: School of Public Health > Behavioral and Community Health Sciences
Degree: MPH - Master of Public Health
Thesis Type: Master's Thesis
Refereed: Yes
Uncontrolled Keywords: Cesarean
Date Deposited: 29 Jun 2017 22:37
Last Modified: 29 Jun 2017 22:37


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