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Reducing Primary Cesareans

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Preparing for Change

Documents here will help you prepare your team for change. These include background documents on how to make the case for change, details about the bundles that you will be implementing, how to think about staffing for change, a checklist to evaluate your readiness to implement the bundle, examples of charters, and sample policies that support the change bundles.

The Case for Change

Nearly one third of births in the US are delivered by cesarean section each year. After a 60% increase in cesarean births from 1996 to 2009, reaching a high of 32.9%, there was a slight decline to 32.7% in 2013.1 While cesarean birth can be a lifesaving procedure in situations when vaginal delivery is not a safe option, for most low-risk women giving birth for the first time, cesarean deliveries create more risk, including hemorrhage, uterine rupture, abnormal placentation, and respiratory problems for infants.2 Furthermore, mothers who have had cesarean sections have increased chance of these risks in subsequent cesarean deliveries. In addition to these risks, mothers who undergo cesareans have longer recovery times, slower returns to productive activities, and difficulty breastfeeding

This trend has received worldwide attention from various stakeholders as a maternal and child quality issue. In 2000, the American Congress of Obstetricians and Gynecologists (ACOG) published a report on the trend in cesarean births, with a proposed national goal of 15.5%. More recently, the federal Healthy People 2020 guideline established a target rate cesarean delivery rate of no more than 23.9% for low-risk women without a prior cesarean. These births to low risk, first time mothers are referred to as NTSV births.3

Research and analysis about this recent rise in cesarean births has identified several contributing factors. Key contributing factors may include: variation in medical education; pressure in hospital environments that may lead to early intervention, rather than letting labor take its natural course; risks associated with common labor interventions, such as inductions; continuous fetal monitoring; concern about medical malpractice; and payment models.

Concern about higher than target cesarean rates is driven by both quality concerns and costs. For example, national data shows that, on average, a cesarean birth costs $3,432 to $7,000 more than a vaginal birth.4,5 In response, a range of stakeholders, including professional societies and purchasers, have now focused attention on this issue.

Bundles to Support Change

The concept of the bundle was developed by the Institute for Healthcare Improvement (IHI) as a way to support health care professionals to provide the best care possible based on available evidence. According to IHI “A bundle is a structured way of improving the processes of care and patient outcomes by using a small, straightforward set of evidence-based practices— generally three to five— that, when performed collectively and reliably, have been proven to improve patient outcomes”1. The process of improvement through the use of a bundle is that it ties the evidence based care practices together into a package of approaches to care or interventions that are “followed for every patient, every single time”2.

With funding support from the Transforming Birth Fund, ACNM has launched the Reducing Primary Cesarean Project. This project is focused on the development of hospital based perinatal collaboratives that implement one of three bundles which aim to reduce unnecessary cesareans. The three bundles, available in the bundles tool box on the Healthy Birth Initiative website, and also available below, are:

Staffing to Support Change

Davies article on assessing nurse self efficacy for labor support

Davies scale to assess nurse self efficacy

Also, check Birthtools at:

And video training at IHI on Front Line Nurses Driving Change these are the slides

Policies and Training to Support Change

If you are an RPC member, please consult the Implementation Guide and resources on the Basecamp site. 

For non-RPC members -- the policies here have been contributed by RPC member sites and advisors. They are not intended to be used verbatim. Please use them only as examples as you prepare your own documents for your own hospital.

Progress in Labor Policies

Comfort in Labor Policies

IA Policies and Training





  3. This measure refers to first-time pregnancies (Nulliparous) that have reached at least 37 weeks gestation (Term), with one fetus (Singleton) in the head-down position (Vertex).

  4., accessed 7/25/16.



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