There are many ways to improve maternal mortality and maternal health outcomes. Reducing unnecessary cesarean sections (C-sections) and promoting vaginal births should be a top priority for hospitals and obstetric care teams, as this has been shown to result in better health outcomes for mothers and save lives.

Maternal mortality rates continue to be distressingly high. A March 2023 report from the Centers for Disease Control and Prevention revealed that maternal deaths rose 40% in the U.S. in 2021 compared to 2020. For non-Hispanic Black women, the maternal mortality rate was 69.9 deaths per 100,000 live births, 2.6 times higher than the rate for non-Hispanic White women.

Meanwhile, C-section rates have generally been climbing. The overall cesarean delivery rate in the U.S. increased from 20.7% in 1996 to 32.1% in 2021, the latest data available.

Medically necessary C-sections can be a life-saving intervention for both mother and child. But C-sections are associated with significantly higher maternal mortality — in addition to complications like bleeding and longer hospital stays — compared to vaginal births.

Why C-Sections remain common despite the risks

It’s easier to understand why C-sections occur when we look more closely at the underlying factors. The U.S. lags significantly behind other countries when it comes to paid maternity leave. The Family and Medical Leave Act guarantees 12 weeks of unpaid maternity leave, but paid leave is not mandated. Only 40% of U.S. employers offer paid maternity leave.

For many expectant working mothers who lack paid leave benefits, being able to schedule a cesarean delivery is less disruptive to their employer. Additionally, many mothers have limited awareness about the risks of C-sections, and some believe that C-sections are medically superior to vaginal births.

There are also significant variations of maternal care among obstetric care teams of different hospitals. One Harvard School of Public Health study found that C-section rates at Massachusetts hospitals varied between 14% and 38%. The same first-time mother with a low risk of complications may be more than twice as likely to have a C-section at one hospital than with another.

Two critical measures to reduce unnecessary C-sections

The World Health Organization has set a target of between 10 and 15% as the “ideal rate” for C-sections. In the U.S., we can accomplish this reduction in C-sections in two ways, broadly speaking:

• Educating mothers — especially first-time mothers — on the risks associated with C-sections Many patients have inaccurate information about cesarean deliveries; in fact, many providers and birthing classes do not offer comprehensive or factual training that adequately explains the risks of cesarian birth to expecting parents. The entire healthcare ecosystem (primary care facilities, urgent care centers, OB/GYN providers, etc.) need to develop patient education programs that explain why, for lower-risk pregnancies, vaginal births are often the safer option and less likely to lead to complications for mother or baby during the prenatal period. It is during this stage that women should be informed of cesarian birth risks and whether they are medically necessary. Underlying issues that lead many women to choose C-sections, such as a lack of paid leave, are harder to solve. But medical professionals should help dispel prevalent myths about C-sections so that every expectant mother can make informed choices that will result in better health outcomes for herself and her baby.
• Educating and training obstetric care teams to reduce variations in clinical care It’s no accident that an expectant mother can be 2-3 times more likely to have a C-section in one hospital compared to another. Hospital administrators should understand how their institution’s C-section rates compare to target rates. They should implement education and training programs focused on evidence-based practices that have been validated by an accredited organization focused on obstetric or neonatal care. Obstetric care teams must detect clinical variations in care and take steps to address one delivery provider at a time. This could include a provider justifying scheduled C-sections at the time of scheduling a C-section. One best practice is to have an OB leader review these requests prior to the date of the scheduled C-section. If the request for the surgery doesn’t meet published guidelines from ACOG as an example, then the C-section is canceled and/or the physician leader has a direct conversation about medical necessity to the scheduling provider. While this approach may seem heavy handed, it has demonstrated a reduction in low-risk primary C-sections, saved many unnecessary surgeries and costs, and reduced maternal harm. This requires a shift in culture at the physician leadership level and support from senior leadership within the organization.

It takes an average of 17 years for new evidence-based practices to be incorporated into general healthcare protocols. Given the recent spike in maternal deaths and variations in care between hospitals, healthcare institutions need to take urgent action to address the overuse of C-sections.

Reducing C-sections that are not medically necessary will save lives and reduce complications such as excessive bleeding and infections. Only through comprehensive education and awareness can we give both mothers and obstetric care teams the tools they need to make the right decision about whether a C-section is medically indicated.

Photo: damircudic, Getty Images