Approximately 1 in 5 hospitals fully met national standards for performing lower rates of cesarean sections and other maternal care medical interventions that may unnecessarily increase health risks for mothers and infants, according to a report released Wednesday.
The Leapfrog Group surveyed more than 2,000 U.S. hospitals and found most providers failed to meet all of the organization's standards for best practices for three maternity care interventions, including C-sections, early elective deliveries and episiotomies.
There has been little progress in reducing the national C-section rate, and they are performed in 1 in 3 births in the U.S. Leapfrog found the average rate of C-sections performed in first-time pregnancies remained relatively unchanged at around 26% since 2015 and still above Leapfrog's target standard of 23.9%.
Experts have linked C-sections with longer hospital stays and increased risk of respiratory issues, infections and more frequent stays within intensive care. For mothers, C-sections have been associated with increased rates of infection, bleeding and hospital readmissions.
The group found a significant decline in early elective deliveries, with the average rate falling from 17% in 2010 to 1.5% in 2018, well under Leapfrog's target rate of 5% or less.
Similar to C-sections, experts have recommended against inducing delivery before 39 weeks for nonmedical reasons. Research has shown early elective deliveries can increase health risks in both children and mothers.
Leapfrog's survey found episiotomy rates fell from 7.8% in 2017 to 6.9% in 2018. The average rate of episiotomies began to decline after the American College of Obstetricians and Gynecologists in 2006 recommended clinicians restrict performing the procedure for most births, stating it did not result in maternal or fetal benefit.
But the rate still remained above Leapfrog's target rate of 5% or less. The procedure involves making an incision in the birth canal and was once routinely performed during childbirth as a means of preventing extensive vaginal tears.
Leapfrog CEO Leah Binder said the results overall show hospitals have the ability to make great strides toward improving maternal care when they make it a key focus.
"When the healthcare industry decides it's time to improve care they accomplish that," Binder said. "When they don't put their minds to a goal of improving maternity care we see stagnation."
For years, the U.S. has had one of the highest maternal mortality rates among wealthy countries. In 2015 the U.S. rate was at more than 26 deaths for every 100,000 births in 2015, according to a 2016 analysis published in Lancet.
Solutions for improving both maternal and infant health are multifactorial and include expanding access to healthcare coverage and quality health services and addressing nonmedical social factors, such as poverty, food insecurity and housing instability.
Yet the survey's findings raise questions as to why some hospitals haven't taken steps on their own to reduce the frequency of these practices, especially when the evidence and guidelines discouraging the procedures have been around for years.
Binder felt that had less to do with educating clinicians on best practices than with changing cultural norms.
"Even when one individual physician may have strong ideas about avoiding C-sections, if that physician is in a hospital setting where C-sections are more common they will probably end up there as well," Binder said. "It's very hard to change a culture."
Binder said she found encouragement when she saw most hospitals that improve their practices are able to maintain their success over time. Approximately 90% of hospitals that achieved Leapfrog standards for early elective deliveries and episiotomy rates in 2017 repeated that achievement in 2018, while 70% of hospitals that met standards on C-section rates did so a year later.
"It is this continued success year after year that will have the farthest-reaching impact in giving mothers and children a healthy start," Binder said.