Cesarean Birth

Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean birth

Measure specifications are in the Public Domain.

LOINC(R) copyright 2004-2023 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2023 International Health Terminology Standards Development Organisation. ICD-10 copyright 2023 World Health Organization. All Rights Reserved.

These performance measures are not clinical guidelines and do not establish a standard of medical care and have not been tested for all potential applications. The measures and specifications are provided without warranty.

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The removal of any pressure to not perform a cesarean birth has led to a skyrocketing of hospital, state and national cesarean birth (CB) rates. Some hospitals’ CB rates were over 50%. Hospitals with CB rates at 15-20% have infant outcomes that are just as good and better maternal outcomes (Symum & Zayas-Castro, 2023). There is no data that higher rates improve any outcomes, yet the CB rates continue to rise (Bailit, Garrett, Miller, McMahon, & Cefalo, 2002; Main, Bloomfield, & Hunt, 2004). This measure seeks to focus attention on the most variable portion of the CB epidemic, the term labor CB in nulliparous women. This population segment accounts for the large majority of the variable portion of the CB rate and is the area most affected by subjectivity.

As compared to other CB measures, what is different about Nulliparous, Term, Singleton, Vertex (NTSV) CB rate is that there are clear cut quality improvement activities that can be done to address the differences. Main et al. (2012) found that over 60% of the variation among hospitals can be attributed to first birth labor induction rates and first birth early labor admission rates (Main et al., 2006). The results showed if labor was forced when the cervix was not ready the outcomes were poorer. Rosenstein et al. (2021) also showed that labor and delivery guidelines can make a difference in labor outcomes. Many authors have shown that physician factors, rather than patient characteristics or obstetric diagnoses are the major driver for the difference in rates within a hospital (Berkowitz, Fiarman, Mojica, Bauman, & de Regt, 1989; Goyert, Bottoms, Treadwell, & Nehra, 1989; Luthy, Malmgren, Zingheim, & Leininger, 2003; Symum & Zayas-Castro, 2023; Main et al., 2006). The dramatic variation in cesarean rates seen in all populations studied is striking. Cesarean rates varied tenfold in US hospitals nationwide across hospitals (Agency for Healthcare Research and Quality [AHRQ], 2002), from 7.1% to 69.9%, and there was a 15-fold variation among low-risk women, from 2.4% to 36.5% (Kozhimannil, Law, & Virnig, 2013).

A reduction in the number of NTSV patients delivering by cesarean birth will result in increased patient safety, a substantial decrease in maternal and neonatal morbidity and substantial savings in health care costs (Main et al., 2019). Successful quality improvement efforts incorporate audit and feedback strategies combined with provider and nurse education, guidelines and peer review.

The measure will assist health care organizations to track NTSV patients delivering by cesarean birth to reduce the occurrence. Nulliparous women have 4-6 times the cesarean birth rate than multiparous women thus the NTSV population is the largest driver of primary cesarean birth rate (Sakala, Belanoff, & Declercq, 2020). NTSV has a large variation among facilities, thus identifying an important population on which to focus quality improvement efforts.

In accordance with the American College of Obstetricians and Gynecologists (ACOG) recommendations (2020), cesarean delivery is indicated for patients with active genital lesions of genital herpes or prodromal symptoms (i.e., vulvar pain or burning at delivery) that may indicate viral shedding. Therefore, the measure will exclude encounters with a diagnosis of active genital herpes.

In addition, the accepted approach to treat placenta accreta spectrum, or the range of pathologic adherence of the placenta that includes placenta increta, placenta percreta, and placenta accreta, as well as placenta previa, is cesarean delivery (ACOG & Society for Maternal-Fetal Medicine (SMFM), 2018). Vasa previa is an indication for cesarean delivery (SMFM Publications Committee, Sinkey, Odibo, & Dashe, 2015). Accordingly, placenta previa, vasa previa, and placenta accreta spectrum are all qualifying conditions to also be excluded from the measure. 
 
Ultimately, a reduction in primary cesarean births will reduce the number of women having repeat cesarean births (almost 90% of mothers who have a primary cesarean birth will have subsequent cesarean birth (CDC, 2020)). Thus, improvement in the rates of cesarean birth for the first birth will reduce the morbidity of all future births and avoid all the controversies with trial of labor after cesarean/elective repeat cesareans.

The  ACOG report, Evaluation of Cesarean Delivery (2000), recognizes the importance of the Nulliparous, Term Singleton Vertex (NTSV) population as the optimal focus for measurement and quality improvement action. A reduction in the number of nulliparous patients with live term singleton newborns in vertex position delivering by cesarean birth will result in increased patient safety, a substantial decrease in maternal and neonatal morbidity and substantial savings in health care costs.

Within Optimal Range. The Joint Commission does not want to encourage inappropriately low Cesarean rates that may be unsafe to patients. Acceptable PC-02 rates are 30% or lower (U.S. Department of Health and Human Services, n.d.), however there is not an established threshold for what rate may be too low. PC-06 serves as a balancing measure for PC-02 to guard against any unanticipated or unintended consequences and to identify unforeseen complications that might arise as a result of quality improvement activities and efforts for this measure. In order to identify areas for improvement, hospitals may want to review results based on specific ICD-10 codes or patient populations. Data could then be analyzed further determine specific patterns or trends to help reduce cesarean births.

Reference Type: CITATION

Reference Text: 'Agency for Healthcare Research and Quality. (2002). AHRQ Quality Indicators Guide to Inpatient Quality Indicators: Quality of Care in Hospitals Volume, Mortality, and Utilization. Revision 4 (2004, December 22). AHRQ Pub. No. 02-RO204.'

Reference Type: CITATION

Reference Text: 'American College of Obstetricians and Gynecologists. (2000). Task Force on Cesarean Delivery Rates. Evaluation of Cesarean Delivery. (Developed under the direction of the Task Force on Cesarean Delivery Rates, Roger K. Freeman, MD, Chair, Arnold W. Cohen, MD, Richard Depp III, MD, Fredric D. Frigoletto Jr, MD, Gary D.V. Hankins, MD, Ellice Lieberman, MD, DrPH, M. Kathryn Menard, MD, David A. Nagey, MD, Carol W. Saffold, MD, Lisa Sams, RNC, MSN and ACOG Staff: Stanley Zinberg, MD, MS, Debra A. Hawks, MPH, and Elizabeth Steele)'

Reference Type: CITATION

Reference Text: 'American College of Obstetricians and Gynecologists. (2014). Revitalize: Obstetrics Data Definitions Version 1.0. American College of Obstetricians and Gynecologists. Revitalize: Obstetrics Data Definitions Version 1.0 - Search (bing.com)'

Reference Type: CITATION

Reference Text: 'American College of Obstetricians and Gynecologists. (2020, May). ACOG Practice Bulletin No. 220: Management of Genital Herpes in Pregnancy. Obstetrics & Gynecology, 135(5), e193-e200.'

Reference Type: CITATION

Reference Text: 'American College of Obstetricians and Gynecologists, & Society for Maternal-Fetal Medicine (2018). Obstetric Care Consensus No. 7: Placenta Accreta Spectrum. Obstetrics and Gynecology, 132(6), e259–e275. https://doi.org/10.1097/AOG.0000000000002983'

Reference Type: CITATION

Reference Text: 'Bailit, J.L., Garrett, J.M., Miller, W.C., McMahon, M.J., & Cefalo, R.C. (2002). Hospital primary cesarean delivery rates and the risk of poor neonatal outcomes. American Journal of Obstetrics & Gynecology, 187(3):721-727.'

Reference Type: CITATION

Reference Text: 'Berkowitz, G. S., Fiarman, G. S., Mojica, M. A., Bauman, J., & de Regt, R. H. (1989). Effect of physician characteristics on the cesarean birth rate. American Journal of Obstetrics and Gynecology, 161(1), 146–149. https://doi.org/10.1016/0002-9378(89)90252-4'

Reference Type: CITATION

Reference Text: 'Center for Disease Control. (2020) Recent trends in vaginal birth after cesarean delivery: United States, 2016-2018. Retrieved from National Center for Health Statistics: https://www.cdc.gov/nchs/products/databriefs/db359.htm'

Reference Type: CITATION

Reference Text: 'Goyert, G. L., Bottoms, S. F., Treadwell, M. C., & Nehra, P. C. (1989). The physician factor in cesarean birth rates. The New England Journal of Medicine, 320(11), 706–709. https://doi.org/10.1056/NEJM198903163201106'

Reference Type: CITATION

Reference Text: 'Kozhimannil, K. B., Law, M. R., & Virnig, B. A. (2013). Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues. Health Affairs (Project Hope), 32(3), 527–535. https://doi.org/10.1377/hlthaff.2012.1030'

Reference Type: CITATION

Reference Text: 'Luthy, D. A., Malmgren, J. A., Zingheim, R. W., & Leininger, C. J. (2003). Physician contribution to a cesarean delivery risk model. American Journal of Obstetrics and Gynecology, 188(6), 1579–1587. https://doi.org/10.1067/mob.2003.389'

Reference Type: CITATION

Reference Text: 'Main E.K., Bloomfield, L., & Hunt, G. (2004). Development of a large-scale obstetric quality-improvement program that focused on the nulliparous patient at term. American Journal of Obstetrics and Gynecology, 190, 1747-58.'

Reference Type: CITATION

Reference Text: 'Main, E. K., Chang, S. C., Cape, V., Sakowski, C., Smith, H., & Vasher, J. (2019). Safety assessment of a large-scale improvement collaborative to reduce nulliparous cesarean delivery rates. Obstetrics and Gynecology, 133(4), 613–623. https://doi.org/10.1097/AOG.0000000000003109'

Reference Type: CITATION

Reference Text: 'Main, E. K., Moore, D., Farrell, B., Schimmel, L. D., Altman, R. J., Abrahams, C.,... Sterling, J. (2006). Is there a useful cesarean birth measure? Assessment of the nulliparous term singleton vertex cesarean birth rate as a tool for obstetric quality improvement. American Journal of Obstetrics and Gynecology, 194(6), 1644–1652. https://doi.org/10.1016/j.ajog.2006.03.013'

Reference Type: CITATION

Reference Text: 'Main, E. K., Morton, C. H., Melsop, K., Hopkins, D., Giuliani, G., & Gould, J. B. (2012). Creating a public agenda for maternity safety and quality in cesarean delivery. Obstetrics and Gynecology, 120(5), 1194–1198. https://doi.org/10.1097/aog.0b013e31826fc13d'

Reference Type: CITATION

Reference Text: 'Rosenstein, M. G., Chang, S. C., Sakowski, C., Markow, C., Teleki, S., Lang, L.,... Main, E. K. (2021). Hospital quality improvement interventions, statewide policy initiatives, and rates of cesarean delivery for nulliparous, term, singleton, vertex births in California. JAMA, 325(16), 1631–1639. https://doi.org/10.1001/jama.2021.3816'

Reference Type: CITATION

Reference Text: 'Sakala, C., Belanoff, C., & Declercq, E. R. (2020). Factors Associated with Unplanned Primary Cesarean Birth: Secondary analysis of the listening to mothers in california survey. BMC Pregnancy and Childbirth, 20(1), 462. https://doi.org/10.1186/s12884-020-03095-4'

Reference Type: CITATION

Reference Text: 'Society of Maternal-Fetal (SMFM) Publications Committee, Sinkey, R. G., Odibo, A. O., & Dashe, J. S. (2015). SMFM consult series #37: Diagnosis and management of vasa previa. American Journal of Obstetrics & Gynecology, 213(5), 615-619. https://doi.org/10.1016/j.ajog.2015.08.031'

Reference Type: CITATION

Reference Text: 'Symum, H., & Zayas-Castro, J. L. (2023). A multistate decomposition analysis of cesarean rate variations, associated health outcomes, and financial implications in the United States. American Journal of Perinatology, 40(13), 1473-1483. https://doi.org/10.1055/s-0041-1736538'

Reference Type: CITATION

Reference Text: 'U.S. Department of Health and Human Services. (n.d.). Reduce cesarean births among low-risk women with no prior births-MICH-06. https://health.gov/healthypeople/objectives-and-data/browse-objectives/pregnancy-and-childbirth/reduce-cesarean-births-among-low-risk-women-no-prior-births-mich-06'

Parity: The number of pregnancies reaching 20 weeks gestation regardless of the number of fetuses or outcomes
Gravidity: The number of pregnancies, current and past, regardless of the pregnancy outcome  
Preterm Birth: The number of births >= 20 weeks and < 37 weeks gestation, regardless of outcome 
Term Birth: The number of births >= 37 weeks gestation, regardless of outcome
Nulliparous: Parity = 0 or Gravidity = 1 or Preterm & Term Births both = 0

Vertex position is modeled implicitly, as the measure excludes deliveries with abnormal presentations.

Patients who do not receive prenatal care and have no documented gestational age or estimated due date are implicitly excluded from the measure, as gestational age is required to meet denominator criteria. 

This measure allows for 3 approaches to determine gestational age (GA) in the following order of precedence:

1. The GA is calculated using the American College of Obstetricians and Gynecologists ReVITALize guidelines.*
2. The GA is obtained from a discrete field in the electronic health record. This option is only used when the calculated GA is not available.
3. The GA is based on ICD10 or SNOMED codes indicative of weeks gestation. This option is only used when results from items #1 and #2 (see above) are not available.

Wherever gestational age is mentioned, relative to the delivery, the intent is to capture the last estimated gestational age prior to or at the time of delivery.
 
*ACOG ReVITALize Guidelines for Calculating Gestational Age (ACOG, 2014):      
     
                                Gestational Age = (280-(EDD minus Reference Date))/7

--Estimated Due Date (EDD): The best obstetrical Estimated Due Date is determined by last menstrual period if confirmed by early ultrasound or no ultrasound performed, or early ultrasound if no known last menstrual period or the ultrasound is not consistent with last menstrual period, or known date of fertilization (e.g., assisted reproductive technology) 
--Reference Date is the date on which you are trying to determine gestational age. For purposes of this eCQM, Reference Date would be the Date of Delivery.

Note however the calculation may yield a non-whole number and gestational age should be rounded off to the nearest completed week. For example, an infant born on the 5th day of the 36th week (35 weeks and 5/7 days) is at a gestational age of 35 weeks, not 36 weeks.

The timing relationship of relevantDatetime 42 weeks or less before TimeOfDelivery is applied to the data elements of parity, gravida, preterm/term live births for which prenatal records may include relevant information. 

Note: The eCQM and chart-based measure slightly digress in the denominator and denominator exclusion logic. The chart-based measure excludes single stillbirth and patients with multiple gestations from the denominator. These concepts are mutually exclusive of the denominator requirement of live singleton newborn and therefore the logic does not address single stillbirth nor multiple gestation.

Parity, preterm and term live births may be updated by the electronic health record software or by clinicians during a delivery encounter. To capture the pre-delivery value, organizations may need to create a rule or calculation to capture the number prior to the delivery start time.

"Gravida", "PretermBirth", "TermBirth" and "Parity" results should be submitted via QRDA I as integer and not as number or quantity.

This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.

This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

TBD

Inpatient hospitalizations for patients age >= 8 years and < 65 admitted to the hospital for inpatient acute care who undergo a delivery procedure with a discharge date that ends during the measurement period

Inpatient hospitalizations for nulliparous patients who delivered a live term singleton newborn >= 37 weeks' gestation

See Guidance and Definition Sections for more details.

Inpatient hospitalizations for patients with any of the following conditions during the encounter:
- abnormal presentation
- genital herpes
- placenta previa
- vasa previa
- placenta accreta spectrum

Inpatient hospitalizations for patients who deliver by cesarean section

Not Applicable

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For every patient evaluated by this measure also identify payer, race, ethnicity, sex and calculated gestational age

eMeasure Perinatal Care (ePC)