Reducing NTSV cesarean rates

Matthew Larsen

Clinical Issue/Practice Problem: Over the past 21 years, U.S. cesarean deliveries have increased 53%, with interventions showing only a 0.2% reduction (2009 to 2013). A national goal to reduce the overall cesarean rate targets NTSV (nulliparous, term, singleton, vertex) pregnancies. A nationwide, midwifery-driven initiative has had success in lowering NTSV cesarean rates. The aim of this project was to evaluate facilitating factors and barriers encountered by hospital teams in reducing NTSV cesarean rates.

Summary of Supporting Literature: Studies supported reduction of primary cesareans through promotion of physiological birth and reduction of medical interventions as appropriate.

Project Implementation: Semi-structured telephone interviews were performed with ten hospital leadership teams using an interview guide developed in collaboration with initiative staff. Interviews were recorded and transcribed and a thematic analysis was conducted. Six themes were identified: leadership, team attributes, planning synchronicity, adaptive practices, motivation, and administrative dysfunction.

Outcomes: The evaluation was guided by Solberg’s conceptual framework for practice improvement. Data was categorized into two groups, more efficacious teams and less efficacious teams (teams in top and bottom 50th percentile of NTSV change, respectively). More efficacious teams had visionary and strategic leaders for their multidisciplinary team; used collaborative team processes and adaptive practices; and were driven by multiple motivations. Less efficacious teams demonstrated unproductive leadership, maladaptive and inflexible tendencies, individuated planning, unequal contributions, and irresolute motivation.

Clinical Implications for Practice and Next Steps: This evaluation demonstrated that the team, over any other factor, is the most important contributor to NTSV rate reduction. Hospital units must create a team that is collaborative and instill adaptive team practices and leadership skills.