All 49 of the hospitals that deliver babies in New Jersey have signed on to an initiative to reduce the number of unnecessary cesarean section births, a potentially risky procedure that is used here more frequently than in most states.

The New Jersey Hospital Association announced earlier this month that Garden State birthing facilities will implement additional training, embrace the work of doulas who can provide women comprehensive birthing assistance, and adopt new clinical protocols and monitoring practices based on policies developed by the NJHA’s Institute for Quality and Patient Safety and the state Department of Health. The goal is to cut the number of these procedures by nearly a third.

While C-sections are an important option for some deliveries, experts agree it is essential to limit their use to critical cases — not questions of convenience for the doctor or patient. The practice increases the risk of blood clots, cardiac complications, infection, and pelvic pain for the mother, and can create challenges for future pregnancies. For infants, they can result in breathing problems, asthma, and diabetes, and can lead to more time in a critical-care unit.

“Delivering a baby is one of the most important times in which more medical intervention isn’t always best,” noted NJHA president and CEO Cathy Bennett, the former state health commissioner. “We must approach this challenge as a partnership — with well-trained hospital teams working with well-prepared women and their support teams to ensure that every mother and baby has the very best care without incurring any unnecessary risks.”

C-sections well above target rate

The NJHA said while Garden State hospitals have made some improvements in recent years, its C-section rate for 2016 was 30.3 percent of all births, well above the target 23 percent. Recent findings by the Leapfrog Group, a nonprofit watchdog, based on 2017 data, showed only 9 of the 47 hospitals that shared their results met their C-section goal of less than 24 percent, down from 11 facilities that made the cut in 2016.

Maternal and infant health has become a growing focus recently in New Jersey, where more than 100,000 babies are born each year. While the state has a strong system of public healthcare, and outcomes overall are improving, it has been the subject of recent reports that raise questions about C-sections and racial disparitiesin maternal health, among other things. While overall maternal- and infant-mortality rates are below the national average, black women and babies die at more than three times the rate of their white counterparts — one of the larger gaps nationwide.

Under Gov. Phil Murphy, who took office in January, state officials have devoted new attention to various aspects of maternal, infant, and women’s health. Department of Health Commissioner Dr. Shereef Elnahal has also zeroed in on women’s health, working with community providers to boost awareness and understanding of the issues and joining with hospitals and other clinicians to encourage best-practice protocols.

“Improving maternal and infant birth outcomes is a key priority for the Murphy administration, so we are pleased that all of the state’s birthing hospitals have joined forces with the New Jersey Department of Health and the NJHA,” Elnahal said. By encouraging the use of these best practices and taking other measures, facilities can “ensure that care delivery is of the highest quality when a woman presents for delivery,” he added.

Focusing on first-time moms

The new initiative — announced at the New Jersey Perinatal Safety Conference in early June — is focused on first-time, low-risk pregnancies with a single fetus in the proper position for vaginal birth; mothers who deliver a first child by C-section will usually end up delivering future babies the same way. The project, which began in April and will continue through next year, is part of the larger work of the New Jersey Perinatal Quality Collaborative, a joint effort of the NJHA and the DOH.

The work has begun with additional education for nurses and other staff on modern, supportive labor techniques, including efforts to improve pain assessments and better inform and engage partners and family members. Steps will also be shared about how to integrate doulas with the clinical team and improve communications between all caregivers involved in a birth.

Hospitals will also be asked to adopt proven best-practice strategies and clear protocols for the use of regional anesthesia, like an epidural. Facilities will also need to adopt policies to ensure proper monitoring of all mothers, including low-risk patients, as the labor begins to progress.

The C-section initiative also drew praise from Linda Schwimmer, president and CEO of the New Jersey Health Care Quality Institute, which has worked in recent years with the perinatal collaborative and other experts to improve birth outcomes. Schwimmer said she was pleased to see the NJHA and the DOH working together on the issue — and that hospitals “are acknowledging that there is a problem with C-section rates in New Jersey and acknowledge that they have a key role in addressing the problem.”

“In our work, we’ve seen that physician and nurse leadership is the most important ingredient to improving the outcomes,” she continued, noting that birth teams should discuss each C-section to determine if it is truly necessary. “Also, early and clear communication with patients about their birth plan and setting expectations is also important.”

But Schwimmer said there are other tools providers should deploy to reduce the rate of C-sections even further, like improving communication and health-record sharing between prenatal caregivers and the hospital delivery team. And hospitals should be required by law to report C-section rates to Leapfrog, she said.

In addition, health insurance plans, unions, businesses, and other groups that pay for care — including state and local government, which covers the cost of care for some 800,000 public workers — also “have a role in changing the payment system so the incentives are removed for keeping the status quo,” Schwimmer said, urging them not to reimburse providers for C-sections that are considered early-elective deliveries, or C-sections or induced births before 39 weeks that are not for medical reasons.