Arkansas has one of the nation's highest rates of cesarean births among low-risk pregnancies. A year ago, the Arkansas Perinatal Quality Collaborative wrapped up an initiative aimed at lowering that number. Ozarks at Large's Aiden Dixon has more.
For Dr. Constance Chapman, an obstetrician who took part in the effort, caring for mothers has been a calling for most of her life.
"The heart and focus of my desire to practice medicine has always been just wanting to help people. That's where it started. My father was sick when I was little, and just seeing how his doctors and the nurses helped him feel better, that's where it all started.
"And then I just somewhere developed an affinity for pregnant women, and it just never left me. So I was in about the sixth grade when I knew for sure I wanted to be an OB-GYN, and it's just stuck."
Since then, the Arkansas Perinatal Quality Collaborative, or ARPQC, works to improve outcomes for mothers and their babies across the state. Dr. Jennifer Callaghan-Koru is the executive director at the ARPQC. She says she came to Arkansas specifically to start a perinatal quality collaborative where there wasn't one, and one improvement that needed to be made was reducing unnecessary C-sections.
"Cesarean births are life-saving procedures when they're medically necessary, but what we're seeing in the United States is that in the early 2000s, the rate of C-section rose pretty dramatically.
"And we understand from a lot of investigation into C-section rates and what are the contributing factors that a good proportion of them could have been prevented. And C-sections contribute to increased risk for different types of complications postpartum.
"And then where you see the highest risks are for women who have multiple C-sections, so three or four C-sections for each pregnancy. And then there are much higher risk of very serious complications."
The reasons Arkansas sees higher cesarean rates are complex. Callaghan-Koru says one major factor is a mother's health before pregnancy.
"So how healthy is she? Is she at a healthy weight? Does she have other chronic conditions that might contribute to an increased risk of pregnancy complications that would result in a C-section?
"And that's something that we're seeing across the board nationally, is increasing the proportion of new mothers who are obese or who have hypertension or develop pregnancy-related hypertension, for example. And Arkansas is particularly high in some of those risk factors. So it's the fifth highest state for obesity, and that has been increasing.
"So in just about a 10-year period, the birth certificate data, which includes the weight of the mother and whether it was a healthy weight or not, the proportion of women who were giving birth that were obese was 27% in 2016, and now it's 37% just 10 years later. So we're seeing a lot of increase in some of the pre-existing risk factors that can contribute to C-section rates."
The collaborative's goal wasn't simply to reduce cesarean births. Part of it was also helping providers identify situations where labor could safely continue before turning to surgery. Chapman says that often starts with health care workers paying attention.
"Babies will tell us when, during the labor process, if something is wrong. Their heart rate looks different depending on what's happening. So say their umbilical cord is being compressed, their heart rate is like a jagged V, we call them variables. So they're telling us that the cord is compressed. If mom needs some extra fluids, she might have a different kind of deceleration in the baby's heart rate. So that gives us information on what we should do.
"And so there are different things that you can do to manage those situations in labor, but you have to take the time to do it and not just proceed with the cesarean."
To address the challenges in front of them, the collaborative brought hospitals together from across the state to compare data. Callaghan-Koru says that friendly competition between participating hospitals could actually yield positive outcomes.
"So just understanding how you compare to your peers can really help motivate change, if you decide that you're not in alignment with best practices that are happening elsewhere and you want to make that change. So some friendly competition around helping them track their progress, and then sharing with them, this is how you're doing in comparison with others.
"And then the other thing is really the peer-to-peer sharing. So we bring the hospitals together on a monthly basis, and the majority of those meetings involve hospitals sharing back what work they're doing, what challenges they're facing, and what solutions have worked for them. And so they do a lot of learning from each other and supporting each other in coming up with local solutions to some of the implementation challenges they might have."
The initiative's goal was simply stated: more than 70% of participating hospitals will be at or below the targeted 23.6% low-risk first-birth cesarean rate. So was the goal reached?
"Unfortunately, we didn't quite get to that goal. As a state, the C-section rate were pretty much where we started. So before the initiative, we were at about 28%, and currently at a state level, we're at 28% again. C-section rates tend to go up and down a bit for different, sometimes unexplained variation.
"But what I want to say about that is that we don't have a measure of the counterfactual. So in research studies, we're always trying to understand, did things improve or not, and also what would have happened without the intervention. So what would have happened to C-section rates without the perinatal quality collaborative, because we had every birthing hospital participate, which was wonderful, participation that we're really proud of.
"And so we don't know what would have happened to C-section rates if we hadn't been supporting hospitals to make these improvements, and there's a strong possibility that C-section rates would have gone up. So we're similar to where we started, but they didn't go up. And nationally, C-section rates have been trending upwards.
"So I think while we don't have a measurable reduction in C-section rates, there is a strong possibility that they would have increased more in Arkansas without this quality improvement work that the hospitals were investing in to improve care for their patients."
At the end of the day, Chapman reminds us that the care all comes down to the relationship between the physician and the patient. She says that some things are worth remembering when it comes to maternal care.
"We have two patients in one, and that's kind of why people don't go into OB-GYN, because you want to just deal with your one patient, but we have two patients in one. So when we talk through things, we really should be using a team-based approach, like the patient is a part of the team, and we have to take into consideration what you want.
"As much as we hope that the conversation surrounds what we know medically, and when we say, well, maybe we should try something else, it's not because we don't want to, it's not because we're trying to just get something done faster. We're considering a number of different things. And unfortunately, I think sometimes we don't do a great job of talking through those things because of time constraints, etc.
"But I think realize that your OB-GYN is very excited and wants to take care of you and your baby. You're a package to us."
You can find data about the ARPQC's initiatives and statistics about C-section births in Arkansas at ARPQC.org. For Ozarks at Large, I'm Aiden Dixon.
Aiden Dixon is one of our student reporters this year with Ozarks at Large, focusing on maternal and women's health in Arkansas. Funding for his reporting is supported by the Women's Giving Circle with the University of Arkansas.
Ozarks at Large transcripts are created on a rush deadline and edited for length and clarity. Copy editors utilize AI tools to review work. KUAF does not publish content created by AI. Please reach out to kuafinfo@uark.edu to report an issue. The audio version is the authoritative record of KUAF programming.
