Having a baby is a life-changing experience, so women and families often research carefully before choosing where to give birth. Indeed, maternity care varies greatly from hospital to hospital, even within the same city, as data from the Leapfrog Hospital Survey reveals. The Leapfrog Group is an independent nonprofit that tracks and reports hospital quality nationally using data provided voluntarily by hospitals.
The maternity care section of the Leapfrog Hospital Survey examines three medical interventions that experts say unnecessarily increase risks to women and babies: cesarean sections, episiotomy, and early elective deliveries. Comparing hospital performance on these procedures can help women choose the best facility for their family and give them information to use in a frank conversation with their doctor or nurse prior to the time of delivery. This report examines national trends revealed in the 2018 Leapfrog Hospital Survey. To search rates and other data for individual hospitals, visit www.leapfroggroup.org/compare.
In the U.S., nearly one in three women gives birth by cesarean section. In some cases, a cesarean section is necessary to protect the health of the mother and baby, but according to the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine, cesarean birth remains too common in the United States. C-sections carry serious risks of infection or blood clots, and many women experience longer recoveries and difficulty with future pregnancies. C-sections can also cause problems for babies, including breathing difficulties that need treatment in a newborn intensive care unit (NICU). In the long-term, research shows that C-sections can cause chronic pelvic pain in some women, and babies born by C-section are at increased risk of developing chronic childhood diseases like asthma and diabetes.
The Leapfrog Hospital Survey uses the NTSV C-section measure, a nationally endorsed measure in use by entities including the Joint Commission. NTSV refers to a first-time pregnancy (nulliparous) that has reached its 37th week or later (term) and consists of one fetus (singleton) in the head-down position (vertex). This measure captures the C-section rate of the lowest risk group of women who are least likely to need a C-section. Leapfrog’s standard, based on the advice of its Maternity Care Expert Panel, for NTSV C-section is 23.9% or lower. Many hospitals have successfully used the performance tracking and benchmarking offered by the Leapfrog Hospital Survey to reduce and sustain a C-section rate that meets or exceeds Leapfrog’s standard, including Virginia Hospital Center which participated in a recent case study.
Use the sliding bar to view progress by state over time. States with five or fewer reporting hospitals were excluded.
Unfortunately, hospitals have not demonstrated progress on reducing C-sections for pregnancies where there should be less of a need for surgical intervention during labor. Since Leapfrog began reporting on this metric in 2015, the average rate of NTSV C-sections across reporting hospitals has remained virtually stagnant and there is little difference in performance between urban and rural hospitals. Furthermore, less than 40% of hospitals are meeting Leapfrog’s standard. To protect the health of women and babies in their care, hospitals must advance their efforts to reduce C-sections, particularly those in low-risk first-time mothers.
Early Elective Delivery
The ACOG and the Society for Maternal-Fetal Medicine have defined a full term pregnancy as 39 weeks gestation. Scheduling a delivery via medical induction or cesarean section prior to 39 weeks without medical necessity, known as an early elective delivery, carries risks to both babies and mothers. Early elective deliveries can result in NICU admissions, longer hospital stays and higher costs to both patients and payors. Studies also suggest long-term developmental risks for infants.
In 2010, Leapfrog became the first organization to report on rates of early elective delivery by individual hospital. This public reporting galvanized a movement to reduce early elective deliveries nationwide, ultimately decreasing the national average from over 17% in 2010 to less than 1.5% in 2018 and improving the start to life for thousands of babies.
An episiotomy is an incision made in the perineum (the birth canal) during childbirth. Although once routine in childbirth, medical guidelines today recommend against episiotomy due to the risk of perineal tears, loss of bladder or bowel control, and pelvic floor defects, among other significant risks that can cause infection and other problems, slow the mother’s recovery and sometimes cause lifelong discomfort. Due to these concerns, ACOG has called for the use of episiotomy only in highly restricted circumstances.
Leapfrog is the only organization to track rates of episiotomy by hospital. Based on the advice of its Maternity Care Expert Panel, Leapfrog’s target rate for episiotomy is 5% or less.
Over the seven years that Leapfrog has reported on episiotomies, many hospitals have made significant strides in reducing and sustaining a low rate. One such hospital, Texas Children’s Hospital Pavilion for Women, recently shared their story in a case study on using the Leapfrog Hospital Survey as a tool to reduce their episiotomy rate.
To Fully Meet the Standard: Episiotomy Rate must be <= 5%
While hospitals have made steady progress in reducing the rate of episiotomy, nearly half of hospitals are not meeting Leapfrog’s standard of five percent or less. The national average rate of 6.94% amongst all reporting hospitals still remains well above the standard. Still, continued improvement seen in both urban and rural hospitals offers hope that use of this potentially harmful and often unnecessary practice will continue to decline.
Only 1 in 5 hospitals fully meets Leapfrog's standards for maternity care for all three measures.
How likely is it that a hospital will meet the Leapfrog Standard for a procedure again after meeting it the year before?
Across all three measures, once a hospital fully meets Leapfrog’s standards, they are more likely to continue doing so the following year. Specifically:
Among hospitals that fully met the standard for early elective delivery rates in any given year, 95% of them succeeded the following year. Among hospitals that fully met the standard for episiotomy rates, 90% of them succeeded the following year. And among hospitals that fully met the standard for cesarean birth, 70% of them succeeded the following year. It is critical for hospitals to sustain adherence to best practices and vigilance in avoiding unnecessary birth interventions in order to continue meeting standards on the Leapfrog Hospital Survey and protect the women and babies in their care.
Expectant mothers should review Leapfrog’s maternity care results at www.leapfroggroup.org/compare to find the highest performing hospital available to them for delivery. Leapfrog is the only publicly available source of this maternity care quality data; most but not all hospitals are willing to make their data public. If Leapfrog reports that your hospital “declines to respond,” express concern and ask them to report to the Leapfrog Hospital Survey.
About the Data
The Leapfrog Group annually invites all adult general acute care and free-standing pediatric hospitals in the United States to voluntarily report to the Leapfrog Hospital Survey, which collects and publicly reports data by hospital on quality and safety including surgical volumes, maternity care, healthcare-associated infections, medication safety, nursing workforce, and Never Events through its annual Survey. In 2018, 2,021 hospitals submitted a Survey, representing nearly 70% of inpatient beds. Participation is free to hospitals and results are free to the public. This report uses final hospital data from the 2018 Leapfrog Hospital Survey (data submitted through December 31, 2018).
The Leapfrog Hospital Survey includes measures that are endorsed by the National Quality Forum (NQF) and/or aligned with those of other significant data collection entities, including the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission. Leapfrog partners with the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine to review survey measures and standards, and updates them annually to reflect the latest science. Additionally, panels of volunteer experts meet regularly to review the survey measures and recommend performance standards for each subject area covered in the Leapfrog Hospital Survey. The full list of measures included is available at www.leapfroggroup.org/Survey.
In 2019, Leapfrog will expand its Survey to Ambulatory Surgery Centers (ASCs) via the Leapfrog ASC Survey as well as begin asking hospitals about safety and quality metrics in their outpatient departments via a new section of the Leapfrog Hospital Survey. Results from these Surveys will be summarized in an aggregate report to be released in fall 2019. Individual facility results will be publicly reported beginning in 2020.