Hospital Context and Strategies for Cesarean Delivery Quality Improvement

OBJECTIVE: To compare hospitals with lower nulliparous, term, singleton, vertex (NTSV) cesarean delivery rates against those with higher rates, with a goal of identifying key organizational contextual factors and strategies for cesarean delivery quality improvement (QI) efforts. METHODS: We conducted a comparative multiple case study of hospitals participating in the Obstetrics Initiative, a statewide quality collaborative funded by Blue Cross Blue Shield of Michigan and Blue Care Network. Hospitals with more than 1,000 annual births were purposively selected from sites with low cesarean delivery rates (defined as an NTSV cesarean delivery rate of 25% or lower) and those with high cesarean delivery rates (defined as a rate of 28% or higher) to represent diverse regions and health systems. In 2023, we conducted semi-structured key informant interviews during site visits from February to April. Data collection and analysis were guided by the Consolidated Framework for Implementation Research and the Expert Recommendations for Implementing Change’s constructs and strategies. Qualitative content analysis was used to identify contextual barriers, facilitators, and hospital improvement strategies. Consolidated Framework for Implementation Research constructs with nonneutral associations in at least one third of sites were retained and classified as broadly influential and were assigned a quantitative rating (from −2, barrier, to +2, facilitator). Descriptive contextual scores were calculated by summing site-level construct ratings. Cross-case synthesis and thematic analysis were used to elucidate patterns across low- and high-rate hospitals. RESULTS: We interviewed 110 clinicians and administrators across five hospitals with low cesarean delivery rates and 12 hospitals with high cesarean delivery rates. Fifteen contextual factors, which include 11 hospital conditions and four improvement processes, differentiated low-rate and high-rate hospitals. Compared with high-rate hospitals, low-rate hospitals had higher descriptive contextual scores, reflecting more frequent facilitators and fewer barriers. Hospitals with high cesarean delivery rates had differing combinations of barriers, suggesting that each faced a unique pattern of challenges. Thematically, low-rate sites demonstrated a higher perceived value of evidence-based medicine and cesarean delivery rate QI, more supportive leadership and structural characteristics, stronger cultures of collaboration and learning, and more robust processes for QI teaming, planning, engagement, and evaluation. We identified 28 core strategies consistently observed among hospitals with low rates and nine context-dependent strategies that may help address site-specific barriers. CONCLUSION: Lower NTSV cesarean delivery rates were associated with a more favorable organizational context and more robust improvement processes. The hospital conditions and QI strategies identified herein may enable systematic assessment of hospital-specific barriers and facilitators, selection of corresponding QI strategies, and sufficient resourcing of these activities to support successful cesarean delivery QI efforts.