Reducing overuse of c-sections and cervical cancer screening

Overuse is ubiquitous across medical specialties, and obstetrics and gynecology are no exceptions. Many procedures in women’s health specialties are overused, including hysterectomy for benign conditions, cesarean sections (c-sections) for low-risk births, elective labor induction, giving blood thinners to women after c-sections, and unnecessary cervical cancer screening, just to name a few.

Two recent studies shine a light on the problem of overuse in women’s health. One shows the scope of cervical cancer screening overuse and another provides a successful example of reducing overuse of c-sections.

Cervical cancer screening overuse

It wasn’t too long ago that cervical cancer was the leading cause of cancer deaths in women. The discovery of the Pap smear in the 1920s by Dr. George Papanicolaou and Anna Marion Hilliard’s creation of a simplified test in 1957 made cervical cancer deaths largely preventable. However, access to these tests are still uneven. Four thousand women still die each year from cervical cancer and eight million women do not get necessary screening, according to the Centers for Disease Control and Prevention (CDC). Black, Hispanic/Latinx, and Asian American and Pacific Islander women are more likely to be diagnosed with–and die from–cervical cancer.

At the same time, many women are being over-screened for cervical cancer, which can lead to patient anxiety, unnecessary biopsies and other procedures, and increased cost of care. Specialty guidelines for cervical cancer screening recommend Pap smears every 3 years or co-testing with an HPV test and Pap smear every 5 years in women aged 30 to 65 years. For women age 21-29, Pap smears every three years are recommended. However, it’s unclear the extent to which gynecologists are adhering to these (relatively new) guidelines.

“How often are cervical cancer screening tests overused in women with average risk in the United States?”

In a recent study in JAMA Network Open, Dr. Jason Wright, chief of gynecologic oncology at Columbia University Irving Medical Center, and colleagues explored the question, “How often are cervical cancer screening tests overused in women with average risk in the United States?” They analyzed a sample of more than 2 million women age 30-65 years with commercial insurance who underwent cervical cancer screening in 2013 through 2014. They looked at how often these women received a follow-up test within three years of receiving their first test.

They found that among these women, cervical cancer screening tests were frequently overused. About half of the women they studied received more than one Pap test within two years, and nearly two-thirds of patients in their sample had repeated screening within three years. Interestingly, overuse of testing was more common in the Northeastern US, despite the low rates of overuse often found in this region.

Why is overscreening for cervical cancer so common? The authors point out a few factors: clinicians may not know the most recent guidelines, patients may request screening every year, clinicians often screen out of habit, and clinicians may be worried about getting sued if they don’t screen and the patient has cancer. Another potential reason is that patients are less likely to see their doctor every year if they don’t have to come in for a screening. Clinicians may try to use screening as a way to make sure they have a chance to check up on their patients each year and maintain the relationship. Some doctors may fear that not providing screening will lower their patient ratings, although new research shows no connection between low-value care and patient satisfaction scores for primary care clinicians.

Electronic health record alerts, clinician education, and point of care guidelines have been used to try and reduce overscreening, but the authors point out that more research on these interventions — especially randomized trials– are needed.

How California reduced unnecessary c-sections

The next study is a success story about overuse in obstetrics. Overuse of c-section for low-risk births is a growing global health concern, because the procedure exposes mothers and infants to unnecessary risks. Cesarean section is associated with greater maternal mortality, as well as increased risks of “uterine rupture, abnormal placentation, ectopic pregnancy, stillbirth, and preterm birth,” according to a 2018 series in The Lancet.

In 2014, California’s rate of c-sections for first-time mothers with low-risk pregnancies was 26%, about the national average. By 2019, the state had brought that rate down to 22.8%, according to a recent study in JAMA.

How did they do it? It took four years of public health messaging, data reporting, incentive programs, and quality improvement, in coordination with state government agencies, nonprofits, media partners, and health plans.

Reporting c-section rates at each hospital in the state laid the groundwork. Hospitals that achieved c-section rates of 23.9% or lower (the benchmark set by the CDC’s Healthy People 2020 program) were awarded by the state’s Department of Health and Human Services. For hospitals not doing as well, the peer comparison information was a wake-up call, showing hospitals and physicians how they could improve.

“It’s that balance of monitoring the baby and observing the baby’s tolerance of the labor, as well as giving Mom more support to have that labor and not rush to interventions.”

California Maternal Quality Care Collaborative, NBC News

Hospitals that had rates above the benchmark were offered an 18-month quality improvement initiative. The California Maternal Quality Care Collaborative (CMQCC) and Smart Care California, an initiative of the California Healthcare Foundation (CHCF), led the quality improvement effort. This included educational tools, peer mentorship, giving labor nurses more power to help support vaginal births, and providing access to national guidelines. Physicians and nurses gave grand round presentations at hospitals on reducing c-sections for low-risk pregnancies to help educate clinicians.

At the same time, CHCF, CMQCC, and Consumer Reports created “My Birth Matters,” an educational campaign for expectant mothers to let them know about risks of unnecessary c-sections, and give them tools for communicating their birth plan to their clinical team.

Not all hospitals improved their rates equally. According to another study of the initiative in the Annals of Family Medicine, hospitals with some of the greatest improvements in c-section rates had some characteristics in common: a culture of flexibility and collaboration, leadership that were engaged in the process, and access to resources on best practices. Still, California’s reduction in c-section rates is a remarkable achievement, and this research can help other hospitals and states improve their rates as well.