Leapfrog: Patient safety in maternity care slow to improve

Dismal C-section rates remain stagnant

The Leapfrog report showed that C-section rates did not get worse in the past year, but they also have not gotten better since C-section rates spiked during the COVID-19 pandemic.

C-sections are sometimes medically necessary, even among NTSV births, but Leapfrog said clinicians should avoid them when possible.

"While sometimes necessary, C-sections carry risks like infection, blood clots, longer recovery times and complications in future pregnancies," the Leapfrog report authors added as a caveat. "They can also affect newborn health, increasing the likelihood of NICU admission due to breathing difficulties."

Leapfrog has set a benchmark goal of an NTSV C-section rate of 23.6% or lower by 2030, which the nation was on track to achieve until COVID hit. In 2020, the average nationwide NTSV C-section rate was 24.5%. After only a modest increase in 2021, the rate spiked to 25% in 2022, where it's generally remained ever since.

What's more, The Leapfrog Group flagged racial disparities in NTSV C-section rates, with non-Hispanic Black people being more likely to have an NTSV C-section than their non-Hispanic White counterparts.

This disparity is pervasive, with one in five hospitals reporting to Leapfrog having an NTSV C-section disparity between Black and White patients.

The report also called attention to NTSV C-section disparities affecting other races. For example, 5% of hospitals have a disparity between Hispanic and White patients, 14.7% have a disparity between Asian and White people and 11.5% have a disparity between American Indian and White people.

Episiotomy rates dropped significantly

While The Leapfrog Group reported little progress in NTSV C-sections, the change in the nation's episiotomy rate was a bright spot for the report.

Episiotomies, which are discouraged for routine use, carry serious risks, including severe perineal tears, loss of bladder or bowel control, pelvic floor disorders, infections and prolonged recovery, often leading to chronic discomfort, Leapfrog said.

Leapfrog's benchmark for episiotomies is a rate of 5% or lower, and the nation's hospitals are delivering on that. Since 2012, the average episiotomy rate has declined by 73%. As of 2024, the national average has dropped to 3.4%.

Still, Leapfrog cautioned that episiotomy rates vary by hospital, so it is important for patients and their families to research specific hospitals to assess risk.

Early elective delivery rates remain elusive

The Leapfrog Group didn't have a perfect measure of early elective delivery rates, primarily due to changes in reporting to other healthcare bodies on whose data Leapfrog's report relies.

Early elective delivery, or scheduling birth without medical necessity before 39 weeks of gestation, has serious risks. These risks include increased likelihood of C-section, postpartum complications for parent and baby, higher neonatal mortality rates and increased NICU admissions. They also usually result in longer hospital stays and higher healthcare costs for patients and payers.

The Leapfrog Group is not able to report on early elective delivery rates by hospitals anymore because that metric is no longer required by governing bodies like CMS and the Joint Commission. Instead, The Leapfrog Group asked reporting hospitals whether they have an organizational policy to prevent early elective deliveries.

In 2024, 85.9% of reporting hospitals said that they do have such a policy.

"While this is a credit to the vast majority of hospitals, still one in seven hospitals reporting to Leapfrog have not adopted policies to reduce early elective deliveries," the report authors said.

Added maternity care services become more common

Perhaps a second bright spot of the report is the growing prevalence of additional maternity care services, like midwife/doula support and lactation support.

For example, 60.9% of reporting hospitals offer certified midwives, a key step forward as evidence continues to indicate that certified midwives can reduce unnecessary C-sections, the report authors said.

However, there is some regional variation in this. Access to certified midwives is lower in the South (45%) compared to the Northeast (more than 75%). Washington has the highest rate of hospitals offering access to certified midwives at 88%.

Meanwhile, just around 90% of reporting hospitals allow doulas to support patients during labor and delivery. Doulas are linked to improved birthing experiences and outcomes. However, although many hospitals allow doulas during labor and delivery, only 7.5% employ or contract with doulas directly.

The most widely available maternity care service was lactation support, with 96% of reporting hospitals saying they offer lactation support to new mothers. Of those hospitals, 94% said they offer lactation specialists in the hospital, 63% on an outpatient basis and 17% on an at-home, post-discharge basis.

In addition to those services, 84% of reporting hospitals said they offer opportunities for vaginal birth after cesarean and 81.6% offer postpartum tubal ligation.

Leapfrog's report was based on data from over 2,400 hospitals that self-reported to the group. Leapfrog said the information represented in the report is intended to empower patients and their family members to make informed decisions about where they will access certain shoppable services, including the birth of a child.

Sara Heath has covered news related to patient engagement and health equity since 2015.