Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

With the rates of birth by cesarean section on the rise, what factors influence (and which have the greatest impact on) the probability of delivery by cesarean in low-risk women? Which interventions are most effective at reducing the risk of needing an emergency and/or medically unnecessary, planned cesareans?

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

I would like to know the comparative effectiveness/impact of patient level, clinician level and health system level interventions such as:

1. Consultation and/or prenatal care from a midwife
2. Presence of a doula or birth partner
3. Trimester at which prenatal care begins
4. Different pain management strategies, including anesthesia
5. Maternal diet
6. Maternal exercise
7. Birth facility
8. Health insurance status
9. Geographic region

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

The patient population of most interest is low-risk, pregnant women. This would exclude women who have had a prior cesarean delivery, women carrying multiples, women with a non-vertex fetus, and women that are not full-term (minimum 37 weeks gestation).

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

Socioeconomic and ethnic/racial differences would be of interest if there are known differences

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

Overall healthy outcomes for both mother and baby.

Describe any health-related risks, side effects, or harms that you are concerned about.

Morbidity for both mother and baby. This includes maternal hemorrhage, blod clots, bowel obstruction, surgical site infection, mental health, delayed breastfeeding, and impact on future reproduction such as reduced fertility, increased risk of ectopic pregnancy, placenta previa etc. For infants potential risks include respiratory issues, and the development of asthma. The research should include the health risks of not delivering by cesarean when medically necessary.

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Pregnancy, including preterm birth

AHRQ Priority Populations

• Low income groups
• Minority groups
• Women
• Children

Federal Health Care Program

• Medicaid

Importance

Describe why this topic is important.

Approximately 31% of deliveries in the US are performed by cesarean section. Recognizing the need to address this issue, Healthy People 2010 outlined as one of the goals the reduction of cesarean sections performed in the US. It is critical to have access to a thoughtful review of the evidence to inform clinician and patient decisions.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

Simply the knowledge of the increasing and highly variable rates of Cesarean section for the people of the U.S. and knowledge of the general potential morbidity from inappropriate use and of non-use of this.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

This information could be shared with members and clinicians within our health insurance network to inform healthcare decisions. This information could additionally be utilized to service gaps beneficial to this population.

Describe the timeframe in which an answer to your question is needed.

No specific emergent need other than that of informing the people of our country

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

There is wide variation in rates of cesarean across ethnic, racial and socioeconomic populations.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

This information could be shared with members and clinicians within our health insurance network to inform healthcare decisions. This information could additionally be utilized to service gaps beneficial to this population.

Are you making a suggestion as an individual or on behalf of an organization?

Individual

Please tell us how you heard about the Effective Health Care Program