Better nurse staffing linked to fewer C-sections

"Our findings highlight how crucial nurse staffing is for optimal maternal outcomes," said Audrey Lyndon, the Vernice D. Ferguson Professor in Health Equity and executive vice dean at NYU Rory Meyers College of Nursing.

C-sections account for nearly a third of births in the US and are the most common surgery performed in hospitals. While C-sections can be lifesaving and some are necessary for the health of the mother and child, the surgery carries more risks and a longer recovery than vaginal births and can complicate future pregnancies.

"If we can safely lower the C-section rate, we are improving outcomes for childbearing people and their families," added Lyndon, the study's lead author.

Nurses play an important role during childbirth, providing emotional and physical support at the bedside, monitoring the health of the mother and baby, and administering medication. When hospitals are understaffed, nurses are forced to prioritize tasks that require the most immediate attention at the expense of other care.

"While nurses intuitively know that having enough nurses to provide the attentive care that mother and babies need and deserve improves outcomes, research has been minimal in linking maternity nurse staffing and patient outcomes," said Kathleen Rice Simpson, a perinatal clinical nurse specialist at Mercy Hospital St. Louis and study author.

To determine if nurse staffing influences C-section rates, the researchers examined how well maternity units adhere to staffing standards established by the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). The evidence-based standards call for one nurse to one birthing person during many parts of labor, two nurses at birth, and one nurse for each mother-newborn pair in the first few hours after birth.

The researchers surveyed 2,786 nurses from 193 hospitals across 23 states about staffing on their maternity units. Their responses, collected in 2018 and 2019, were matched with hospital-level administrative data and rates of C-sections and vaginal births.

Better nurse staffing during labor and birth was linked to lower C-section rates and higher vaginal birth rates, including vaginal births among mothers who had previously had C-sections. C-section rates were 11 percent lower in hospitals with nurse staffing aligned with the national standards.

"Concern about cesarean section rates in the US has been high for many years, and there has been little progress toward improvement. This study points us toward one important solution: aligning labor and delivery nurse staffing with consensus- and expert-developed guidelines," said Joanne Spetz, director of the Institute for Health Policy Studies at the University of California, San Francisco (UCSF) and a study author.

"We hope our findings will encourage hospitals to see the value in nurse staffing consistent with standards to support healthy outcomes for mothers and babies," said Simpson.

Hospitals and policymakers often point to increased costs related to both C-sections and nurse staffing. The researchers note that the cost of adequate nurse staffing during labor and birth can be balanced by the savings of avoiding unnecessary C-sections, including shorter hospital stays and fewer complications.

"Nursing care is looked at as a cost center as opposed to a revenue center in hospitals, so it's often one of the first things cut when hospitals are trying to keep costs in line. But research continues to show that nurse staffing is a key contributor to patient safety across departments," said Lyndon.

"While increasing nurse staffing during a period of shortage can be challenging, this investment could reduce overall costs by reducing rates of surgical cesarean sections and longer-term adverse outcomes for mothers and babies," said Spetz.

To hold hospitals accountable, the researchers encourage the Centers for Medicare and Medicaid Services (CMS) to consider establishing regulatory standards for nurse staffing as part of their "Birthing-Friendly" designation for high-quality maternity care.

Additional study authors include Jason Fletcher of NYU Meyers, Gay Landstrom of Trinity Health in Michigan, and Caryl Gay of UCSF. The research was supported by the Agency for Healthcare Research and Quality (grant R01HS025715).