Training Reduces Cesarean Delivery and Neonatal Morbidity

Caroline Helwick

February 07, 2014

NEW ORLEANS — A multifaceted intervention program for health professionals aimed at reducing the rate of cesarean delivery succeeded in doing just that, according to a new multihospital study.

"Our hypothesis was that intervention at the right time would provide the chance to improve the quality of obstetrical care and reduce morbidity," said Nils Chaillet, MD, assistant researcher in the Department of Obstetrics-Gynecology at the CHU Sainte-Justine Research Center in Montreal. "The primary outcome — the cesarean delivery rate — was significantly reduced by the intervention."

Dr. Chaillet presented results from the QUARISMA study here at the Society for Maternal-Fetal Medicine 34th Annual Meeting.

The researchers conducted a 3.5-year randomized controlled trial that involved 32 public hospitals with at least 300 deliveries each year, a cesarean rate of at least 17%, and no previous intervention aimed at reducing the cesarean rate. Sixteen hospitals received the intervention program and 16 served as control hospitals.

The program involved a 2-day on-site training workshop for health professionals that focused on the best clinical practices for intrapartum care. Instructors were certified by the Society of Obstetricians and Gynaecologists of Canada.

In addition, internal audits on cesarean deliveries and the implementation of best practices were performed by local audit committees under the leadership of an opinion leader identified by his or her peers.

A total of 105,351 deliveries that occurred from 2008 to 2012 were analyzed. All babies were at least 500 g at delivery and no younger than 24 weeks' gestation.

After a 12-month period of data collection, hospitals were randomized to either the intervention or control group. The 18-month intervention period consisted of the initial training followed by 12 months of auditing with support from the intervention staff. This was followed by 12 months of auditing without support.

Multiple Improvements in Intervention Group

In the intervention group, the cesarean rate dropped from 22.5% at baseline to 21.8% at year 4. In the control group, the rate was stable; it was 23.2% at baseline and 23.5% at year 4 (odds ratio [OR], 0.90; P = .044).

Analysis stratified by the mother's risk level (a secondary outcome measure) revealed that the intervention was statistically significant only in low-risk women.

Table 1. Effect of the Intervention on Cesarean Delivery Rates

Type of Hospital by Risk Level Adjusted Odds Ratio P Value
Low risk 0.80 .027
   Community 0.98 .956
   Regional 0.79 .048
   Tertiary care 0.76 .051
High risk 0.96 .354
   Community 0.68 .179
   Regional 0.95 .416
   Tertiary care 1.00 .998


The intervention had no significant effect on maternal morbidity, but did significantly reduce neonatal major morbidity (OR, 0.81; P = .028) and effect minor morbidity (OR, 0.88; P < .001).

Major morbidity included intrapartum and neonatal mortality, a 5-minute APGAR score below 4, major acidosis, major trauma, intraventricular hemorrhage, seizure damage, neurologic damage, invasive mechanical ventilation, necrotizing enterocolitis, and hypoxic-ischemic encephalopathy. Minor morbidity included cardiopulmonary morbidity, a 5-minute APGAR score between 4 and 7, moderate acidosis, minor trauma, noninvasive mechanical ventilation, blood transfusion, neonatal infection, and sepsis.

Sometimes it's the relatively simple things that can substantially affect maternal and child health.

"These differences remained significant even when we excluded preterm births," Dr. Chaillet reported.

Among the medical procedures that were significantly lower in the intervention than the control group were operative vaginal delivery (OR, 0.88; P = .042) and pharmacologic labor induction (OR, 0.82; P < .001). The use of oxytocin during labor was significantly higher in the intervention group (OR, 1.16; P < .001).

This study of more than 100,000 women shows that an interventional program can not only reduce the chance of cesarean delivery, but can also reduce neonatal morbidity, noted William Grobman, MD, professor of obstetrics and gynecology-maternal fetal medicine at the Northwestern University Feinberg School of Medicine in Chicago.

"The important thing is that this did not involve new therapies or methods. This was totally about the delivery of health services," Dr. Grobman told Medscape Medical News. "We often focus on new treatments, but sometimes it's the relatively simple things — education, quality improvements, quality control, and feedback — that can substantially affect maternal and child health."

Dr. Chaillet and Dr. Grobman have disclosed no relevant financial relationships.

Society for Maternal-Fetal Medicine (SMFM) 34th Annual Meeting: Abstract 1. Presented February 6, 2014.


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