Unnecessary Cesarean Deliveries Decrease With Intervention

Laurie Barclay, MD

April 30, 2015

An intervention to reduce cesarean delivery rates led to a modest but significant reduction without adverse maternal or neonatal effects, according to a cluster-randomized controlled trial published in the April 30 issue of the New England Journal of Medicine. The benefit was mostly attributable to lower cesarean delivery rates in low-risk pregnancies.

"High rates of cesarean delivery are of substantial concern owing to the potential harm to the mother and her baby associated with a medically unnecessary cesarean delivery and to the related costs of health care," write Nils Chaillet, PhD, from the Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada, and colleagues from the Quality of Care, Obstetrical Risk Management and Mode of Delivery in Quebec (QUARISMA) Trial Research Group.

"Providing evidence-based guidance to health professionals regarding the appropriate selection of women who could benefit from cesarean delivery is now a priority."

This trial studied the effect of a multifaceted, 1.5-year intervention on the cesarean delivery rate in the year after the intervention was implemented at 32 hospitals in Quebec. The intervention included initial onsite professional training in evidence-based management of labor and delivery, clinical audits of indications for cesarean delivery, feedback to health professionals, and implementation of best practices.

Overall, 184,952 participants were involved in the study, including 53,086 women who delivered in the year before the intervention and 52,265 who delivered in the year after the intervention.

Compared with the control group receiving usual care, the intervention group had a small but significant reduction in the rate of cesarean delivery from the preintervention period to the postintervention period. Rates decreased from 22.5% to 21.8% in the intervention group and increased from 23.2% to 23.5% in the control group.

After adjustment for hospital and patient factors, the odds ratio for incremental change over time was 0.90 (95% confidence interval [CI], 0.80 - 0.99 [P = .04]; adjusted risk difference, −1.8%; 95% CI, −3.8% to −0.2%).

Women with low-risk pregnancies had a significant reduction in cesarean delivery rate, whereas those with high-risk pregnancies did not (adjusted risk difference, −1.7%; 95% CI, −3.0% to −0.3%; P = .03 vs P = .35; P = .03 for interaction).

Compared with the control group, the intervention group also had a reduction in major neonatal morbidity (adjusted risk difference, −0.7%; 95% CI, −1.3% to −0.1%; P = .03). Both groups had increases in minor neonatal morbidity but the increase was smaller in the intervention group (adjusted risk difference, −1.7%; 95% CI, −2.6% to −0.9%; P < .001). The groups had no significant differences in changes in minor and major maternal morbidity.

"This multifaceted intervention...led to a statistically significant but clinically small reduction in the rate of cesarean deliveries," the study authors write. "The reduction was observed among women with low-risk pregnancies but not among those with high-risk pregnancies. Furthermore, the intervention was associated with a significant reduction in minor and major neonatal morbidity among babies born to women with low-risk pregnancies and among those born to women with high-risk pregnancies."

Limitations of this study include differences in the distribution of certain hospital characteristics across groups at baseline and the inability to determine which of the intervention components was most effective.

The Canadian Institutes of Health Research funded this study. The authors have disclosed no relevant financial relationships.

N Engl J Med. 2015;372:1710-1121. Abstract

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