title: Lowered national cesarean section rates after a concerted action.
abstract: OBJECTIVE
  To evaluate national cesarean section (CS) rates and other obstetric indicators after a concerted action to reduce CS rates was undertaken in Portugal from 2010 onwards. This action was based on the transmission of information and training of healthcare professionals, together with the inclusion of CS rates as a criterion for hospital funding.
  
  
  METHODS
  Retrospective observational population-based study.
  
  
  METHODS
  Portugal.
  
  
  METHODS
  Births occurring in Portugal between 2000 and 2014.
  
  
  METHODS
  Governmental sources were used to obtain data on national CS, perinatal and maternal mortality rates. Rates of instrumental vaginal delivery, vaginal birth after cesarean (VBAC), hypoxia-related complications and perineal lacerations were retrieved for state-owned hospitals.
  
  
  METHODS
  CS, perinatal and maternal mortality, instrumental vaginal delivery, VBAC, hypoxia-related complications and perineal lacerations.
  
  
  RESULTS
  After a continuous rise between 2000 and 2009, national CS rates declined significantly over the following 5 years (36.6% vs. 33.1%, time trend p ≤ 0.001). Perinatal mortality maintained a downward trend during this period, while maternal mortality remained unchanged. Rates of instrumental vaginal delivery, VBAC and perineal lacerations increased, while the incidence of hypoxia-related complications decreased.
  
  
  CONCLUSIONS
  A concerted action based on the transmission of information and training of healthcare professionals, together with the inclusion of CS rates as a criterion for hospital funding, was followed by a significant reduction in national CS rates, as well as an improvement in most related obstetric indicators. There may be an association between the reported intervention and the observed changes.
authors.affiliation: Department of Obstetrics and Gynecology, Medical School - University of Porto, S. Joao Hospital, Porto, Portugal.
authors.forename: Diogo
authors.initials: D
authors.lastname: Ayres-De-Campos
authors.forename: Joana
authors.initials: J
authors.lastname: Cruz
authors.forename: Claudia
authors.initials: C
authors.lastname: Medeiros-Borges
authors.forename: Cristina
authors.initials: C
authors.lastname: Costa-Santos
authors.forename: Lisa
authors.initials: L
authors.lastname: Vicente
mesh_terms: D002585:Cesarean Section / Q000706:statistics & numerical data / Q000639:trends*; D005113:Extraction, Obstetrical / Q000706:statistics & numerical data / Q000639:trends; D005260:Female; D006779:Hospitals, Public; D006801:Humans; D000860:Hypoxia / Q000453:epidemiology / Q000209:etiology; D015994:Incidence; D007231:Infant, Newborn; D008428:Maternal Mortality / Q000639:trends; D007744:Obstetric Labor Complications / Q000453:epidemiology / Q000517:prevention & control*; D054238:Perinatal Mortality / Q000639:trends; D011174:Portugal / Q000453:epidemiology; D011247:Pregnancy; D015397:Program Evaluation; D058996:Quality Improvement / Q000706:statistics & numerical data / Q000639:trends*; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data / Q000639:trends*; D012189:Retrospective Studies; D016064:Vaginal Birth after Cesarean / Q000706:statistics & numerical data / Q000639:trends
keywords: Cesarean section; extraction; labor complications; maternal health services; parturition; vaginal birth after cesarean