A cluster-randomized trial to reduce cesarean delivery rates in Quebec.
BACKGROUND
In Canada, cesarean delivery rates have increased substantially over the past decade. Effective, safe strategies are needed to reduce these rates.


METHODS
We conducted a cluster-randomized, controlled trial of a multifaceted 1.5-year intervention at 32 hospitals in Quebec. The intervention involved audits of indications for cesarean delivery, provision of feedback to health professionals, and implementation of best practices. The primary outcome was the cesarean delivery rate in the 1-year postintervention period.


RESULTS
Among the 184,952 participants, 53,086 women delivered in the year before the intervention and 52,265 women delivered in the year following the intervention. There was a significant but small reduction in the rate of cesarean delivery from the preintervention period to the postintervention period in the intervention group as compared with the control group (change, 22.5% to 21.8% in the intervention group and 23.2% to 23.5% in the control group; odds ratio for incremental change over time, adjusted for hospital and patient characteristics, 0.90; 95% confidence interval [CI], 0.80 to 0.99; P=0.04; adjusted risk difference, -1.8%; 95% CI, -3.8 to -0.2). The cesarean delivery rate was significantly reduced among women with low-risk pregnancies (adjusted risk difference, -1.7%; 95% CI, -3.0 to -0.3; P=0.03) but not among those with high-risk pregnancies (P=0.35; P = 0.03 for interaction). The intervention group also had a reduction in major neonatal morbidity as compared with the control group (adjusted risk difference, -0.7%; 95% CI, -1.3 to -0.1; P=0.03) and a smaller increase in minor neonatal morbidity (adjusted risk difference, -1.7%; 95% CI, -2.6 to -0.9; P<0.001). Changes in minor and major maternal morbidity did not differ significantly between the groups.


CONCLUSIONS
Audits of indications for cesarean delivery, feedback for health professionals, and implementation of best practices, as compared with usual care, resulted in a significant but small reduction in the rate of cesarean delivery, without adverse effects on maternal or neonatal outcomes. The benefit was driven by the effect of the intervention in low-risk pregnancies. (Funded by the Canadian Institutes of Health Research; QUARISMA Current Controlled Trials number, ISRCTN95086407.).
From the Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire (CHU) de Sherbrooke, Sherbrooke, QC (N.C., J.-C.P., E.D., W.D.F.), Department of Epidemiology and Biostatistics, McGill University (M.A., R.B.), Department of Obstetrics and Gynecology, University of Montreal, Centre Hospitalier Universitaire Sainte-Justine (F.A.), Department of Obstetrics and Gynecology, McGill University, Royal Victoria Hospital (P.M.), and Department of Obstetrics and Gynecology, McGill University, Jewish Hospital (H.A.A.), Montreal, and the Population Health and Optimal Health Practices Research Unit, CHU de Québec Research Centre, Quebec, QC (M.D.) - all in Canada; and the Research Institute for Development, Université Paris Descartes, Sorbonne Paris Cité, UMR 216, Paris (A.D.).
Nils
N
Chaillet
Alexandre
A
Dumont
Michal
M
Abrahamowicz
Jean-Charles
JC
Pasquier
Francois
F
Audibert
Patricia
P
Monnier
Haim A
HA
Abenhaim
Eric
E
Dubé
Marylène
M
Dugas
Rebecca
R
Burne
William D
WD
Fraser
D000293:Adolescent; D000328:Adult; D002585:Cesarean Section / Q000706:statistics & numerical data*; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D007231:Infant, Newborn; D007318:Inservice Training; D008428:Maternal Mortality; D008485:Medical Audit; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D011256:Pregnancy Outcome; D011792:Quebec; D012306:Risk; D019564:Unnecessary Procedures / Q000706:statistics & numerical data; D055815:Young Adult