title: Using a multifaceted quality improvement initiative to reverse the rising trend of cesarean births.
abstract: OBJECTIVE
  National efforts exist to safely reduce the rate of cesarean delivery, a major source of increased morbidity and healthcare costs. This is a report of a quality improvement study targeting reduction of primary cesarean deliveries.
  
  
  METHODS
  From March 2014 to March 2016, interventions included a nested case-control review of local risk factors, provider and patient education, multidisciplinary reviews based on published guidelines with feedback, provider report cards, commitment to labor duration guidelines, and a focus on natural labor. Primary outcomes were the total primary singleton vertex and the nulliparous term singleton vertex (NTSV) cesarean delivery rates. Secondary outcome measures were postpartum hemorrhage, chorioamnionitis, perineal laceration, operative delivery, neonatal intensive care unit (NICU) admission, stillbirth, and neonatal mortality. Statistical process control charts identified significant temporal trends.
  
  
  RESULTS
  Control chart analysis demonstrated that the institutional cesarean delivery rate was due to culture and not "outlier" obstetricians. The primary singleton vertex cesarean rate decreased from 23.4% to 14.1% and the NTSV rate decreased from 34.5% to 19.2% (both p < .0001). There was a decrease in NICU admission but no significant changes in postpartum hemorrhage, chorioamnionitis, stillbirth, or neonatal mortality.
  
  
  CONCLUSIONS
  Structured quality improvement initiatives may decrease primary cesarean deliveries without increasing maternal or perinatal morbidity.
authors.affiliation: a Division of Maternal-Fetal Medicine, Beaumont Hospital , Royal Oak , MI , USA.|b William Beaumont Hospital - Royal Oak , Royal Oak , MI , USA.
authors.forename: Dotun
authors.identifier: http://orcid.org/0000-0002-4560-0611
authors.initials: D
authors.lastname: Ogunyemi
authors.affiliation: a Division of Maternal-Fetal Medicine, Beaumont Hospital , Royal Oak , MI , USA.|b William Beaumont Hospital - Royal Oak , Royal Oak , MI , USA.
authors.forename: Sara
authors.initials: S
authors.lastname: McGlynn
authors.affiliation: a Division of Maternal-Fetal Medicine, Beaumont Hospital , Royal Oak , MI , USA.|b William Beaumont Hospital - Royal Oak , Royal Oak , MI , USA.
authors.forename: Anne
authors.initials: A
authors.lastname: Ronk
authors.affiliation: a Division of Maternal-Fetal Medicine, Beaumont Hospital , Royal Oak , MI , USA.|b William Beaumont Hospital - Royal Oak , Royal Oak , MI , USA.
authors.forename: Patricia
authors.initials: P
authors.lastname: Knudsen
authors.affiliation: a Division of Maternal-Fetal Medicine, Beaumont Hospital , Royal Oak , MI , USA.|b William Beaumont Hospital - Royal Oak , Royal Oak , MI , USA.
authors.forename: Tonyie
authors.initials: T
authors.lastname: Andrews-Johnson
authors.affiliation: a Division of Maternal-Fetal Medicine, Beaumont Hospital , Royal Oak , MI , USA.|b William Beaumont Hospital - Royal Oak , Royal Oak , MI , USA.
authors.forename: Angeline
authors.initials: A
authors.lastname: Raczkiewicz
authors.affiliation: a Division of Maternal-Fetal Medicine, Beaumont Hospital , Royal Oak , MI , USA.|b William Beaumont Hospital - Royal Oak , Royal Oak , MI , USA.
authors.forename: Andrew
authors.initials: A
authors.lastname: Jovanovski
authors.affiliation: a Division of Maternal-Fetal Medicine, Beaumont Hospital , Royal Oak , MI , USA.|b William Beaumont Hospital - Royal Oak , Royal Oak , MI , USA.
authors.forename: Sangeeta
authors.initials: S
authors.lastname: Kaur
authors.affiliation: a Division of Maternal-Fetal Medicine, Beaumont Hospital , Royal Oak , MI , USA.|b William Beaumont Hospital - Royal Oak , Royal Oak , MI , USA.
authors.forename: Mark
authors.initials: M
authors.lastname: Dykowski
authors.affiliation: a Division of Maternal-Fetal Medicine, Beaumont Hospital , Royal Oak , MI , USA.|b William Beaumont Hospital - Royal Oak , Royal Oak , MI , USA.
authors.forename: Mark
authors.initials: M
authors.lastname: Redman
authors.affiliation: b William Beaumont Hospital - Royal Oak , Royal Oak , MI , USA.|c Department of Obstetrics and Gynecology , Beaumont Health System , Royal Oak , MI , USA.
authors.forename: Ray
authors.initials: R
authors.lastname: Bahado-Singh
mesh_terms: D002585:Cesarean Section / Q000592:standards* / Q000639:trends; D005260:Female; D006801:Humans; D008137:Longitudinal Studies; D008824:Michigan; D015279:Organizational Culture; D010818:Practice Patterns, Physicians' / Q000592:standards* / Q000639:trends; D011247:Pregnancy; D011248:Pregnancy Complications / Q000209:etiology / Q000601:surgery; D011446:Prospective Studies; D058996:Quality Improvement / Q000458:organization & administration*
keywords: Cesarean delivery; patient safety; quality improvement; statistical process control