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Interventions to reduce cesarean rates must take into account the various causes behind the unprecedented rise in this procedure, including clinicians' behavior. A research consortium in Canada conducted a randomized trial involving >100,000 women who delivered at 32 hospitals. The study consisted of a 1-year preintervention (baseline) period, a 1.5-year intervention period, and a 1-year postintervention period. The intervention included review of the obstetric management of women who underwent cesarean delivery, development of best practices, and direct feedback given to clinicians.
From the preintervention period to the postintervention period, the overall rate of cesarean delivery rose from 23.2% to 23.5% in the control group and fell from 22.5% to 21.8% in the intervention group. This modest but statistically significant between-group difference was largely accounted for by reductions in cesarean rates among low-risk women (adjusted risk difference, −1.7%). No concomitant increase in neonatal or maternal morbidity was associated with the intervention.
Chaillet N et al. A cluster-randomized trial to reduce cesarean delivery rates in Quebec. N Engl J Med 2015 Apr 30; [e-pub]. (http://dx.doi.org/10.1056/NEJMoa1407120)
Comment
The route to lowering cesarean delivery rates is necessarily incremental; it's unrealistic to imagine a “magic bullet” that could shoot down a practice that has risen so steadily over decades. The finding that regular audits of practices and feedback to clinicians led to fewer cesareans — without compromising maternal or newborn safety — makes me hopeful. Clearly, clinicians and institutions alike will be critical agents in curbing the threat to women's health represented by unnecessary cesareans. The intervention in this trial would be eminently feasible in most obstetric units, provided that clinicians are able to check their egos at the door and accept critical feedback (even if provided in the open) about their obstetric practices and outcomes.