Evidence-Based Strategies for Reducing Cesarean Section Rates: A Meta-Analysis

Authors

  • Nils Chaillet PhD,

    Corresponding author
    1. Nils Chaillet and Alexandre Dumont are at the Research Centre of Sainte-Justine Hospital and in the Department of Obstetrics and Gynaecology, University of Montréal, Montréal, Quebec, Canada.
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  • Alexandre Dumont MD, PhD

    1. Nils Chaillet and Alexandre Dumont are at the Research Centre of Sainte-Justine Hospital and in the Department of Obstetrics and Gynaecology, University of Montréal, Montréal, Quebec, Canada.
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  • This study was supported by the Research Centre of Sainte-Justine Hospital, Montreal, Quebec, Canada. The sponsors of the study had no role in study design, data collection, data analysis, data interpretation, or writing the report.

Nils Chaillet, PhD, Centre de recherche de l’hôpital Sainte-Justine, Département Obstétrique et Gynécologie, Université de Montréal, 3175 chemin de la Côte Ste-Catherine, Local 4986-B, Montréal, Québec, Canada H3T 1C5.

Abstract

ABSTRACT: Background: Canada’s cesarean section rate reached an all-time high of 22.5 percent of in-hospital deliveries in 2002 and was associated with potential maternal and neonatal complications. Clinical practice guidelines represent an appropriate mean for reducing cesarean section rates. The challenge now lies in implementing these guidelines. Objectives of this meta-analysis were to assess the effectiveness of interventions for reducing the cesarean section rate and to assess the impact of this reduction on maternal and perinatal mortality and morbidity. Methods: The Cochrane Library, EMBASE, and MEDLINE were consulted from January 1990 to June 2005. Additional studies were identified by screening reference lists from identified studies and expert suggestions. Studies involving rigorous evaluation of a strategy for reducing overall cesarean section rates were identified. Randomized controlled trials, controlled before-and-after studies, and interrupted time series studies were evaluated according to Effective Practice and Organisation of Care Group criteria. Results: Among the 10 included studies, a significant reduction of cesarean section rate was found by random meta-analysis (pooled RR = 0.81 [0.75, 0.87]). No evidence of publication bias was identified. Audit and feedback (pooled RR = 0.87 [0.81, 0.93]), quality improvement (pooled RR = 0.74 [0.70, 0.77]), and multifaceted strategies (pooled RR=0.73 [0.68, 0.79]) were effective for reducing the cesarean section rate. However, quality improvement based on active management of labor showed mixed effects. Design of studies showed a higher effect for noncontrolled studies than for controlled studies (pooled RR = 0.76 [0.72, 0.81] vs 0.92 [0.88, 0.96]). Studies including an identification of barriers to change were more effective than other interventions for reducing the cesarean section rate (pooled RR = 0.74 [0.71, 0.78] vs 0.88 [0.82, 0.94]). Among included studies, no significant differences were found for perinatal and neonatal mortality and perinatal and maternal morbidity with respect to the mode of delivery. Only 1 study showed a significant reduction of neonatal and perinatal mortality (p < 0.001). Conclusions: The cesarean section rate can be safely reduced by interventions that involve health workers in analyzing and modifying their practice. Our results suggest that multifaceted strategies, based on audit and detailed feedback, are advised to improve clinical practice and effectively reduce cesarean section rates. Moreover, these findings support the assumption that identification of barriers to change is a major key to success. (BIRTH 34:1 March 2007)

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