How structured cultural changes can reduce cesarean section rate in a Danish tertiary hospital

Cesarean section is rising globally, with the risk of over-use and subsequent iatrogenic consequences for child and maternal health and future pregnancies. This study aims to evaluate the impact of a 12-step initiative implemented by a Danish tertiary hospital, targeting organisational structures, healthcare personnel, and the birthing population, on reducing cesarean section rates, compared to control hospitals that did not adopt a similar approach.

A national retrospective register-based cohort study comparing the index hospital with two control hospitals, five years before implementation until eight years after the initiation of the strategy. Interrupted Time Series Analyses are performed with and without the control group. The study was conducted in a Danish tertiary hospital, Hospital Southern Jutland. A sample of term births in Denmark either at the index hospital (n = 21,232) or at two control hospitals (n = 46,417) from 2003 to 2017. Primary outcome was Cesarean section. Secondary outcomes were severe maternal- and perinatal complications.

During implementation (2008-2017), the cesarean rate decreased at the index hospital from 21.1% to 12.0% (-0.87% annually, p < 0.001). There was no significant change in instrumental birth, uterine ruptures, neonatal intensive care unit admission, or fetal death. The rate of Apgar Score <7/ 5 minutes levelled off after a rising trend (p = 0.009). Both the index hospital and controls had a decline in cesarean rates in the intervention period (-0.87% vs. -0.12% annually), which corresponds to an extra 0,75% annual reduction at the index hospital compared to the control hospitals (p < 0.001).

Implementing a multi-component initiative to reduce cesarean sections has demonstrated both effectiveness and clinical significance. If such a strategic implementation can be conducted elsewhere, it could yield substantial benefits for maternal and fetal health.