Neonatal outcomes after reduction of nulliparous term singleton vertex cesarean deliveries

Rising global cesarean delivery rates have become a marked public health concern, prompting national and international organizations to advocate for measures aimed at reducing primary cesarean rates. The impact of decreasing cesarean rates on neonatal outcomes remains understudied. This study aimed to evaluate the impact of a hospital-wide initiative to reduce nulliparous term singleton vertex cesarean delivery rates on neonatal and maternal outcomes, focusing on identifying improvements or unintended consequences associated with the reduction in nulliparous term singleton vertex cesarean rates. This single-center retrospective study compared 2 cohorts of nulliparous term singleton vertex cesarean deliveries before (2015-2017) and after (2019-2021) implementing a multifaceted initiative aimed at reducing cesarean deliveries. A total of 2023 deliveries were analyzed, with 1438 matched deliveries (719 per cohort) using optimal propensity score matching to balance maternal characteristics. McNemar's test, Bowker test of symmetry, and Wilcoxon signed-rank test were used for statistical analysis, with P<.05 considered significant. The nulliparous term singleton vertex cesarean rate significantly decreased from 44.8% (322/719) to 28.2% (203/719) (P<.001). This reduction was associated with increased neonatal complications, including neonatal intensive care unit admissions (10.9% vs 17.1%, P<.001), birth injuries (2.8% vs 7.9%, P<.001), and Apgar scores <7 (0.4% vs 1.8%, P=.02). Specific increases were observed in neonatal intubation (0.1% vs 1.3%, P=.02) and advanced resuscitation (0.0% vs 0.8%, P=.03). There was no significant increase in maternal complications. The decrease in nulliparous term singleton vertex cesarean deliveries was associated with increased neonatal morbidities, highlighting the need for careful surveillance during practice changes aimed at reducing cesarean rates while achieving optimal outcomes. Further research is needed to verify these findings and ensure safe and effective obstetric care practices.