Impact of a Multifaceted Quality Improvement Initiative Aimed at Reducing Primary Cesarean Delivery Rates

The ideal approach to safely reduce the rising rates of cesarean deliveries (CDs) is unknown. The authors evaluated the impact of a multifaceted quality improvement (QI) initiative aimed at curbing the rising trend in the institutional nulliparous term singleton vertex (NTSV) CD rate at an urban, academic, safety-net hospital.

The primary intervention was a biweekly interdisciplinary educational meeting, wherein NTSV CD cases were reviewed and audited. In addition, an educational bulletin, NTSV score cards, labor position training, and efforts to promote guideline adherence were introduced. The research team examined the institutional NTSV CD rates by quarters and evaluated the trend, modeling the probability of a CD for the pre- and postintervention periods using logistic regression, with time as an ordinal variable. The authors also examined cesarean indications as well as maternal and neonatal complications before and after the QI implementation.

There was a trend toward a decrease in CDs during the postintervention period, falling from 32.9% to 26.3% in the 12 months following implementation. Using an interrupted time series analysis to assess differences in trends, the trend before intervention was +2.63% per quarter (95% confidence interval [CI] 2.30-3.03, p < 0.001), while the change in trend postintervention was -3.78% per quarter (95% CI -4.74 to -2.81, p < 0.001, R² = 0.973). This suggests an increasing trend prior to intervention that was effectively reversed. Both maternal and neonatal complications rates remained comparable between pre- and postintervention periods for those who had NTSV CDs.

Multifaceted strategies incorporating interactive case review meetings can lead to practice change and may be a feasible strategy to reduce an institutional NTSV CD rate.