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Impact of a Structured Caesarean Reduction Strategy on Perinatal Outcomes: A Retrospective Ecological Time-Trend
Stefania Fieni1, Giovanni Morganelli1, Gabriella Maria Celora1
1Department of Obstetrics and Gynecology, Parma University Hospital, Parma, Italy.
Objective:
To evaluate the long-term impact of a structured, multidisciplinary CS reduction strategy in a high-complexity Italian hospital.
Design:
Retrospective ecological time-trend study.
Setting:
Tertiary obstetric care Italian centre.
Sample:
28 577 deliveries, ≥ 22 weeks' gestation, from 2014 to 2024 were analysed.
Methods:
In 2014, a multifaceted improvement program including standardised protocols, continuous staff training, Robson Ten-Group Classification audits, and tailored intrapartum care (revised dystocia criteria, updated induction methods, intrapartum ultrasound, dedicated VBAC clinic, and physiology-based CTG interpretation) was introduced.
Main Outcome Measure:
Temporal trend in CS rate, maternal morbidity (postpartum haemorrhage > 1000 mL, obstetric anal sphincter injuries, hysterectomy) and neonatal morbidity (cord pH < 7.0, resuscitation, therapeutic hypothermia). Temporal trends were assessed using segmented regression.
Results:
Segmented regression analysis of CS rates identified 2016 as a breakpoint. Prior to 2016, the annual change in CS rate was not significant (-0.24 percentage points per year; p = 0.75), whereas after 2016 a significant downward trend was observed (-1.64 percentage points per year; p < 0.001). Conversely, VBAC rates showed a significant increasing trend over time, while uterine rupture rates remained consistently below 0.3% throughout the study period. Maternal outcomes were overall stable, although a modest increase in postpartum haemorrhage was observed. Neonatal outcomes did not show significant changes over time, including the rate of arterial cord pH < 7.0 at birth.
Conclusions:
The implementation of a structured, multifaceted strategy aimed at containing CS rates was associated with a significant change in their temporal trend, with a sustained post-2016 decline identified by segmented regression analysis. This trend was not associated with clinically significant detrimental effects on maternal or neonatal outcomes.
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