Reducing cesarean birth rates with data-driven quality improvement activities

Reduction of cesarean section rates has been a difficult process that has not been easily accomplished by the institution of guidelines. It is more a process of changing physician behavior rather than of medical education. This article analyzed the role of intensive feedback of outcomes to bring about such changes. Two large private obstetric services in San Francisco, CA, were studied. Intensive outcomes feedback using a computerized information system, The Perinatal Data Center, regarding cesarean birth rates and a variety of obstetric outcomes was provided to the medical and nursing staff at one hospital. The other center served as a control. After the first observation period, the outcomes system was introduced to the second hospital. Finally, "open label" feedback, intradepartmental release of everyone's key statistics with names attached, was performed. Active management of labor was not practiced at either hospital. Results. Cesarean birth rates were stable in the baseline period from 1980 through 1988 at 24% to 25%. Introduction of the Perinatal Data Center outcomes system was associated with a reduction to 21% at the first hospital with no change in the control hospital. Subsequent introduction of the system 3 years later in the control hospital resulted in a decline from 25% to 20.5%. After merger of the two obstetric units and the institution of "open label" feedback, an additional decline to 18.5% was observed. Conclusion. Physician practice patterns and cesarean birth rates can be altered with the intensive use of comparative outcome data and strong physician leadership. Nonblinded, intradepartmental distribution of outcomes is an even more effective tool.