NEW ORLEANS – A training program that continually reinforced best practices for labor and delivery reduced the risk of cesarean section by 10% overall, and by up to 32% in a subgroup of high-risk pregnancies.
The program also significantly improved newborn outcomes, with a 12% decrease in the rate of major neonatal morbidity, Dr. Nils Chaillet reported at the Pregnancy Meeting, sponsored by the Society of Maternal-Fetal Medicine. The neonatal benefit remained significant even after excluding all preterm births from the analysis, said Dr. Chaillet of the Sainte-Justine University Hospital Research Center, Montreal.
The QUARISMA (Quality of Care, Management of Obstetrical Risk, and Mode of Delivery in Quebec) study examined the effects of a clinician training program designed to promote optimal management of labor and delivery. QUARISMA was a multifaceted evidence-medicine program based on audit, feedback, and educational activities that followed the World Health Organization guidelines for quality obstetrical care.
Dr. Nils Chaillet
A 2-day training session at each participating hospital introduced the program. Throughout the 3.5-year study, a local audit committee, headed by a peer-selected leader, regularly evaluated performance and provided feedback on results and suggestions on quality improvement. These audits were conducted every 3 months. They included an analysis of each cesarean case, centering on whether and how it could have been prevented.
The study randomized 32 public hospitals in Quebec to the intervention or to a control arm of usual practice. The hospitals all had a cesarean section rate of at least 17% and no prior program aimed at reducing that rate. They had to perform more than 300 deliveries annually. All women who gave birth to an infant of at least 500 grams and 24 weeks’ gestation were included in the study.
A total of 105,351 deliveries occurred. In the control group, the baseline rate of cesarean section was 23%; that remained unchanged. The rate did decrease in the intervention group, dropping from 22.5% at baseline to 21.8% at study’s end – a 10% risk reduction that was statistically significant.
Women with low-risk pregnancies experienced a considerable benefit, Dr. Chaillet noted, with an overall risk reduction of 20%. That varied among hospital type. It was smallest (2%) at community hospitals, followed by 21% at regional hospitals and 24% at tertiary care hospitals.
Among high-risk pregnancies, the risk of a cesarean decreased by 4% overall. It did not change in tertiary care centers, but decreased by 5% at regional hospitals and 32% at community hospitals.
Medical interventions were a secondary endpoint. There were no changes in the rates of episiotomy, epidurals, or artificial rupture of membranes. However, the risk of operative vaginal delivery dropped by 12%, and pharmacologic labor induction by 18%. The odds of using oxytocin during labor increased by16%.
There were no significant changes in the composite measures of minor or major maternal morbidities. But neonatal outcomes did improve. The risk of a minor neonatal morbidity decreased by a significant 12%; the risk of a major problem decreased by 19%.
Dr. Chaillet made no financial disclosures.
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