Composite non-clinical interventions for a safe cesarean section rate reduction: results of a pre-post interventional study

Objective: To evaluate the impact on cesarean section (CS) rate with of a program of multiple non-clinical interventions targeted at health-care professional within a hospital maternity ward. Materials and methods: Retrospective quasi-experimental pre-post intervention study with an historical control group conducted in a second-level teaching hospital. All women who gave birth in the period 2014 to 2018 were included. A series of multiple non-clinical interventions including a dedicated team of obstetricians for delivery room and antenatal counseling, monthly internal audits and physician education by local opinion leader were prospectively introduced from September 2016. The primary outcome of the study was the CS rate. The incidences of operative vaginal delivery, 3rd−/4th-degree perineal tears and further maternal and neonatal complications were considered as secondary outcomes. Results: The CS rate dropped from 33.05 to 26.06% after starting the interventions (p < 0.01); in particular, the cumulative rate of CS performed during labor decreased significantly from 19.46 to 14.11% (p < 0.01). CS reduction was still statistically significant after multivariate correction (OR = 0.66, CI.95 = 0.57–0.76, p < 0.01). Results further showed an increased prevalence of 3rd-degree perineal tears (0.97% versus 2.24%, p < 0.01), present also after correcting for possible confounding factors (OR = 2.36, CI.95 = 1.48–3.76, p < 0.01). No differences were found in the rate of vaginal-operative births and further maternal complications, while the composite neonatal outcome was found to be improved (OR = 0.73, CI.95 = 0.57–0.93, p = 0.010). Conclusions: The introduction of multiple non-clinical interventions can significantly reduce the CS rate. However, beside an improvement in neonatal composite outcome, a potential increase in high-degree perineal tears should be taken in account.