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Association of a Health Care Provider Review Meeting With Cesarean Delivery Rates

A Quality Improvement Program

Skeith, Ashley E., BA; Valent, Amy M., DO; Marshall, Nicole E., MD; Pereira, Leonardo M., MD; Caughey, Aaron B., MD, PhD

doi: 10.1097/AOG.0000000000002793
Contents: Cesarean Delivery: Original Research

OBJECTIVE: To examine the association of a quality improvement effort that was mediated through weekly review of all criteria for cesarean delivery on cesarean delivery prevalence and indications.

METHODS: We conducted a retrospective cohort study using a natural experiment model that compared two timeframes, from 2009 to 2013, at a single institution. We introduced a weekly retrospective review conference to discuss all cesarean deliveries in 2010 that continued over time. The conferences were attended by obstetric care providers, anesthesiology, and labor and delivery nurses. Date of delivery was dichotomized by those delivering before July 1, 2010, and those delivering after. We included women with term singleton vertex gestations in our study population and then examined the rates of cesarean delivery by date of delivery. We then examined indications for the cesarean deliveries during the study period based on surgeon documentation. χ2 tests were used for statistical comparisons and a P value of <.05 was used to indicate statistical significance.

RESULTS: There were 5,541 term singleton cephalic births during the study period. The rate of cesarean delivery declined significantly after our intervention in all women (22.2% vs 27.4%, P<.001) and nulliparous women (23.3% vs 30.9%, P<.001). The adjusted odds ratio of cesarean delivery in all women as related to time cohort is 0.68 (95% CI 0.58–0.79) and 0.56 (95% CI 0.44–0.70) in nulliparous women. We examined indications for the 1,315 cesarean deliveries during the study period by date of delivery. The indications of active-phase arrest, second-stage arrest, failed induction, repeat cesarean delivery, and maternal request decreased significantly between delivery cohorts in all women (P<.001) and in nulliparous women specifically (P<.001). Between delivery cohorts, we found that the prevalence of labored indications for cesarean delivery decreased more than nonlabored indications.

CONCLUSION: Implementation of a weekly review conference was associated with a reduction in both overall cesarean delivery prevalence and labored indications at our institution.

Implementation of a weekly review of cesarean delivery indications was associated with a significant decrease in the rate of cesarean delivery.

Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon.

Corresponding author: Ashley E. Skeith, BA, c/o Department of Obstetrics and Gynecology, Oregon Health & Science University, Mail Code L466, 3181 SW Sam Jackson Park Road, Portland, OR 97239; email:

Financial Disclosure The authors did not report any potential conflicts of interest.

Presented as a poster at the 38th annual meeting of the Society for Maternal-Fetal Medicine, January 29–February 3, 2018, Dallas, Texas.

Each author has indicated that he or she has met the journal's requirements for authorship.

Received March 22, 2018

Received in revised form May 18, 2018

Accepted June 07, 2018

© 2018 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.