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Safety Assessment of a Large-Scale Improvement Collaborative to Reduce Nulliparous Cesarean Delivery Rates

Main, Elliott K., MD; Chang, Shen-Chih, MS, PhD; Cape, Valerie; Sakowski, Christa, MSN, RN; Smith, Holly, MPH, MSN; Vasher, Julie, DNP, RNC-OB

doi: 10.1097/AOG.0000000000003109
Contents: Cesarean Delivery: Original Research
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OBJECTIVE: To evaluate maternal and neonatal safety measures in a large-scale quality improvement program associated with reductions in nulliparous, term, singleton, vertex cesarean delivery rates.

METHODS: This is a cross-sectional study of the 2015–2017 California Maternal Quality Care Collaborative (CMQCC) statewide collaborative to support vaginal birth and reduce primary cesarean delivery. Hospitals with nulliparous, term, singleton, vertex cesarean delivery rates greater than 23.9% were solicited to join. Fifty-six hospitals with more than 119,000 annual births participated; 87.5% were community facilities. Safety measures were derived using data collected as part of routine care and submitted monthly to CMQCC: birth certificates, maternal and neonatal discharge diagnosis and procedure files, and selected clinical data elements submitted as supplemental data files. Maternal measures included chorioamnionitis, blood transfusions, third- or fourth-degree lacerations, and operative vaginal delivery. Neonatal measures included the severe unexpected newborn complications metric and 5-minute Apgar scores less than 5. Mixed-effect multivariable logistic regression model was used to calculate odds ratios (Ors) and 95% CIs.

RESULTS: Among collaborative hospitals, the nulliparous, term, singleton, vertex cesarean delivery rate fell from 29.3% in 2015 to 25.0% in 2017 (2017 vs 2015 adjusted OR [aOR] 0.76, 95% CI 0.73–0.78). None of the six safety measures showed any difference comparing 2017 to 2015. As a sensitivity analysis, we examined the tercile of hospitals with the greatest decline (31.2%–20.6%, 2017 vs 2015 aOR 0.54, 95% CI 0.50–0.58) to evaluate whether they had greater risk of poor maternal and neonatal outcomes. Again, no measure was statistically worse, and the severe unexpected newborn complications composite actually declined (3.2%–2.2%, aOR 0.71, 95% CI 0.55–0.92).

CONCLUSION: Mothers and neonates participating in a large-scale Supporting Vaginal Birth collaborative had no evidence of worsened birth outcomes, even in hospitals with large cesarean delivery rate reductions, supporting the safety of efforts to reduce primary cesarean delivery using American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine guidelines and enhanced labor support.

Evidence from a large-scale quality improvement collaborative supports the safety of efforts to reduce nulliparous cesarean delivery rates.

California Maternal Quality Care Collaborative, Stanford University School of Medicine, Stanford, California.

Corresponding author: Elliott K. Main, MD, 1265 Welch Road, MSOB, Stanford, CA 94305; email:

Funding for this project was provided by the California Health Care Foundation.

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

The California Maternal Quality Care Collaborative thanks the following collaborative mentors for providing leadership and support to their hospital teams making this project possible: Paola Aghajanian, MD; Robert Altman, MD; Jennifer Butler, MD; Susan Crowe, MD; Terri Deeds, RN, MSN; Sharon Dey-Layne, CNS; Kimberly Gregory, MD; Valerie Huwe, RNC, MS; David Lagrew, MD; Timothy Leach, MD; Katie Lydon, RN; Alina Miller, RN; Marlin Mills, MD; Karen Perdion, RN; Melissa Rosenstein, MD; Cynthia Sawyer, RN; Maryam Tarsa, MD; Janet Trial, EdM, CNM, MSN; and Jamie Vincent, MSN.

Presented at the Society for Maternal-Fetal Medicine's annual meeting, February 11–16, 2019, Las Vegas, Nevada.

Each author has confirmed compliance with the journal's requirements for authorship.

Peer reviews are available at

Received September 28, 2018

Received in revised form November 14, 2018

Accepted November 29, 2018

© 2019 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.