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The intervention program included onsite training in best-practice guidelines for C-sections, audits by a committee, and feedback for doctors.
"The benefit was driven by the effect of the intervention in low-risk pregnancies," said lead author Nils Chaillet, an associate professor of obstetrics and gynecology at the University of Sherbrooke in Quebec, Canada.
In hospitals with the program, fewer serious complications occurred in newborns, too, "suggesting that the reduction in the cesarean section rate is safe and that the program could improve the health of children," Chaillet added.
"The results suggested that by improving our knowledge about prenatal care programs and effectiveness, we can help reduce the rate of cesarean sections and not-medically-necessary procedures, thereby improving the quality of care and the health of mothers and their children," Chaillet said.
The findings were published in the April 30 issue of the New England Journal of Medicine.
C-section rates have climbed in many developed countries, including Canada and the United States, in recent decades, according to background information in the study.
Reasons for this increase include hospital factors, legal concerns, training resources, socioeconomic issues, health changes over time among mothers, insurance programs and information provided to mothers, among others, Chaillet said. But C-sections should only be considered for medical reasons, he said.
One medical reason for a C-section is labor problems, such as a baby not dropping down into the pelvis or the cervix not dilating appropriately, said Dr. Sheryl Ross, an obstetrician and gynecologist at Providence Saint John's Health Center in Santa Monica, Calif. Other reasons may include a baby positioned feet first (breech), a previous C-section, a baby over 9.5 pounds, twins or triplets, or a concerning fetal heart rate.
The current study aimed to reduce the rate of C-sections, and involved 32 hospitals throughout Quebec, Canada, and lasting one and a half years.
In the hospitals randomly assigned to use the program, a collaborating team of doctors, nurses and midwives reviewed the reasons for each C-section. Then health professionals received feedback, and the hospitals put in place best practices for when to perform C-sections.
More than 50,000 women delivered each year in the years before and after the intervention. In the year following the program, the rate of C-sections was slightly lower -- about 1.8 percent less -- in the hospitals with the program.
"This study suggested that joint decision-making from a group of health care professionals involved in a patient's pregnancy and delivery may actually lower the overall cesarean section rate," Ross said. "I suspect that other areas of medicine and patients would also benefit from this multifaceted intervention style of practicing medicine."
There wasn't a statistically significant change in the C-section rate for high-risk pregnancies, according to the study. But the C-section rate was reduced 1.7 percent for low-risk pregnancies in hospitals with the intervention.
In addition, slightly fewer minor and major complications for the newborns occurred in intervention hospitals compared to those without the program.
"Although the decrease in the rate of cesarean sections was small, it was significant and had the added benefit of improved neonatal outcomes," said Dr. Mitchell Maiman, chairman of the department of obstetrics and gynecology at Staten Island University Hospital in New York.
"Hospitals in the U.S. with even higher cesarean section rates are likely to reap even greater benefit," Maiman said.
Nothing on this scale has been done in the United States, according to Dr. Kevin Ault, a professor of obstetrics and gynecology at the University of Kansas Medical Center in Kansas City. "It is very challenging to get 32 hospitals together and agree to standardized clinical care," he said.
But in many hospitals throughout the United States, less formal versions of this kind of intervention have been implemented due to the influence of credentialing committees, insurance companies and hospital regulatory agencies, said Dr. Andre Hall, an obstetrician and gynecologist at Birth and Women's Care in Fayetteville, N.C.
"Specifically, indications that have been delineated by the American Congress of Obstetrics and Gynecology, such as no elective C-sections prior to 39 weeks for social reasons, have led to a small but statistically significant decrease in the rate of C-sections," Hall said.
One take-home message of this study, Hall added, is that patients should develop good relationships with their doctors and discuss labor and delivery plans ahead of time so that decisions can be made collectively.
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