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Quality Improvement Initiatives Lead to Reduction in Nulliparous Term Singleton Vertex Cesarean Delivery Rate

      Background

      The nulliparous term singleton vertex (NTSV) cesarean delivery rate has been recognized as a meaningful benchmark. Variation in the NTSV cesarean delivery rate among hospitals and providers suggests many hospitals may be able to safely improve their rates. The NTSV cesarean delivery rate at the authors' institution was higher than state and national averages. This study was conducted to determine the influence of a set of quality improvement interventions on the NTSV cesarean delivery rate.

      Methods

      From 2008 through 2015, at a single tertiary care academic medical center, a multi-strategy approach that included provider education, provider feedback, and implementation of new policies was used to target evidence-based and inferred factors that influence the NTSV cesarean delivery rate. Data on mode of delivery, maternal outcomes, and neonatal outcomes were collected from birth certificates and administrative claims data. The Cochran-Armitage test and linear regression were used to calculate the p-trend for categorical and continuous variables, respectively.

      Results

      More than 20,000 NTSV deliveries were analyzed, including more than 15,000 during the intervention period. The NTSV cesarean delivery rate declined from 35% to 21% over eight years. The total cesarean delivery rate declined as well. Increase in meconium aspiration syndrome and maternal transfusion were observed.

      Conclusion

      Quality improvement initiatives can decrease the NTSV cesarean delivery rate. Any increased incidence of fetal or maternal complications associated with decreased NTSV cesarean delivery rate should be considered in the context of the risks and benefits of vaginal delivery compared to cesarean delivery.
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      Biography

      Mary A. Vadnais, MD, is Clinical Instructor, Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, and Maternal Fetal Medicine Physician, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center and Harvard Vanguard Medical Associates, Boston.

      Biography

      Michele R. Hacker, ScD, is Associate Professor, Obstetrics and Gynecology, Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, and Vice Chair for Research, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center.

      Biography

      Neel T. Shah, MD, is Assistant Professor, Obstetrics and Gynecology, Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, and Associate Faculty, Ariadne Labs for Health Systems Innovation, Boston.

      Biography

      JoAnn Jordan, BA, is Director of Quality Programs, and Anna M. Modest, MPH, is Clinical Research Assistant, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center.

      Biography

      Molly Siegel, MD, formerly Medical Student, Harvard Medical School, is Resident, Department of Obstetrics and Gynecology, University of California, San Francisco.

      Biography

      Toni H. Golen, MD, is Assistant Professor, Obstetrics and Gynecology, Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, and Vice Chair, Quality and Safety, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center.