OBJECTIVES: The Evidence-based Practice Center systematically reviewed evidence addressing strategies to reduce cesarean birth.
DATA SOURCES: We searched MEDLINE(®) via PubMed and the Cumulative Index of Nursing and Allied Health Literature as well as the reference lists of included studies.
REVIEW METHODS: We included studies published in English from 1968 to February 2012. We excluded publications that did not address a Key Question, were not an eligible study design, or did not aim to reduce cesarean birth among low-risk women.
RESULTS: Of the 97 studies included, 16 were good quality, 28 fair, and 53 poor. In this review, all studies compared the novel strategy to usual care or to variations in the same strategy. Few studies addressed prenatal strategies; the one such strategy that reduced cesarean was treatment of the cervix with hyaluronidase in the clinic at term to promote cervical softening. Strategies intended for use in labor included four trials that favored active management of labor, with 2.8- to 7.4-percent decreases in cesarean; one study showed a significant decrease. Doula support in labor was associated with significant reductions in cesarean (5.0 to 22.0%) in three studies. One of six trials of fetal assessment reported a significant reduction in total cesareans (20.6%). Three of eight trials of amnioinfusion reported a significant reduction in total cesareans (15 to 34.2%). Virtually all studies within health care systems that changed policies or procedures evaluated strategies with more than one component. Seventeen of 31 studies reported statistically significant reductions in cesarean from 1.6 to 17.0 percent. Ten of the 17 effective strategies included audit and feedback of cesarean trend data to participating units and/or care providers, 7 included protocols for vaginal birth after prior cesarean, 6 included agreement on overarching labor and delivery guidelines, and 5 included active management of labor protocols. Overall, it is not possible to determine which components are definitively associated with reductions.
CONCLUSIONS: No single strategy was uniformly successful in reducing cesareans. Strength of evidence was low to insufficient for all strategies. No approach dominated as a strategy appropriate to reduce use of cesarean among low-risk women in the United States.
The literature on continuous quality improvement (CQI) has produced some evidence, based on nonrandomized studies, that its clinical application can improve outcomes of care while reducing costs. Its effectiveness is enhanced by a nucleus of physician involvement, individual practitioner feedback, and a supportive organizational culture. The few randomized studies, however, suggest no impact of CQI on clinical outcomes and no evidence to date of organization-wide improvement in clinical performance. Further, most studies address misuse issues and avoid examining overuse or underuse of services. The clinical application of CQI is more likely to have a pervasive impact when it takes place within a supportive regulatory and competitive environment, when it is aligned with financial incentives, and when it is under the direction of an organizational leadership that is committed to integrating all aspects of the work.
OBJECTIVE: To establish what is known about the role of feedback of statistical information in changing clinical practice. DESIGN: Review of 36 studies of interventions entailing the use of statistical information for audit or practice review, which used a formal research design. SUBJECTS: Papers identified from computer searches of medical and health service management publications, of which 36 describing studies of interventions designed to influence clinical care and including information feedback from clinical or administrative data systems were reviewed. MAIN OUTCOME MEASURES: Evidence for effect of information feedback on change in clinical practice. RESULTS: Information feedback was most likely to influence clinical practice if it was part of strategy to target decision makers who had already agreed to review their practice. A more direct effect was discernable if the information was presented close to the time of decision making. The questions of the optimum layout and quantity of information were not addressed; the 36 papers were insufficient for defining good formats for information to be used for audit or quality assurance. CONCLUSIONS: Given the cost of information processing and the current emphasis on closing the audit loop in the health services, it is important that the use of information in the audit process should be critically evaluated.
The Evidence-based Practice Center systematically reviewed evidence addressing strategies to reduce cesarean birth.
DATA SOURCES:
We searched MEDLINE(®) via PubMed and the Cumulative Index of Nursing and Allied Health Literature as well as the reference lists of included studies.
REVIEW METHODS:
We included studies published in English from 1968 to February 2012. We excluded publications that did not address a Key Question, were not an eligible study design, or did not aim to reduce cesarean birth among low-risk women.
RESULTS:
Of the 97 studies included, 16 were good quality, 28 fair, and 53 poor. In this review, all studies compared the novel strategy to usual care or to variations in the same strategy. Few studies addressed prenatal strategies; the one such strategy that reduced cesarean was treatment of the cervix with hyaluronidase in the clinic at term to promote cervical softening. Strategies intended for use in labor included four trials that favored active management of labor, with 2.8- to 7.4-percent decreases in cesarean; one study showed a significant decrease. Doula support in labor was associated with significant reductions in cesarean (5.0 to 22.0%) in three studies. One of six trials of fetal assessment reported a significant reduction in total cesareans (20.6%). Three of eight trials of amnioinfusion reported a significant reduction in total cesareans (15 to 34.2%). Virtually all studies within health care systems that changed policies or procedures evaluated strategies with more than one component. Seventeen of 31 studies reported statistically significant reductions in cesarean from 1.6 to 17.0 percent. Ten of the 17 effective strategies included audit and feedback of cesarean trend data to participating units and/or care providers, 7 included protocols for vaginal birth after prior cesarean, 6 included agreement on overarching labor and delivery guidelines, and 5 included active management of labor protocols. Overall, it is not possible to determine which components are definitively associated with reductions.
CONCLUSIONS:
No single strategy was uniformly successful in reducing cesareans. Strength of evidence was low to insufficient for all strategies. No approach dominated as a strategy appropriate to reduce use of cesarean among low-risk women in the United States.
