Reducing Caesarean Section Rates in Robson Groups 1 and 3: a Quality Improvement Initiative in a Private Brazilian Hospital

Overview

Journal BMJ Open Qual

Publisher BMJ Publishing Group

Specialty Health Services

Date 2025 Mar 4

PMID 40037900

Authors

Mario Macoto Kondo

Vera Denise de Toledo Leme

Daniela Cristina da Silva Carvalho

Lissandra Borba da Cunha

Elaine Galvao

Andreia Fratoni Ledo

Monica M Siaulys

Ana Pilar Betran

Maria Regina Torloni

Affiliations

Soon will be listed here.

Abstract

Private Brazilian hospitals have one of the highest caesarean section (CS) rates in the world. Caesareans may have short- and long-term implications for the health of mothers and babies. The primary objective of this project was to assess the effects of an intrapartum quality improvement (QI) initiative on CS rates and on maternal/perinatal outcomes. A bundle targeted at internal healthcare providers (HCP) on-duty in the labour and delivery (LD) ward of a private Brazilian hospital was created in 2020 (first period) and implemented in 2021-2022 (second period). External HCPs managing their own private patients served as a control group. The bundle focused on improving intrapartum care in women without previous CS in spontaneous labour with single cephalic pregnancies at term (Robson groups 1 and 3). The bundle included a collaborative midwifery-obstetrician intrapartum model of care, a new LD ward medical coordinator, daily supportive supervision, updated LD guidelines and internal HCP refresher training on teamwork and intrapartum care. We analysed changes in outcomes between the two periods and the two HCP teams. The analyses included data on 24 414 women who gave birth (≥500 g) over a 30-month period.Among women managed by internal HCPs, there was a 32% relative decrease in Robson-1 CS rates (65.7% vs 44.6%, first vs second period, relative rate ratio (RRR)=0.68, p<0.0001), a 43% relative decrease in Robson-3 CS rates (25.4% vs 14.5%, RRR=0.57, p=0.007) and an 11% relative decrease in the overall CS rates (82.7% vs 73.8%, RRR=0.89, p<0.0001). There were no significant changes in adverse maternal and perinatal outcomes nor in maternal satisfaction (primary outcomes), in Robson-1 and 3 groups managed by internal HCPs.In summary, an intrapartum care QI initiative was associated with a safe reduction of CS rates in Robson-1 and 3 women managed by on-duty HCPs in a private Brazilian hospital.

References

Delgado Nunes V, Gholitabar M, Sims J, Bewley S . Intrapartum care of healthy women and their babies: summary of updated NICE guidance. BMJ. 2014; 349:g6886. PMC: 4707719. DOI: 10.1136/bmj.g6886. View

Quibel T, Chesnais M, Bouyer C, Rozenberg P, Bouyer J . Cesarean section rate changes after audit and feedback with the Ten Group Classification System in a French perinatal network: A retrospective pre-post study. Acta Obstet Gynecol Scand. 2022; 101(4):388-395. PMC: 9564817. DOI: 10.1111/aogs.14327. View

Kingdon C, Downe S, Betran A . Interventions targeted at health professionals to reduce unnecessary caesarean sections: a qualitative evidence synthesis. BMJ Open. 2018; 8(12):e025073. PMC: 6303601. DOI: 10.1136/bmjopen-2018-025073. View

DAgostini Marin D, da Rosa Wernke A, Dannehl D, de Araujo D, Koch G, Marcal Zanoni K . The Project Appropriate Birth and a reduction in caesarean section rates: an analysis using the Robson classification system. BJOG. 2021; 129(1):72-80. DOI: 10.1111/1471-0528.16919. View

. WHO Statement on caesarean section rates. Reprod Health Matters. 2015; 23(45):149-50. DOI: 10.1016/j.rhm.2015.07.007. View

Roberts C, Algert C, Ford J, Todd A, Morris J . Pathways to a rising caesarean section rate: a population-based cohort study. BMJ Open. 2012; 2(5). PMC: 3437430. DOI: 10.1136/bmjopen-2012-001725. View

Ogrinc G, Davies L, Goodman D, Batalden P, Davidoff F, Stevens D . SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process. BMJ Qual Saf. 2015; 25(12):986-992. PMC: 5256233. DOI: 10.1136/bmjqs-2015-004411. View

Boerma T, Ronsmans C, Melesse D, Barros A, Barros F, Juan L . Global epidemiology of use of and disparities in caesarean sections. Lancet. 2018; 392(10155):1341-1348. DOI: 10.1016/S0140-6736(18)31928-7. View

Koladycz R, Fernandez G, Gray K, Marriott H . The Net Promoter Score (NPS) for Insight Into Client Experiences in Sexual and Reproductive Health Clinics. Glob Health Sci Pract. 2018; 6(3):413-424. PMC: 6172123. DOI: 10.9745/GHSP-D-18-00068. View

10.

Altieri E, Grove J, Davies O, Habersaat K, Okeibunor J, Samhouri D . Harnessing the power of behavioural science to improve health. Bull World Health Organ. 2021; 99(11):754-754A. PMC: 8542273. DOI: 10.2471/BLT.21.287375. View

11.

Betran A, Ye J, Moller A, Zhang J, Gulmezoglu A, Torloni M . The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990-2014. PLoS One. 2016; 11(2):e0148343. PMC: 4743929. DOI: 10.1371/journal.pone.0148343. View

12.

Negrini R, da Silva Ferreira R, Albino R, Daltro C . Reducing caesarean rates in a public maternity hospital by implementing a plan of action: a quality improvement report. BMJ Open Qual. 2020; 9(2). PMC: 7223294. DOI: 10.1136/bmjoq-2019-000791. View

13.

Kingdon C, Downe S, Betran A . Non-clinical interventions to reduce unnecessary caesarean section targeted at organisations, facilities and systems: Systematic review of qualitative studies. PLoS One. 2018; 13(9):e0203274. PMC: 6122831. DOI: 10.1371/journal.pone.0203274. View

14.

Scarella A, Chamy V, Sepulveda M, Belizan J . Medical audit using the Ten Group Classification System and its impact on the cesarean section rate. Eur J Obstet Gynecol Reprod Biol. 2010; 154(2):136-40. DOI: 10.1016/j.ejogrb.2010.09.005. View

15.

Hamilton D, Lane J, Gaston P, Patton J, MacDonald D, Simpson A . Assessing treatment outcomes using a single question: the net promoter score. Bone Joint J. 2014; 96-B(5):622-8. DOI: 10.1302/0301-620X.96B5.32434. View

16.

Flodgren G, OBrien M, Parmelli E, Grimshaw J . Local opinion leaders: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2019; 6:CD000125. PMC: 6589938. DOI: 10.1002/14651858.CD000125.pub5. View

17.

Blustein J, Liu J . Time to consider the risks of caesarean delivery for long term child health. BMJ. 2015; 350:h2410. PMC: 4707565. DOI: 10.1136/bmj.h2410. View

18.

Kumari P, Singh M, Sinha S, Ranjan R, Sharma P, Maitra C . Observation of a quality improvement initiative to contextually adapt and use Robson classification in real time to collect data around CS delivery and to develop strategies to reduce CS rate. BMJ Open Qual. 2023; 12(Suppl 3). PMC: 10603507. DOI: 10.1136/bmjoq-2023-002315. View

19.

Negrini R, DAlbuquerque I, de Cassia Sanchez E Oliveira R, da Silva Ferreira R, De Stefani L, Podgaec S . Strategies to reduce the caesarean section rate in a private hospital and their impact. BMJ Open Qual. 2021; 10(3). PMC: 8362699. DOI: 10.1136/bmjoq-2020-001215. View

20.

Betran A, Temmerman M, Kingdon C, Mohiddin A, Opiyo N, Torloni M . Interventions to reduce unnecessary caesarean sections in healthy women and babies. Lancet. 2018; 392(10155):1358-1368. DOI: 10.1016/S0140-6736(18)31927-5. View