Impact of a Structured Caesarean Reduction Strategy on Perinatal Outcomes: A Retrospective Ecological Time-Trend Study.

OBJECTIVE

To evaluate the long-term impact of a structured, multidisciplinary CS reduction strategy in a high-complexity Italian hospital.

DESIGN

Retrospective ecological time-trend study.

SETTING

Tertiary obstetric care Italian centre.

SAMPLE: 28 577 deliveries, ≥ 22 weeks' gestation, from 2014 to 2024 were analysed.

METHODS

In 2014, a multifaceted improvement program including standardised protocols, continuous staff training, Robson Ten-Group Classification audits, and tailored intrapartum care (revised dystocia criteria, updated induction methods, intrapartum ultrasound, dedicated VBAC clinic, and physiology-based CTG interpretation) was introduced.

MAIN OUTCOME MEASURE: Temporal trend in CS rate, maternal morbidity (postpartum haemorrhage > 1000 mL, obstetric anal sphincter injuries, hysterectomy) and neonatal morbidity (cord pH < 7.0, resuscitation, therapeutic hypothermia). Temporal trends were assessed using segmented regression.

RESULTS

Segmented regression analysis of CS rates identified 2016 as a breakpoint. Prior to 2016, the annual change in CS rate was not significant (-0.24 percentage points per year; p = 0.75), whereas after 2016 a significant downward trend was observed (-1.64 percentage points per year; p < 0.001). Conversely, VBAC rates showed a significant increasing trend over time, while uterine rupture rates remained consistently below 0.3% throughout the study period. Maternal outcomes were overall stable, although a modest increase in postpartum haemorrhage was observed. Neonatal outcomes did not show significant changes over time, including the rate of arterial cord pH < 7.0 at birth.

CONCLUSIONS

The implementation of a structured, multifaceted strategy aimed at containing CS rates was associated with a significant change in their temporal trend, with a sustained post-2016 decline identified by segmented regression analysis. This trend was not associated with clinically significant detrimental effects on maternal or neonatal outcomes.