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Impact of Audits and Multifaceted Intervention on Vaginal Birth After Caesarean: Secondary Analysis of the QUARISMA Trial

Published:January 11, 2019DOI:https://doi.org/10.1016/j.jogc.2018.05.044

      Abstract

      Objectives

      This study estimated the effect that a multifaceted intervention aiming to improve the quality of obstetrical care and reduce Caesarean section (CS) had on the rate of vaginal birth after Caesarean (VBAC).

      Methods

      This is a secondary analysis of the cluster randomized controlled trial Quality of Care, Obstetrics Risk Management, and Mode of Delivery involving (1) audits regarding the indications for CS, (2) provision of feedback to health professionals, and (3) implementation of best practices to reduce CS rates in Quebec. The impact of intervention on VBAC, trial of labour (TOL), and maternal and neonatal morbidity was reported using adjusted odds ratios (ORs) with 95% confidence intervals (CIs).

      Results

      Out of 105 351 women who delivered during the pre- and postintervention period, 12 493 (11.9%) had a previous CS. We observed no significant impact of the multifaceted intervention on the rates of TOL (adjusted OR 1.22; 95% CI 0.96–1.56, P = 0.11) and VBAC (adjusted OR 1.20; 95% CI 0.97–1.48, P = 0.10) in women with one previous CS. However, the rate of TOL was reduced (adjusted OR 0.38; 95% CI 0.14–0.99) in women with more than one previous CS. The intervention has no influence on maternal and neonatal morbidity.

      Conclusions

      A multifaceted intervention including audits, feedback to health professionals, and implementation of best practices did not affect VBAC rates or maternal and neonatal morbidity. Our results pointed out the need for decision-making processand risk management tools specific to women with previous CS.

      Résumé

      Objectifs

      Cette étude a évalué les effets qu'une intervention multidimensionnelle visant à améliorer la qualité des soins obstétricaux et à réduire le taux de césarienne a eus sur le taux d'AVAC.

      Méthodologie

      Il s'agit d'une analyse secondaire de l'essai clinique randomisé par grappes Qualité des soins, gestion du risque obstétrical et du mode d'accouchement au Québec, qui comprenait : 1) des audits des indications de la césarienne; 2) de la rétroaction pour les professionnels de la santé; et 3) la mise en œuvre de pratiques exemplaires visant à réduire le taux de césarienne au Québec. Les effets de l'intervention sur les taux d'AVAC et d'essais de travail (EDT) et sur la morbidité maternelle etnéonatale ont été établis au moyen de RC ajustés avec des ICà95 %.

      Résultats

      Parmi les 105 351 femmes qui ont accouché dans les périodes précédant et suivant l'intervention, 12 493 (11,9 %) avaient des antécédents de césarienne. Nous avons constaté que l'intervention multidimensionnelle n'avait eu aucun effet significatif sur les taux d'EDT (RC ajusté : 1,22; IC à 95 % : 0,96–1,56; P = 0,11) et d'AVAC (RC ajusté : 1,20; IC à 95 % : 0,97–1,48; P = 0,10) chez les femmes qui avaient subi une seule césarienne antérieure. Toutefois, le taux d'EDT était réduit (RC ajusté : 0,38; IC à 95 % : 0,14–0,99) chez les femmes qui en avaient subi plus d'une. L'intervention n'a eu aucune influence sur la morbidité maternelle et néonatale.

      Conclusions

      Une intervention multidimensionnelle comportant des audits, de la rétroaction pour les professionnels de la santé et la mise en œuvre de pratiques exemplaires n'a eu aucun effet sur le taux d'AVAC et la morbidité maternelle et néonatale. Nos résultats ont mis en évidence la nécessité d'un processus décisionnel et d'un outil de gestion des risques pour les femmes ayant des antécédents de césarienne.

      Key Words

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