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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Article info
Publication history
Published online: January 11, 2019
Accepted:
May 29,
2018
Received:
April 20,
2018
Footnotes
Competing interests: See Acknowledgements. Each author has indicated that they meet the journal's requirements for authorship.
Identification
Copyright
© 2019 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc.
