Reducing the cesarean section rate in a rural community hospital.

OBJECTIVE To determine the success of a program designed to reduce the cesarean section rate in a rural community hospital, to identify reasons for any reduction in the rate and to identify any accompanying increases in the maternal and neonatal morbidity and mortality rates. DESIGN Longitudinal study of modes of delivery. SETTING A 44-bed community hospital with a medical staff of nine family physicians serving a population of 9000. PATIENTS All 1161 women who gave birth at the hospital from Jan. 1, 1985, to Dec. 31, 1989. Routinely recorded data were manually extracted from medical charts and entered into a computer database. INTERVENTION The guidelines of the National Consensus Conference on Aspects of Cesarean Birth (NCCACB) for vaginal birth after cesarean section (VBAC), management of breech presentation and the diagnosis of dystocia requiring cesarean section were introduced at the hospital in 1985. OUTCOME MEASURES The annual overall cesarean section rates and the rates among nulliparous women, multiparous women eligible for VBAC and multiparous women ineligible for VBAC. RESULTS The overall cesarean section rate decreased from 23% in 1985 to 13% in 1989 (p = 0.001). Among the nulliparous women the rate decreased from 23% to 12%, but the difference was insignificant (p = 0.069); this decrease was due to a drop in the number of dystocia-related cesarean sections. The rate among VBAC-eligible multiparous women decreased from 93% to 36% (p less than 0.001) because of an increased acceptance of VBAC by the patients and the physicians. The rate among multiparous women ineligible for VBAC was virtually unchanged. There were 20 neonatal transfers to an intensive care unit, with no tendency toward an increase over the study period. None of the mothers died; one newborn, of a nulliparous woman, died from a prolapsed umbilical cord. CONCLUSIONS The program was accompanied by a significant decrease in the cesarean section rate. Rural hospitals with facilities and personnel for emergency cesarean sections should consider the introduction of a similar program.