@article{PAR00013057,
  title = {{A} cluster-randomized trial to reduce cesarean delivery rates in {Q}uebec},
  author = {{C}haillet, {N}. and {D}umont, {A}lexandre and {A}brahamowicz, {M}. and {P}asquier, {J}. {C}. and {A}udibert, {F}. and {M}onnier, {P}. and {A}benhaim, {H}. {A}. and {D}ube, {E}. and {D}ugas, {M}. and {B}urne, {R}. and {F}raser, {W}. {D}.},
  editor = {},
  language = {{ENG}},
  abstract = {{BACKGROUND} {I}n {C}anada, cesarean delivery rates have increased substantially over the past decade. {E}ffective, safe strategies are needed to reduce these rates. {METHODS} {W}e conducted a cluster-randomized, controlled trial of a multifaceted 1.5-year intervention at 32 hospitals in {Q}uebec. {T}he intervention involved audits of indications for cesarean delivery, provision of feedback to health professionals, and implementation of best practices. {T}he primary outcome was the cesarean delivery rate in the 1-year postintervention period. {RESULTS} {A}mong the 184,952 participants, 53,086 women delivered in the year before the intervention and 52,265 women delivered in the year following the intervention. {T}here was a significant but small reduction in the rate of cesarean delivery from the preintervention period to the postintervention period in the intervention group as compared with the control group (change, 22.5% to 21.8% in the intervention group and 23.2% to 23.5% in the control group; odds ratio for incremental change over time, adjusted for hospital and patient characteristics, 0.90; 95% confidence interval [{CI}], 0.80 to 0.99; {P} = 0.04; adjusted risk difference, -1.8%; 95% {CI}, -3.8 to -0.2). {T}he cesarean delivery rate was significantly reduced among women with low-risk pregnancies (adjusted risk difference, -1.7%; 95% {CI}, -3.0 to -0.3; {P} = 0.03) but not among those with high-risk pregnancies ({P} = 0.35; {P} = 0.03 for interaction). {T}he intervention group also had a reduction in major neonatal morbidity as compared with the control group (adjusted risk difference, -0.7%; 95% {CI}, -1.3 to -0.1; {P} = 0.03) and a smaller increase in minor neonatal morbidity (adjusted risk difference, -1.7%; 95% {CI}, -2.6 to -0.9; {P}<0.001). {C}hanges in minor and major maternal morbidity did not differ significantly between the groups. {CONCLUSIONS} {A}udits of indications for cesarean delivery, feedback for health professionals, and implementation of best practices, as compared with usual care, resulted in a significant but small reduction in the rate of cesarean delivery, without adverse effects on maternal or neonatal outcomes. {T}he benefit was driven by the effect of the intervention in low-risk pregnancies.},
  keywords = {{QUEBEC}},
  booktitle = {},
  journal = {{N}ew {E}ngland {J}ournal of {M}edicine},
  volume = {372},
  numero = {18},
  pages = {1710--1721},
  ISSN = {0028-4793},
  year = {2015},
  DOI = {10.1056/{NEJM}oa1407120},
  URL = {https://www.documentation.ird.fr/hor/{PAR}00013057},
}