@article{fdi:010069550,
  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 = {{I}n developed countries, cesarean delivery rates are high and increasing. {S}trategies to reduce cesarean delivery rates have been the subject of recent studies and guidelines. {W}hile these studies suggest strategies involving audits and feedback are generally effective, there have not been large randomized trial data assessing the effects of a multifaceted strategy. {T}his trial aims to assess whether the rate of cesarean delivery would be reduced by a multifaceted intervention promoting on-site training with audits and feedback. {T}he {QUARISMA} ({Q}uality of {C}are, {O}bstetrics {R}isk {M}anagement and {M}ode of {D}elivery) trial was conducted between {A}pril 1, 2008, and {O}ctober 31, 2011, at 32 public hospitals in {Q}uebec. {H}ospitals included had to have a 17% cesarean delivery rate or higher and at least 300 deliveries the year before. {F}or inclusion, infants had to be born at least 24 weeks' gestation and weigh at least 500 g at delivery. {H}ospitals were randomly assigned to either a control or intervention group. {T}he study spanned 3.5 years, first with a yearlong baseline period followed by a 1.5-year intervention period, and concluded with a yearlong postintervention period. {I}nstructors from the {S}ociety of {O}bstetricians and {G}ynecologists of {C}anada provided training in evidence-based clinical practices. {T}he intervention program also included clinical audits. {T}here was no financial incentive. {T}here was no intervention in the control groups. {A} total of 184,952 women delivered during the study period. {I}n the control group, the baseline cesarean delivery rate was 23.2%, and in the intervention group, the rate was 22.5%. {A}fter intervention, the rate of cesarean delivery was 23.5% in the control group and 21.8% in the intervention group ({P} = 0.04). {I}n both groups, rates of labor induction increased, but increased more in the control group than in the intervention group (adjusted odds ratio, 0.82; 95% confidence interval, 0.76-0.87; {P} < 0.001; adjusted risk difference, -3.8%; 95% confidence interval, -5.1% to -2.7%). {A} statistically significant reduction in the cesarean delivery rate was seen in low-risk pregnancies (-1.7%, {P} = 0.03) but not among high-risk pregnancies ({P} = 0.35). {T}he reduction was significant but small. {I}nterestingly, both major and minor neonatal morbidity in both low- and high-risk pregnancies was significantly reduced after intervention (adjusted risk difference, -0.7% for major morbidity [{P} = 0.03] and -1.7% for minor morbidity [{P} < 0.001]). {T}his trial confirmed previous studies suggesting benefits of a multifaceted strategy involving audits and feedback. {I}t is not clear, however, which aspects of the intervention program were responsible for the reduction in the rate of cesarean deliveries.},
  keywords = {{CANADA} ; {QUEBEC}},
  booktitle = {},
  journal = {{O}bstetrical and {G}ynecological {S}urvey},
  volume = {70},
  numero = {9},
  pages = {546--548},
  ISSN = {0029-7828},
  year = {2015},
  DOI = {10.1097/01.ogx.0000471595.46762.64},
  URL = {https://www.documentation.ird.fr/hor/fdi:010069550},
}