# Safe Reduction of Nulliparous, Term, Singleton, Vertex Cesarean Delivery Rates Using Multidisciplinary Quality Improvement Efforts

## TL;DR

A hospital reduced cesarean delivery rates for first-time mothers without harming newborn outcomes by using data and multidisciplinary efforts.

## Contribution

A multidisciplinary quality improvement approach reduced NTSV cesarean rates and racial disparities without compromising safety.

## Key findings

- NTSV cesarean delivery rates decreased from 31.0% to 27.7% after quality improvement efforts.
- Non-Hispanic White patients saw a significant reduction in cesarean rates, while non-Hispanic Black patients showed a trend toward reduction.
- Newborn complication rates remained unchanged before and after the intervention.

## Abstract

Multidisciplinary quality improvement efforts that integrate data disaggregation with hospital-specific drivers can lead to reductions in nulliparous, term, singleton, vertex cesarean delivery rates and racial and ethnic disparities without compromising neonatal outcomes.

The rate of cesarean deliveries in nulliparous, term, singleton, vertex (NTSV) patients at our hospital has been about 30% since we began tracking this measure in 2016. Our aim was to evaluate the effect of quality improvement (QI) initiatives on this metric.

Our Level IV urban academic center formed a multidisciplinary workgroup in April 2023. We reviewed NTSV cesarean delivery rates stratified by indication, physician practice, and race and ethnicity, which were regularly presented to the department and practice leaders. Nurses audited oxytocin management for adherence to hospital protocol and introduced nonpharmacologic options to help patients cope with labor pain. Retrospective chart review of all NTSV cesarean deliveries from May to October 2023 determined whether the indication for cesarean delivery met American College of Obstetricians and Gynecologists (ACOG) criteria for failed induction of labor, active-phase arrest, second-stage arrest, and prelabor/scheduled cesarean delivery. Results were presented at departmental meetings, and each physician was sent a scorecard with their total NTSV cesarean delivery and adherence to ACOG criteria. A retrospective cohort study was conducted around implementation of the QI efforts to safely reduce the NTSV cesarean delivery rate.

Overall and race-stratified NTSV cesarean delivery rates decreased over the time period of the hospital QI efforts. The overall preintervention rate was 31.0%, and this decreased significantly to 27.7% after intervention (P=.02). The rate for non-Hispanic White patients decreased significantly (27.7% vs 22.2%, P=.02), whereas non-Hispanic Black patients experienced a trend toward rate reduction from before to after intervention (38.3% vs 31.6%, P=.05). The rate of severe newborn complications was the same before and after intervention (0.5% vs 0.5%, P=.99). Chart review identified 298 NTSV cesarean deliveries, of which 13.8% did not meet ACOG criteria. Failed induction of labor was the most common indication (23.4%) that did not meet criteria across all racial and ethnic groups. Scheduled cesarean delivery rates not meeting ACOG criteria were highest for White and Hispanic patients, driven by cesarean delivery for estimated fetal weight lower than ACOG thresholds.

Our hospital NTSV cesarean delivery rate decreased without an increase in severe newborn complication rates. Our chart audit allowed us to identify an opportunity to target specific QI interventions. Sharing disaggregated data and detailed chart review to identify hospital-specific drivers of nonmedically indicated cesarean delivery may be strategies to safely reduce NTSV cesarean delivery rates and drive QI initiatives.