REDUCING CESAREAN BIRTHS AT A PRIMARILY PRIVATE UNIVERSITY HOSPITAL

OBJECTIVE: The rise in cesarean birth at Northwestern Memorial Hospita l in 1986 to 27.3% prompted implementation of three initiatives to rev erse the escalating cesarean section rate. STUDY DESIGN: First, vagina l birth after cesarean section was more strongly encouraged. Second, a fter the 1988 calendar year the cesarean section rate of every obstetr ician was circulated annually to each attending physician. Third, on c ompletion of a prospective, randomized trial of the active management of labor in early 1991, this protocol was recommended as the preferred method of labor management for term nulliparous patients. RESULTS: Th e total, primary, and repeat cesarean section rates declined from 27.3 %, 18.2%, and 9.1% in 1986 to 16.9%, 10.6%, and 6.4%, respectively, in 1991. At the same time the perinatal mortality dropped from 19.5 to 1 0.3. Significant reductions in abdominal deliveries occurred for both private patients (30.3% to 19.1%, p < 0.0001) and clinic patients (20. 8% to 11.5%, p < 0.0001). A decline in operative deliveries for dystoc ia and an increase in vaginal birth after prior cesarean section were the principal factors contributing to the lower cesarean section rates . However, in 1991 individual private physicians still had wide variat ions in primary cesarean section rates (4.6% to 21.1%) and use of vagi nal birth after prior cesarean section (5.3% to 90%). CONCLUSION: The cesarean section rate has been significantly reduced for both private and clinic patients. Differences in population demographics and indivi dual physician practice patterns contributed to a higher incidence of cesarean birth on the private service.