The Use of a Quality Indicator to Reduce Elective Repeat Caesarean Section for Low-Risk Women Before 39 Weeks’ Gestation: The Eastern Ontario Experience

Abstract Objective Elective repeat Caesarean section (ERCS) for low-risk women at < 39 weeks’ gestation has consistently been associated with increased risks to the neonate, including respiratory morbidity, NICU admission, and lengthier hospital stays than ERCS at 39 to 40 weeks’ gestation. The objective of this quality improvement project was to reduce high rates of ERCS < 39 weeks across the Eastern Ontario region. Methods All hospitals within the region providing care during labour and birth (n = 10) were asked to participate. Representatives from each hospital received information about their site-specific rates and knowledge-translation resources to assist them with the project. A benchmark rate for ERCS < 39 weeks was set at 30%. The rates of ERCS < 39 weeks were calculated for two different times (the 2009–2010 and 2010–2011 fiscal years) and the relative difference and 95% confidence intervals were calculated to quantify the magnitude and statistical significance of any change. Qualitative interviews were completed with key informants from each hospital. Results The proportion of ERCS at < 39 weeks’ gestation across the region in the fiscal year 2010–2011 (n = 197/497; 39.6%) was significantly decreased (relative difference: −21%; 95% CI −31% to −8%, P = 0.002) from the previous fiscal year 2009–2010 (n = 229/459; 49.9%). A number of barriers to, and facilitators of, practice change were identified. Conclusion A reduction in the rate of ERCS < 39 weeks among low-risk women was achieved across the region. Awareness of the issue, possession of site-specific data, and agreement about the evidence and the need for change are critical first steps to improving practice.