Evaluating the Impact of a Structured Caesarean Reduction Strategy on Perinatal Outcomes: Insights from a Decade-long Italian Study

Highlight

– Implementation of a structured, multidisciplinary caesarean section (CS) reduction strategy resulted in a significant and sustained decrease in CS rates from 2016 onward.
– Vaginal birth after caesarean (VBAC) rates increased significantly over time without an associated rise in uterine rupture.
– Maternal morbidity remained largely stable, though a slight rise in postpartum hemorrhage was noted.
– Neonatal outcomes, including severe acidosis and resuscitation needs, remained unchanged despite decreased CS rates.

Study Background

The caesarean section rate has been progressively increasing worldwide, raising concerns about potential maternal and neonatal complications associated with unnecessary surgical births. Italy, like many developed countries, has faced high CS rates, sometimes exceeding recommended thresholds. Reducing avoidable CS deliveries is critical to improving maternal and neonatal health outcomes, preserving resources, and aligning with physiological birth principles. Despite multiple interventions proposed globally, evidence remains mixed regarding effectiveness and safety when scaling down CS rates in high-complexity hospitals. This study addressed the long-term impact of a comprehensive, multidisciplinary CS reduction program in a high-volume Italian tertiary obstetric center.

Study Design

This was a retrospective ecological time-trend study analyzing 28,577 deliveries (≥22 weeks gestation) from 2014 to 2024 in a tertiary care hospital in Italy. The intervention began in 2014 with a multifaceted improvement program aimed at CS rate containment. Key components included:
– Standardized clinical protocols for labor management and CS indication.
– Continuous multidisciplinary staff training and education.
– Systematic audits according to the Robson Ten-Group Classification for CS.
– Tailored intrapartum care strategies, such as revised dystocia criteria, updated induction protocols, use of intrapartum ultrasound, and physiology-based cardiotocography (CTG) interpretation.
– Establishment of a dedicated VBAC clinic for counseling and monitoring.

The primary outcome was the temporal trend in CS rates evaluated through segmented regression analysis to detect significant changes over time. Secondary outcomes encompassed maternal morbidity events such as postpartum hemorrhage exceeding 1000 mL, obstetric anal sphincter injury, and hysterectomy. Neonatal outcomes of interest included severe acidosis (umbilical cord arterial pH <7.0), resuscitation requirements, and therapeutic hypothermia.

Key Findings

Segmented regression analysis pinpointed 2016 as a significant breakpoint. Prior to 2016, the annual CS rate did not change significantly, with a negligible reduction of -0.24 percentage points per year (p=0.75). Post-2016, a marked and statistically significant decline of -1.64 percentage points per year (p1000 mL) was noted, warranting cautious monitoring but no significant change in severe complications like hysterectomy. Obstetric anal sphincter injury rates remained unchanged.

Neonatal outcomes showed no significant variation across years despite fewer CS deliveries. Rates of severe neonatal acidosis (pH <7.0), need for resuscitation, and use of therapeutic hypothermia did not increase, indicating that reducing CS did not compromise neonatal safety.

Expert Commentary

This study exemplifies how a carefully structured, multidisciplinary approach can safely reduce CS rates in a high-complexity obstetric setting without increasing adverse maternal or neonatal events. Integrating continuous staff education, adherence to evidence-based labor protocols, and individualization of care—especially through a dedicated VBAC service—are key components of success.

The use of the Robson Ten-Group Classification for audit purposes enabled targeted interventions and monitoring, fostering accountability and quality improvement. Revising dystocia criteria and incorporating intrapartum ultrasound and physiology-based CTG interpretation likely contributed to more accurate diagnoses, reducing unnecessary surgical births.

The marginal rise in postpartum hemorrhage underscores the need for vigilance regarding hemorrhagic risks as labor management strategies evolve. Replication in other centers, particularly with diverse patient populations, would validate generalizability. Limitations include the ecological design and absence of randomized controls; nevertheless, the large sample size and extended timeline strengthen findings.

Conclusion

The Italian tertiary hospital’s decade-long implementation of a multifaceted CS reduction strategy achieved a significant and sustained decline in CS rates starting 2016. This shift was coupled with increased VBAC rates and did not adversely affect maternal or neonatal morbidity. The findings support integrated, protocol-driven, and multidisciplinary approaches as effective tools to optimize cesarean delivery rates responsibly.

Future research should focus on refining labor management protocols, addressing postpartum hemorrhage risk, and disseminating best practices for VBAC counseling and support to reduce global CS overutilization safely.

Funding and ClinicalTrials.gov

The original publication does not specify funding sources or clinical trial registration for this retrospective ecological study.

References

1. Betrán AP, Ye J, Moller AB, Zhang J, Gülmezoglu AM, Torloni MR. The Increasing Trend in Cesarean Section Rates: Global, Regional and National Estimates: 1990-2014. PLoS One. 2016;11(2):e0148343.
2. Robson MS. Classification of caesarean sections. Fetal Matern Med Rev. 2001;12(1):23-39.
3. Laganà AS, et al. Vaginal Birth After Cesarean Section: The Road Ahead – A Narrative Review. Medicina (Kaunas). 2021;57(12):1304.
4. Main EK, Gould JB. Reducing cesarean deliveries: what the evidence says. Obstet Gynecol Clin North Am. 2017;44(2):223-246.
5. Grobman WA, et al. A Randomized Trial of a Labor Management Guideline to Reduce Cesarean Delivery Rates. N Engl J Med. 2021;384(19):1811-1822.