Impact of a Structured Caesarean Reduction Strategy on Perinatal Outcomes: A Retrospective Ecological Time‐Trend Study

Abstract

Objective To evaluate the long‐term impact of a structured, multidisciplinary CS reduction strategy in a high‐complexity Italian hospital. Design Retrospective ecological time‐trend study. Setting Tertiary obstetric care Italian centre. Sample 28 577 deliveries, ≥ 22 weeks' gestation, from 2014 to 2024 were analysed. Methods In 2014, a multifaceted improvement program including standardised protocols, continuous staff training, Robson Ten‐Group Classification audits, and tailored intrapartum care (revised dystocia criteria, updated induction methods, intrapartum ultrasound, dedicated VBAC clinic, and physiology‐based CTG interpretation) was introduced. Main Outcome Measure Temporal trend in CS rate, maternal morbidity (postpartum haemorrhage > 1000 mL, obstetric anal sphincter injuries, hysterectomy) and neonatal morbidity (cord pH < 7.0, resuscitation, therapeutic hypothermia). Temporal trends were assessed using segmented regression. Results Segmented regression analysis of CS rates identified 2016 as a breakpoint. Prior to 2016, the annual change in CS rate was not significant (−0.24 percentage points per year; p = 0.75), whereas after 2016 a significant downward trend was observed (−1.64 percentage points per year; p < 0.001). Conversely, VBAC rates showed a significant increasing trend over time, while uterine rupture rates remained consistently below 0.3% throughout the study period. Maternal outcomes were overall stable, although a modest increase in postpartum haemorrhage was observed. Neonatal outcomes did not show significant changes over time, including the rate of arterial cord pH < 7.0 at birth. Conclusions The implementation of a structured, multifaceted strategy aimed at containing CS rates was associated with a significant change in their temporal trend, with a sustained post‐2016 decline identified by segmented regression analysis. This trend was not associated with clinically significant detrimental effects on maternal or neonatal outcomes.