May 22 2017
In Canada, one in four women delivers by cesarean section. This procedure can save the life of the mother and baby. But the steady increase in the rate of cesareans in industrialized countries is cause for concern because a medically unnecessary cesarean entails the risk of additional complications for the mother and her child, as well as costs for the health system.
For the first time, a study published today in BMC Medicine evaluated the economic impact and benefits of a training program developed jointly with the Society of Obstetricians and Gynecologists of Canada (SOGC).
"We have shown that professional training to reinforce skills in obstetric clinical practice and self-assessment are effective in reducing the rate of medically unnecessary cesareans and in improving the quality of care offered to mothers and babies. This training program resulted in a cost reduction of approximately $180 per birth. If a similar program were offered in all Quebec hospitals, it would amount to a savings of $15.8 million annually," declared Mira Johri, Principal Scientist at the University of Montreal Hospital Research Centre (CRCHUM), Professor at the university's School of Public Health and the lead author of the study.
The QUARISMA (QUAlity of Care, Obstetrics RISk MAnagement and Mode of Delivery in Quebec) study is a cluster-randomized clinical trial that took place in 32 hospitals in Quebec between 2008 and 2012. In half of the hospitals targeted, the health professionals were trained to follow the QUARISMA program, which is based on training in clinical best practices and self-assessment through audit and feedback. The remaining hospitals -; the control group -; received standard care, with no special intervention.
"We observed that a multifaceted audit and feedback intervention aimed at health professionals results in a slight reduction in the rate of cesareans for low-risk pregnancies, without adverse effects on maternal and neonatal health," revealed Nils Chaillet, principal investigator of the QUARISMA trial, researcher at the CHU de Québec-Université Laval Research Centre and professor at Université Laval's Faculty of Medicine.
These results showing the program's effectiveness were published in The New England Journal of Medicine in April 2015. Today, after analyzing the effect of the program on 105,351 women included in the study, the researchers conclude that, in addition to reducing the number of medically unjustified cesareans, the program has made it possible to save money.
How can a slight reduction in the rate of cesareans generate several millions of dollars in savings per year? Does this mean that cesareans are expensive interventions? "The main source of cost savings was not the modest reduction in the number of cesareans," explained Johri. "We discovered that better case management by clinicians led to fewer neonatal complications, and therefore better use of resources by the intervention group." The $15.8 million in savings can therefore be attributed mainly to optimizing the use of health interventions.
"Caesareans are important for the reduction of perinatal mortality and morbidity in cases of high-risk pregnancies," added Chaillet. "However, medically unnecessary cesareans do not provide any benefits and can even lead to unnecessary complications."
"When the time comes to decide whether to perform a cesarean or not, clinical factors do not always prevail," Johri concluded. "Improving health care quality is in everyone's interest. We have shown that a training program for health professionals reduces the number of medically unnecessary cesareans and benefits public finances and the health of mothers and babies."
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