The REDUCED trial: a cluster randomized trial for REDucing the utilization of CEsarean delivery for dystocia.

BACKGROUND: To reduce cesarean delivery rates in nulliparous women, guidelines for diagnosing nonprogressive labor have been developed by the National Institute of Child Health and Human Development, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine. These are mainly based on data from the Consortium for Safe Labor study. The guidelines have not been tested in a clinical trial, so the efficacy and safety of this new approach is uncertain. OBJECTIVE: This study aimed to assess whether adoption of new guidelines for diagnosing nonprogressing labor would reduce cesarean delivery rates. STUDY DESIGN: We conducted a cluster randomized controlled trial of a knowledge translation program of the guidelines in 26 Canadian hospitals (13 control sites and 13 intervention sites). The sites included all intrapartum care sites in Alberta that perform cesarean delivery and deliver at least 70 nulliparous women annually. The baseline period started on January 1, 2015. The intervention was initiated at the first intervention site in January 2017. The follow-up period began at the first intervention site in February 2017 and lasted till February 2020. The primary outcome was the rate of cesarean delivery in nulliparous women with vertex presentation in labor at term. The secondary outcomes included spontaneous vaginal birth and maternal and neonatal safety. The main data source for the primary and secondary outcomes was the Alberta Perinatal Health Program database. The cesarean delivery rates were assessed using repeated measures mixed effects logistic regression applied to individual births. RESULTS: The analysis was based on 45,193 deliveries at intervention sites and 43,725 deliveries at control sites. There was no evidence of a decrease in the rate of cesarean delivery in association with the intervention (baseline-adjusted odds ratio, 0.94; 95% confidence interval [0.85-1.05]; P=.259). The rate of spontaneous vaginal delivery increased slightly (baseline-adjusted odds ratio, 1.10; 95% confidence interval, [1.01-1.18]; P=.024). We did not observe any differences in adverse maternal or neonatal outcomes. CONCLUSION: Cesarean delivery rates in nulliparous women were not reduced by the application of recent guidelines for the diagnosis of nonprogressive labor. Spontaneous vaginal delivery-a secondary outcome-was increased in the intervention group. The intervention appears to be safe.

Social Media Recruitment Strategies to Recruit Pregnant Women Into a Longitudinal Observational Cohort Study: Usability Study.

BACKGROUND: Use of social media for study recruitment is becoming increasingly common. Previous studies have typically focused on using Facebook; however, there are limited data to support the use of other social media platforms for participant recruitment, notably in the context of a pregnancy study. OBJECTIVE: Our study aimed to evaluate the effectiveness of Facebook, Twitter, and Instagram in recruiting a representative sample of pregnant women in a longitudinal pregnancy cohort study in Calgary, Alberta, between September 27, 2021, and April 24, 2022. METHODS: Paid advertisements were targeted at 18- to 50-year-old women in Calgary, with interests in pregnancy. Data regarding reach, link clicks, and costs were collected through Facebook Ads Manager (Meta Platforms, Inc) and Twitter Analytics (Twitter, Inc). The feasibility of each platform for recruitment was assessed based on the recruitment rate and cost-effectiveness. The demographic characteristics of the participants recruited through each source were compared using the chi-square test. RESULTS: Paid advertisements reached 159,778 social media users, resulting in 2390 link clicks and 324 participants being recruited. Facebook reached and recruited the highest number of participants (153/324, 47.2%), whereas Instagram saw the highest number of link clicks relative to the number of users who saw the advertisement (418/19,764, 2.11%). Facebook and Instagram advertisements were cost-effective, with an average cost-per-click of CAD $0.65 (US $0.84; SD $0.27, US $0.35) and cost-per-completer of CAD $7.89 (US $10.25; SD CAD $4.08, US $5.30). Twitter advertisements were less successful in terms of recruitment and costs. Demographic characteristics of participants did not differ based on recruitment source, except for education and income, where more highly educated and higher-income participants were recruited through Instagram or Twitter. Many issues related to fraudulent responses were encountered throughout the recruitment period. CONCLUSIONS: Paid social media advertisements (especially Facebook and Instagram) are feasible and cost-effective methods for recruiting a large sample of pregnant women for survey-based research. However, future research should be aware of the potential for fraudulent responses when using social media for recruitment and consider strategies to mitigate this problem.

Impact of Provider Payment Structure on Obstetric Interventions and Outcomes: A Difference-in-Differences Analysis.

OBJECTIVE: Traditionally, Canadian physicians provide care on a fee-for-service (FFS) basis; however, this model has been criticized as it incentivizes quantity of care over quality of care. Consequently, all Canadian provinces and territories have implemented some form of alternative payment plan. Evaluation of the impact of these policy changes, however, has typically focused on family physicians as opposed to specialists. METHODS: On January 1, 2004, obstetricians at the Medicine Hat Regional Hospital (MHRH) transitioned from FFS to salary. A difference-in-differences analysis was used to examine the impact of changes in obstetrician payment structure on the use of obstetric interventions and neonatal outcomes controlling for temporal trends at MHRH (intervention group) and the Chinook Regional Hospital (CRH; comparison group) from 2002 to 2005. RESULTS: Between the pre-intervention period (2002-2003) and the post-intervention period (2004-2005), the rate of cesarean delivery increased significantly at both sites. Following adjustment for time of day, day of week, and antepartum risk score, the difference-in-difference estimator demonstrated a 5.8% (95% CI 1.5-10.0) increase in cesarean deliveries performed by obstetricians at MHRH compared with cesarean deliveries done at CRH after accounting for baseline differences and temporal trends. No significant differences were observed for family physicians. No significant differences were observed for other obstetric interventions or neonatal outcomes. CONCLUSION: Under an FFS model, obstetricians are incentivized to cesarean delivery due to the increased reimbursement rate; however, the increase in cesarean deliveries at MHRH following the transition to a salary model was unexpected. This finding suggests that, in Canada, financial incentives are not a factor that explains the increasing rate of cesarean delivery.

Potential Impact of Guidelines for the Prevention of Cesarean Deliveries in a Contemporary Canadian Population.

OBJECTIVE: This study sought to describe how the implementation of recent labour guidelines may affect the cesarean delivery rate in a population in Alberta. METHODS: This retrospective study was conducted on primiparous women who were in labour with singleton term fetuses with cephalic presentation in Alberta from 2007 to 2016 (n = 181 738), and it used data from a perinatal database. Modelled cesarean delivery rates were calculated to determine the potential impact of the recent guidelines on the cesarean delivery rate by using the percentage of cesarean deliveries that occurred outside the threshold of the recent labour guidelines. RESULTS: A total of 21.7% of the cesarean deliveries for dystocia occurred outside of the guidelines related to the first stage of labour arrest for spontaneous labour (n = 9282), and 45.4% occurred outside of the guidelines related to the first stage of labour arrest for induced labours (n = 11 712). A total of 69.0% of the cesarean deliveries for dystocia occurred outside of the failed induction of labour guidelines (n = 4921), and 55.4% occurred outside of the second stage labour arrest guidelines (n = 6632). Assuming that the labour arrest guidelines are effective at reducing the cesarean delivery rate 25% of the time, the cesarean delivery rate for primiparous women in labour would be reduced from 22.5% to 20.7%. Assuming a 75% adherence/effectiveness rate, the cesarean delivery rate would be reduced to 17.1%. CONCLUSION: The recent labour guidelines have the potential to have a substantial impact on the intrapartum cesarean delivery rate in primiparous women with singleton fetuses with cephalic presentation at term if the guidelines are put into practice.