This study has several limitations. Data collection relied on birth certificate and discharge diagnoses without a robust quality audit. As such, ascertainment bias, random error, and undercounting cannot be excluded. Although the population was heterogeneous, most women had more than a high school education and private insurance, and only 1 in 5 were obese. Whether these findings are generalizable to other areas within the United States is not known.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
All reasonable efforts to decrease the CD rate in the United States should be encouraged, with particular attention paid to avoiding the first CD. However, this should not be done at the expense of patient safety. Large-scale quality improvement initiatives, similar to CMQCC efforts in California in 2016, appear to be one such strategy. Other successful strategies may include, for example, routine induction of labor for all low-risk nulliparous women at 39 weeks' gestation.7 The current report suggests that implementing a large-scale quality improvement initiative to reduce the primary CD rate can likely be done safely, without a significant increase in maternal or neonatal morbidity.
All reasonable efforts to decrease the CD rate in the United States should be encouraged, with particular attention paid to avoiding the first CD. However, this should not be done at the expense of patient safety. Large-scale quality improvement initiatives, similar to CMQCC efforts in California in 2016, appear to be one such strategy. Other successful strategies may include, for example, routine induction of labor for all low-risk nulliparous women at 39 weeks' gestation.7 The current report suggests that implementing a large-scale quality improvement initiative to reduce the primary CD rate can likely be done safely, without a significant increase in maternal or neonatal morbidity.