OBJECTIVES The Evidence-based Practice Center systematically reviewed evidence addressing strategies to reduce cesarean birth. DATA SOURCES We searched MEDLINE(®) via PubMed and the Cumulative Index of Nursing and Allied Health Literature as well as the reference lists of included studies. REVIEW METHODS We included studies published in English from 1968 to February 2012. We excluded publications that did not address a Key Question, were not an eligible study design, or did not aim to reduce cesarean birth among low-risk women. RESULTS Of the 97 studies included, 16 were good quality, 28 fair, and 53 poor. In this review, all studies compared the novel strategy to usual care or to variations in the same strategy. Few studies addressed prenatal strategies; the one such strategy that reduced cesarean was treatment of the cervix with hyaluronidase in the clinic at term to promote cervical softening. Strategies intended for use in labor included four trials that favored active management of labor, with 2.8- to 7.4-percent decreases in cesarean; one study showed a significant decrease. Doula support in labor was associated with significant reductions in cesarean (5.0 to 22.0%) in three studies. One of six trials of fetal assessment reported a significant reduction in total cesareans (20.6%). Three of eight trials of amnioinfusion reported a significant reduction in total cesareans (15 to 34.2%). Virtually all studies within health care systems that changed policies or procedures evaluated strategies with more than one component. Seventeen of 31 studies reported statistically significant reductions in cesarean from 1.6 to 17.0 percent. Ten of the 17 effective strategies included audit and feedback of cesarean trend data to participating units and/or care providers, 7 included protocols for vaginal birth after prior cesarean, 6 included agreement on overarching labor and delivery guidelines, and 5 included active management of labor protocols. Overall, it is not possible to determine which components are definitively associated with reductions. CONCLUSIONS No single strategy was uniformly successful in reducing cesareans. Strength of evidence was low to insufficient for all strategies. No approach dominated as a strategy appropriate to reduce use of cesarean among low-risk women in the United States.
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