2 - A Cluster-Randomized Trial to Reduce Perinatal Morbidity among Women with a Prior Cesarean Delivery (PRISMA)

Thursday, February 9, 2023

8:15 AM – 8:30 AM

Location: Moscone West, Level 3

Objective: To assess whether a multifaceted intervention, promoting person-centered decision making and best practices in intrapartum care for women with one prior cesarean delivery, reduces major perinatal and maternal morbidity.

Study Design: A 3.5-year cluster-randomized controlled trial in 40 hospitals in Quebec. The study included a 1-year baseline period, a 6-month implementation period, and a 2-year intervention period. After the baseline, hospitals were stratified by level of care and randomly assigned to either a multifaceted intervention or a control group. The intervention consisted of an initial training on best practices in intrapartum care and provision of tools that aimed to: support women’s decision-making about mode of delivery; estimate the chance of vaginal birth after cesarean (VBAC); and estimate the risk of uterine rupture using ultrasound measurement of the lower uterine segment. The primary outcome was a composite risk of major perinatal morbidity. Analyses were intention-to-treat, and used generalised estimating equations (GEE) with adjustment for hospital and patient characteristics, to estimate the effect of the intervention.

Results: 21,281 eligible women delivered during the study. The rate of major perinatal morbidity was significantly reduced by the intervention (OR=0.72, 95%CI 0.52-0.99, p=0.04). This reduction was driven by the effect of the intervention among women who chose a trial of labor (OR=0.52, 95%CI 0.31-0.89, p=0.02), while there was no significant difference among those who chose a planned cesarean delivery (OR=0.85, 95%CI 0.64-1.14, p=0.29). Major maternal morbidity was also significantly reduced by the intervention (OR=0.54, 95%CI 0.33-0.89, p=0.02). There was no significant difference in the rates of VBAC (OR=1.12, 95%CI 0.96-1.30, p=0.15) or uterine rupture (OR=0.37, 95%CI 0.09-1.62, p=0.19).

Conclusion: A multifaceted intervention aimed at supporting women in their choice of mode of delivery and promoting best practices in intrapartum care resulted in a significant reduction in rates of major perinatal and maternal morbidity.

Primary & Presenting Author(s)

Nils Chaillet, PhD (he/him/his)

Full Professor
Department of Obstetrics and Gynecology, Laval University
Québec, QC, Canada

Slides

Coauthor(s)

BM

Benoit Masse, PhD

Full Professor
Department of Epidemiology and Biostatistics, University of Montréal
Montréal, QC, Canada
William A. Grobman, MD, MBA

Vice Chair, Clinical Operations, Maternal Fetal Medicine
The Ohio State University
Columbus, Ohio, United States
AS

Allison Shorten, PhD

Full Professor
School of Nursing, University of Alabama at Birmingham
Birmingham, AL, United States
RG

Robert Gauthier, MD

Full Professor
Department of Obstetrics and Gynecology, University of Montréal
Montreal, QC, Canada
PR

Patrick Rozenberg, MD

Centrre Hospitalier Poissy Saint-Germain
Poissy, Paraguay, Paraguay
MD

Marylène Dugas, PhD

Assistant Professor
Department of Psychosociology and Social Work, University of Québec at Rimouski (UQAR)
Rimouski, QC, Canada
JP

Jean-Charles Pasquier, MD

University of Sherbrooke
Sherbrooke, QC, Canada
FA

Francois Audibert, MD, MSc

Department of Obstetrics and Gynaecology, CHU Sainte-Justine, Université de Montréal
Montreal, QC, Canada
HA

Haim A. Abenhaim, MD, MPH

Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University
Montreal, Quebec, Canada
SD

Suzanne Demers, MD, PhD

Associate Professor
Department of Obstetrics and Gynecology, Laval University
Quebec, QC, Canada
BP

Bruno Piedboeuf, MD

Full Professor
Department of Pediatrics, Laval University
Quebec, QC, Canada
WF

William Fraser, MD

University of Sherbrooke
Sherbrooke, QC, Canada
RG

Robert Gagnon, MD

Full Professor
Department of Obstetrics and Gynecology, McGill University
Montréal, QC, Canada
PM

Patricia Monnier, MD, PhD

Full Professor
Department of Obstetrics and Gynecology, McGill University
Montréal, QC, Canada
GG

Guy-Paul Gagné, MD

Department of Obstetrics and Gynecology, McGill University
Montréal, QC, Canada
DF

Diane Francoeur, MD

Full Professor
Department of Obstetrics and Gynecology, University of Montréal
Montréal, QC, Canada
IG

Isabelle Girard, MD

St. Mary's
Montreal, QC, Canada
LD

Louise Duperron, MD

Full Professor
Department of Obstetrics and Gynecology, University of Montréal
Montréal, QC, Canada
MB

Marie-Josée Bédard, MD

Full Professor
Department of Obstetrics and Gynecology, University of Montréal
Montréal, QC, Canada
MJ

Mira Johri, MPH, PhD

Full Professor
University of Montreal Hospital Research Center (CRCHUM), University of Montreal
Montréal, QC, Canada
ED

Eric Dubé, MSc

Research Center of the CHU de Québec-Université Laval, Laval University
Quebec, QC, Canada
TD

Thierry Ducruet, MSc

CHU Ste-Justine Research Center
Montréal, QC, Canada
MG

Mario Girard, N/A

Research Center of the CHU de Québec-Université Laval, Laval University
Quebec, QC, Canada
Emmanuel Bujold, MD, MSc

Professor
CHU de Québec—Université Laval Research Center, Université Laval
Quebec, QC, Canada