Do perinatal guidelines have an impact on obstetric practices?

Abstract

Background: The publication of several sets of French guidelines was unfortunately not accompanied by planned assessment of their impact on practices. The goal of this study was to assess the impact of eight French perinatal guidelines on actual obstetric practices.

Methods: Historical cohort setting in France: the Audipog database of 299,412 pregnancies from 1994 to 2006, from which we extracted a sub-sample by randomLy selecting from each participating maternity ward all births occurring during a single month of each year (n=107,450 pregnancies). The main outcome measure was the incidence of pertinent perinatal indicators related to these guidelines. These included site of delivery for low-birth-weight infants (1998), caesarean delivery (2000), preterm delivery (2002), breastfeeding (2002), smoking and pregnancy (2004), immediate postpartum hemorrhages (2004), early discharge after delivery (2004) and episiotomies (2005). Standardised rates, before and after the year of each guideline, were compared using a Chi(2) test.

Results: The percentage of children weighing less than 1500 g at birth born in Level III hospitals increased through 1999 but dropped subsequently, without ever returning to the 1994 level (P<0.0001). The overall caesarean rate climbed slowly but regularly from 1994 through 2006 (P<0.0001). Use of antenatal corticosteroids for women hospitalised for threatened preterm labour and in children born before 33 weeks has fluctuated since the release of the guideline (P>0.05). Exclusive breastfeeding at discharge from the maternity ward has increased slowly (P<0.0001). The percentage of deliveries with active management of the third stage of labour rose notably from 1999 to 2006 (P<0.0001), and smoking cessation during pregnancy rose slightly in 2006 (P<0.0001). Since 1994, early discharges have become slowly, slightly, but regularly more frequent for all women (P<0.0001). The guideline on episiotomies has had a slight positive effect in the short term (P<0.0001).

Conclusions: Globally, the impact on actual practices of clinical practice guidelines, except the guideline concerning the active management of the third stage of labour, was low. Most of the changes observed in practices began before the pertinent guideline was published.