Case Study

Markham Stouffville Hospital

Upsetting the apple cart: Changing the status quo hierarchy and high C-section rates

Markham Stouffville Hospital set a goal of reducing C-section rates by 5 percent—and surpassed it using targeted interventions. The interventions included group learning sessions for pregnant women with a previous history of C-section; supportive care in labour practices; regular sharing of individual and provider group C-section, VBAC, and induction rates; and updating policies and procedures for non-medically indicated inductions. The team believes it is possible to replicate its results in other units by following the same strategy of stratifying the data, targeting the leading contributors to the C-section rate, and using best evidence to guide and sustain practice.

Background and overview

Markham Stouffville Hospital (MSH) is a community-based, Level 2 hospital in York Region, one of the fastest growing regions in Ontario, Canada. It is experiencing a steady increase in the number of births each year. In 2014, the hospital welcomed close to 4,000 babies. MSH has a neonatal ICU allowing for management of gestation above 32 weeks. Since 2007, it has participated in the MOREOB Program.

As we gained experience with the Program, the team focused not only on the clinical areas of risk identified in the program, but on addressing unit-specific needs and goals as a collaborative effort. At MSH, maternity care providers, obstetricians, family physicians, midwives, and nurses now function as a well-integrated multidisciplinary team and have learned to collaborate. Providers meet regularly and jointly develop clinical guidelines and policies reflecting various scopes of practice


In 2010, after a rise in C-sections and induction rates and a decrease in VBAC, the MOREOB Core Team created a Caesarean Reduction Strategies Task Force to examine the reasons for these trends and identify, implement, and evaluate a range of evidence-based interventions. The long-term goal was to reduce C-section rates by 5 percent. The task force brought together a multidisciplinary team of maternity care providers including midwives, nurses, obstetricians, anesthesiologists, pediatricians, and administrators.


The team stratified data by multiple variables and decided to focus on induction and VBAC. After a review of the literature on intervention strategies, the task force designed a specific plan to decrease these interventions and reduce the C-section rate. The interventions fell into three main categories: those aimed at pregnant women planning to deliver at MSH; those aimed at MSH providers; and those that would affect hospital policies.

Targeted interventions

Interventions targeting pregnant women included meetings with local prenatal educators to ensure consistency of information between educators and providers, and a revision of all patient education material to ensure that the descriptions of caesarean birth, VBAC, induction of labour, and supportive care in labour in those materials reflected best evidence. Based on the principles of informed choice and group learning, a session for all women with a history of previous C-section was established and led by the midwives. The Options for Birth Following Caesarean Birth sessions are an opportunity for women and their partners to discuss the reasons for their C-section and explore options for subsequent births. The session facilitator together with women who attend discuss the benefits and risks of both elective repeat C-section and VBAC and use a patient decision-making tool that assists women to fully explore their own specific risks and values. Session surveys demonstrate a high rate of satisfaction among participants.

Supportive care in labour practices is a focused intervention where staff have the education and tools to enhance one-to-one care for labouring women. Newly cross-trained perinatal nurses attend supportive care sessions with midwives, auscultation practices are encouraged in order to minimize the use of the electronic fetal monitor, and there is an area in the room for the nurse/midwife to sit comfortably. Necessary supplies, tools for documentation, and a Vocera communication device were also integrated into the room design.

Interventions aimed at practitioners began with rounds and data collection. The decision was made to communicate individual and provider group C-section birth rates, VBAC rates, and induction rates. At the start of this process, the chief of obstetrics provided each physician and midwife with a copy of their own personal rate along with their peer group’s rate; these results were blinded. After two cycles of releasing quarterly rates, the results were unblinded at the request of all caregivers, and became known to all individuals in the peer group. These individual rates, overall unit rates, and the work done on reduction strategies are now part of each department and division meeting. Overall hospital rates for C-section, VBAC, and induction are posted by management on the unit in a place visible to the public. Stories describing our C-section reduction initiative, birth option sessions, and overall rates have appeared several times in the local newspapers. Our experience is now growing as the go-to place for other hospitals looking to reduce their C-section and induction rates. Staff members have remarked that Markham Stouffville has a strong reputation for lowering C-section rates.

All policies related to care of women in labour, VBAC, and induction of labour were reviewed and revised by our Patient Quality Committee, working closely with the task force members.

One of the discoveries we made during our data review was the number of non-medically indicated inductions that were specifically listed as “post-dates.” Our focus on the policy and process around this issue saw this rate fall to 1% in 2011–2012. Furthermore, our overall induction of labour rate decreased from 26% to 12% over the intervention period. The task force, together with management and professional practice, rolled out the policy changes as a package at varying times. It is difficult to know which had the most impact or whether the entire group of interventions working together achieved our results. It will likely be possible to replicate results in other units by using our strategy of stratifying the data, targeting the leading contributors to the C-section rate, and using best evidence to guide and sustain practice.


Our journey to reduce C-sections began in April 2010, when our rate was 29.6%. In 2010–2011, this fell to 26.3%, to 26% in 2011–2012, to 25.8% in 2012–2013, to 23.7% in 2013–2014. We surpassed our original goal of reducing the rate to 25%. While only 15% of women attempted VBAC in 2009–2010, this increased to 33.6% of women in 2013–2014, and approximately 80% of those had vaginal births.

We continue to work to improve care for women and hold each other accountable for high-quality, evidence-based practice. Our rates and indicators are tracked and reported monthly. Should the induction and C-section rates rise two months in a row, we strategize countermeasures that can be adopted to return to our goal.

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