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Delivery After Previous Cesarean Section

Jonathan Lomas, MA; Murray Enkin, MD, FRCSC; Geoffrey M. Anderson, MD, PhD; Walter J. Hannah, MD, FRCSC; Eugene Vayda, MD, FRCPC; Joel Singer, PhD

JAMA. 1991;265(17):2202-2207.

Abstract
A randomized controlled trial with 76 physicians in 16 community hospitals evaluated audit and feedback and local opinion leader education as methods of encouraging compliance with a guideline for the management of women with a previous cesarean section. The guideline recommended clinical actions to increase trial of labor and vaginal birth rates. Charts for all 3552 cases in the study groups were audited. After 24 months the trial of labor and vaginal birth rates in the audit and feedback group were no different from those in the control group, but rates were 46% and 85% higher, respectively, among physicians educated by an opinion leader. Duration of hospital stay was lower in the opinion leader education group than in the other two groups. The overall cesarean section rate was reduced only in the opinion leader education group. There were no adverse clinical outcomes attributable to the interventions. The use of opinion leaders improved the quality of care.

(JAMA. 1991;265:2202-2207)

Author Affiliations
From the Centre for Health Economics and Policy Analysis (Mr Lomas) and the Departments of Clinical Epidemiology and Biostatistics (Mr Lomas and Dr Enkin) and Obstetrics and Gynaecology (Dr Enkin), McMaster University, Hamilton, Ontario; the Division of Health Services, Research and Development (Dr Anderson), and the Department of Health Care and Epidemiology (Dr Singer), University of British Columbia, Vancouver (Dr Anderson); and the Department of Obstetrics and Gynaecology (Dr Hannah) and the Department of Health Administration, Division of Community Health (Dr Vayda), University of Toronto, Ontario.

Footnotes
Reprint requests to Centre for Health Economics and Policy Analysis, Health Sciences Centre, McMaster University, Hamilton, Ontario, Canada, L8N 3Z5 (Mr Lomas).

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