{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,9]],"date-time":"2026-06-09T22:07:21Z","timestamp":1781042841226,"version":"3.54.1"},"reference-count":34,"publisher":"Wiley","issue":"4","license":[{"start":{"date-parts":[[2015,3,2]],"date-time":"2015-03-02T00:00:00Z","timestamp":1425254400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"content-domain":{"domain":["obgyn.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Acta Obstet Gynecol Scand"],"published-print":{"date-parts":[[2015,4]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Objective<\/jats:title><jats:p>To evaluate national cesarean section (<jats:styled-content style=\"fixed-case\">CS<\/jats:styled-content>) rates and other obstetric indicators after a concerted action to reduce<jats:styled-content style=\"fixed-case\">CS<\/jats:styled-content>rates was undertaken in Portugal from 2010 onwards. This action was based on the transmission of information and training of healthcare professionals, together with the inclusion of<jats:styled-content style=\"fixed-case\">CS<\/jats:styled-content>rates as a criterion for hospital funding.<\/jats:p><\/jats:sec><jats:sec><jats:title>Design<\/jats:title><jats:p>Retrospective observational population\u2010based study.<\/jats:p><\/jats:sec><jats:sec><jats:title>Setting<\/jats:title><jats:p>Portugal.<\/jats:p><\/jats:sec><jats:sec><jats:title>Population<\/jats:title><jats:p>Births occurring in Portugal between 2000 and 2014.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Governmental sources were used to obtain data on national<jats:styled-content style=\"fixed-case\">CS<\/jats:styled-content>, perinatal and maternal mortality rates. Rates of instrumental vaginal delivery, vaginal birth after cesarean (<jats:styled-content style=\"fixed-case\">VBAC<\/jats:styled-content>), hypoxia\u2010related complications and perineal lacerations were retrieved for state\u2010owned hospitals.<\/jats:p><\/jats:sec><jats:sec><jats:title>Main outcome measures<\/jats:title><jats:p><jats:styled-content style=\"fixed-case\">CS<\/jats:styled-content>, perinatal and maternal mortality, instrumental vaginal delivery,<jats:styled-content style=\"fixed-case\">VBAC<\/jats:styled-content>, hypoxia\u2010related complications and perineal lacerations.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>After a continuous rise between 2000 and 2009, national<jats:styled-content style=\"fixed-case\">CS<\/jats:styled-content>rates declined significantly over the following 5\u00a0years (36.6% vs. 33.1%, time trend<jats:italic>p<\/jats:italic>\u00a0\u2264\u00a00.001). Perinatal mortality maintained a downward trend during this period, while maternal mortality remained unchanged. Rates of instrumental vaginal delivery,<jats:styled-content style=\"fixed-case\">VBAC<\/jats:styled-content>and perineal lacerations increased, while the incidence of hypoxia\u2010related complications decreased.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>A concerted action based on the transmission of information and training of healthcare professionals, together with the inclusion of<jats:styled-content style=\"fixed-case\">CS<\/jats:styled-content>rates as a criterion for hospital funding, was followed by a significant reduction in national<jats:styled-content style=\"fixed-case\">CS<\/jats:styled-content>rates, as well as an improvement in most related obstetric indicators. 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