Labor: Original Research
Evaluation of a Quality Improvement
Intervention to Increase Vaginal Birth
for Twins
Sarah Rae Easter, MD, Carolina Bibbo, MD, Danielle Panelli,
Downloaded from https://journals.lww.com/greenjournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3w7SK+r5dgwMwHo5hr5RCGKEoJkeltJC3SRy8IqQMIxF1S2KDvZST2g== on 02/09/2019
Daniela Carusi, MD, MSc, and Julian N. Robinson, MD
OBJECTIVE: To evaluate whether there was an associ-
ation between the systematic promotion of twin vaginal
delivery and an increase in the rates of twin vaginal
birth.
METHODS: We conducted a retrospective cohort study.
We implemented a quality improvement initiative pro-
moting twin vaginal delivery at an academic tertiary care
center in 2013. The program included a needs assessment,
simulation of vaginal twin delivery, online educational
material, and the expansion of a dedicated twin clinic. We
analyzed rates of twin vaginal birth in pregnancies at or
beyond 24 weeks of gestation without a contraindication
to labor, prior uterine surgery, or a demise or lethal
anomaly of either twin. Using linear regression, we
calculated annual adjusted rates of twin vaginal birth from
2010 to 2015 and in the 3 years before and after our
intervention. We performed an interrupted time-series
analysis estimating rates of change before and after the
intervention to account for the influence of secular trend.
From the Division of Maternal-Fetal Medicine and the Department of Obstetrics,
Gynecology, and Reproductive Biology, Brigham and Women’s Hospital, Har-
vard Medical School, Boston, Massachusetts.
The Brigham and Women’s Hospital Twin Initiative was funded by The Brig-
ham & Women’s Physician Organization Care Redesign and Incubator Start-up
Program (BCRISP).
Presented at the Society for Maternal-Fetal Medicine’s Annual Meeting, January
29–February 3, 2018, Dallas, Texas.
Each author has indicated that he or she has met the journal’s requirements for
authorship.
Received December 7, 2017. Received in revised form February 8, 2018, and
February 28, 2018. Accepted March 15, 2018.
Corresponding author: Sarah Rae Easter, MD, Division of Maternal-Fetal
Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA
02215; email: sreaster@partners.org.
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2018 by the American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/18
VOL. 132, NO. 1, JULY 2018
Copyright ª by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
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MD, Sarah E. Little, MD, MPH,
RESULTS: Of 1,574 patients delivering twins, 897 (57%)
were included, with 479 in the 3 years before and 418 in the
3 years after the intervention. Adjusted rates of vaginal
delivery increased from 32.1% (n5153) to 44.2% (n5185)
before and after the intervention (P,.01), with a decrease in
elective cesarean delivery from 54.6% (n5479) to 44.3%
(n5185) (P,.01). Rates of breech extraction increased after
the intervention (5.7% vs 9.3%, P5.04). However, there was
no difference in the rate of change in twin vaginal birth in
the time period before (1.35% annual increase, P5.76) or
after (5.8% annual increase, P5.40) the intervention.
CONCLUSIONS: Although we observed an increased
rate of twin vaginal birth in the time period after our
intervention, because the rates of increase before and
after the intervention were not statistically different, the
increase is not attributable to our intervention and is
more properly attributed to secular trend.
(Obstet Gynecol 2018;132:85–93)
DOI: 10.1097/AOG.0000000000002680
T he contribution of cesarean delivery to maternal
morbidity and mortality in the United States placed
decreasing the primary cesarean delivery rate at the top
of the national public health agenda.1–3 Rates of cesarean
delivery vary 10-fold with no discernible association
between a hospital’s cesarean delivery rate and rates of
adverse obstetric outcomes.4–9 Consensus guidelines
outline an evidence-based approach to prevent primary
cesarean delivery, yet integration of these recommenda-
tions into practice is challenging.4,10
Prior interventions targeted low-risk women and
emphasized the nulliparous term singleton vertex
cesarean delivery rate.11–14 The diverse indications
for cesarean delivery in even a low-risk subset of
women may explain the modest effect of these quality
improvement initiatives. Focusing on a specific indi-
cation for cesarean delivery such as twin pregnancy
may be a more feasible alternative. Rates of cesarean
OBSTETRICS & GYNECOLOGY 85
delivery for multiples rose from 52.9% in 1995 to
73.2% in 2008, with many twin cesarean deliveries
occurring without medical indication.10,15–18
Although evidence-based guidelines discourage elec-
tive cesarean deliveries for twins, the influence of
patient and health care provider preferences in this
high-risk group may yield changes in public policy
meaningless in the context of clinical practice.17–19
The aim of the present study is to test the ability
of a targeted intervention to decrease rates of primary
cesarean delivery for twins. We used available evi-
dence to implement an educational and clinical
support program to promote twin vaginal delivery at
our center.4,20–22 We hypothesized this multifaceted
quality improvement intervention in a contemporary
national climate supporting vaginal delivery would
improve institutional rates of twin vaginal birth.
MATERIALS AND METHODS
This retrospective cohort study assessed mode of
delivery for twins at a single urban academic tertiary
care center during the 6 years surrounding the
implementation of the twin vaginal delivery promo-
tion in 2013. The study considered deliveries between
January 2010 and December 2012 compared with
those between January 2013 and December 2015. The
program was informed by the results of a 25-item
needs assessment to faculty practicing obstetrics at our
institution to survey current knowledge and approach
to mode of delivery for twins.18 From our pilot work
we created a cohesive intervention launched as a single
entity in 2013 (Box 1).
Educational components of the initiative included
lecture- and simulation-based health care provider
education on twin vaginal birth.23 The expert lecture
focused on the evidence supporting the safety of twin
vaginal birth and approach to counseling and deliv-
ery. The 2-hour simulation consisted of a standardized
patient counseling session, a breech extraction skills
station, and a high-fidelity simulation emphasizing op-
tions for expedited delivery of a vertex-presenting
Box 1. Components of Twin Vaginal Birth
Intervention
 Health care provider needs assessment
 Expert lecture on approach to twin vaginal birth
 Health care provider simulation on twin vaginal birth23
 Launch of multiple pregnancy website encouraging
vaginal birth24
 Expansion of dedicated twin clinic
 Creation of health care provider backup system for
twin deliveries
86 Easter et al Intervention to Decrease Twin Cesarean Deliveries
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second twin after vaginal birth of the first.23 An insti-
tutional grant supported the development of a dedi-
cated multiple pregnancy website for patients and
a complementary version for health care providers
encouraging twin vaginal birth.24 The website outlines
general aspects of twin pregnancy and emphasizes
twin delivery through online videos including ad-
dressing medical indications for cesarean delivery
for twins and familiarizing patients with methods of
twin delivery including internal podalic version and
breech extraction. To further support health care pro-
viders, we expanded and promoted a specialized mul-
tiple pregnancy clinic consisting of two maternal–fetal
medicine providers and a dedicated nurse with
expertise in multiple gestations. Within this clinic, we
used available data to provide concise and objective
counseling about mode of delivery for twins. Simply
put, if the presenting twin was breech, we recom-
mended cesarean delivery. If the presenting fetus was
head down or vertex, we recommended vaginal birth
based on the absence of demonstrated improved
outcomes with cesarean delivery.21,22 If a patient
declined an attempt at vaginal birth, we supported her
autonomy and performed an elective cesarean
delivery.17
Our institutional obstetric staff consisted of
a diverse group of health care providers with varying
levels of experience. We therefore dedicated renewed
energy into a health care provider backup system to
support obstetricians with less comfort and experience
with twin vaginal birth. For this backup system, the
weekly supervising maternal–fetal medicine provider
for the hospital was available to provide in-house sup-
port for doctors requesting assistance with twin vagi-
nal deliveries. The two health care providers
spearheading the multiples clinic (J.N.R., C.B.) com-
mitted to serving as an additional level of support in
the event that the attending of the week had limited
experience or comfort with twin vaginal birth. Backup
physicians provided in-room support to the primary
clinician performing the delivery to facilitate a safe
vaginal birth and promote development of health care
provider skill.
For this retrospective study, we used hospital
birth records to identify all women with twin preg-
nancies of at least 24 0/7 weeks of gestation delivering
between January 2010 and December 2015. We
excluded women with a contraindication to vaginal
birth including those with placenta previa, a nonvertex
presenting twin, prior transmural uterine surgery
(including cesarean delivery), abdominal cerclage,
monoamniotic gestation, category 3 fetal heart rate
tracing at admission, or fetal anomalies precluding
OBSTETRICS & GYNECOLOGY
labor or vaginal birth such as an open neural tube
defect or large omphalocele. We also excluded
patients with an intrauterine fetal demise or lethal
fetal anomaly of either twin. Patients were then
classified according to year of delivery. Obstetric
records were reviewed to obtain data regarding
maternal, obstetric, fetal, and health care provider
factors as previously described.25 Labor management
and choice of delivery method throughout the study
period were at the discretion of the delivering
provider.
Over the study period, our institutional obstetric
staff consisted of eight health care provider groups
with 97 clinicians. The largest of these health care
provider groups was the academic faculty practice
consisting of 62 maternal–fetal medicine sub-
specialists and specialists in obstetrics and gynecology
supervising the resident physicians present to perform
all faculty deliveries. The remainder of the groups
consisted of private practice providers performing
deliveries at the hospital but seeing patients at other
locations in the community. Resident physicians were
involved in the deliveries of all of the faculty patients
and present for the patients of private physicians at the
discretion of the delivering obstetrician. Private
physicians typically perform deliveries independently
but can be supported by the in-house faculty physi-
cian on request. The intervention was developed
within the infrastructure of the academic faculty prac-
tice. However, patients and health care providers in
the private practice groups had access to these educa-
tional opportunities, online resources, and health care
provider backup system throughout the study period.
Our primary outcome of interest was vaginal
birth of both twins and included operative vaginal
delivery for one or both twins or breech extraction of
the second twin. Secondary outcomes of interest
included rates of cesarean delivery overall and rates
of elective cesarean delivery. Because we excluded
patients with a contraindication to labor, all patients
who deferred an attempt at a trial of labor in favor of
cesarean delivery were classified as undergoing elec-
tive cesarean delivery. All admission notes were
reviewed by the primary author (S.R.E.), with com-
plete ascertainment as to the intended mode of
delivery. Patients undergoing vaginal delivery fol-
lowed by cesarean delivery of the nonpresenting twin,
also referred to as combined delivery, were classified
as undergoing cesarean delivery.
Additional secondary outcomes of interest
include rates of maternal or neonatal morbidity. The
composite maternal outcome was based on the
definition of maternal morbidity used by Barrett
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et al and consisted of one or more of the following:
death, hemorrhage (estimated blood loss greater than
or equal to 1,500 mL or need for transfusion),
infection, major procedure (hysterectomy, uterine
artery embolization, intraperitoneal drain placement),
readmission for infection or reoperation, need for
dilation and evacuation for hemorrhage or infection,
venous thromboembolism, small bowel obstruction or
ileus, or intensive care unit admission.21,25 Infection
was defined as a clinical endometritis (based on mater-
nal fever greater than 38°C occurring more than 24
hours after delivery requiring antibiotics), significant
wound cellulitis (wound infection prolonging hospital-
ization for more than 3 days with vaginal birth and 5
days with cesarean delivery or requiring readmission),
intraabdominal or pelvic abscess, bacteremia, pneu-
monia, or Clostridium difficile colitis. We analyzed
composite neonatal morbidity for the pregnancy over-
all and separately for presenting and nonpresenting
twins. The composite neonatal outcome included
one or more of the following: intubation for 2 or more
days, birth trauma (including cephalohematoma, cla-
vicular fracture, or long-bone fracture), need for blood
transfusion, infection requiring antibiotics, intraven-
tricular hemorrhage, and death.
The associations between year of delivery and
patient characteristics of interest were evaluated with
the Cochran Mantel-Haenszel test for trend for
categorical variables and the Kruskal-Wallis test for
continuous variables. We analyzed our primary out-
come of interest in three ways. We first used least-
squares means methodology from linear regression to
calculate adjusted rates of outcomes of interest ac-
cording to year of the study period. To better
understand the effect of the intervention on rates of
outcomes of interest, we then examined adjusted rates
of outcomes of interest for the 3 years before and the 3
years after our 2013 interventions using similar
methodology. To account for secular trends influenc-
ing rates of twin vaginal birth, we performed an
interrupted time-series analysis using a linear autore-
gression model to estimate the rate of change before
and after the intervention.26
All models contained all variables that modified
the adjusted rate of the primary outcome by 10% or
more and necessarily included parity. We report
omnibus P values to examine the presence of an asso-
ciation between delivery year and the outcome of
interest while adjusting for covariates. Statistical sig-
nificance for all analyses was defined with a two-tailed
P value ,.05. The attending obstetricians based in the
faculty practice, the residents they supervise, and the
patients for whom they cared likely had more
Intervention to Decrease Twin Cesarean Deliveries 87
Table 1. Baseline Maternal, Fetal, and Health Care Provider Characteristics According to Year of Delivery
2010 2011 2012
Characteristic (n5169) (n5146) (n5164)

Maternal age (y) 35 (31–38) 34 (30–38) 34 (31–38)

Nulliparous 114 (67.5) 93 (63.7) 112 (68.3)
Race–ethnicity
White 115 (68.0) 97 (66.4) 115 (70.1)
Black 18 (10.6) 17 (11.6) 15 (9.1)
Hispanic 17 (10.1) 18 (12.3) 16 (9.8)
Asian 16 (9.5) 11 (7.5) 16 (9.8)
Other or missing 3 (1.8) 3 (2.1) 2 (1.2)
BMI at delivery (kg/m2) 31 (28–33) 31 (28–34) 30 (28–33)
Hypertension (any) 42 (24.9) 43 (29.5) 45 (27.4)
Preeclampsia 35 (20.7) 40 (27.4) 42 (25.6)
Diabetes 11 (6.5) 3 (2.1) 5 (3.0)
Spontaneous conception 64 (37.9) 57 (39.0) 60 (36.6)
Monochorionic 27 (16.0) 21 (14.4) 25 (15.2)
Gestational age (wk) 36 (34–37) 37 (34–37) 36 (35–37)
Nonvertex 2nd twin 77 (45.6) 60 (41.1) 72 (43.9)
20% or greater discordance 20 (11.8) 23 (15.8) 23 (14.0)
Small for gestational age 68 (40.2) 63 (43.2) 83 (50.6)
Birth weight (g)
Twin A 2,381 (1,927–2,721) 2,404 (1,927–2,721) 2,466 (2,112–2,749)
Twin B 2,296 (1,956–2,664) 2,239 (1,899–2,721) 2,353 (1,970–2,672)
Nonlethal anomaly 5 (3.0) 12 (8.2) 10 (6.1)
Prenatal care by faculty provider 82 (48.5) 74 (50.7) 63 (38.4)
Prenatal care by MFM provider 48 (28.4) 54 (37.0) 51 (31.1)
Care in specialized twin clinic 8 (4.7) 8 (5.5) 2 (1.2)
Delivered by MFM provider 58 (34.3) 55 (37.7) 47 (28.7)
BMI, body mass index; MFM, maternal–fetal medicine.
Data are median (range) or n (%) unless otherwise specified.
* Calculated by Cochran-Mantel-Haenszel test comparing rates across years unless otherwise indicated, with statistical significance defined
as P,.05.
†
P value determined by Kruskal-Wallis test.

exposure to the patient- and health care provider-
focused interventions. They also cared for patients
with higher rates of maternal or fetal comorbidities
that may differentially affect their probability of a suc-
cessful vaginal birth. As opposed to adjusting for pre-
natal care provider, we chose to perform a stratified
analysis according to whether a patient received care
in the faculty practice compared with a private prac-
tice. This study was approved by the Partners Human
Research Committee (Protocol #2012P001737,
approved September 12, 2012). All analyses were per-
formed with SAS 9.4.
RESULTS
Of 1,574 patients delivering twins at 24 weeks of
gestation or greater, 897 patients (57%) were eligible
for inclusion in the present study. Table 1 compares the
maternal, fetal, and health care provider characteristics
according to year of delivery. There were no significant
changes in rates of nulliparity, fetal presentation, cho-
rionicity, or other maternal or fetal characteristics
across the study period. There was an expected
increase in rates of prenatal care by maternal–fetal
medicine subspecialists in general or in the special-
ized twin clinic specifically across the study period.
When considering patient characteristics stratified by
practice type, patients in the faculty practice tended to
have higher rates of monochorionicity (27.4% vs 7.8%,
P,.01), spontaneous conception (46.9% vs 31.6%,
P,.01), and fetal anomalies (8.7% vs 1.5%, P,.01)
compared with patients seen by private practitioners
(Appendix 1, available online at http://links.lww.com/
AOG/B101). Faculty patients delivered at a lower
median gestational age (36 weeks of gestation, inter-
quartile range 33–37 weeks of gestation) compared
with patients of private health care providers (median
37 weeks of gestation, interquartile range 35–38 weeks
of gestation, P,.01).
The frequency and adjusted rates of the primary
and secondary outcomes of interest according to year
of delivery are presented in Table 2. In an analysis
adjusted for maternal age and parity, adjusted rates of
vaginal delivery increased over the study period, with
a nadir in 2010 (28.2%) to a peak in 2015 (55.7%), with

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 2013 2014 2015
(n5158) (n5149) (n5111) P*

35 (32–38) 34 (31–37) 34 (31–38) .69†

101 (63.9) 105 (70.5) 66 (59.5) .46
.84
110 (69.6) 102 (68.5) 76 (68.5)
19 (12.0) 13 (8.7) 9 (8.1)
17 (10.8) 15 (10.1) 13 (11.7)
12 (7.6) 18 (12.1) 7 (6.3)
0 (0) 1 (0.67) 6 (5.4)
30 (27–33) 30 (27–34) 30 (28–34) .58†
38 (24.1) 49 (32.9) 25 (22.5) .38
35 (22.2) 44 (29.5) 21 (18.9) .26
5 (3.2) 5 (3.4) 6 (5.4) .33
58 (36.7) 61 (40.9) 50 (45.0) .73
25 (15.8) 29 (19.5) 28 (25.2) .21
36 (34–37) 36 (35–37) 37 (36–37) .29†
66 (41.8) 72 (48.3) 54 (48.6) .72
21 (13.3) 23 (15.4) 23 (20.7) .44
70 (44.3) 65 (43.6) 47 (42.3) .54

2,438 (2,012–2,749) 2,551 (2,126–2,806) 2,530 (2,110–2,889) .07†

2,381 (1,984–2,693) 2,353 (1,927–2,721) 2,439 (2,090–2,807) .39†
6 (3.8) 6 (4.0) 6 (5.4) .32
75 (47.5) 75 (50.3) 66 (59.5) .03
54 (34.2) 53 (35.6) 52 (46.8) .04
12 (7.6) 29 (19.5) 22 (19.8) ,.01
51 (32.3) 50 (33.6) 49 (44.1) .15

a statistically significant difference in rates of vaginal
birth across years (P,.01). Conversely, rates of elective
cesarean delivery showed a stable decrease over the
study period from a peak 59.5% in 2010 to a nadir of
27.6% in 2015 (P,.01 across years). Delivery by breech
extraction increased over the time period from a nadir
of 4.3% in 2010 to a peak of 13.3% in 2014 (P5.03
across years). Rates of combined delivery, operative
vaginal delivery, and composite maternal morbidity
were similar over time. Rates of composite neonatal
morbidity for the nonpresenting twin specifically
decreased over time even after controlling for gesta-
tional age. Table 3 presents these outcomes of interest
stratified by health care provider type. The adjusted rate
of vaginal delivery increased substantially for patients
seen in the faculty practice (24.8% in 2010 vs 60.9% in
2016, P,.01 across years) with no statistically significant
difference in the adjusted rate of vaginal delivery
(P5.21) or elective cesarean delivery (P5.39) for lower
risk patients cared for in the private practices.
We next analyzed outcomes in the 3 years before
and after our 2013 intervention. The adjusted rates of
primary and secondary outcomes of interest for the
group overall and stratified by health care provider
type are presented in Table 4. Rates of vaginal birth
and breech extraction increased among faculty patients
but not private patients. Similarly, rates of elective cesar-
ean delivery decreased for faculty patients while remain-
ing stable for patients of private health care providers.
Even after controlling for gestational age, adjusted rates
of neonatal morbidity decreased among patients of pri-
vate practitioners after the 2013 intervention. This may
reflect a decrease in the number of high-risk patients
such as monochorionic twins seen by private health care
providers after promotion of the specialized twin clinic.
Figure 1 displays the annual adjusted rate of vagi-
nal birth for the cohort overall and stratified by health
care provider type before and after the 2013 interven-
tion (unadjusted rates demonstrated in Appendix 2,
available online at http://links.lww.com/AOG/B101).
In the interrupted time-series analysis controlling for
secular trend, there was no significant effect of calendar
year on the rate of twin vaginal birth in the time period
before (1.35% annual increase, P5.76) or after (5.8%
annual increase, P5.40) the intervention. Similarly,
the rate of change of twin vaginal birth was similar
before and after the intervention for faculty patients
(4.7%, P5.31; 3.2%, P5.58) or private patients
(3.6%, P5.28; 1.6%, P5.70). There was no statisti-
cally significant difference in the slope of the

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Table 2. Adjusted* Rates of Primary and Secondary Outcomes According to Year of Delivery

2010 2011 2012 2013 2014 2015

Outcome† (n5169) (n5146) (n5164) (n5158) (n5149) (n5111) P‡

Vaginal delivery 47 (28.2) 57 (38.1) 49 (30.9) 65 (41.4) 64 (44.2) 56 (55.7) ,.01

Operative vaginal delivery 7 (4.1) 12 (8.2) 8 (4.8) 9 (5.8) 18 (11.9) 9 (10.0) .06
Breech extraction 7 (4.3) 13 (8.6) 7 (4.6) 10 (6.3) 19 (13.3) 10 (9.5) .02
Any cesarean delivery 117 (68.8) 81 (56.5) 108 (64.7) 87 (54.8) 80 (52.3) 53 (42.5) ,.01
Elective cesarean delivery 101 (59.5) 67 (46.7) 94 (56.5) 74 (46.5) 71 (46.7) 40 (27.6) ,.01
Combined delivery 5 (3.0) 8 (5.4) 7 (4.4) 6 (3.8) 5 (3.5) 2 (1.8) .77
Composite maternal 19 (11.2) 21 (14.5) 12 (7.2) 14 (8.8) 23 (15.3) 10 (10.1) .16
morbidity
Composite neonatal
morbidity§
Any 25 (11.6) 16 (8.8) 13 (7.0) 9 (4.6) 11 (6.7) 7 (8.7) .16
Twin A 17 (7.8) 11 (6.3) 12 (7.1) 7 (3.8) 9 (6.0) 7 (9.0) .51
Twin B 17 (6.6) 13 (6.2) 7 (2.6) 6 (1.5) 3 (0.48) 5 (5.4) .03
Data are n (%) unless otherwise specified.
* Rates adjusted for maternal age and parity unless otherwise noted.
†
Vaginal delivery refers to vaginal birth of both twins, including operative vaginal delivery of either twin and breech extraction of the
second twin. Any cesarean delivery includes elective cesarean deliveries, intrapartum cesarean deliveries, and cesarean deliveries for
the second twin after vaginal birth of the first.
‡
Omnibus P value across years.
§
Rates of composite neonatal morbidity adjusted for maternal age, maternal race, and gestational age at delivery.

regression lines before and after the intervention for DISCUSSION

the overall cohort and for faculty and private pa-
tients. The similar rates of change before and after
our intervention suggest the increase in the rates of
twin vaginal birth is a product of secular change and
not our intervention.
The increased rates of twin vaginal birth over the
6-year study period appear to reflect secular trend
as opposed to a direct effect from our quality
improvement intervention. These observed
changes seem to be a product of declining rates of

Table 3. Adjusted* Rates of Primary and Select Secondary Outcomes According to Year of Delivery and
Affiliation of Delivering Provider

2010 2011 2012 2013 2014 2015 P†

Faculty Provider
n 82 74 63 75 75 66
Vaginal delivery 20 (24.8) 28 (36.9) 21 (34.1) 32 (45.3) 37 (49.2) 37 (60.9) ,.01
Operative vaginal delivery 3 (3.5) 6 (8.2) 3 (4.5) 6 (8.3) 11 (14.4) 5 (7.8) .17
Breech extraction 4 (5.1) 7 (9.1) 2 (3.6) 5 (7.3) 14 (18.8) 8 (12.8) .01
Any cesarean delivery 62 (75.3) 46 (63.3) 42 (65.9) 43 (54.9) 38 (50.9) 29 (46.4) ,.01
Elective cesarean delivery 52 (63.0) 35 (48.1) 36 (56.5) 31 (39.2) 30 (40.1) 18 (19.0) ,.01
Combined delivery 2 (2.5) 5 (6.7) 1 (1.6) 4 (5.4) 3 (4.0) 2 (2.9) .62
Composite maternal morbidity 11 (13.5) 11 (15.0) 7 (11.2) 9 (11.2) 14 (19.0) 7 (12.7) .76
Any composite neonatal morbidity‡ 18 (15.5) 9 (10.3) 7 (10.4) 6 (7.0) 8 (11.6) 7 (13.6) .54
Private provider
n 87 72 101 83 74 45
Vaginal delivery 27 (31.4) 29 (39.5) 28 (28.6) 33 (38.0) 27 (39.1) 19 (48.3) 0.21
Operative vaginal delivery 4 (4.6) 6 (8.4) 5 (4.9) 3 (3.7) 7 (9.3) 4 (8.9) 0.56
Breech extraction 3 (3.6) 6 (8.2) 5 (5.2) 5 (5.5) 5 (7.5) 2 (4.5) 0.82
Any cesarean delivery 60 (68.8) 43 (60.7) 73 (71.5) 50 (62.2) 47 (61.0) 26 (68.9) 0.41
Elective cesarean delivery 49 (56.1) 32 (45.2) 58 (56.6) 43 (53.2) 41 (53.2) 22 (40.3) 0.39
Combined delivery 3 (3.5) 3 (4.0) 6 (6.1) 2 (2.1) 2 (3.2) 0 (0) 0.47
Composite maternal morbidity 8 (9.1) 10 (13.9) 5 (4.8) 5 (6.3) 9 (11.8) 3 (6.0) 0.27
Any composite neonatal morbidity‡ 7 (5.3) 7 (5.8) 6 (2.5) 3 (0.14) 3 (0.35) 0 (0.83) 0.36
* Adjusted for maternal age and parity.
†
Omnibus P value across years.
‡
Adjusted for gestational age.

90 Easter et al Intervention to Decrease Twin Cesarean Deliveries OBSTETRICS & GYNECOLOGY

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Table 4. Adjusted Rates of Primary and Secondary Outcomes of Interest Before and After Intervention for
the Group Overall and Stratified by Health Care Provider Type

All 2010– All 2013– Faculty Faculty Private Private

2012 2015 2010–2012 2013–2015 2010–2012 2013–2015
Outcome* (n5479) (n5418) P (n5219) (n5216) P (n5260) (n5202) P

Vaginal delivery 153 (32.1) 185 (44.2) ,.01 69 (31.5) 106 (49.1) ,.01 84 (32.4) 79 (39.0) .12
Operative 27 (5.6) 36 (8.7) .07 12 (5.4) 22 (10.3) .06 15 (5.8) 14 (6.9) .61
vaginal
delivery
Breech 27 (5.7) 39 (9.3) .04 13 (6.0) 27 (12.5) .02 14 (5.4) 12 (5.9) .83
extraction
Any cesarean 326 (68.0) 233 (55.8) ,.01 150 (68.5) 110 (50.9) ,.01 176 (67.6) 123 (61.0) .12
delivery
Elective 262 (54.6) 185 (44.3) ,.01 123 (56.2) 79 (36.6) ,.01 139 (53.4) 106 (52.5) .84
cesarean
delivery
Combined 20 (4.2) 13 (3.1) .38 8 (3.7) 9 (4.2) .79 12 (4.6) 4 (1.9) .11
delivery
Maternal morbidity 52 (10.9) 47 (11.3) .85 29 (13.3) 30 (13.8) .89 23 (8.8) 17 (8.5) .91
Neonatal 54 (10.5) 27 (7.3) .06 34 (13.7) 21 (11.5) .42 20 (7.4) 6 (3.4) .04
morbidity†
Morbidity of twin 40 (7.7) 23 (6.3) .35 23 (8.9) 18 (9.9) .67 17 (6.3) 5 (2.8) .06
A†
Morbidity of twin 37 (7.1) 14 (4.0) .02 26 (10.6) 11 (6.4) .08 11 (4.0) 14 (1.8) .13
B†
* Rates adjusted for maternal age and parity unless otherwise indicated.
†
Rates of neonatal outcomes of interest adjusted for gestational age.

elective cesarean delivery rather than a greater
likelihood of success among women laboring with
twins. Notably, this increase in attempted vaginal
birth was accompanied by higher rates of breech
extraction and operative vaginal delivery without
a rise in morbidity or combined delivery. Although
our targeted intervention had no effect on the
naturally rising institutional rate of twin vaginal
birth, these observed secular changes do have
important implications for clinicians and policy-
makers interested in decreasing rates of primary
cesarean delivery.

Fig. 1. Annual adjusted rates of

twin vaginal birth for cohort overall
and stratified by health care pro-
vider type. Data points demonstrate
the adjusted annual rate of vaginal
birth, with the line demonstrating
the regression line before and after
the 2013 intervention.
Easter. Intervention to Decrease Twin
Cesarean Deliveries. Obstet Gynecol
2018.

VOL. 132, NO. 1, JULY 2018 Easter et al Intervention to Decrease Twin Cesarean Deliveries 91

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Unauthorized reproduction of this article is prohibited.
 National recommendations support attempts at
twin vaginal birth to decrease rates of primary
cesarean delivery and increase health care provider
exposure to operative obstetrics.4 Our institutional
observations offer evidentiary support to current
guidelines. The decrease in elective cesarean delivery
decreased the overall rate of primary cesarean deliv-
ery for twins while increasing exposure to breech
extraction as anticipated by the guidelines.4 With
recent concerns about the ability of guideline changes
to improve outcomes, our findings offer reassurance
about the safety and efficacy of this recommended
practice change.27 The differential findings between
rates of vaginal birth over time in our faculty com-
pared with private practitioners warrant further con-
sideration. We planned our stratified analysis to
demonstrate an association between our initiative
and changes in outcomes in the faculty practice con-
ceptualizing private practice patients as a control
group unexposed to the intervention. Comparing
the naturally rising rates of vaginal birth among fac-
ulty patients with the stable rates seen among the
lower risk patients of our private practice colleagues
suggest that spontaneous clinical practice change may
be less fluid within this population. With this in mind,
a targeted intervention such as ours could potentially
have an effect among patients in community settings
as a direction for future research.
Our study is one of many to examine the effect of
an intervention on rates of cesarean delivery, yet we
failed to demonstrate a statistically significant effect of
our intervention on the rate of change.12–14,28 These
negative findings within the context of an apparently
clinically significant result highlight the limitations of
our study design. Our intervention was inspired by
new evidence and society guidelines supporting at-
tempts at vaginal birth.4 Implementing this interven-
tion within the context of a natural increase in
vaginal birth limits our power to change the rate of
change. By comparison, the intervention by Rosenstein
et al increased vaginal birth after cesarean delivery
rates at an institution with a previously stable decline
in vaginal birth after cesarean delivery rates.12 These
authors demonstrate statistical significance by altering
the direction and not just the magnitude of the rate of
change. Similarly, the interventions decreasing the sin-
gleton cesarean delivery rate by Vadnais et al14
occurred over 8 years among 51,973 deliveries lending
stability to the data points over time. It may be that our
single-institution sample over a 6-year time period sim-
ply lacks power to demonstrate a statistically significant
difference in the rate of change.26 Given its low cost
and reproducibility, analyzing the effect of our inter-
92 Easter et al Intervention to Decrease Twin Cesarean Deliveries
Copyright ª by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
vention in an adequately powered cluster-randomized
trial could overcome these potential limitations in
methodology before abandoning health care provider
support interventions such as ours entirely.13
The observed increase in rates of twin vaginal
birth reflect secular trend as opposed to an effect of
our quality improvement intervention.27 Despite
these negative findings, this study addresses a chal-
lenge at the heart of the national public health debate
on cesarean delivery. The majority of patients with
twin pregnancies appear to prefer vaginal birth, but
the increased risk of complications in twin relative to
singleton pregnancies may dissuade patients from an
attempted vaginal birth.25,29 These same concerns in
conjunction with lack of health care provider comfort
with operative vaginal delivery and breech extraction
may inform health care provider preference for elec-
tive cesarean delivery for twins.18,19 Operative obstet-
rics offer an alternative to cesarean delivery in many
settings, but may not be entertained despite appropri-
ate clinical situations based solely on patient or health
care provider preference.18,19,30 Rigorous prospective
studies testing the ability of targeted patient education
and health care provider support interventions to
safely increase utilization of operative obstetrics in
both community and academic settings may be a crit-
ical tool to curb the rising rate of cesarean delivery.
Until the optimal approach is available, our findings
lend evidentiary support to guidelines encouraging
vaginal delivery of twins. Increasing access to twin
vaginal birth appears to be an effective strategy to
decrease primary cesarean delivery while ensuring
obstetricians maintain the requisite obstetric skills to
facilitate safe vaginal birth.19,30
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Intervention to Decrease Twin Cesarean Deliveries 93