Tools or culture? Human factors, not technology, drive cesarean section rates for suspected fetal distress

Objective Cesarean section (CS) rates are rising worldwide. Abnormal fetal heart rate patterns (aFHRp) are a leading indication for primary CS. We evaluated whether different monitoring policies and training approaches influence CS rate performed for suspected fetal distress and influence neonatal outcomes. Methods This multicenter retrospective study included 3408 nulliparous and multiparous low‐risk, term, singleton, cephalic pregnancies in spontaneous labor during 2017 at Hospital A ( n = 1428), Hospital B ( n = 1113), and Hospital C ( n = 867). Monitoring policies were: (i) intermittent auscultation (IA) with cardiotocography (CTG) reserved for high risk pregnancies or in case of evolving concerns combined with structured team training; (ii) universal CTG with structured training; and (iii) universal CTG without structured training. Primary outcomes were intrapartum CS for aFHRp and neonatal outcomes. Results Overall intrapartum CS rates were 3.7% (Hospital A), 2.8% (Hospital B), and 11.4% (Hospital C). CS rate for aFHRp was lower in Hospital B (0.8%) and A (1.5%) and significantly higher in Hospital C (4.5%, P < 0.001). Neonatal indicators such as Apgar <7 at 5 min, umbilical pH <7.0, and neonatal intensive care unit (NICU) admission were comparable across hospitals. However, neonatal resuscitation was more frequent in Hospital C (12.1%) compared to Hospital A (0%, P = 0.008). Conclusion Continuous CTG combined with structured team training was strongly associated with the lowest rates of CS performed for suspected fetal distress, without compromising neonatal safety. In contrast, universal continuous CTG without training led to higher intervention rates. Human factors, particularly training and organizational culture, appear to be more influential than monitoring technology alone in determining cesarean delivery rates for suspected fetal compromise.