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do Carmo Leal M, Domingues RMSM, Fonseca TCO, Leite TH, Figueiró AC, Pereira APE, Theme-Filha MM, da Silva Ayres BV, Scott O, de Cássia Sanchez R, Borem P, de Maio Osti MC, Rosa MW, Andrade AS, Filho FMP, Nakamura-Pereira M, Torres JA. The effects of a quality improvement project to reduce caesarean sections in selected private hospitals in Brazil. Reprod Health 2024; 20:194. [PMID: 39232837 PMCID: PMC11375826 DOI: 10.1186/s12978-024-01851-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 07/10/2024] [Indexed: 09/06/2024] Open
Abstract
BACKGROUND Brazil is one of the countries with the highest rates of caesarean sections (CS), reaching almost 90% of births in the private sector. A quality improvement project called "Adequate Childbirth Project (PPA)" was conceived to reduce CS in the private sector. This project consisted of four primary components: "Governance", "Participation of Women", "Reorganization of Care" and "Monitoring". This paper aims to evaluate: (1) which specific activities of the PPA had the largest effect on the probability of a woman having a vaginal delivery; (2) which primary component of the PPA had the largest effect on the probability of vaginal delivery and (3) which scenarios combining the implementation of different activities planned in the PPA had a higher effect on the probability of vaginal delivery. METHODS A sample of 12 private hospitals participating in the PPA was evaluated. We used a Bayesian Network (BN) to capture both non-linearities and complex cause-effect relations. The BN integrated knowledge from experts and data from women to estimate 26 model parameters. The PPA was evaluated in 2473 women belonging to groups 1-4 of the Robson classification, who were divided into two groups: those participating or not participating in the PPA. RESULTS The probability of a woman having a vaginal delivery was 37.7% higher in women participating in the PPA. The most important component of the project that led to an increase in the probability of vaginal delivery was "Reorganization of Care", leading to a 73% probability of vaginal delivery among women in labor. The activity that had the greatest effect on the type of delivery was access to best practices during labor, with a 72% probability of vaginal delivery. Considering the 12 scenarios combining the different activities of the PPA, the best scenarios included: a non-scheduled delivery, access to information about best practices, access to at least 4 best practices during labor and respect of the birth plan, with an 80% probability of vaginal delivery in the best combinations. CONCLUSION PPA has been shown to be an effective quality improvement program, increasing the likelihood of vaginal delivery in private Brazilian hospitals.
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Affiliation(s)
- Maria do Carmo Leal
- Department of Epidemiology and Quantitative Methods On Health, National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil.
| | | | | | | | | | - Ana Paula Esteves Pereira
- Department of Epidemiology and Quantitative Methods On Health, National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Mariza Miranda Theme-Filha
- Department of Epidemiology and Quantitative Methods On Health, National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Bárbara Vasques da Silva Ayres
- Department of Epidemiology and Quantitative Methods On Health, National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | | | | | - Paulo Borem
- Institute for Healthcare Improvement, Boston, USA
| | | | | | | | | | - Marcos Nakamura-Pereira
- National Institute of Health for Women, Children and Adolescents Fernandes Figueira, Oswaldo Cruz Foundation (IFF/Fiocruz), Rio de Janeiro, Brazil
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Adeniran AS, Nwachukwu DC, Ocheke AN, Mohammed SO, Musa AO, Ochejele S, Ibraheem RS, Pam S, Mairami AB, Gobir AA, Olateju EK, Baba FJ, Medupin PF, Ahmed G, Ango S, Akaba G, Ogunkunle TO, Agada E, Gibbons L, Oladapo OT, Lavin T, Tukur J, Aboyeji AP. Outcomes and quality of care for women and their babies after caesarean section in Nigeria. BJOG 2024; 131 Suppl 3:78-87. [PMID: 38576257 DOI: 10.1111/1471-0528.17815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 03/05/2024] [Accepted: 03/13/2024] [Indexed: 04/06/2024]
Abstract
OBJECTIVE To describe the outcomes and quality of care for women and their babies after caesarean section (CS) in Nigerian referral-level hospitals. DESIGN Secondary analysis of a nationwide cross-sectional study. SETTING Fifty-four referral-level hospitals. POPULATION All women giving birth in the participating facilities between 1 September 2019 and 31 August 2020. METHODS Data for the women were extracted, including sociodemographic data, clinical information, mode of birth, and maternal and perinatal outcomes. A conceptual hierarchical framework was employed to explore the sociodemographic and clinical factors associated with maternal and perinatal death in women who had an emergency CS. MAIN OUTCOME MEASURES Overall CS rate, outcomes for women who had CS, and factors associated with maternal and perinatal mortality. RESULTS The overall CS rate was 33.3% (22 838/68 640). The majority of CS deliveries were emergency cases (62.8%) and 8.1% of CS deliveries had complications after delivery, which were more common after an emergency CS. There were 179 (0.8%) maternal deaths in women who had a CS and 29.6% resulted from complications of hypertensive disorders of pregnancy. The overall maternal mortality rate in women who delivered by CS was 778 per 100 000 live births, whereas the perinatal mortality at birth was 51 per 1000 live births. Factors associated with maternal mortality in women who had an emergency CS were being <20 or >35 years of age, having a lower level of education and being referred from another facility or informal setting. CONCLUSIONS One-third of births were delivered via CS (mostly emergency), with almost one in ten women experiencing a complication after a CS. To improve outcomes, hospitals should invest in care and remove obstacles to accessible quality CS services.
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Affiliation(s)
- Abiodun S Adeniran
- Department of Obstetrics & Gynaecology, University of Ilorin/University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Duum C Nwachukwu
- Department of Obstetrics & Gynaecology, Federal Medical Centre, Bida, Nigeria
| | - Amaka N Ocheke
- Department of Obstetrics & Gynaecology, Jos University Teaching Hospital, Jos, Nigeria
| | - Salisu O Mohammed
- Department of Obstetrics & Gynaecology, Dalhatu Araf Specialist Hospital, Lafia, Nigeria
| | - Abdulkarim O Musa
- Department of Obstetrics & Gynaecology, Federal Medical Centre, Lokoja, Nigeria
| | - Silas Ochejele
- Department of Obstetrics & Gynaecology, Federal Medical Centre, Makurdi, Nigeria
| | - Rais S Ibraheem
- Department of Obstetrics & Gynaecology, IVF Centre, National Hospital, Abuja, Nigeria
| | - Samuel Pam
- Department of Obstetrics & Gynaecology, Federal Medical Centre, Keffi, Nigeria
| | - Amsa B Mairami
- Department of Paediatrics, National Hospital, Abuja, Nigeria
| | - Aishatu A Gobir
- Department of Paediatrics, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Eyinade K Olateju
- Department of Paediatrics, University of Abuja Teaching Hospital, Gwagwalada, Nigeria
| | - Fatimah J Baba
- Department of Paediatrics, Jos University Teaching Hospital, Jos, Nigeria
| | | | - Grace Ahmed
- Department of Paediatrics, Federal Medical Centre, Bida, Nigeria
| | - Sarah Ango
- Department of Paediatrics, Federal Medical Centre, Keffi, Nigeria
| | - Godwin Akaba
- Department of Obstetrics and Gynaecology, University of Abuja Teaching Hospital, Gwagwalada, Nigeria
| | - Taofik O Ogunkunle
- Department of Paediatrics, Dalhatu Arafa Specialist Hospital, Lafia, Nigeria
| | - Egwu Agada
- Department of Paediatrics, Federal Medical Centre, Makurdi, Nigeria
| | - Luz Gibbons
- Department of Mother & Child Health Research, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Olufemi T Oladapo
- Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, World Health Organization, Geneva, Switzerland
| | - Tina Lavin
- Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, World Health Organization, Geneva, Switzerland
| | - Jamilu Tukur
- Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Abiodun P Aboyeji
- Department of Obstetrics & Gynaecology, University of Ilorin/University of Ilorin Teaching Hospital, Ilorin, Nigeria
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Torres JA, Leite TH, Fonseca TCO, Domingues RMSM, Figueiró AC, Pereira APE, Theme-Filha MM, da Silva Ayres BV, Scott O, de Cássia Sanchez R, Borem P, de Maio Osti MC, Rosa MW, Andrade AS, Filho FMP, Nakamura-Pereira M, do Carmo Leal M. An implementation analysis of a quality improvement project to reduce cesarean section in Brazilian private hospitals. Reprod Health 2024; 20:190. [PMID: 38671479 PMCID: PMC11052714 DOI: 10.1186/s12978-024-01773-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 03/11/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Brazil has one of the highest prevalence of cesarean sections in the world. The private health system is responsible for carrying out most of these surgical procedures. A quality improvement project called Adequate Childbirth Project ("Projeto Parto Adequado"- PPA) was developed to identify models of care for labor and childbirth, which place value on vaginal birth and reduce the frequency of cesarean sections without a clinical indication. This research aims to evaluate the implementation of PPA in private hospitals in Brazil. METHOD Evaluative hospital-based survey, carried out in 2017, in 12 private hospitals, including 4,322 women. We used a Bayesian network strategy to develop a theoretical model for implementation analysis. We estimated and compared the degree of implementation of two major driving components of PPA-"Participation of women" and "Reorganization of care" - among the 12 hospitals and according to type of hospital (belonging to a health insurance company or not). To assess whether the degree of implementation was correlated with the rate of vaginal birth data we used the Bayesian Network and compared the difference between the group "Exposed to the PPA model of care" and the group "Standard of care model". RESULTS PPA had a low degree of implementation in both components "Reorganization of Care" (0.17 - 0.32) and "Participation of Women" (0.21 - 0.34). The combined implementation score was 0.39-0.64 and was higher in hospitals that belonged to a health insurance company. The vaginal birth rate was higher in hospitals with a higher degree of implementation of PPA. CONCLUSION The degree of implementation of PPA was low, which reflects the difficulties in changing childbirth care practices. Nevertheless, PPA increased vaginal birth rates in private hospitals with higher implementation scores. PPA is an ongoing quality improvement project and these results demonstrate the need for changes in the involvement of women and the care offered by the provider.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Paulo Borem
- Institute for Healthcare Improvement, Brasília, Brazil
| | | | | | | | - Fernando Maia Peixoto Filho
- Oswaldo Cruz Foundation, National Institute of Health for Women, Children and Adolescents Fernandes Figueira, Rio de Janeiro, Brazil
| | - Marcos Nakamura-Pereira
- Oswaldo Cruz Foundation, National Institute of Health for Women, Children and Adolescents Fernandes Figueira, Rio de Janeiro, Brazil
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Domingues RMSM, Dias MAB, do Carmo Leal M. Women's preference for a vaginal birth in Brazilian private hospitals: effects of a quality improvement project. Reprod Health 2024; 20:188. [PMID: 38549093 PMCID: PMC10976663 DOI: 10.1186/s12978-024-01771-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 03/11/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND In 2015, a quality improvement project called "Adequate Childbirth Project" (PPA) was implemented in Brazilian private hospitals in order to reduce cesarean sections without clinical indication. The PPA is structured in four components, one of which is directed at women and families. The objective of this study is to evaluate the effects of PPA on women's preference for vaginal birth (VB) at the end of pregnancy. METHODS Evaluative research conducted in 12 private hospitals participating in the PPA. Interviews were carried out in the immediate postpartum period and medical record data were collected at hospital discharge. The implementation of PPA activities and women's preference for type of birth at the beginning and end of pregnancy were compared in women assisted in the PPA model of care and in the standard of care model, using a chi-square statistical test. To estimate the effect of PPA on women's preference for VB at the end of pregnancy, multiple logistic regression was performed with selection of variables using a causal diagram. RESULTS Four thousand seven hundred ninety-eight women were interviewed. The implementation of the planned activities of PPA was less than 50%, but were significantly more frequent among women assisted in the PPA model of care. Women in this group also showed a greater preference for VB at the beginning and end of pregnancy. The PPA showed an association with greater preference for VB at the end of pregnancy in primiparous (OR 2.54 95% CI 1.99-3.24) and multiparous women (OR 1.44 95% CI 0.97-2.12), although in multiparous this association was not significant. The main factor associated with the preference for VB at the end of pregnancy was the preference for this type of birth at the beginning of pregnancy, both in primiparous (OR 18.67 95% CI 14.22-24.50) and in multiparous women (OR 53.11 95% CI 37.31-75.60). CONCLUSIONS The PPA had a positive effect on women's preference for VB at the end of pregnancy. It is plausible that more intense effects are observed with the expansion of the implementation of the planned activities. Special attention should be given to information on the benefits of VB in early pregnancy.
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Affiliation(s)
- Rosa Maria Soares Madeira Domingues
- Instituto Nacional de Infectologia Evandro Chagas/Fundação Oswaldo Cruz, Laboratório de Pesquisa Clínica em DST/Aids, Av. Brasil, 4365, Manguinhos, Rio de Janeiro, CEP 21040-360, Brazil.
| | - Marcos Augusto Bastos Dias
- Instituto Nacional da Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira/Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Maria do Carmo Leal
- Escola Nacional de Saúde Pública Sérgio Arouca/ Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
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Abdallah W, Abi Tayeh G, Kesrouani A, Nassar M, Finan R, Mansour F, Attieh E, Suidan J, Bou Saba C, El Kassis N, Yaghi N, Aouad N, Atallah D. The rate of cesarean delivery changes after internal audit based on the Robson Ten Group Classification System in Lebanon. Int J Gynaecol Obstet 2023; 161:314-319. [PMID: 36479965 DOI: 10.1002/ijgo.14610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 10/06/2022] [Accepted: 10/28/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate the efficiency of the Robson classification as an internal clinical audit and feedback of the high rate of cesarean delivery at Hotel Dieu de France, a tertiary referral hospital. METHODS A pre-post study was conducted, with a retrospective approach in 2018 and 2019, identified as the pre-period (before the implementation of the Robson classification), and with a prospective approach in 2020 and 2021, labeled the post-period. RESULTS The total number of deliveries during the study period was 2560; 1305 patients were included in the pre-period and 1255 patients delivered in the post-period. No significant differences between the two groups were found. No significant difference was found in the overall rate of cesarean delivery between the first and second periods (57.86% vs 56.72%; P = 0.2). However, a significant decrease in the absolute contribution of groups 3 and 4 (multiparous women without a previous uterine scar with a single cephalic pregnancy, ≥37 weeks of gestation, with spontaneous labor or induced labor) in the overall rate of cesarean delivery was remarked (P = 0.02 and 0.01, respectively). CONCLUSION The Robson classification seems to be appropriate to monitor and audit the rate of cesarean delivery, but not sufficient to decrease the rate and change the practice.
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Affiliation(s)
- Wael Abdallah
- Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Georges Abi Tayeh
- Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Assaad Kesrouani
- Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Malek Nassar
- Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Ramzi Finan
- Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Fersan Mansour
- Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Elie Attieh
- Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Joe Suidan
- Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Camille Bou Saba
- Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Nadine El Kassis
- Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Nancy Yaghi
- Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Norma Aouad
- Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - David Atallah
- Department of Obstetrics and Gynecology, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
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Monari F, Menichini D, Bertucci E, Neri I, Perrone E, Facchinetti F. Implementation of guidelines about women with previous cesarean section through educational/motivational interventions. Int J Gynaecol Obstet 2022; 159:810-816. [PMID: 35396724 PMCID: PMC9790249 DOI: 10.1002/ijgo.14212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/28/2022] [Accepted: 04/04/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To investigate the effect of a quality improvement project with an educational/motivational intervention in northern Italy on the implementation of the trial of labor after cesarean section (CS). METHOD A pre-post study design was used. Every birth center (n = 23) of the Emilia-Romagna region was included. Gynecologist opinion leaders were first trained about Italian CS recommendations. Barriers to implementation were discussed and shared. Educational/motivational interventions were implemented. Data of multipara with previous CS, with a single, cephalic pregnancy at term, were collected during two periods, before (2012-2014) and after (2017-2019) the intervention (2015-2016). The primary outcome was the rate of vaginal birth after CS (VBAC) and perinatal outcomes. RESULTS A total of 20 496 women were included. The VBAC rate increased from 18.1% to 23.1% after intervention (P < 0.001). The likelihood of VBAC-adjusted for age 40 years or older, Caucasian, body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) at least 30, previous vaginal delivery, and labor induction-was increased by the intervention by 42% (odds ratio 1.42, 95% confidence interval 1.31-1.54). Neonatal well-being was improved by intervention; neonates requiring resuscitation decreased from 2.1% to 1.6% (P = 0.001). CONCLUSION Educating and motivating gynecologists toward the trial of labor after CS is worth pursuing. Health quality improvement is demonstrated by increased VBAC even improving neonatal well-being.
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Affiliation(s)
- Francesca Monari
- Obstetrics Unit, Department of Medical and Surgical Sciences for Mother, Child and AdultUniversity of Modena and Reggio Emilia. University Hospital Policlinico of Modena, ItalyModenaItaly
| | - Daniela Menichini
- International Doctorate School in Clinical and Experimental Medicine, Department of Biomedical, Metabolic and Neural SciencesUniversity of Modena and Reggio EmiliaModenaItaly
| | - Emma Bertucci
- Obstetrics Unit, Department of Medical and Surgical Sciences for Mother, Child and AdultUniversity of Modena and Reggio Emilia. University Hospital Policlinico of Modena, ItalyModenaItaly
| | - Isabella Neri
- Obstetrics Unit, Department of Medical and Surgical Sciences for Mother, Child and AdultUniversity of Modena and Reggio Emilia. University Hospital Policlinico of Modena, ItalyModenaItaly
| | - Enrica Perrone
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Hygiene and Preventive Medicine Section, Alma Mater StudiorumUniversity of BolognaBolognaItaly
| | - Fabio Facchinetti
- Obstetrics Unit, Department of Medical and Surgical Sciences for Mother, Child and AdultUniversity of Modena and Reggio Emilia. University Hospital Policlinico of Modena, ItalyModenaItaly
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Crespo FA, Verma U. High Primary Cesarean Section Rates: Strategies for Improvement. Jt Comm J Qual Patient Saf 2022; 48:617-624. [PMID: 36050212 DOI: 10.1016/j.jcjq.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/27/2022] [Accepted: 07/29/2022] [Indexed: 12/30/2022]
Abstract
Approximately one in three women giving birth in the United States will undergo cesarean delivery.1 Certain high-risk pregnancy conditions, such as placenta previa, may warrant a cesarean delivery, but most low-risk pregnancies are candidates for a vaginal birth. Low risk can be defined as nulliparous, term, singleton, and vertex (NTSV). As of 2020, the Centers for Disease Control and Prevention (CDC) ranked Florida, Mississippi, and Louisiana as the three states with the highest overall cesarean delivery rate, at 35.9%, 38.2%, and 36.8%, respectively.2 (See Figure 1.) According to the Maternal Safety Foundation, Florida’s 2017 NTSV cesarean section rate was 31%, the highest in the nation.3 Rising health care costs, increasing placenta accreta spectrum cases, factors affecting breastfeeding and bonding, and the current opioid use crisis all indicate a need to address these high rates. Compared to a vaginal delivery, cesarean delivery poses greater maternal and neonatal risks. These include a higher risk of maternal mortality, hemorrhage, infection, thromboembolism, amniotic fluid embolism, neonatal respiratory distress syndrome, and other long-term sequalae such as chronic pelvic pain and abnormal placentation.4 This commentary will provide an update on evidence-based approaches to lowering cesarean rates among NTSV births. It will also discuss the influence of provider and hospital unit culture, as well as the potential application of perinatal collaborative best practices across state lines. The goal is to provide recommendations to help lower NTSV cesarean births.
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di Pasquo E, Ricciardi P, Valenti A, Fieni S, Ghi T, Frusca T. Achieving an appropriate cesarean birth (CB) rate and analyzing the changes using the Robson Ten-Group Classification System (TGCS): Lessons from a Tertiary Care Hospital in Italy. Birth 2022; 49:430-439. [PMID: 35118720 DOI: 10.1111/birt.12612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/19/2021] [Accepted: 01/03/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND To describe the interventions that were implemented at a Tertiary University Hospital and how they affected the rate of cesarean birth (CB) and main obstetrics and neonatal outcomes. STUDY DESIGN An analysis of the contemporaneously collected data from all deliveries that occurred from 2014 to 2018. Major obstetric and neonatal outcomes were analyzed and grouped according to the Ten-Group Classification System (TGCS). RESULTS A significant decrease in CB rates, from 28.4% to 23.0% (P < 0.001), was found over the study period. Although the relative sizes of both nulliparous (groups 1 + 2) and multiparous (groups 3 + 4) women remained stable over the study period, a significantly higher incidence of CB was reported in 2014 for both groups, compared with 2018 (2.6% vs. 13.0%, P < 0.001 for nulliparous women and 7.5% vs. 3.3%, P < 0.001 for multiparous women). In contrast, the relative size of Group 5 was significantly lower in 2014 than in 2018 (9.9% vs. 11.5%, P = 0.003), but a 13.3% reduction in CB was also reported for this group. No significant differences were noted in the occurrence of major obstetrics and neonatal outcomes that were reported. CONCLUSIONS A reduction in CB rate may be safely achieved through implementing a multifaceted strategy.
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Affiliation(s)
- Elvira di Pasquo
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy
| | - Piera Ricciardi
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy
| | - Alissa Valenti
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy
| | - Stefania Fieni
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy
| | - Tullio Ghi
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy
| | - Tiziana Frusca
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy
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The role of implementation science in improving epilepsy surgery utilization. Epilepsy Behav 2022; 130:108669. [PMID: 35334257 PMCID: PMC9064925 DOI: 10.1016/j.yebeh.2022.108669] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/24/2022]
Abstract
Randomized controlled studies demonstrated that patients with intractable epilepsy could benefit significantly more from epilepsy surgery than from continuing medical therapy. Unfortunately, robust efforts over the last few decades, including the formation and dissemination of guidelines and practice parameters, did not improve the utilization of epilepsy surgery. Epilepsy surgery remains one of the most underutilized evidence-based interventions in modern medicine. A new scientific study of methods has emerged to improve uptake of evidence-based practices, named implementation science (IS). Despite its tremendous rise in popularity in various domains, its usage to mitigate epilepsy surgery underutilization is very limited. In fact, the application of principles and methods of IS are somewhat restricted in the entire neuroscience field, where quality improvement (QI) efforts primarily drive the provision of high-quality health care. Although both QI efforts and IS have a similar goal of improving healthcare quality, they differ significantly in associated terminologies, concepts, and approaches. For implementing high-quality, evidence-based practices in routine clinical settings, we need a better understanding of IS methods and closer integration between QI and IS fields. Recognizing a dearth of awareness of IS in the neuroscience community, the first part of the review addresses the fundamentals of IS, focusing on multifaceted implementation strategies that neurologists can apply in their clinical practice. In the second part of the review, an entire illustrative case is presented to familiarize neurologists with the practical application of diverse implementation strategies to mitigate the underutilization of epilepsy surgery.
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Edmonds JK, Woodbury SR, Lipsitz SR, Weiseth A, Farrell ME, Shah NT, Greene N, Gregory KD. Comparing Methods of Identifying Outlying Nurses in Audits of Low-Risk Cesarean Delivery Rates. J Nurs Care Qual 2022; 37:149-154. [PMID: 34446663 DOI: 10.1097/ncq.0000000000000588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The low-risk cesarean delivery (CD) rate is an established performance indicator for providers in maternity care for quality improvement purposes. PURPOSE Our objectives were to assess nurse performance using adjusted nurse-level CD rates and to compare methods of identifying nurse outliers. METHODS We conducted a retrospective, cohort study of 6970 births attended by 181 registered nurses in one hospital's maternity unit. Adjusted and unadjusted nurse-level CD rates were compared and agreement between 3 definitions (statistical, top decile, over a benchmark) of outliers calculated. RESULTS Adjusted nurse-level CD rates varied from 5.5% to 53.2%, and the unadjusted rates varied from 5% to 50%. Risk adjustment had little impact on the ranking of nurses, and outliers were consistently identified by 3 definitions. CONCLUSIONS Trade-offs between statistical certainty and feasibility need to be considered when classifying nurse outliers. Findings can help target interventions to improve nurse performance.
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Affiliation(s)
- Joyce K Edmonds
- Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts (Dr Edmonds); Science and Technology, Ariadne Labs, Boston, Massachusetts (Mr Woodbury and Drs Lipsitz, Weiseth, and Shah); Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, and the Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts (Dr Farrell); Division of Maternal Fetal Medicine (Dr Gregory), Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California (Dr Greene)
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Quibel T, Chesnais M, Bouyer C, Rozenberg P, Bouyer J. Cesarean section rate changes after audit and feedback with the Ten Group Classification System in a French perinatal network: A retrospective pre-post study. Acta Obstet Gynecol Scand 2022; 101:388-395. [PMID: 35277968 DOI: 10.1111/aogs.14327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/12/2022] [Accepted: 01/14/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The rise in the number of cesarean sections (CS) is a major health public problem which concerns nearly all countries. It is suggested that the Ten Group Classification System be adapted to a procedure of audit/feedback cycles, which could have an effect on CS practice. Therefore, we aimed to study changes in CS rates between maternity wards in a perinatal network after implementation of the Ten Group Classification System in an audit with feedback. MATERIAL AND METHODS This was a retrospective pre-post study of all births from 1 January 2012 to 31 December 2018, in a French perinatal network of 10 maternity wards in the Yvelines district of France. All live births occurring at a gestational age ≥24 weeks in the network were included. During the pre-period (1 January 2012 to 31 December 2014), the audit and feedback provided only overall CS rates. During the post-period (1 January 2015 to 31 December 2018), CS rates for each Robson Ten Group Classification System group were provided. Regression models, adjusted for maternal characteristics and maternity ward, were used to compare CS rates globally and for each group of the system. Variability of CS rates between maternity wards was analyzed using the coefficients of variation. RESULTS There were 51 082 women who delivered during the pre-period and 63 964 during the post-period. The overall CS rate did not decrease (24.5% during the pre-period vs 25.1% during the post-period). There were no significant differences in CS rates for any group of the Ten Group Classification System after adjustment for maternity, maternal age and sociodemographic characteristics, nor did audit implementation decrease CS rate variability between maternity wards or within groups of the system. CONCLUSIONS Implementation of an audit-and-feedback cycle using the Ten Group Classification System did not decrease either CS rates or variability between maternity wards.
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Affiliation(s)
- Thibaud Quibel
- Department of Gynecology and Obstetrics, Intercommunal Hospital Centre of Poissy-Saint-Germain-en-Laye, Poissy, France.,EA 7285, Research Unit "Risk and Safety in Clinical Medicine for Women and Perinatal Health", Versailles-Saint- Quentin University (UVSQ), Montigny le Bretonneux, France
| | - Marion Chesnais
- Department of Gynecology and Obstetrics, Intercommunal Hospital Centre of Poissy-Saint-Germain-en-Laye, Poissy, France.,EA 7285, Research Unit "Risk and Safety in Clinical Medicine for Women and Perinatal Health", Versailles-Saint- Quentin University (UVSQ), Montigny le Bretonneux, France
| | - Camille Bouyer
- Department of Gynecology and Obstetrics, Intercommunal Hospital Centre of Poissy-Saint-Germain-en-Laye, Poissy, France.,French Perinatal Network (Réseau de périnatalité Maternité en Yvelines et Périnatalité Active MYPA), Poissy, France
| | - Patrick Rozenberg
- Department of Gynecology and Obstetrics, Intercommunal Hospital Centre of Poissy-Saint-Germain-en-Laye, Poissy, France.,EA 7285, Research Unit "Risk and Safety in Clinical Medicine for Women and Perinatal Health", Versailles-Saint- Quentin University (UVSQ), Montigny le Bretonneux, France
| | - Jean Bouyer
- CESP Center for Research in Epidemiology and Population Health, INSERM, Villejuif, France
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Vikhareva O, Nedopekina E, Kristensen K, Dahlbäck C, Pihlsgård M, Rickle GS, Herbst A. Strategies to increase the rate of vaginal deliveries after cesarean without negative impact on outcomes. Midwifery 2022; 106:103247. [DOI: 10.1016/j.midw.2021.103247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 12/27/2021] [Indexed: 11/28/2022]
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Eliner Y, Gulersen M, Chervenak FA, Lenchner E, Grunebaum A, Phillips K, Bar-El L, Bornstein E. Maternal education and racial/ethnic disparities in nulliparous, term, singleton, vertex cesarean deliveries in the United States. AJOG GLOBAL REPORTS 2022; 2:100036. [PMID: 36274969 PMCID: PMC9563532 DOI: 10.1016/j.xagr.2021.100036] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 11/30/2021] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Racial and ethnic disparities in obstetrical and neonatal outcomes are prevalent in the United States. Such racial or ethnic disparities have also been documented in the prevalence of cesarean deliveries. OBJECTIVE We aimed to evaluate the impact of maternal education on racial or ethnic disparities in the prevalence of low-risk nulliparous, term, singleton, vertex cesarean deliveries in the United States. STUDY DESIGN This is a retrospective analysis of the Centers for Disease Control and Prevention live births database (2016–2019). Nulliparous, term, singleton, vertex births from the following racial/ethnic groups were included: non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Hispanic. Pregnancies complicated by gestational or pregestational diabetes mellitus and hypertensive disorders were excluded. Data were analyzed on the basis of the level of maternal education (less than high school graduate, high school graduate, college graduate, and advanced degree). We compared the prevalence of cesarean deliveries among the different racial or ethnic groups within each education level using Pearson chi-square test with Bonferroni adjustment. Multivariate logistic regression was performed to assess the association between cesarean deliveries and maternal race/ethnicity, maternal education, and the interaction between maternal race or ethnicity and education level, while controlling for potential confounders. To demonstrate the effect of the interaction, separate logistic regression models with similar covariates were performed for each education level and for each race/ethnicity group. Statistical significance was determined as P<.05, and results were displayed as adjusted odds ratios with 95% confidence intervals. RESULTS The overall prevalence of cesarean deliveries during the study period was 23.4% (695,214 of 2,969,207 births). All racial or ethnic minority groups had higher rates of cesarean deliveries than non-Hispanic White women (non-Hispanic Black, 27.4%; non-Hispanic Asian, 25.6%; Hispanic, 23.0%; and non-Hispanic White, 22.4%; [P<.001 for all comparisons]). Similar racial or ethnic differences in cesarean delivery rates were detected among all education levels. Higher levels of education were associated with a lower likelihood of cesarean delivery (adjusted odds ratio, 0.88; [95% confidence interval, 0.87–0.89]) in women with advanced degrees than in women who did not graduate from high school. However, although maternal education was associated with a protective effect in non-Hispanic White and non-Hispanic Asian women (adjusted odds ratio, 0.83 [95% confidence interval, 0.81–0.85] and adjusted odds ratio, 0.81 [95% confidence interval, 0.77–0.86], respectively, for women with advanced degrees), it had a smaller protective effect in non-Hispanic Black women (adjusted odds ratio, 0.93 [95% confidence interval, 0.89–0.97]) and no protective effect in Hispanic women (adjusted odds ratio, 0.98 [95% confidence interval, 0.96–1.01]). CONCLUSION We document a significant racial/ethnic disparity in the prevalence of low-risk nulliparous, term, singleton, vertex cesarean deliveries in the United States. Furthermore, our findings suggest that although a higher level of maternal education is associated with a lower likelihood of cesarean delivery, this protective effect varies among racial or ethnic groups. Further research is needed to investigate the underlying causes for this racial/ethnic disparity.
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Recio Alcaide A, Arranz JM. An impact evaluation of the strategy for normal birth care on caesarean section rates and perinatal mortality in Spain. Health Policy 2022; 126:24-34. [PMID: 34848110 DOI: 10.1016/j.healthpol.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/15/2021] [Accepted: 11/11/2021] [Indexed: 11/04/2022]
Abstract
The objectives of this research are to evaluate the impact of a health policy (the Strategy for Normal Birth Care, EAPN) on caesarean rates and perinatal mortality in Spanish public hospitals belonging to the National Health System (NHS) and to assess the related cost savings. Data from the Spanish Ministry of Health for the period 2002-2011 and quantitative impact evaluation techniques (double difference method) are used to compare the effects of this policy in a treatment group composed of the NHS hospitals and a control group made up of private for-profit hospitals outside the scope of the EAPN. Both groups are compared some years before and after the health policy initiated in 2006 and approved in October 2007. The estimation results show that the EAPN had a significant effect in reducing caesarean rates of approximately 2 percentage points between 2007 and 2011, with increasing cost savings over the years ranging from 24 to 44 million euros depending on the year. Furthermore, EAPN reduced perinatal mortality levels by 0.08% in years 2008-2009.
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Affiliation(s)
- Adela Recio Alcaide
- Instituto de Estudios Fiscales. Avda. Cardenal Herrera Oria, 378 Ed. B 1.59 28035 Madrid (Spain); Public Health Unit, School of Medicine, Universidad de Alcalá, Alcalá de Henares 28871 Madrid-España.
| | - José M Arranz
- Departamento de Economía. Facultad de CCEE y Turismo. Universidad de Alcalá. Plaza de la Victoria 2. Alcalá de Henares 28802 Madrid-España.
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15
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Fruscalzo A, Reinecke K, Londero AP, Gantert M. Composite non-clinical interventions for a safe cesarean section rate reduction: results of a pre-post interventional study. BMC Pregnancy Childbirth 2021; 21:783. [PMID: 34798862 PMCID: PMC8603588 DOI: 10.1186/s12884-021-04245-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 10/26/2021] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To evaluate the impact on cesarean section (CS) rate with of a program of multiple non-clinical interventions targeted at health-care professional within a hospital maternity ward. MATERIALS AND METHODS Retrospective quasi-experimental pre-post intervention study with an historical control group conducted in a second-level teaching hospital. All women who gave birth in the period 2014 to 2018 were included. A series of multiple non-clinical interventions including a dedicated team of obstetricians for delivery room and antenatal counseling, monthly internal audits and physician education by local opinion leader were prospectively introduced from September 2016. The primary outcome of the study was the CS rate. The incidences of operative vaginal delivery, 3rd-/4th-degree perineal tears and further maternal and neonatal complications were considered as secondary outcomes. RESULTS The CS rate dropped from 33.05 to 26.06% after starting the interventions (p < 0.01); in particular, the cumulative rate of CS performed during labor decreased significantly from 19.46 to 14.11% (p < 0.01). CS reduction was still statistically significant after multivariate correction (OR = 0.66, CI.95 = 0.57-0.76, p < 0.01). Results further showed an increased prevalence of 3rd-degree perineal tears (0.97% versus 2.24%, p < 0.01), present also after correcting for possible confounding factors (OR = 2.36, CI.95 = 1.48-3.76, p < 0.01). No differences were found in the rate of vaginal-operative births and further maternal complications, while the composite neonatal outcome was found to be improved (OR = 0.73, CI.95 = 0.57-0.93, p = 0.010). CONCLUSIONS The introduction of multiple non-clinical interventions can significantly reduce the CS rate. However, beside an improvement in neonatal composite outcome, a potential increase in high-degree perineal tears should be taken in account.
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Affiliation(s)
- A. Fruscalzo
- Obstetrics and Gynecology, St. Franziskus Hospital of Ahlen, Ahlen, Germany
- Present address: Obstetrics and Gynecology, University Hospital of Fribourg, Fribourg, Switzerland
| | - K. Reinecke
- Obstetrics and Gynecology, St. Franziskus Hospital of Ahlen, Ahlen, Germany
| | - A. P. Londero
- Obstetrics and Gynecology, University Hospital of Udine, Udine, Italy
- Ennergi Research (non-profit organisation), Lestizza, UD 33050 Italy
| | - M. Gantert
- Obstetrics and Gynecology, St. Franziskus Hospital of Ahlen, Ahlen, Germany
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Farrell ME, Lutgendorf MA. Term Singleton Vertex Cesarean Birth Rates in the Military Health System. J Perinat Neonatal Nurs 2021; 35:313-319. [PMID: 34726647 DOI: 10.1097/jpn.0000000000000578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cesarean births have increased in the United States, accounting for approximately one-third of all births. There is concern that cesarean birth is overused, due to the wide variation in rates geographically and at different institutions within the same region. Despite the rising rate, there has not been an improvement in maternal or neonatal outcomes. Consequently, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine published recommendations aimed at the safe prevention of primary cesarean births in 2014. The purpose of this project was to identify the term singleton vertex cesarean birth rates in the Military Health System's hospitals; to compare the Military Health System's rate of term singleton vertex cesarean birth to published benchmarks; and to compare term singleton vertex cesarean birth rates over time and among facilities within the Military Health System to determine whether variation existed. This was a retrospective review of aggregate data reported by the National Perinatal Information Center. Data were analyzed over 9 years at 2-year intervals from 2011 through 2019 inclusively. The Military Health System exceeded national benchmarks for term singleton vertex cesarean birth rates and had less variation over time and among facilities.
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Affiliation(s)
- Maureen E Farrell
- Medical Directory Gynecologic Surgical Services, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Dr Farrell); Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, Massachusetts (Dr Farrell); and Division of Maternal Fetal Medicine, Naval Medical Center San Diego, San Diego, California (Dr Lutgendorf)
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Breman RB, Hamm RF, Callaghan-Koru JA. Letter to the editor of implementation science in response to "Implementation Science in maternity care, A scoping Review" by Dadich, Piper, and Coates (2021). Implement Sci 2021; 16:79. [PMID: 34392829 PMCID: PMC8365971 DOI: 10.1186/s13012-021-01129-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 05/18/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Rachel Blankstein Breman
- Department of Partnerships, Professional Education and Practice, School of Nursing, University of Maryland, Baltimore, MD, USA.
| | - Rebecca Feldman Hamm
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Jennifer A Callaghan-Koru
- Department of Sociology, Anthropology and Public Health, University of Maryland, Baltimore County, Baltimore, USA
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Prediger B, Heu-Parvaresch A, Polus S, Bühn S, Neugebauer EAM, Dawid P. A systematic review on the effectiveness of implementation strategies to postpone elective caesarean sections to ≥ 39 + (0-6) weeks of gestation. Syst Rev 2021; 10:176. [PMID: 34127077 PMCID: PMC8201675 DOI: 10.1186/s13643-021-01718-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 05/25/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Caesarean sections often have no urgent indication and are electively planned. Research showed that elective caesarean section should not be performed until 39 + (0-6) weeks of gestation to ensure best neonatal and maternal health if there are no contraindications. This was recommended by various guidelines published in the last two decades. With this systematic review, we are looking for implementation strategies trying to implement these recommendations to reduce elective caesarean section before 39 + (0-6) weeks of gestation. METHODS We performed a systematic literature search in MEDLINE, EMBASE, CENTRAL, and CINAHL on 3rd of March 2021. We included studies that assessed implementation strategies aiming to postpone elective caesarean section to ≥ 39 + (0-6) weeks of gestation. There were no restrictions regarding the type of implementation strategy or reasons for elective caesarean section. Our primary outcome was the rate of elective caesarean sections before 39 + (0-6) weeks of gestation. We used the ROBINS-I Tool for the assessment of risk of bias. We did a narrative analysis of the results. RESULTS We included 10 studies, of which were 2 interrupted time series and 8 before-after studies, covering 205,954 elective caesarean births. All studies included various types of implementation strategies. All implementation strategies showed success in decreasing the rate of elective caesarean sections performed < 39 + (0-6) weeks of gestation. Risk difference differed from - 7 (95% CI - 8; - 7) to - 45 (95% CI - 51; - 31). Three studies reported the rate of neonatal intensive care unit admission and showed little reduction. CONCLUSION This systematic review shows that all presented implementation strategies to reduce elective caesarean section before 39 + (0-6) weeks of gestation are effective. Reduction rates differ widely and it remains unclear which strategy is most successful. Strategies used locally in one hospital seem a little more effective. Included studies are either before-after studies (8) or interrupted time series (2) and the overall quality of the evidence is rather low. However, most of the studies identified specific barriers in the implementation process. For planning an implementation strategy to reduce elective caesarean section before 39 + (0-6) weeks of gestation, it is necessary to consider specific barriers and facilitators and take all obstetric personal into account. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017078231.
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Affiliation(s)
- Barbara Prediger
- Institute for Research in Operative Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Haus 38, 51109 Cologne, Germany
| | - Anahieta Heu-Parvaresch
- Institute for Medical Sociology, Health Services Research, and Rehabilitation Science, The University Hospital of Cologne (AöR), Cologne, Germany
| | - Stephanie Polus
- Institute for Medical Information Processing, Biometry and Epidemiology, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, LMU Munich, Munich, Germany
| | - Stefanie Bühn
- Institute for Research in Operative Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Haus 38, 51109 Cologne, Germany
| | - Edmund A. M. Neugebauer
- Faculty of Health, Brandenburg Medical School — Theodor Fontane, Campus Neuruppin, Fehrbelliner Str.38, 16816 Neuruppin, Germany
| | - Pieper Dawid
- Institute for Research in Operative Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Haus 38, 51109 Cologne, Germany
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Domingues RMSM, Luz PM, da Silva Ayres BV, Torres JA, do Carmo Leal M. Cost-effectiveness analysis of a quality improvement program to reduce caesarean sections in Brazilian private hospitals: a case study. Reprod Health 2021; 18:93. [PMID: 33964941 PMCID: PMC8106214 DOI: 10.1186/s12978-021-01147-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 05/02/2021] [Indexed: 12/02/2022] Open
Abstract
Background In 2015, a quality improvement project of childbirth care called Adequate Childbirth Project (“Projeto Parto Adequado”- PPA) was implemented in Brazilian public and private hospitals, aiming to improve the quality of childbirth care and to reduce caesarean sections without clinical indications. The objective of this study is to conduct an economic analysis of two models of care existing in a private Brazilian hospital—the model following the recommendations of the PPA and the standard of care model—in reducing the proportion of caesarean sections. Methods We conducted a cost-effectiveness analysis using data from one of the private hospitals included in the PPA project. The main outcome was the proportion of caesarean section. We used total cost of hospitalization for women and newborns, from the health care sector perspective, during the length of the observed hospital stay. We did not apply discount rates and inflation rate adjustments due to the short time horizon. We conducted univariate sensitivity analysis using the minimum and maximum costs observed in hospitalizations and variation in the probabilities of caesarean section and of maternal and neonatal complications. Results 238 puerperal women were included in this analysis. The PPA model of care resulted in a 56.9 percentage point reduction in the caesarean section probability (88.6% vs 31.7%, p < 0.001) with an incremental cost-effectiveness ratio of US$1,237.40 per avoided caesarean section. Women in the PPA model of care also had a higher proportion of spontaneous and induced labor and a lower proportion of early term births. There were no maternal, fetal or neonatal deaths and no significant differences in cases of maternal and neonatal near miss. The cost of uncomplicated vaginal births and caesarean sections was the parameter with the greatest impact on the cost-effectiveness ratio of the PPA model of care. Conclusion The PPA model of care was cost-effective in reducing caesarean sections in women assisted in a Brazilian private hospital. Moreover, it reduced the frequency of early term births and did not increase the occurrence of severe negative maternal and neonatal outcomes. Caesarean section is a safe intervention to save the lives of women and newborns. However, it is associated with negative health consequences for women and children in the short, medium and long term. Therefore, its harmful effects can outweigh its benefits when used excessively. Caesarean rates are increasing globally. In Brazil, caesarean section is the most frequent type of birth since 2009. In 2015, a quality improvement project, called “Adequate Childbirth Project” (PPA), was implemented in Brazilian public and private hospitals with the aim of improving the quality of childbirth care and reducing caesarean sections without clinical indications. In this study, we compared the caesarean rate and the hospitalization costs of women assisted in this new model of care and in the standard of care model. The women attended in the PPA model of care had a lower rate of caesarean section (31.7% vs 88.6% in the standard of care model), with no differences in severe negative maternal and neonatal outcomes. Women in the PPA model of care also had a higher frequency of spontaneous or induced labor and a lower frequency of early term births, that is, less than 39 weeks of gestation. The PPA model of care was considered cost-effective, that is, it produced good results for the amount of money spent. This is a promising result for services that face the problem of increasing numbers of caesarean sections and are looking for strategies to improve the quality of childbirth care.
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Affiliation(s)
- Rosa Maria Soares Madeira Domingues
- Fundação Oswaldo Cruz, Laboratório de Pesquisa Clínica Em DST/Aids, Instituto Nacional de Infectologia Evandro Chagas, Av. Brasil, 4365, Manguinhos, Rio de Janeiro, RJ, CEP 21040-360, Brazil.
| | - Paula Mendes Luz
- Fundação Oswaldo Cruz, Instituto Nacional de Infectologia Evandro Chagas, Rio de Janeiro, Brazil
| | | | | | - Maria do Carmo Leal
- Fundação Oswaldo Cruz, Escola Nacional de Saúde Pública Sérgio Arouca, Rio de Janeiro, Brazil
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Rosenstein MG, Chang SC, Sakowski C, Markow C, Teleki S, Lang L, Logan J, Cape V, Main EK. Hospital Quality Improvement Interventions, Statewide Policy Initiatives, and Rates of Cesarean Delivery for Nulliparous, Term, Singleton, Vertex Births in California. JAMA 2021; 325:1631-1639. [PMID: 33904868 PMCID: PMC8080226 DOI: 10.1001/jama.2021.3816] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Safe reduction of the cesarean delivery rate is a national priority. OBJECTIVE To evaluate the rates of cesarean delivery for nulliparous, term, singleton, vertex (NTSV) births in California in the context of a statewide multifaceted intervention designed to reduce the rates of cesarean delivery. DESIGN, SETTING, AND PARTICIPANTS Observational study of cesarean delivery rates from 2014 to 2019 among 7 574 889 NTSV births in the US and at 238 nonmilitary hospitals providing maternity services in California. From 2016 to 2019, California Maternal Quality Care Collaborative partnered with Smart Care California to implement multiple approaches to decrease the rates of cesarean delivery. Hospitals with rates of cesarean delivery greater than 23.9% for NTSV births were invited to join 1 of 3 cohorts for an 18-month quality improvement collaborative between July 2016 and June 2019. EXPOSURES Within the collaborative, multidisciplinary teams implemented multiple strategies supported by mentorship, shared learning, and rapid-cycle data feedback. Partnerships among nonprofit organizations, state governmental agencies, purchasers, and health plans addressed the external environment through transparency, award programs, and incentives. MAIN OUTCOMES AND MEASURES The primary outcome was the change in cesarean delivery rates for NTSV births in California and a difference-in-differences analysis was performed to compare cesarean delivery rates for NTSV births in California vs the rates in the rest of the US. A mixed multivariable logistic regression model that adjusted for patient-level and hospital-level confounders also was used to assess the collaborative and the external statewide actions. The cesarean delivery rates for NTSV births at hospitals participating in the collaborative were compared with the rates from the nonparticipating hospitals and the rates in the participating hospitals prior to participation in the collaborative. RESULTS A total of 7 574 889 NTSV births occurred in the US from 2014 to 2019, of which 914 283 were at 238 hospitals in California. All California hospitals were exposed to the statewide actions to reduce the rates of cesarean delivery, including the 149 hospitals that had baseline rates of cesarean delivery greater than 23.9% for NTSV births, of which 91 (61%) participated in the quality improvement collaborative. The rate of cesarean delivery for NTSV births in California decreased from 26.0% (95% CI, 25.8%-26.2%) in 2014 to 22.8% (95% CI, 22.6%-23.1%) in 2019 (relative risk, 0.88; 95% CI, 0.87-0.89). The rate of cesarean delivery for NTSV births in the US (excluding California births) was 26.0% in both 2014 and 2019 (relative risk, 1.00; 95% CI, 0.996-1.005). The difference-in-differences analysis revealed that the reduction in the rate of cesarean delivery for NTSV births in California was 3.2% (95% CI, 1.7%-3.5%) higher than in the US (excluding California). Compared with the hospitals and the periods not exposed to the collaborative activities, and after adjusting for patient characteristics and time using a modified stepped-wedge analysis, exposure to collaborative activities was associated with a lower odds of cesarean delivery for NTSV births (24.4% vs 24.6%; adjusted odds ratio, 0.87 [95% CI, 0.85-0.89]). CONCLUSIONS AND RELEVANCE In this observational study of NTSV births in California from 2014 to 2019, the rates of cesarean delivery decreased over time in the setting of the implementation of a coordinated hospital-level collaborative and statewide initiatives designed to support vaginal birth.
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Affiliation(s)
- Melissa G. Rosenstein
- California Maternal Quality Care Collaborative, Stanford University, Stanford
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
| | - Shen-Chih Chang
- California Maternal Quality Care Collaborative, Stanford University, Stanford
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Christa Sakowski
- California Maternal Quality Care Collaborative, Stanford University, Stanford
| | - Cathie Markow
- California Maternal Quality Care Collaborative, Stanford University, Stanford
| | | | | | - Julia Logan
- California Department of Health Care Services, Sacramento
- California Public Employees’ Retirement System, Sacramento
| | - Valerie Cape
- California Maternal Quality Care Collaborative, Stanford University, Stanford
| | - Elliott K. Main
- California Maternal Quality Care Collaborative, Stanford University, Stanford
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
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Cesarean delivery in low- and middle-income countries: A review of quality of care metrics and targets for improvement. Semin Fetal Neonatal Med 2021; 26:101199. [PMID: 33546999 PMCID: PMC8026747 DOI: 10.1016/j.siny.2021.101199] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Improving quality of care in low-and middle-income countries (LMICs) is a global priority, specifically around maternal and newborn care, where mortality and morbidity remain unacceptably high. Cesarean delivery is the most common procedure in women, thus evaluating quality around the provision of this intervention provides insight into overall quality of care around childbirth. In this review we provide an overview on the quality of care around cesarean delivery using the six domains of quality proposed by the Institute of Medicine: equity, effectiveness, efficiency, safety, timeliness and patient-centered care. We review evidence of potential quality gaps in each of these domains around cesarean delivery in LMICs, discuss opportunities for improvement and provide suggestions on metrics for tracking quality in each of these domains. As cesarean delivery rates increase globally, efforts to ensure quality will be essential to drive continued and sustained improvements in global maternal and newborn outcomes.
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Pinto P, Crispín-Milart PH, Rojo E, Adiego B. Impact of clinical audits on cesarean section rate in a Spanish hospital: Analysis of 6 year data according to the Robson classification. Eur J Obstet Gynecol Reprod Biol 2020; 254:308-314. [PMID: 33039839 DOI: 10.1016/j.ejogrb.2020.09.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/08/2020] [Accepted: 09/11/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The aim of this study is to analyze the impact of the introduction of an internal clinical audit on the cesarean section (CS) rate, evaluated according to the Robson Ten Group Classification System (TGCS), and to identify the main contributors to the overall CS rate in order to plan further interventions. STUDY DESIGN In 2014, an internal clinic audit committee was established in our center. Modifications of clinical management protocols were also implemented. A retrospective review of clinical records was conducted and pre-audit (2011-2014) results were compared against audit (2015-2018) results. Patients were clustered according to the Robson TGCS and the analyzed outcomes were CS rate and maternal and neonatal results. RESULTS Between January 2011 and December 2018, 12,766 women gave birth at our institution among which 2,281 CS were analyzed. After the establishment of the clinical audit, the overall CS rate decreased from 20.27% to 14.82 % (p < 0.01). The major contribution to the overall CS rate in both periods were made by Group 2a (nulliparous with a single cephalic pregnancy at term who underwent labor induction: 4.86 % of all cases), followed by Group 5 (patients with a previous C-section: 3.26 %) and Group 1 (nulliparous with a single cephalic pregnancy at term with spontaneous labor: 2.39 %), representing 59.6 % of all CS. The group that showed the greatest reduction to the overall Cs rate was Group 2 (5.77 % vs 3.96 %, OR 1.48 (p < 0.01). No differences in perinatal and maternal results were found between preaudit and audit group. CONCLUSION Audit, feedback, and modification of clinical management protocols may be effective in changing clinical practice and reducing CS rates without worsening maternal and neonatal morbimortality. Robson TGCS allowed us to identify which groups had the greatest impact on CS rate in order to establish new strategies that may lead us to optimize the use of this intervention. It seems that efforts to reduce the overall CS rate should be directed on increasing vaginal birth after CS and reducing CS rates in nulliparous women with single cephalic full-term pregnancy.
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Affiliation(s)
- Patricia Pinto
- Department of Obstetrics and Gynaecology, Fundación Alcorcón University Hospital, Alcorcón, Madrid, Spain.
| | - Patricia H Crispín-Milart
- Department of Obstetrics and Gynaecology, Fundación Alcorcón University Hospital, Alcorcón, Madrid, Spain
| | - Elena Rojo
- Department of Obstetrics and Gynaecology, Fundación Alcorcón University Hospital, Alcorcón, Madrid, Spain
| | - Begoña Adiego
- Department of Obstetrics and Gynaecology, Fundación Alcorcón University Hospital, Alcorcón, Madrid, Spain
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Miazga E, Reed C, Tunde-Byass M, Cipolla A, Shapiro J, Shore EM. Decreasing Cesarean Delivery Rates Using a Trial of Labour After Cesarean (TOLAC) Bundle. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 42:1111-1115. [DOI: 10.1016/j.jogc.2020.02.113] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/12/2020] [Accepted: 02/13/2020] [Indexed: 01/26/2023]
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Hildebrand E, Nelson M, Blomberg M. Long-term effects of the nine-item list intervention on obstetric and neonatal outcomes in Robson group 1 - A time series study. Acta Obstet Gynecol Scand 2020; 100:154-161. [PMID: 32767668 PMCID: PMC7754388 DOI: 10.1111/aogs.13970] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 07/24/2020] [Accepted: 07/25/2020] [Indexed: 01/25/2023]
Abstract
Introduction The nine‐item list, with organizational and cultural changes, was implemented at the delivery unit in Linköping, Sweden between 2007 and 2010, aiming at improving the quality of care by offering more women a safe and attractive vaginal delivery. The target group for the intervention was nulliparous women at term with spontaneous onset of labor and cephalic presentation (Robson group 1). The aim of this study was to evaluate pregnancy outcomes before, during, early post and late post introduction of the nine‐item list. Material and methods Robson group 1 births (n = 12 763) from 2004 to 2018 were divided into four time periods; before the nine‐item list (2004‐2006), during introduction of the nine‐item list (2007‐2010), early post introduction of the nine‐item list (2011‐2014) and late post introduction of the nine‐item list (2015‐2018). The nine‐item list consists of monitoring of obstetric results, midwife coordinator, risk classification of women, three midwife‐competence levels, teamwork—the midwife, obstetrician and nurse working as a team with the common goal of a normal delivery, obstetric morning round, fetal monitoring skills and obstetric skills training. Perinatal outcomes before, during, early post and late post introduction were compared using a Student's t test for numerical variables and a Pearson chi‐squared test for categorical variables. Results Apgar score <7 at 5 minutes, Apgar score <4 at 5 minutes and umbilical cord arterial pH <7 did not differ significantly between the four time periods. Between before introduction and early post introduction, instrumental vaginal delivery decreased from 19.8% to 12.2% and cesarean section from 9.6% to 4.5%. The late post introduction period showed a maintained effect with 10.7% instrumental deliveries and 3.9% cesarean sections. Obstetric anal sphincter injury grade III decreased instantly during the introduction of the nine‐item list from 7.8% to 5.1% and thereafter remained unchanged. Conclusions Implementation of the nine‐item list increased the proportion of spontaneous vaginal deliveries by reducing the number of instrumental deliveries and cesarean sections without affecting the neonatal outcomes in nulliparous women with spontaneous onset of labor. The nine‐item list intervention seems to provide long‐term sustainable results.
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Affiliation(s)
- Eric Hildebrand
- Department of Obstetrics and Gynecology and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Marie Nelson
- Department of Obstetrics and Gynecology and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Marie Blomberg
- Department of Obstetrics and Gynecology and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Improving the Caesarean Decision by Robson Classification: A Population-Based Study by 5,323,500 Livebirth Data. Ann Glob Health 2020; 86:101. [PMID: 32874932 PMCID: PMC7442169 DOI: 10.5334/aogh.2615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Caesarean section is a major obstetric intervention for saving lives of women and their newborns from pregnancy- and childbirth-related complications. C-Section rate is considered an important indicator for measuring obstetric services in any country, region, or institution. In many countries, based on population, all-cause C-Section rates have increased steadily during the past half century. The high and rising C-Section rate is certainly a cause for concern, and evidence-based information is needed as to how or why the C-Section rate has increased and what needs to be done. In this study, we tried to demonstrate how the Robson Classification can be used as a common starting point to audit caesarean deliveries. Objectives Given the lack of a scientifically proven classification system to observe and compare caesarean rates, the WHO proposes adopting the Robson's criteria-related grouping as an internationally applicable C-Section classification system. Methods We conducted a retrospective study to look into the relation of Robson Criteria and C-Section. Our four years of study encompass 5,323,500 livebirths in Turkey and provide an important source of information for evaluating statistical data. Findings We analysed pregnancies according to the percentage of live births in Robson's groups and the caesarean rate within the Robson's groups. In total, 2,764,373 pregnant women have undergone caesarean over 4 years with a 51.9% C-Section rate. According to our findings, as time progresses, the R5 group are expanding due to the caesarean sections groups R1-R4.The R5 group C-Section rate increased regularly from 22.2% in 2013 to 24.3% in 2016. Caesarean sections performed in R1-R4 groups cause subsequent pregnancies of these women to result in caesarean section. Conclusions Our results suggest the Robson classification system will help in analysing, screening, auditing, and comparing caesarean rates across different hospitals, countries, or regions and will help to create and implement effective strategies specifically to reach WHO recommended C-Section rates.
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Sakala C, Belanoff C, Declercq ER. Factors Associated with Unplanned Primary Cesarean Birth: Secondary Analysis of the Listening to Mothers in California Survey. BMC Pregnancy Childbirth 2020; 20:462. [PMID: 32795305 PMCID: PMC7427718 DOI: 10.1186/s12884-020-03095-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 07/06/2020] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND In many countries, cesarean section has become the most common major surgical procedure. Most nations have high cesarean birth rates, suggesting overuse. Due to the excess harm and expense associated with unneeded cesareans, many health systems are seeking approaches to safe reduction of cesarean rates. Surveys of childbearing women are a distinctive and underutilized source of data for examining factors that may contribute to cesarean reduction. METHODS To identify factors associated with unplanned primary cesarean birth, we carried out a secondary analysis of the Listening to Mothers in California Survey, limited to the subgroup who had not had a previous cesarean birth and did not have a planned primary cesarean (n = 1,964). Participants were identified through birth certificate sampling and contacted initially by mail and then by telephone, text message and email, as available. Sampled women could participate in English or Spanish, on any device or with a telephone interviewer. Following bivariate demographic, knowledge and attitude, and labor management analyses, we carried out multivariable analyses to adjust with covariates and identify factors associated with unplanned primary cesarean birth. RESULTS Whereas knowledge, attitudes, preferences and behaviors of the survey participants were not associated with having an unplanned primary cesarean birth, their experience of pressure from a health professional to have a cesarean and a series of labor management practices were strongly associated with how they gave birth. These practices included attempted induction of labor, early hospital admission, and labor augmentation. Women's reports of pressure from a health professional to have a primary cesarean were strongly related to the likelihood of cesarean birth. CONCLUSIONS While women largely wish to avoid unneeded childbirth interventions, their knowledge, preferences and care arrangement practices did not appear to impact their likelihood of an unplanned primary cesarean birth. By contrast, a series of labor management practices and perceived health professional pressure to have a cesarean were associated with unplanned primary cesarean birth. Improving ways to engage childbearing women and implementing changes in labor management and communication practices may be needed to reduce unwarranted cesarean birth.
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Affiliation(s)
- Carol Sakala
- National Partnership for Women & Families, 1875 Connecticut Avenue, NW, Suite 650, Washington, DC 20009 USA
| | - Candice Belanoff
- Boston University School of Public Health, 801 Massachusetts Avenue Crosstown Center, 4th Floor, Boston, MA 02118 USA
| | - Eugene R. Declercq
- Boston University School of Public Health, 801 Massachusetts Avenue Crosstown Center, 4th Floor, Boston, MA 02118 USA
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Ayorinde AA, Williams I, Mannion R, Song F, Skrybant M, Lilford RJ, Chen YF. Publication and related bias in quantitative health services and delivery research: a multimethod study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Bias in the publication and reporting of research findings (referred to as publication and related bias here) poses a major threat in evidence synthesis and evidence-based decision-making. Although this bias has been well documented in clinical research, little is known about its occurrence and magnitude in health services and delivery research.
Objectives
To obtain empirical evidence on publication and related bias in quantitative health services and delivery research; to examine current practice in detecting/mitigating this bias in health services and delivery research systematic reviews; and to explore stakeholders’ perception and experiences concerning such bias.
Methods
The project included five distinct but interrelated work packages. Work package 1 was a systematic review of empirical and methodological studies. Work package 2 involved a survey (meta-epidemiological study) of randomly selected systematic reviews of health services and delivery research topics (n = 200) to evaluate current practice in the assessment of publication and outcome reporting bias during evidence synthesis. Work package 3 included four case studies to explore the applicability of statistical methods for detecting such bias in health services and delivery research. In work package 4 we followed up four cohorts of health services and delivery research studies (total n = 300) to ascertain their publication status, and examined whether publication status was associated with statistical significance or perceived ‘positivity’ of study findings. Work package 5 involved key informant interviews with diverse health services and delivery research stakeholders (n = 24), and a focus group discussion with patient and service user representatives (n = 8).
Results
We identified only four studies that set out to investigate publication and related bias in health services and delivery research in work package 1. Three of these studies focused on health informatics research and one concerned health economics. All four studies reported evidence of the existence of this bias, but had methodological weaknesses. We also identified three health services and delivery research systematic reviews in which findings were compared between published and grey/unpublished literature. These reviews found that the quality and volume of evidence and effect estimates sometimes differed significantly between published and unpublished literature. Work package 2 showed low prevalence of considering/assessing publication (43%) and outcome reporting (17%) bias in health services and delivery research systematic reviews. The prevalence was lower among reviews of associations than among reviews of interventions. The case studies in work package 3 highlighted limitations in current methods for detecting these biases due to heterogeneity and potential confounders. Follow-up of health services and delivery research cohorts in work package 4 showed positive association between publication status and having statistically significant or positive findings. Diverse views concerning publication and related bias and insights into how features of health services and delivery research might influence its occurrence were uncovered through the interviews with health services and delivery research stakeholders and focus group discussion conducted in work package 5.
Conclusions
This study provided prima facie evidence on publication and related bias in quantitative health services and delivery research. This bias does appear to exist, but its prevalence and impact may vary depending on study characteristics, such as study design, and motivation for conducting the evaluation. Emphasis on methodological novelty and focus beyond summative assessments may mitigate/lessen the risk of such bias in health services and delivery research. Methodological and epistemological diversity in health services and delivery research and changing landscape in research publication need to be considered when interpreting the evidence. Collection of further empirical evidence and exploration of optimal health services and delivery research practice are required.
Study registration
This study is registered as PROSPERO CRD42016052333 and CRD42016052366.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 33. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Abimbola A Ayorinde
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Iestyn Williams
- Health Services Management Centre, School of Social Policy, University of Birmingham, Birmingham, UK
| | - Russell Mannion
- Health Services Management Centre, School of Social Policy, University of Birmingham, Birmingham, UK
| | - Fujian Song
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Magdalena Skrybant
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Richard J Lilford
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Yen-Fu Chen
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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Carrillo-Aguirre G, Dalmau-Bueno A, Campillo-Artero C, García-Altés A. Caesarean section trends in Catalonia between 2013 and 2017 based on the Robson classification system: A cross-sectional study. PLoS One 2020; 15:e0234727. [PMID: 32544171 PMCID: PMC7297373 DOI: 10.1371/journal.pone.0234727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 06/01/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION In Catalonia caesarean rates have always been analysed as a single percentage. The objective is to estimate caesarean section rates using the Robson classification in publicly funded hospitals in Catalonia between 2013 and 2017, considering sociodemographic, institutional and obstetric characteristics. MATERIALS AND METHODS Cross-sectional population-based study in Catalonia including all women delivering within publicly funded hospitals between 2013-2017 (n = 210 020). The modified Robson classification distribution was estimated, the caesarean rate and the overall contribution, analysed for each year, and by confounders, through logistic regression models. RESULTS CS rates decreased steadily between 2013 and 2017 in Catalonia within publicly funded hospitals from 24.3% to 22.8% (cOR 0.92, 95% CI; 0.89 to 0.95). Once adjusted for changes in sociodemographic, institutional and obstetric characteristics the observed decline was even more pronounced (aOR 0.87, 95% CI; 0.84 to 0.90). Within the different groups of Robson once adjusted for confounders, groups 1+2 (aOR 0.88, 95% CI; 0.83 to 0.93), 3+4 (aOR 0.83, 95% CI; 0.78 to 0.89) and 10 (aOR 0.78, 95% CI; 0.68 to 0.90) presented a reduction in caesarean section rates, whereas group 5 showed no significant decrease (aOR 0.95, 95% CI; 0.87 to 1.03%). CONCLUSIONS The decrease in caesarean section rates in Catalonia is more pronounced when adjusted for known confounders, suggesting retrospective overutilization of caesarean section and percentages of (in)adequacy in the past. In any case, it remains above the recommended by experts. Further efforts should be made to achieve optimum rates, including improvement on obstetric data collection.
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Affiliation(s)
- Garazi Carrillo-Aguirre
- Master’s Degree Public Health, Pompeu Fabra University (UPF), Barcelona, Spain
- Department of Health, Health Evaluation and Quality Agency of Catalonia (AQuAS), Government of Catalonia, Barcelona, Catalonia, Spain
| | - Albert Dalmau-Bueno
- Department of Health, Health Evaluation and Quality Agency of Catalonia (AQuAS), Government of Catalonia, Barcelona, Catalonia, Spain
| | - Carlos Campillo-Artero
- Center for Research in Health and Economics, Pompeu Fabra University, IB-Salut, Barcelona, Spain
| | - Anna García-Altés
- Department of Health, Health Evaluation and Quality Agency of Catalonia (AQuAS), Government of Catalonia, Barcelona, Catalonia, Spain
- Biomedical Research Networking Center for Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
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Pinto NM, Henry KA, Grobman WA, Ness A, Miller S, Ellestad S, Gotteiner N, Tacy T, Wei G, Minich LL, Kinney AY. Physician Barriers and Facilitators for Screening for Congenital Heart Disease With Routine Obstetric Ultrasound: A National United States Survey. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:1143-1153. [PMID: 31875341 PMCID: PMC7357993 DOI: 10.1002/jum.15199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 11/06/2019] [Accepted: 11/29/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Prenatal detection of congenital heart disease with obstetric screening remains at less than 50% in most population studies, far from what is thought to be achievable. We sought to identify barriers/facilitators for screening from the perspective of interpreting physicians and to understand how these barriers/facilitators may be associated with interpretation of screening images. METHODS Our mixed-methods studies included 4 focus groups in centers across the United States with obstetric, maternal-fetal medicine, and radiology providers who interpreted obstetric ultrasound studies. Themes around barriers/facilitators for fetal heart screening were coded from transcripts. A national Web-based survey was then conducted, which quantitatively measured reported barriers/facilitators and measured physicians' ability to interpret fetal heart-screening images. Multivariable generalized linear random-effect models assessed the association between barriers/facilitators and the accuracy of image interpretation at the image level. RESULTS Three main themes were identified in the focus groups: intrinsic barriers (ie, comfort with screening), external barriers (ie, lack of feedback), and organizational barriers (ie, study volumes). Among 190 physician respondents, 104 interpreted ultrasound studies. Perceptions of barriers varied by practice setting, with nontertiary providers having lower self-efficacy and perceived usefulness of cardiac screening. Facilitators associated with the odds of accurate interpretation of screening images were knowledge (odds ratio, 2.54; P = .002) and the volume of scans per week (odds ratio, 1.01 for every additional scan; P = .04). CONCLUSIONS Some of the main barriers to cardiac screening identified and prioritized by physicians across the United States were knowledge of screening and minimal volumes of scans. Targeting these barriers will aid in improving prenatal detection of congenital heart disease.
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Affiliation(s)
- Nelangi M Pinto
- Division of Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Kevin A Henry
- Department of Geography, Temple University, Philadelphia, Pennsylvania, USA
| | - William A Grobman
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Amen Ness
- Department of Obstetrics and Gynecology, Stanford University, Palo Alto, California, USA
| | - Stephen Miller
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sarah Ellestad
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nina Gotteiner
- Division of Pediatric Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Theresa Tacy
- Division of Cardiology, Department of Pediatrics, Stanford University, Palo Alto, California, USA
| | - Guo Wei
- Division of Biostatistics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - L LuAnn Minich
- Division of Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Anita Y Kinney
- Department of Biostatistics and Epidemiology, School of Public Health, and Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, New Jersey, USA
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30
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Mittal P, Pandey D, Suri J, Bharti R. Trend Prediction for Cesarean Deliveries Based on Robson Classification System at a Tertiary Referral Unit of North India. J Obstet Gynaecol India 2020; 70:111-118. [PMID: 32255948 PMCID: PMC7109230 DOI: 10.1007/s13224-019-01275-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 09/03/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND World Health Organization proposed use of Robson Classification as a global standard for assessing, maintaining and comparing Cesarean section (CS) rates. This paper aimed to examine CS trend at a tertiary center according to Robson Ten-Group Classification System (TGCS) over three-year period (2015-2017) and to predict future Cesarean trends. METHODS This prospective observational study was conducted at a tertiary teaching institute and included 81,784 females who delivered at this hospital over three-year duration (2015-2017). The data compilation was done according to Robson TGCS. The main outcome measures were overall annual CS rates, Robson group-wise CS rates, future overall and Robson group-wise CS trend. These parameters were calculated, trend analysis was done and trend over future 3 years was predicted. RESULTS There were 81,784 deliveries (62,336 vaginal and 19,448 Cesarean deliveries) over the study period. The year-wise CS rate was 22.4%, 23.5% and 25.5%, respectively. The largest contribution was by group 5 followed by group 2 and group 1. Based on 3-year data, it was predicted that CS rate will increase by 0.905% annually over coming 3 years. In groups 3, 4, 6, 7 and 8, predicted trend value showed an annual increase by 0.65%, 0.05%, 0.05%, 0.05% and 0.10%, respectively; in groups 1, 2, 5, 9 and 10, it showed an annual decrease of 0.45%, 0.05%, 1.50%, 0.50% and 0.05%, respectively. CONCLUSION Increasing CS rate trend was seen over last 3 years with a predicted rise of 0.905% per year. Robson groups 5, 2 and 1 were at present major contributors; however, the trend analysis predicted a decreasing trend. Trend analysis predicted annual increment in groups 3, 4, 6, 7 and 8 over next 3 years, thereby suggesting need to focus on these groups as well.
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Affiliation(s)
- Pratima Mittal
- Department of Obstetrics and Gynecology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029 India
| | - Divya Pandey
- Department of Obstetrics and Gynecology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029 India
| | - Jyotsna Suri
- Department of Obstetrics and Gynecology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029 India
| | - Rekha Bharti
- Department of Obstetrics and Gynecology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029 India
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Palacios-Marques AM, Quijada-Cazorla MA, Marcos-Sanmartin J, Garcia-Villalba A, Perez-Silvestre L, Jimenez-Martinez MD, Martinez-Escoriza JC. Rationalisation of the caesarean section rate in a tertiary referral hospital using the Robson classification. J OBSTET GYNAECOL 2020; 41:200-206. [PMID: 32172631 DOI: 10.1080/01443615.2020.1718625] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The aim of this study was to implement the Robson Ten Groups Classification System (RTGCS) to identify the main contributors to the caesarean section (CS) rate and to evaluate whether the introduction of a plan of obstetrical interventions reduced this rate. An observational retrospective cross-sectional study was conducted during two time periods at Alicante University General Hospital. In the pre-implementation period (2009-2012), RTGCS was applied to identify the main groups contributing to the overall CS rate. In the post-implementation period (2013-2017), RTGCS was applied again to identify changing trends in CS rates. In all, 11,034 deliveries during the pre-intervention period and 11,453 during the post-intervention period were analysed. The overall CS rate was 23.9% and 20.9%, respectively. There were no changes in perinatal outcomes. In the post-intervention period, there was a significant decrease of the CS rate in the groups of targeted interventions 1, 2, 3, 4, 5, and 8B.Impact statementWhat is already known on this subject? High CS rates are becoming a public health problem because of risks, costs, excessive medicalisation, and abuse of resources. RTGCS provides a framework for auditing and analysing CS rates.What do the results of this study add? RTGCS can identify the groups that have the greatest impact on the CS rate and monitor changes in it consequent to policy changes.What are the implications of these findings for clinical practice? The introduction of a strategic plan with evidence-based clinical interventions may have a greater effect on the CS rate than other features justifying the increase in the incidence of CS.
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Affiliation(s)
- Ana Maria Palacios-Marques
- Obstetrics and Gynecology Department, Alicante University General Hospital, Alicante, Spain.,Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain.,Department of Public Health, History of Science and Gynecology, Miguel Hernández University of Elche, Campus of San Juan, Alicante, Spain
| | - Maria Asunción Quijada-Cazorla
- Obstetrics and Gynecology Department, Alicante University General Hospital, Alicante, Spain.,Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Josefa Marcos-Sanmartin
- Obstetrics and Gynecology Department, Alicante University General Hospital, Alicante, Spain.,Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain.,Department of Public Health, History of Science and Gynecology, Miguel Hernández University of Elche, Campus of San Juan, Alicante, Spain
| | - Alejandra Garcia-Villalba
- Obstetrics and Gynecology Department, Alicante University General Hospital, Alicante, Spain.,Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Lucia Perez-Silvestre
- Obstetrics and Gynecology Department, Alicante University General Hospital, Alicante, Spain.,Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Maria Dolores Jimenez-Martinez
- Obstetrics and Gynecology Department, Alicante University General Hospital, Alicante, Spain.,Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Juan Carlos Martinez-Escoriza
- Obstetrics and Gynecology Department, Alicante University General Hospital, Alicante, Spain.,Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain.,Department of Public Health, History of Science and Gynecology, Miguel Hernández University of Elche, Campus of San Juan, Alicante, Spain
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Moran PS, Daly D, Wuytack F, Carroll M, Turner M, Normand C, Begley C. Predictors of choice of public and private maternity care among nulliparous women in Ireland, and implications for maternity care and birth experience. Health Policy 2020; 124:556-562. [PMID: 32284156 DOI: 10.1016/j.healthpol.2020.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 02/13/2020] [Accepted: 02/17/2020] [Indexed: 11/28/2022]
Abstract
Maternity care in Ireland is provided through a mixture of free public and fee-based private or semi-private services. We examined factors associated with choice of care pathway among nulliparous women and how this influences the care they receive and their experience of childbirth using data from a prospective cohort study. Complete data were available for 1,789 women on choice of care pathway and birth outcomes, and for 1,336 women on birth experience. Maternal age (marginal effect [ME] 1.6 percentage points [ppts], p < 0.01), socioeconomic status (ME 0.5ppts, p < 0.01) and being born in Ireland (ME 10.3ppts, p < 0.01) were all positively associated with choosing private care, but level of risk in early pregnancy did not influence this decision. Intervention rates in public and semi-private care were comparable, but women in private care were more likely to receive epidural anaesthesia (odds ratio [OR] 1.65, p < 0.01) and give birth by caesarean section (ratio of relative risks [RRR] 1.98, p < 0.01). Private care was also associated with longer hospital stays (28 % longer, p < 0.01). Increased risk was negatively correlated with birth experience in public and semi-private care, but not in private care. Policies promoting the allocation of maternity care resources by level of risk, along with the standardisation of clinical practice across care pathways, could reduce rates of obstetric intervention and address risk-based disparities in birth experience outcomes.
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Affiliation(s)
- Patrick S Moran
- School of Nursing and Midwifery, Trinity College Dublin, Ireland.
| | - Deirdre Daly
- School of Nursing and Midwifery, Trinity College Dublin, Ireland.
| | | | - Margaret Carroll
- School of Nursing and Midwifery, Trinity College Dublin, Ireland.
| | | | - Charles Normand
- Centre for Health Policy and Management, Trinity College Dublin, Ireland; Economics of Palliative Care and Rehabilitation, Cicely Saunders Institute, King's College London, United Kingdom.
| | - Cecily Begley
- School of Nursing and Midwifery, Trinity College Dublin, Ireland.
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Zhang L, Zhang L, Li M, Xi J, Zhang X, Meng Z, Wang Y, Li H, Liu X, Ju F, Lu Y, Tang H, Qin X, Ming Y, Huang R, Li G, Dai H, Zhang R, Qin M, Zhu L, Zhang J. A cluster-randomized field trial to reduce cesarean section rates with a multifaceted intervention in Shanghai, China. BMC Med 2020; 18:27. [PMID: 32054535 PMCID: PMC7020498 DOI: 10.1186/s12916-020-1491-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 01/07/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cesarean section (CS) rate has risen dramatically and stayed at a very high level in China over the past two to three decades. Given the short- and long-term adverse effects of CS, effective strategies are needed to reduce unnecessary CS. We aimed to evaluate whether a multifaceted intervention would decrease the CS rate in China. METHODS We carried out a cluster-randomized field trial with a multifaceted intervention in Shanghai, China, from 2015 to 2017. A total of 20 hospitals were randomly allocated into an intervention or a control group. The intervention consisted of more targeted health education to pregnant women, improved hospital CS policy, and training of midwives/doulas for 8 months. The study included a baseline survey, the intervention, and an evaluation survey. The primary outcome was the changes of overall CS rate from the pre-intervention to the post-intervention period. A subgroup analysis stratified by the Robson classification was also conducted to examine the CS change among women with various obstetric characteristics. RESULTS A total of 10,752 deliveries were randomly selected from the pre-intervention period and 10,521 from the post-intervention period. The baseline CS rates were 42.5% and 41.5% in the intervention and control groups, respectively, while the post-intervention CS rates were 43.4% and 42.4%, respectively. Compared with the control group, the intervention did not significantly reduce the CS rate (adjusted OR = 0.92; 95% CI 0.73, 1.15). Similar results were obtained in subgroup analyses stratified by the risk level of pregnancy, maternal age, number of previous CS, or parity. Scarred uterus and maternal request remained the primary reasons for CS after the interventions in both groups. The intervention did not alter the perinatal outcomes (adjusted change of risk score = - 0.06; 95%CI - 0.43, 0.31). CONCLUSIONS A multifaceted intervention including more targeted prenatal health education, improved hospital CS policy, and training of midwives/doulas, did not significantly reduce the CS rate in Shanghai, China. However, our experience in implementing a multifaceted intervention may provide useful information to other similar areas with high CS use. TRIAL REGISTRATION This trial was registered at the Chinese Clinical Trial Registry (www.chictr.org.cn) (ChiCTR-IOR-16009041) on 17 August 2016.
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Affiliation(s)
- Lulu Zhang
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lin Zhang
- Department of Obstetrics and Gynecology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Meng Li
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Jiao Tong University School of Public Health, Shanghai, China
| | - Jie Xi
- Department of Obstetrics, Jiading District Maternal and Child Health Hospital, Shanghai, China
| | - Xiaohua Zhang
- Department of Maternal Health Care, Minhang District Maternal and Child Health Hospital, Shanghai, China
| | - Zhenni Meng
- Department of Obstetrics, First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ying Wang
- Department of Obstetrics, Songjiang District Maternal and Child Health Hospital, Shanghai, China
| | - Huaping Li
- Department of Obstetrics and Gynecology, Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaohua Liu
- Department of Obstetrics, First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Obstetrics, China Welfare Association International Peace Maternal and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Feihua Ju
- Department of Obstetrics and Gynecology, Pudong New District Maternal and Child Health Hospital, Shanghai, China
| | - Yuping Lu
- Department of Obstetrics and Gynecology, Pudong New Area People's Hospital, Shanghai, China
| | - Huijun Tang
- Department of Obstetrics, Putuo District Maternal and Child Health Hospital, Shanghai, China
| | - Xianju Qin
- Department of General Surgery, Eighth People's Hospital, Shanghai, China
| | - Yanhong Ming
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Rong Huang
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guohong Li
- Shanghai Jiao Tong University School of Public Health, Shanghai, China.,Center for HTA, China Hospital Development Institute, Shanghai Jiao Tong University, Shanghai, China
| | - Hongying Dai
- Nursing College, Shanghai University of Medicine & Health Sciences, Shanghai, China
| | - Rong Zhang
- Shanghai Maternal and Child Health Center, Shanghai, China
| | - Min Qin
- Shanghai Maternal and Child Health Center, Shanghai, China.
| | - Liping Zhu
- Shanghai Maternal and Child Health Center, Shanghai, China.
| | - Jun Zhang
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Moradi F, Aryankhesal A, Heidari M, Soroush A, Sadr SR. Interventions in Reducing Caesarean Section in the World: A Systematic Review. Malays J Med Sci 2019; 26:21-37. [PMID: 31728116 PMCID: PMC6839664 DOI: 10.21315/mjms2019.26.5.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 04/21/2019] [Indexed: 10/28/2022] Open
Abstract
Caesarean section without medical indication imposes many problems to families, personnel and medical equipment causing some side effects to pregnant woman and foetus, compared to natural childbirth. The present study aimed to evaluate the interventions in reducing caesarean section in the world. This study was a systematic review using Embase, PubMed, Scopus, Web of Science, Science Direct, Magiran and SID databases and grey literature. All studies conducted during 2000-2018 were reviewed and finally the studies with inclusion and exclusion criteria were selected. A total of 19 studies were selected among 5,559 studies. The interventions conducted for reducing caesarean section included training the specialists and women by using Six Sigma method, changing the guidelines, reviewing the definition of natural childbirth various stages, encouraging the natural childbirth and expanding painless childbirth. All interventions were divided into educational strategy and managerial strategy. The interventions can be implemented to change the behaviour of physicians and attitude of pregnant women in order to reduce caesarean section. In this regard, the authorities are recommended to make more efforts.
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Affiliation(s)
- Farideh Moradi
- Life Style Modification Research Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran.,Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Aidin Aryankhesal
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Heidari
- Community-Oriented Nursing Midwifery Research Center, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Ali Soroush
- Life Style Modification Research Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Sara Rahimi Sadr
- Life Style Modification Research Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Association of a Health Care Provider Review Meeting With Cesarean Delivery Rates: A Quality Improvement Program. Obstet Gynecol 2019; 132:637-642. [PMID: 30095772 DOI: 10.1097/aog.0000000000002793] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine the association of a quality improvement effort that was mediated through weekly review of all criteria for cesarean delivery on cesarean delivery prevalence and indications. METHODS We conducted a retrospective cohort study using a natural experiment model that compared two timeframes, from 2009 to 2013, at a single institution. We introduced a weekly retrospective review conference to discuss all cesarean deliveries in 2010 that continued over time. The conferences were attended by obstetric care providers, anesthesiology, and labor and delivery nurses. Date of delivery was dichotomized by those delivering before July 1, 2010, and those delivering after. We included women with term singleton vertex gestations in our study population and then examined the rates of cesarean delivery by date of delivery. We then examined indications for the cesarean deliveries during the study period based on surgeon documentation. χ tests were used for statistical comparisons and a P value of <.05 was used to indicate statistical significance. RESULTS There were 5,541 term singleton cephalic births during the study period. The rate of cesarean delivery declined significantly after our intervention in all women (22.2% vs 27.4%, P<.001) and nulliparous women (23.3% vs 30.9%, P<.001). The adjusted odds ratio of cesarean delivery in all women as related to time cohort is 0.68 (95% CI 0.58-0.79) and 0.56 (95% CI 0.44-0.70) in nulliparous women. We examined indications for the 1,315 cesarean deliveries during the study period by date of delivery. The indications of active-phase arrest, second-stage arrest, failed induction, repeat cesarean delivery, and maternal request decreased significantly between delivery cohorts in all women (P<.001) and in nulliparous women specifically (P<.001). Between delivery cohorts, we found that the prevalence of labored indications for cesarean delivery decreased more than nonlabored indications. CONCLUSION Implementation of a weekly review conference was associated with a reduction in both overall cesarean delivery prevalence and labored indications at our institution.
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Microsimulation model of child and adolescent overweight: making use of what we already know. Int J Obes (Lond) 2019; 43:2322-2332. [PMID: 31391516 DOI: 10.1038/s41366-019-0426-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 04/28/2019] [Accepted: 06/08/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND New Zealand has high rates of child overweight and obesity when compared with other countries. Despite an abundance of research documenting the problem, it is unclear what the most effective policy changes or interventions are, and how policy changes might unfold over time within complex systems. METHODS We use estimates derived from meta-analyses to create a dynamic microsimulation model of child overweight (including obesity). Using census records we created a synthetic birth cohort of 10,000 children. Information on parental education, ethnicity and father's socio-economic position at birth were taken from census records. We used the New Zealand Health Survey to estimate population base rates for the prevalence of overweight and obesity. Information on other modifiers (such as maternal smoking, breastfeeding, preterm birth, regular breakfast consumption and so forth) were taken from three birth cohorts: Christchurch Health and Development Study, The Dunedin Multidisciplinary Health and Development Study and the Pacific Islands Families Study. Published intervention studies were used to derive plausible estimates for changes to modifiers. RESULTS Reducing the proportion of mothers classified as overweight and obesity (-3.31(95% CI -3.55; -3.07) percentage points), reducing the proportion of children watching two or more hours of TV (-3.78(95% CI -4.01; -3.54)), increasing the proportion of children eating breakfast regularly (-1.71(95% CI -1.96; -1.46)), and reducing the proportion of children born with high birth weights (-1.36(95% CI -1.61; -1.11)), lead to sizable decreases in the estimated prevalence of child overweight (including obesity). Reducing the proportion of mothers giving birth by caesarean (-0.23(95% CI -0.49; -0.23)) and increasing parental education (-0.07(95% CI -0.31; 0.18)) did not impact upon child overweight rates. CONCLUSIONS We created a working simulation model of New Zealand children that can be accessed by policy makers and researchers to determine known relationships between predictors and child overweight, as well as potential gains from targeting specific pathways.
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Chapman A, Nagle C, Bick D, Lindberg R, Kent B, Calache J, Hutchinson AM. Maternity service organisational interventions that aim to reduce caesarean section: a systematic review and meta-analyses. BMC Pregnancy Childbirth 2019; 19:206. [PMID: 31286892 PMCID: PMC6615143 DOI: 10.1186/s12884-019-2351-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 06/04/2019] [Indexed: 12/13/2022] Open
Abstract
Background Caesarean sections (CSs) are associated with increased maternal and perinatal morbidity, yet rates continue to increase within most countries. Effective interventions are required to reduce the number of non-medically indicated CSs and improve outcomes for women and infants. This paper reports findings of a systematic review of literature related to maternity service organisational interventions that have a primary intention of improving CS rates. Method A three-phase search strategy was implemented to identify studies utilising organisational interventions to improve CS rates in maternity services. The database search (including Cochrane CENTRAL, CINAHL, MEDLINE, Maternity and Infant Care, EMBASE and SCOPUS) was restricted to peer-reviewed journal articles published from 1 January 1980 to 31 December 2017. Reference lists of relevant reviews and included studies were also searched. Primary outcomes were overall, planned, and unplanned CS rates. Secondary outcomes included a suite of birth outcomes. A series of meta-analyses were performed in RevMan, separated by type of organisational intervention and outcome of interest. Summary risk ratios with 95% confidence intervals were presented as the effect measure. Effect sizes were pooled using a random-effects model. Results Fifteen articles were included in the systematic review, nine of which were included in at least one meta-analysis. Results indicated that, compared with women allocated to usual care, women allocated to midwife-led models of care implemented across pregnancy, labour and birth, and the postnatal period were, on average, less likely to experience CS (overall) (average RR 0.83, 95% CI 0.73 to 0.96), planned CS (average RR 0.75, 95% CI 0.61 to 0.93), and episiotomy (average RR 0.84, 95% CI 0.74 to 0.95). Narratively, audit and feedback, and a hospital policy of mandatory second opinion for CS, were identified as interventions that have potential to reduce CS rates. Conclusion Maternity service leaders should consider the adoption of midwife-led models of care across the maternity episode within their organisations, particularly for women classified as low-risk. Additional studies are required that utilise either audit and feedback, or a hospital policy of mandatory second opinion for CS, to facilitate the quantification of intervention effects within future reviews. PROSPERO registration CRD42016039458; prospectively registered. Electronic supplementary material The online version of this article (10.1186/s12884-019-2351-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anna Chapman
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Deakin University, Geelong, VIC, Australia.,Monash Medical Centre, Monash Health, Level 2 I Block, 246 Clayton Rd, Clayton, 3168, VIC, Australia
| | - Cate Nagle
- Centre for Nursing and Midwifery Research, James Cook University, Townsville, Queensland, Australia.,Townsville Hospital and Health Service, Townsville, Queensland, Australia
| | - Debra Bick
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Rebecca Lindberg
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Victoria, Australia
| | - Bridie Kent
- Faculty of Health and Human Sciences, University of Plymouth, Plymouth, Devon, UK
| | - Justin Calache
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Deakin University, Geelong, VIC, Australia.,Monash Medical Centre, Monash Health, Level 2 I Block, 246 Clayton Rd, Clayton, 3168, VIC, Australia
| | - Alison M Hutchinson
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Deakin University, Geelong, VIC, Australia. .,Monash Medical Centre, Monash Health, Level 2 I Block, 246 Clayton Rd, Clayton, 3168, VIC, Australia.
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Xia X, Zhou Z, Shen S, Lu J, Zhang L, Huang P, Yu J, Yang L, Wang P, Lam KBH, Jacobsson B, Mol BW, Xia H, Qiu X. Effect of a two-stage intervention package on the cesarean section rate in Guangzhou, China: A before-and-after study. PLoS Med 2019; 16:e1002846. [PMID: 31283770 PMCID: PMC6613675 DOI: 10.1371/journal.pmed.1002846] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 05/31/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The cesarean section (CS) rate has risen globally during the last two decades. Effective and feasible strategies are needed to reduce it. The aim of this study was to assess the CS rate change after a two-stage intervention package that was designed to reduce the overall CS rate in Guangzhou, China. METHODS AND FINDINGS This intervention package was implemented by the Health Commission of Guangzhou Municipality in 2 stages (October 2010-September 2014 and October 2014-December 2016) and included programs for population health education, skills training for healthcare professionals, equipment and technical support for local healthcare facilities, and capacity building for the maternal near-miss care system. A retrospective repeated cross-sectional study was conducted to evaluate influences of the intervention on CS rates. A pre-intervention period from January 2008 to September 2010 served as the baseline. The primary outcome was the CS rate, and the secondary outcomes included maternal mortality ratio (MMR) and perinatal mortality rate (PMR), all obtained from the Guangzhou Perinatal Health Care and Delivery Surveillance System (GPHCDSS). The Cochran-Armitage test was used to examine the trends of the overall CS rate, MMR, and PMR across different stages. Segmented linear regression analysis was used to assess the change of the CS rate over the intervention period. A total of 1,921,932 records of births and 108 monthly CS rates from 2008 to 2016 were analyzed. The monthly CS rate declined across the intervention stages (Z = 75.067, p < 0.001), with an average rate of 42.4% at baseline, 39.8% at Stage 1, and 35.0% at Stage 2. The CS rate declined substantially among nulliparous women who delivered term singletons, with an accelerating decreasing trend observed across Stage 1 and Stage 2 (the difference in slopes: -0.09 [95% CI -0.16 to -0.02] between Stage 1 and baseline, p = 0.014; -0.11 [95% CI -0.20 to -0.02] between Stage 1 and Stage 2, p = 0.017). The CS rate in the remaining population increased during baseline and Stage 1 and subsequently decreased during Stage 2. The sensitivity analysis suggested no immediate impact of the universal two-child policy on the trend of the CS rate. The MMR (Z = -4.368, p < 0.001) and PMR (Z = -13.142, p < 0.001) declined by stage over the intervention period. One of the main limitations of the study is the lack of a parallel control group. Moreover, the influence of temporal changes in the study population on the CS rate was unknown. Given the observational nature of the present study, causality cannot be confirmed. CONCLUSIONS Apparent decline in the overall CS rate was observed in Guangzhou, China, after the implementation of a two-stage intervention package. The decline was most evident among nulliparous women who delivered term singletons. Despite some limitations for causal inference, Guangzhou's experience in controlling the CS rate by implementing composite interventions with public health education and perinatal healthcare service improvement could have implications for other similar areas with high rates of CS.
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Affiliation(s)
- Xiaoyan Xia
- Division of Birth Cohort Study, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- Department of Woman and Child Health Care, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- Department of Obstetrics and Gynecology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Zehong Zhou
- Division of Birth Cohort Study, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Songying Shen
- Division of Birth Cohort Study, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Jinhua Lu
- Division of Birth Cohort Study, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- Department of Woman and Child Health Care, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Lifang Zhang
- Division of Birth Cohort Study, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- Department of Woman and Child Health Care, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Peiyuan Huang
- Division of Birth Cohort Study, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Jia Yu
- Department of Woman and Child Health Care, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Li Yang
- Guangzhou Women and Children’s Health Information Center, Guangzhou, China
| | - Ping Wang
- Guangzhou Women and Children’s Health Information Center, Guangzhou, China
| | - Kin-bong Hubert Lam
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Bo Jacobsson
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Genetics and Bioinformatics, Domain of Health Data and Digitalisation, Institute of Public Health, Oslo, Norway
| | - Ben Willem Mol
- Department of Obstetrics and Gynecology, Monash University, Clayton, Victoria, Australia
- Department of Obstetrics and Gynecology, University of Birmingham, Birmingham, United Kingdom
| | - Huimin Xia
- Department of Neonatal Surgery, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- * E-mail: , (HX); , (XQ)
| | - Xiu Qiu
- Division of Birth Cohort Study, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- Department of Woman and Child Health Care, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- Department of Obstetrics and Gynecology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- * E-mail: , (HX); , (XQ)
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Mulchandani R, Power HS, Cavallaro FL. The influence of individual provider characteristics and attitudes on caesarean section decision-making: a global review. J OBSTET GYNAECOL 2019; 40:1-9. [PMID: 31208243 DOI: 10.1080/01443615.2019.1587603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Caesarean section (CS) rates have risen worldwide in the past two decades, particularly in middle and high-income countries. In addition to changing maternal and health system factors, there is growing evidence that provider factors may contribute to rising unnecessary caesareans. The aim of this review was to assess the evidence for the association between individual provider characteristics, attitudes towards CS and decision-making for CS. A search was conducted in May 2018 in PubMed and Web of Science with 23 papers included in our final review. Our results show that higher anxiety scores and more favourable opinions of CS were associated with increased likelihood of performing CS. These findings highlight a need for appropriate interventions to target provider attitudes towards CS to reduce unnecessary procedures.
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Affiliation(s)
- Ranya Mulchandani
- Polygeia, Global Health Student Think Tank, London, United Kingdom.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Harvinder Singh Power
- Polygeia, Global Health Student Think Tank, London, United Kingdom.,Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Francesca L Cavallaro
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Kaboré C, Ridde V, Chaillet N, Yaya Bocoum F, Betrán AP, Dumont A. DECIDE: a cluster-randomized controlled trial to reduce unnecessary caesarean deliveries in Burkina Faso. BMC Med 2019; 17:87. [PMID: 31046752 PMCID: PMC6498483 DOI: 10.1186/s12916-019-1320-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 04/10/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND In Burkina Faso, facility-based caesarean delivery rates have markedly increased since the national subsidy policy for deliveries and emergency obstetric care was implemented in 2006. Effective and safe strategies are needed to prevent unnecessary caesarean deliveries. METHODS We conducted a cluster-randomized controlled trial of a multifaceted intervention at 22 referral hospitals in Burkina Faso. The evidence-based intervention was designed to promote the use of clinical algorithms for caesarean decision-making using in-site training, audits and feedback of caesarean indications and SMS reminders. The primary outcome was the change in the percentage of unnecessary caesarean deliveries. Unnecessary caesareans were defined on the basis of the literature review and expert consensus. Data were collected daily using a standardized questionnaire, in the same way at both the intervention and control hospitals. Caesareans were classified as necessary or unnecessary in the same way, in both arms of the trial using a standardized computer algorithm. RESULTS A total of 2138 and 2036 women who delivered by caesarean section were analysed in the pre and post-intervention periods, respectively. A significant reduction in the percentage of unnecessary caesarean deliveries was evident from the pre- to post-intervention period in the intervention group compared with the control group (18.96 to 6.56% and 18.27 to 23.30% in the intervention and control groups, respectively; odds ratio [OR] for incremental change over time, adjusted for hospital and patient characteristics, 0.22; 95% confidence interval [CI], 0.14 to 0.34; P < 0.001; adjusted risk difference, - 17.02%; 95% CI, - 19.20 to - 13.20%). The intervention did not significantly affect the rate of maternal death (0.75 to 0.19% and 0.92 to 0.40% in the intervention and control groups, respectively; adjusted OR 0.32; 95% CI 0.04 to 2.23; P = 0.253) or intrapartum-related neonatal death (4.95 to 6.32% and 5.80 to 4.29% in the intervention and control groups, respectively, adjusted OR 1.73; 95% CI 0.82 to 3.66; P = 0.149). The overall perinatal mortality data were not available. CONCLUSION Promotion and training on clinical algorithms for decision-making, audit and feedback and SMS reminders reduced unnecessary caesarean deliveries, compared with usual care in a low-resource setting. TRIAL REGISTRATION The DECIDE trial is registered on the Current Controlled Trials website: ISRCTN48510263 .
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Affiliation(s)
- Charles Kaboré
- IRD (French Institute for Research on sustainable Development), CEPED (IRD-Université Paris Descartes), Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, Paris, France. .,Research Institute of Health Sciences, Ouagadougou, Burkina Faso.
| | - Valéry Ridde
- IRD (French Institute for Research on sustainable Development), CEPED (IRD-Université Paris Descartes), Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, Paris, France.,University of Montreal Public Health Research Institute (IRSPUM), Montreal, Canada
| | - Nils Chaillet
- Hospital Center of Laval University (CHUL), Quebec, Canada
| | | | - Ana Pilar Betrán
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, CH-1211, Geneva 27, Switzerland
| | - Alexandre Dumont
- IRD (French Institute for Research on sustainable Development), CEPED (IRD-Université Paris Descartes), Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, Paris, France
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Roberge S, Boutin A, Bujold E, Dubé E, Blouin S, Chaillet N. Impact of Audits and Multifaceted Intervention on Vaginal Birth After Caesarean: Secondary Analysis of the QUARISMA Trial. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:608-615. [PMID: 30642816 DOI: 10.1016/j.jogc.2018.05.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 05/29/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study estimated the effect that a multifaceted intervention aiming to improve the quality of obstetrical care and reduce Caesarean section (CS) had on the rate of vaginal birth after Caesarean (VBAC). METHODS This is a secondary analysis of the cluster randomized controlled trial Quality of Care, Obstetrics Risk Management, and Mode of Delivery involving (1) audits regarding the indications for CS, (2) provision of feedback to health professionals, and (3) implementation of best practices to reduce CS rates in Quebec. The impact of intervention on VBAC, trial of labour (TOL), and maternal and neonatal morbidity was reported using adjusted odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS Out of 105 351 women who delivered during the pre- and postintervention period, 12 493 (11.9%) had a previous CS. We observed no significant impact of the multifaceted intervention on the rates of TOL (adjusted OR 1.22; 95% CI 0.96-1.56, P = 0.11) and VBAC (adjusted OR 1.20; 95% CI 0.97-1.48, P = 0.10) in women with one previous CS. However, the rate of TOL was reduced (adjusted OR 0.38; 95% CI 0.14-0.99) in women with more than one previous CS. The intervention has no influence on maternal and neonatal morbidity. CONCLUSIONS A multifaceted intervention including audits, feedback to health professionals, and implementation of best practices did not affect VBAC rates or maternal and neonatal morbidity. Our results pointed out the need for decision-making processand risk management tools specific to women with previous CS.
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Affiliation(s)
- Stéphanie Roberge
- Centre de recherche du CHU de Québec-Université Laval, Québec City, QC; Harris Birthright Research Centre of Fetal Medicine, King's College Hospital, London, United Kingdom
| | - Amélie Boutin
- Centre de recherche du CHU de Québec-Université Laval, Québec City, QC
| | - Emmanuel Bujold
- Centre de recherche du CHU de Québec-Université Laval, Québec City, QC; Department of Obstetrics, Gynecology and Reproduction, Faculty of Medicine, Université Laval, Québec City, QC
| | - Eric Dubé
- Centre de recherche du CHU de Québec-Université Laval, Québec City, QC
| | - Simon Blouin
- Centre de recherche du CHU de Québec-Université Laval, Québec City, QC
| | - Nils Chaillet
- Centre de recherche du CHU de Québec-Université Laval, Québec City, QC; Department of Obstetrics, Gynecology and Reproduction, Faculty of Medicine, Université Laval, Québec City, QC.
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Kingdon C, Downe S, Betran AP. Interventions targeted at health professionals to reduce unnecessary caesarean sections: a qualitative evidence synthesis. BMJ Open 2018; 8:e025073. [PMID: 30559163 PMCID: PMC6303601 DOI: 10.1136/bmjopen-2018-025073] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 10/10/2018] [Accepted: 10/15/2018] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To establish the views and experiences of healthcare professionals in relation to interventions targeted at them to reduce unnecessary caesareans. DESIGN Qualitative evidence synthesis. SETTING Studies undertaken in high-income, middle-income and low-income settings. DATA SOURCES Seven databases (CINAHL, MEDLINE, PsychINFO, Embase, Global Index Medicus, POPLINE and African Journals Online). Studies published between 1985 and June 2017, with no language or geographical restrictions. We hand-searched reference lists and key citations using Google Scholar. STUDY SELECTION Qualitative or mixed-method studies reporting health professionals' views. DATA EXTRACTION AND SYNTHESIS Two authors independently assessed study quality prior to extraction of primary data and authors' interpretations. The data were compared and contrasted, then grouped into summary of findings (SoFs) statements, themes and a line of argument synthesis. All SoFs were Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) assessed. RESULTS 17 papers were included, involving 483 health professionals from 17 countries (nine high-income, six middle-income and two low-income). Fourteen SoFs were identified, resulting in three core themes: philosophy of birth (four SoFs); (2) social and cultural context (five SoFs); and (3) negotiation within system (five SoFs). The resulting line of argument suggests three key mechanisms of effect for change or resistance to change: prior beliefs about birth; willingness or not to engage with change, especially where this entailed potential loss of income or status (including medicolegal barriers); and capacity or not to influence local community and healthcare service norms and values relating to caesarean provision. CONCLUSION For maternity care health professionals, there is a synergistic relationship between their underpinning philosophy of birth, the social and cultural context they are working within and the extent to which they were prepared to negotiate within health system resources to reduce caesarean rates. These findings identify potential mechanisms of effect that could improve the design and efficacy of change programmes to reduce unnecessary caesareans. PROSPERO REGISTRATION NUMBER CRD42017059455.
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Affiliation(s)
- Carol Kingdon
- School of Community Health and Midwifery, Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - Soo Downe
- School of Community Health and Midwifery, Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - Ana Pilar Betran
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Torres JA, Leal MDC, Domingues RMSM, Esteves-Pereira AP, Nakano AR, Gomes ML, Figueiró AC, Nakamura-Pereira M, de Oliveira EFV, Ayres BVDS, Sandall J, Belizán JM, Hartz Z. Evaluation of a quality improvement intervention for labour and birth care in Brazilian private hospitals: a protocol. Reprod Health 2018; 15:194. [PMID: 30477517 PMCID: PMC6257968 DOI: 10.1186/s12978-018-0636-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 11/05/2018] [Indexed: 11/16/2022] Open
Abstract
Background In Brazilian private hospitals, caesarean section (CS) is almost universal (88%) and is integrated into the model of birth care. A quality improvement intervention, “Adequate Birth” (PPA), based on four driving components (governance, participation of women and families, reorganisation of care, and monitoring), has been implemented to help 23 hospitals reduce their CS rate. This is a protocol designed to evaluate the implementation of PPA and its effectiveness at reducing CS as a primary outcome of birth care. Methods Case study of PPA intervention conducted in 2017/2018. We integrated quantitative and qualitative methods into data collection and analysis. For the quantitative stage, we selected a convenient sample of twelve hospitals. In each of these hospitals, we included 400 women. This resulted in a total sample of 4800 women. We used this sample to detect a 2.5% reduction in CS rate. We interviewed managers and puerperal women, and extracted data from hospital records. In the qualitative stage, we evaluated a subsample of eight hospitals by means of systematic observation and semi-structured interviews with managers, health professionals and women. We used specific forms for each of the four PPA driving components. Forms for managers and professionals addressed the decision-making process, implemented strategies, participatory process in strategy design, and healthcare practice. Forms for women and neonatal care addressed socio-economic, demographic and health condition; prenatal and birth care; tour of the hospital before delivery; labour expectation vs. real experience; and satisfaction with care received. We will estimate the degree of implementation of PPA strategies related to two of the four driving components: “participation of women and families” and “reorganisation of care”. We will then assess its effect on CS rate and secondary outcomes for each of the twelve selected hospitals, and for the total sample. To allow for clinical, socio-demographic and obstetric characteristics in women, we will conduct multivariate analysis. Additionally, we will evaluate the influence of internal context variables (the PPA driving components “governance” and “monitoring”) on the degree of implementation of the components “participation of women and families” and “reorganisation of care”, by means of thematic content analysis. This analysis will include both quantitative and qualitative data. Discussion The effectiveness of quality improvement interventions that reduce CS rates requires examination. This study will identify strategies that could promote healthier births. Electronic supplementary material The online version of this article (10.1186/s12978-018-0636-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jacqueline Alves Torres
- Agência Nacional de Saúde Suplementar, Av. Augusto Severo, 84 - Glória, Diretoria de Desenvolvimento Setorial, Rio de Janeiro - RJ, 20021-040, Brazil.
| | - Maria do Carmo Leal
- Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | | | | | | | - Maysa Luduvice Gomes
- Faculdade de Enfermagem da Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ana Claudia Figueiró
- Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Marcos Nakamura-Pereira
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | | | | | - Jane Sandall
- Department of Women and children's Health, King's College London, London, England
| | - José M Belizán
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Zulmira Hartz
- Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisboa, Portugal
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Duvillier C, Rousseau A, Bouyer C, Goffinet F, Rozenberg P. Facteurs organisationnels associés à la réalisation d’une césarienne dans une population à bas risque. ACTA ACUST UNITED AC 2018; 46:706-712. [DOI: 10.1016/j.gofs.2018.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Indexed: 10/28/2022]
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Kacerauskiene J, Minkauskiene M, Mahmood T, Bartuseviciene E, Railaite DR, Bartusevicius A, Kliucinskas M, Nadisauskiene RJ, Smigelskas K, Maciuliene K, Drasutiene G, Ramasauskaite D. Lithuania's experience in reducing caesarean sections among nulliparas. BMC Pregnancy Childbirth 2018; 18:419. [PMID: 30359241 PMCID: PMC6202871 DOI: 10.1186/s12884-018-2052-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 10/10/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To evaluate the role of the TGCS to reduce the caesarean section (CS) rate among nulliparas (Robson groups 1 and 2) and to find out which group of women have reduced the CS rate by using this tool. METHODS The Robson classification was introduced in Lithuanian hospitals prospectively classifying all the deliveries in 2012. The CS rate overall and in each Robson group was calculated and the results were discussed. The analysis was repeated in 2014 and the data from the selected hospitals were compared using MS EXCEL and SPSS 23.0. RESULTS Nulliparas accounted for 43% (3746/8718) and 44.6% (3585/8046) of all the deliveries in 2012 and 2014 years, respectively. The CS rate among nulliparas decreased from 23.9% (866/3626) in 2012 to 19.0% (665/3502) in 2014 (p < 0.001).The greatest decrease in absolute contribution to the overall CS rate was recorded in groups 1 (p = 0.005) and 2B (p < 0.001). Perinatal mortality was 3.5 in 2012 and 3.1 in 2014 per 1000 deliveries (p = 0.764). CONCLUSION The TGCS can work as an audit intervention that could help to reduce the CS rate without a negative impact on perinatal mortality.
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Affiliation(s)
| | - Meile Minkauskiene
- Lithuanian University of Health Sciences, Eiveniu str. 2, 50167, Kaunas, Lithuania
| | - Tahir Mahmood
- Victoria Hospital, Kirkcaldy, Fife, KY2 5AH, Scotland, UK
| | - Egle Bartuseviciene
- Lithuanian University of Health Sciences, Eiveniu str. 2, 50167, Kaunas, Lithuania
| | - Dalia R Railaite
- Lithuanian University of Health Sciences, Eiveniu str. 2, 50167, Kaunas, Lithuania
| | | | | | - Ruta J Nadisauskiene
- Lithuanian University of Health Sciences, Eiveniu str. 2, 50167, Kaunas, Lithuania
| | - Kastytis Smigelskas
- Lithuanian University of Health Sciences, Eiveniu str. 2, 50167, Kaunas, Lithuania
| | | | - Grazina Drasutiene
- Vilnius University Hospital Santaros Klinikos, Santariskiu str. 2, 08661, Vilnius, Lithuania
| | - Diana Ramasauskaite
- Vilnius University Hospital Santaros Klinikos, Santariskiu str. 2, 08661, Vilnius, Lithuania
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Bartuseviciene E, Kacerauskiene J, Bartusevicius A, Paulionyte M, Nadisauskiene RJ, Kliucinskas M, Stankeviciute V, Maleckiene L, Railaite DR. Comparison of midwife-led and obstetrician-led care in Lithuania: A retrospective cohort study. Midwifery 2018; 65:67-71. [DOI: 10.1016/j.midw.2018.06.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 06/15/2018] [Accepted: 06/16/2018] [Indexed: 11/27/2022]
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Chen I, Opiyo N, Tavender E, Mortazhejri S, Rader T, Petkovic J, Yogasingam S, Taljaard M, Agarwal S, Laopaiboon M, Wasiak J, Khunpradit S, Lumbiganon P, Gruen RL, Betran AP. Non-clinical interventions for reducing unnecessary caesarean section. Cochrane Database Syst Rev 2018; 9:CD005528. [PMID: 30264405 PMCID: PMC6513634 DOI: 10.1002/14651858.cd005528.pub3] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Caesarean section rates are increasing globally. The factors contributing to this increase are complex, and identifying interventions to address them is challenging. Non-clinical interventions are applied independently of a clinical encounter between a health provider and a patient. Such interventions may target women, health professionals or organisations. They address the determinants of caesarean births and could have a role in reducing unnecessary caesarean sections. This review was first published in 2011. This review update will inform a new WHO guideline, and the scope of the update was informed by WHO's Guideline Development Group for this guideline. OBJECTIVES To evaluate the effectiveness and safety of non-clinical interventions intended to reduce unnecessary caesarean section. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers in March 2018. We also searched websites of relevant organisations and reference lists of related reviews. SELECTION CRITERIA Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series studies and repeated measures studies were eligible for inclusion. The primary outcome measures were: caesarean section, spontaneous vaginal birth and instrumental birth. DATA COLLECTION AND ANALYSIS We followed standard methodological procedures recommended by Cochrane. We narratively described results of individual studies (drawing summarised evidence from single studies assessing distinct interventions). MAIN RESULTS We included 29 studies in this review (19 randomised trials, 1 controlled before-after study and 9 interrupted time series studies). Most of the studies (20 studies) were conducted in high-income countries and none took place in low-income countries. The studies enrolled a mixed population of pregnant women, including nulliparous women, multiparous women, women with a fear of childbirth, women with high levels of anxiety and women having undergone a previous caesarean section.Overall, we found low-, moderate- or high-certainty evidence that the following interventions have a beneficial effect on at least one primary outcome measure and no moderate- or high-certainty evidence of adverse effects.Interventions targeted at women or familiesChildbirth training workshops for mothers alone may reduce caesarean section (risk ratio (RR) 0.55, 95% confidence interval (CI) 0.33 to 0.89) and may increase spontaneous vaginal birth (RR 2.25, 95% CI 1.16 to 4.36). Childbirth training workshops for couples may reduce caesarean section (RR 0.59, 95% CI 0.37 to 0.94) and may increase spontaneous vaginal birth (RR 2.13, 95% CI 1.09 to 4.16). We judged this one study with 60 participants to have low-certainty evidence for the outcomes above.Nurse-led applied relaxation training programmes (RR 0.22, 95% CI 0.11 to 0.43; 104 participants, low-certainty evidence) and psychosocial couple-based prevention programmes (RR 0.53, 95% CI 0.32 to 0.90; 147 participants, low-certainty evidence) may reduce caesarean section. Psychoeducation may increase spontaneous vaginal birth (RR 1.33, 95% CI 1.11 to 1.61; 371 participants, low-certainty evidence). The control group received routine maternity care in all studies.There were insufficient data on the effect of the four interventions on maternal and neonatal mortality or morbidity.Interventions targeted at healthcare professionalsImplementation of clinical practice guidelines combined with mandatory second opinion for caesarean section indication slightly reduces the risk of overall caesarean section (mean difference in rate change -1.9%, 95% CI -3.8 to -0.1; 149,223 participants). Implementation of clinical practice guidelines combined with audit and feedback also slightly reduces the risk of caesarean section (risk difference (RD) -1.8%, 95% CI -3.8 to -0.2; 105,351 participants). Physician education by local opinion leader (obstetrician-gynaecologist) reduced the risk of elective caesarean section to 53.7% from 66.8% (opinion leader education: 53.7%, 95% CI 46.5 to 61.0%; control: 66.8%, 95% CI 61.7 to 72.0%; 2496 participants). Healthcare professionals in the control groups received routine care in the studies. There was little or no difference in maternal and neonatal mortality or morbidity between study groups. We judged the certainty of evidence to be high.Interventions targeted at healthcare organisations or facilitiesCollaborative midwifery-labourist care (in which the obstetrician provides in-house labour and delivery coverage, 24 hours a day, without competing clinical duties), versus a private practice model of care, may reduce the primary caesarean section rate. In one interrupted time series study, the caesarean section rate decreased by 7% in the year after the intervention, and by 1.7% per year thereafter (1722 participants); the vaginal birth rate after caesarean section increased from 13.3% before to 22.4% after the intervention (684 participants). Maternal and neonatal mortality were not reported. We judged the certainty of evidence to be low.We studied the following interventions, and they either made little or no difference to caesarean section rates or had uncertain effects.Moderate-certainty evidence suggests little or no difference in caesarean section rates between usual care and: antenatal education programmes for physiologic childbirth; antenatal education on natural childbirth preparation with training in breathing and relaxation techniques; computer-based decision aids; individualised prenatal education and support programmes (versus written information in pamphlet).Low-certainty evidence suggests little or no difference in caesarean section rates between usual care and: psychoeducation; pelvic floor muscle training exercises with telephone follow-up (versus pelvic floor muscle training without telephone follow-up); intensive group therapy (cognitive behavioural therapy and childbirth psychotherapy); education of public health nurses on childbirth classes; role play (versus standard education using lectures); interactive decision aids (versus educational brochures); labourist model of obstetric care (versus traditional model of obstetric care).We are very uncertain as to the effect of other interventions identified on caesarean section rates as the certainty of the evidence is very low. AUTHORS' CONCLUSIONS We evaluated a wide range of non-clinical interventions to reduce unnecessary caesarean section, mostly in high-income settings. Few interventions with moderate- or high-certainty evidence, mainly targeting healthcare professionals (implementation of guidelines combined with mandatory second opinion, implementation of guidelines combined with audit and feedback, physician education by local opinion leader) have been shown to safely reduce caesarean section rates. There are uncertainties in existing evidence related to very-low or low-certainty evidence, applicability of interventions and lack of studies, particularly around interventions targeted at women or families and healthcare organisations or facilities.
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Affiliation(s)
- Innie Chen
- University of OttawaDepartment of Obstetrics & GynecologyOttawaONCanada
| | - Newton Opiyo
- CochraneCochrane Editorial UnitSt Albans House, 57‐59 HaymarketLondonUKSW1Y 4QX
| | - Emma Tavender
- Monash UniversityAustralian Satellite of the Cochrane EPOC Group, School of Public Health and Preventative MedicineMelbourneVictoriaAustraliaVIC 3004
| | | | - Tamara Rader
- Canadian Agency for Drugs and Technologies in Health (CADTH)600‐865 Carling AvenueOttawaONCanada
| | - Jennifer Petkovic
- University of OttawaBruyère Research Institute43 Bruyère StAnnex E, room 312OttawaONCanadaK1N 5C8
| | | | - Monica Taljaard
- Ottawa Hospital Research InstituteClinical Epidemiology ProgramThe Ottawa Hospital ‐ Civic Campus1053 Carling Ave, Box 693OttawaONCanadaK1Y 4E9
| | | | - Malinee Laopaiboon
- Khon Kaen UniversityDepartment of Epidemiology and Biostatistics, Faculty of Public Health123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
| | - Jason Wasiak
- Austin Health; The University of MelbourneOlivia Newton John Cancer Research Institute; Department of PaediatricsMelbourneVictoriaAustralia
- University of MelbourneDepartment of PediatricsMelbourneVictoriaAustralia
| | - Suthit Khunpradit
- Lamphun HospitalDepartment of Obstetrics and Gynaecology177 Jamthevee RoadLamphunLamphunThailand51000
| | - Pisake Lumbiganon
- Khon Kaen UniversityDepartment of Obstetrics and Gynaecology, Faculty of Medicine123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
| | - Russell L Gruen
- Nanyang Technological UniversityLee Kong Chian School of Medicine11 Mandalay RoadSingaporeSingapore308232
| | - Ana Pilar Betran
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and ResearchGenevaSwitzerland
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Kingdon C, Downe S, Betran AP. Non-clinical interventions to reduce unnecessary caesarean section targeted at organisations, facilities and systems: Systematic review of qualitative studies. PLoS One 2018; 13:e0203274. [PMID: 30180198 PMCID: PMC6122831 DOI: 10.1371/journal.pone.0203274] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 08/19/2018] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE When medically indicated, caesarean section can prevent deaths and other serious complications in mothers and babies. Lack of access to caesarean section may result in increased maternal and perinatal mortality and morbidity. However, rising caesarean section rates globally suggest overuse in healthy women and babies, with consequent iatrogenic damage for women and babies, and adverse impacts on the sustainability of maternity care provision. To date, interventions to ensure that caesarean section is appropriately used have not reversed the upward trend in rates. Qualitative evidence has the potential to explain why and how interventions may or may not work in specific contexts. We aimed to establish stakeholders' views on the barriers and facilitators to non-clinical interventions targeted at organizations, facilities and systems, to reduce unnecessary caesarean section. METHODS We undertook a systematic qualitative evidence synthesis using a five-stage modified, meta-ethnography approach. We searched MEDLINE, CINAHL, PsychINFO, EMBASE and grey literature databases (Global Index Medicus, POPLINE, AJOL) using pre-defined terms. Inclusion criteria were qualitative and mixed-method studies, investigating any non-clinical intervention to reduce caesarean section, in any setting and language, published after 1984. Study quality was assessed prior to data extraction. Interpretive thematic synthesis was undertaken using a barriers and facilitators lens. Confidence in the resulting Summaries of Findings was assessed using GRADE-CERQual. RESULTS 8,219 studies were identified. 25 studies were included, from 17 countries, published between 1993-2016, encompassing the views of over 1,565 stakeholders. Nineteen Summary of Findings statements were derived. They mapped onto three distinct themes: Health system, organizational and structural factors (6 SoFs); Human and cultural factors (7 SoFs); and Mechanisms of effect to achieve change factors (6 SoFs). The synthesis showed how inter- and intra-system power differentials, and stakeholder commitment, exert strong mechanisms of effect on caesarean section rates, independent of the theoretical efficacy of specific interventions to reduce them. CONCLUSIONS Non-clinical interventions to reduce caesarean section are strongly mediated by organisational power differentials and stakeholder commitment. Barriers may be greatest where implementation plans contradict system and cultural norms. PROTOCOL REGISTRATION PROSPERO: CRD42017059456.
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Affiliation(s)
- Carol Kingdon
- Department of Community Health and Midwifery, University of Central Lancashire, Preston, Lancashire, United Kingdom
| | - Soo Downe
- Department of Community Health and Midwifery, University of Central Lancashire, Preston, Lancashire, United Kingdom
| | - Ana Pilar Betran
- Department of Reproductive Health and Research, World Health Organization (WHO), Geneva, Switzerland
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Kingdon C, Downe S, Betran AP. Women's and communities' views of targeted educational interventions to reduce unnecessary caesarean section: a qualitative evidence synthesis. Reprod Health 2018; 15:130. [PMID: 30041661 PMCID: PMC6057083 DOI: 10.1186/s12978-018-0570-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 07/05/2018] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND There is continued debate about the role of women and communities in influencing rising rates of caesarean section (CS). In settings where CS rates exceed recommended levels, mothers and babies are exposed to potential harms that may outweigh the potential benefits. There is therefore a need to understand how educational interventions targeted at women and communities to reduce unnecessary CS are perceived and used. This qualitative evidence synthesis aimed to explore what women and communities say about the barriers and facilitators to intervention effectiveness for these important groups. METHOD Seven electronic databases were searched using predefined search terms. Studies reporting qualitative data pertaining to interventions, published between 1985 and March 2017, with no language restriction were sought. Study quality was independently assessed by two authors before qualitative evidence synthesis was undertaken using an interpretive, meta-ethnography approach. Resulting Statements of Findings were assessed using GRADE-CERQual, and summarised thematically. RESULTS Twelve studies were included. They were published between 2001 and 2016. Eleven were from high-income countries. Twelve Summaries of Findings encompassed the data, and were graded (moderate or high) on CerQual. The Statements of Findings are reported under three final themes: 1) Mutability of women's and communities' beliefs about birth; 2) Multiplicity of individual information needs about birth; 3) Interactions with health professionals and influence of healthcare system on actual birth method. Women and communities value educational interventions that include opportunities for dialogue, are individualised (including acknowledgement of previous birth experiences), and are consistent with available clinical care and the advice of the health professional they come into contact with. CONCLUSION Women's values and preferences for birth, and for information format and content, vary across populations, and evolves in individual women over time. Interactions with health professionals and health system factors can partly be responsible for changes in views. Educational interventions should take into account these dynamic interactions, as well as the women's need for emotional support and dialogue with professionals alongside information about birth. Further research is required to test these findings and the utility of their practical application, particularly in medium and low income settings. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO 2017 CRD42017059453 .
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Affiliation(s)
- Carol Kingdon
- School of Community Health and Midwifery, Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE, UK.
| | - Soo Downe
- School of Community Health and Midwifery, Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE, UK
| | - Ana Pilar Betran
- Department of Reproductive Health and Research, World Health Organization (WHO), Geneva, Switzerland
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Carlson NS. Current Resources for Evidence-Based Practice, May/June 2018. J Midwifery Womens Health 2018; 63:362-365. [DOI: 10.1111/jmwh.12742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 02/23/2018] [Indexed: 11/28/2022]
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