Mass media campaigns to reduce unnecessary caesarean sections: a systematic review

Low-Value Surgical Procedures in Low- and Middle-Income Countries: A Systematic Scoping Review

Importance

Overuse of surgical procedures is increasing around the world and harms both individuals and health care systems by using resources that could otherwise be allocated to addressing the underuse of effective health care interventions. In low- and middle-income countries (LMICs), there is some limited country-specific evidence showing that overuse of surgical procedures is increasing, at least for certain procedures.

Objectives

To assess factors associated with, extent and consequences of, and potential solutions for low-value surgical procedures in LMICs.

Evidence Review

We searched 4 electronic databases (PubMed, Embase, PsycINFO, and Global Index Medicus) for studies published from database inception until April 27, 2022, with no restrictions on date or language. A combination of MeSH terms and free-text words about the overuse of surgical procedures was used. Studies examining the problem of overuse of surgical procedures in LMICs were included and categorized by major focus: the extent of overuse, associated factors, consequences, and solutions.

Findings

Of 4276 unique records identified, 133 studies across 63 countries were included, reporting on more than 9.1 million surgical procedures (median per study, 894 [IQR, 97-4259]) and with more than 11.4 million participants (median per study, 989 [IQR, 257-6857]). Fourteen studies (10.5%) were multinational. Of the 119 studies (89.5%) originating from single countries, 69 (58.0%) were from upper-middle-income countries and 30 (25.2%) were from East Asia and the Pacific. Of the 42 studies (31.6%) reporting extent of overuse of surgical procedures, most (36 [85.7%]) reported on unnecessary cesarean delivery, with estimated rates in LMICs ranging from 12% to 81%. Evidence on other surgical procedures was limited and included abdominal and percutaneous cardiovascular surgical procedures. Consequences of low-value surgical procedures included harms and costs, such as an estimated US $3.29 billion annual cost of unnecessary cesarean deliveries in China. Associated factors included private financing, and solutions included social media campaigns and multifaceted interventions such as audits, feedback, and reminders.

Conclusions and Relevance

This systematic review found growing evidence of overuse of surgical procedures in LMICs, which may generate significant harm and waste of limited resources; the majority of studies reporting overuse were about unnecessary cesarean delivery. Therefore, a better understanding of the problems in other surgical procedures and a robust evaluation of solutions are needed.

Variations in the prevalence of caesarean section deliveries in India between 2016 and 2021 - an analysis of Tamil Nadu and Chhattisgarh

BACKGROUND

The prevalence of C-sections in India increased from 17.2% to 2006 to 21.5% in 2021. This study examines the variations in C-section prevalence and the factors correlating to these variations in Tamil Nadu (TN) and Chhattisgarh (CG).

METHODS

Delivery by C-section as the outcome variable and several demographic, socio-economic, and clinical variables were considered as explanatory variables to draw inferences from unit-level data from the National Family Health Survey (NFHS-4; 2015-16 and NFHS-5; 2019-21). Descriptive statistics, bivariate percentage distribution, Pearson's Chi-square test, and multivariate binary logistic regression models were employed. The Slope Index of Inequality (SII) and the Concentration Index (CIX) were used to analyse absolute and relative inequality in C-section rates across wealth quintiles in public- and private-sector institutions.

RESULTS

The prevalence of C-sections increased across India, TN and CG despite a decrease in pregnancy complications among the study participants. The odds of caesarean deliveries among overweight women were twice (OR = 2.11; 95% CI 1.95-2.29; NFHS-5) those for underweight women. Women aged 35-49 were also twice (OR = 2.10; 95% CI 1.92-2.29; NFHS-5) as likely as those aged 15-24 to have C-sections. In India, women delivering in private health facilities had nearly four times higher odds (OR = 3.90; 95% CI 3.74-4.06; NFHS-5) of having a C-section; in CG, the odds were nearly ten-fold (OR = 9.57; 95% CI:7.51,12.20; NFHS-5); and in TN, nearly three-fold (OR = 2.65; 95% CI-2.27-3.10; NFHS-5) compared to those delivering in public facilities. In public facilities, absolute inequality by wealth quintile in C-section prevalence across India and in CG increased in the five years until 2021, indicating that the rich increasingly delivered via C-sections. In private facilities, the gap in C-section prevalence between the poor (the bottom two quintiles) and the non-poor narrowed across India. In TN, the pattern was inverted in 2021, with an alarming 73% of the poor delivering via C-sections compared to 64% of those classified as non-poor.

CONCLUSION

The type of health facility (public or private) had the most impact on whether delivery was by C-section. In India and CG, the rich are more likely to have C-sections, both in the private and in the public sector. In TN, a state with good health indicators overall, the poor are surprisingly more likely to have C-sections in the private sector. While the reasons for this inversion are not immediately evident, the implications are worrisome and pose public health policy challenges.

Assessing the Effectiveness of COVID-19 Prevention Campaign in Health Volunteers of Urmia City

Holding educational campaigns with the purpose of conveying message about one particular behavior in the target group, is one of the society-based educational strategies. This study aimed to investigate the efficiency of the Campaign of COVID-19 Prevention on Health Volunteers in Urmia. The present study was a semi-experimental research, in which the sampling was done in a census way with 200 people participated. In this study, which was done as pre- and posttest, the amount of knowledge, attitude and behavior of health volunteers were evaluated by the designed questionnaires. The campaign was held for 2 months, which has benefited from the five methods of pamphlet, banners, films, social networking sites, and educational classes. After the campaign, the knowledge level, attitude and behavior of Health Volunteers increased to 35.1%, 30.09%, and 29.2%, respectively, which was meaningful statistically. Holding the campaign can trigger positive changes in improving the knowledge, attitude, and behavior of health volunteers, leading to the prevention of a plethora of health problems in society.

Geographical Inequalities in Access to Bellwether Procedures in Brazil

BACKGROUND

Brazil is a middle-income country that aims to provide universal health coverage, but its surgical system's efficiency has rarely been analyzed. In an effort to strengthen surgical national systems, the Lancet Commission on Global Surgery proposed bellwether procedures as quality indicators of surgical workforces. This study aims to evaluate regional inequalities in access to bellwether procedures and their associated mortality across the five Brazilian geographical regions.

METHODS

Using DATASUS, Brazil's national healthcare database, data were collected on the total amount of performed bellwether procedures-cesarean section, laparotomy, and open fracture management-and their associated mortality, by geographical region. We evaluated the years 2018-2020, both in emergent and elective conditions. Statistical analysis was performed by one-way ANOVA test and Tukey's multiple comparisons test.

RESULTS

During this period, DATASUS registered 2,687,179 cesarean sections, 1,036,841 laparotomies, and 648,961 open fracture treatments. The access and associated mortality related to these procedures were homogeneous between the regions in elective care. There were significant geographical inequalities in access and associated mortality in emergency care (p < 0.05, 95% CI) for all bellwether procedures. The Southeast, the most economically developed region of the country, was the region with the lowest amount of bellwether procedures per 100,000 inhabitants.

CONCLUSION

Brazil's public surgical system is competent at promoting elective surgical care, but more effort is needed to fortify emergency care services. Public policies should encourage equity in the geographic allocation of the surgical workforce.

Sources of information on diabetes and its demographic correlates: a nationwide survey among Singapore residents

Diabetes is a major public health concern in Singapore, and the Singapore Government declared a ‘War on Diabetes’, which included a nationwide public health campaign. It is important to identify what sources of diabetes information reach the general population, whether this differs by socio-demographic characteristics and if the sources of information influence knowledge of diabetes to aid the successful dissemination of health information. Two thousand eight hundred ninety-five respondents were part of a population-based cross-sectional study conducted from February 2019 to September 2020. Respondents rated on a five-point scale whether they had obtained information on diabetes from eight different information sources, and responses were dichotomized into ‘endorsed receiving information’ or ‘not endorsed receiving information’. Poisson regression models were conducted with the ‘endorsement of receiving information’ from each source as the outcome and socio-demographic variables as predictors. 95.9% of the study population had received information on diabetes from at least one source, and the mean number of sources was 4.2 ± 2.0. The leading source was media articles (82.1%), followed by health promotion videos/advertisements (77.9%), online websites (58.5%), books (56.5%), healthcare professionals (55.0%), radio (54.4%), public forums (27.7%) and support groups (15.5%). Endorsing a greater number of informational sources was associated with being younger, belonging to Malay or Indian instead of Chinese ethnicity, and having diabetes. An intensive nationwide diabetes awareness campaign successfully reached the public in Singapore with specific sources of information depending on socio-demographic characteristics. Findings suggest that diabetes information campaigns should utilize multiple channels for dissemination considering the different socio-demographic subgroups.

The portrayal and perceptions of cesarean section in Mexican media Facebook pages: a mixed-methods study

Background

Mexico has one of the highest rates of cesarean sections globally at over 45%. There is limited research about social factors influencing these rates. This study explores the portrayal and perceptions of cesarean section in Facebook media pages to better understand the socio-cultural context of childbirth in Mexico.

Methods

This is a mixed-methods social media analysis using two data sources. First, to study the portrayal of cesarean section, we identified ten Mexican media Facebook pages with the largest audiences (based on number of page “likes”). We searched these pages for articles containing the word “cesárea” (Spanish for cesarean section), and posts (articles) were eligible for inclusion if they contained the word “cesárea”. Second, to understand perceptions of cesarean section portrayal, we extracted comment threads of each Facebook post sharing the included articles. We performed a qualitative thematic analysis of articles and a quantitative content analysis of comments.

Results

We included 133 Facebook posts depicting 80 unique articles and identified three major themes: (1) information about cesarean section, (2) inequality and violence against women, (3) governance failures. Cesarean section was portrayed as a lifesaving procedure when medical necessary, and riskier than vaginal birth, with a longer recovery time, and possible negative health consequences. We extracted comments from 133 Facebook posts, and 6350 comments were included. We inductively developed 20 codes to then classify comments under six major categories: (1) violence and discrimination, (2) health and health services, (3) mode of birth choice, (4) disbelief at information about cesarean section, (5) abortion, and (6) discontent at the government.

Conclusions

We found that Facebook media did not promote cesarean section over vaginal birth, and risks and consequences were mostly represented reliably. Perceptions about the portrayal of cesarean section showed strong discontent and distrust against providers and the health system, as well as rejection of factual information about the consequences of cesarean section. We documented gross gender inequality and violence against women, highlighting the urgent need for human rights approaches to maternal health to address these inequalities and prevent harmful practices. Our study also contributes to the emerging field of social media analysis, and demonstrates clear areas where social media communication can be improved.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-022-01351-8.

Cesarean section is a medical intervention that can save women and babies when there are complications during pregnancy or birth. Mexico has one of the highest rates of cesarean section in the world (45%); much higher than what we would expect. We do not fully understand why this is happening, but we think social influences are important.

We know that traditional and social media are important social influences on health and health-seeking behaviors in other countries. In our study, we aimed to explore how cesarean section is portrayed in Facebook Mexican media pages, and how people (Facebook users) interacted with these articles. To do this, we identified the most popular Facebook media pages in Mexico.

Next, we searched for all articles posted to these pages. We found 80 articles and studied them to understand how they discussed cesarean section. We found that media articles posted on Facebook did not encourage women to have cesarean section, and they correctly showed risks and consequences.

Then, we explored the comments from Facebook users that were attached to these posts about cesarean section. We found 6350 comments, and classified each comment based on the what the Facebook users said.

Lastly, we connected the main themes of the articles to the types of comments. We found that Facebook users distrusted the Mexican health system, rejected information about the consequences of cesarean section, and often responded with the content with sexist and aggressive comments against women.

Our research shows that while there is accurate and useful information on social media about cesarean section, other social issues like gender inequality and violence may influence pregnancy and childbirth.

Collaborative model of intrapartum care: qualitative study on barriers and facilitators to implementation in a private Brazilian hospital

INTRODUCTION

A collaborative (midwife-obstetrician) model of intrapartum care (CMIC) is associated with lower caesarean section (CS) rates than physician-led models. In 2019, the largest private maternity hospital in Latin America (14.000 deliveries/year, 89% CS) created a quality improvement initiative to optimise intrapartum care and safely reduce CS in low-risk women managed by its internal team of healthcare providers (HCP). We conducted formative research to identify potential barriers and facilitators to the implementation of a CMIC.

METHODS

Three groups of stakeholders participated in focus groups and interviews: hospital managers and clinical coordinators, HCP working in labour/delivery wards and pregnant women intending to give birth in the hospital. We explored participants' views about the acceptability of implementing a CMIC where a nurse-midwife (NM) on shift would be the main intrapartum HCP, with continuous support/supervision of a dedicated, in-house, obstetrician-gynaecologist (OB-GYN). A thematic analysis approach was used.

RESULTS

12 HCPs, 5 clinical coordinators, 2 hospital managers and 7 women participated. OB-GYNs, coordinators and managers highlighted health system, organisational and structural factors (NMs' limited experience/skills, professional roles, financial reimbursement) as potential barriers. NMs identified logistical and human resources as additional barriers. Women viewed the CMIC with perplexity and insecurity because of cultural beliefs about the dominant role of OB-GYNs, and limited information about NM's capabilities. All professionals agreed that women's acceptance of a CMIC will require educational interventions and communication strategies to inform potential users about the advantages and safety of this model.

CONCLUSION

There are important barriers and facilitators to implement a CMIC in a private Brazilian maternity hospital. Factors related to health system structure and organisation may have the greatest impact. A CMIC is more likely to succeed if stakeholders' concerns about responsibilities, power and financial revenues are addressed, and educational interventions targeted at users are deployed prior to its implementation.

Neighborhoods, networks, and delivery methods

We examine the contribution of information transmission among pregnant women to geographic variation in C-sections in Lombardy, Italy. Defining networks as pregnant women living in the same municipality, we observe that if the incidence of C-sections within the womans network is one standard deviation higher over the 12 months preceding delivery, then her probability of delivering by C-section is 0.007 percentage points (3%) higher. This result is mainly a network effect on Italian women, while it arises from both network and neighborhood effects on foreign women. Both groups respond to additional information, such as the incidence of C-section complications. The selection of pregnant women across hospitals does not uniquely explain our results, which are robust to alternative sample selections and specifications.

Trend and Inequality in Episiotomy in Southern Brazil, 2007-2016: Evidence of Reduced Abusive Practice

OBJECTIVES

This study aimed to measure the prevalence, to describe the trend over time, and to evaluate socioeconomic inequalities in the occurrence of episiotomies in 2007, 2010, 2013, and 2016 in the municipality of Rio Grande, in Southern Brazil.

METHODS

We included all women who had vaginal delivery in each of the studied years. All the information was obtained through a questionnaire applied at maternity wards within 48 h after delivery. The outcome consisted of episiotomy. A chi-square test was used to evaluate the linear trend. Absolute and relative inequalities were assessed from household income and schooling of the women through the Slope Index of Inequality and Relative Index of Inequality, respectively.

RESULTS

This study included 4,521 parturients. The episiotomy rate in the period fell from 71.0% (95%CI: 68.4-73.5) in 2007 to 40.1% (95%CI: 37.3-42.8) in 2016, and it was more frequent among women with higher income and higher schooling. We observed a reduction in the rate of episiotomy in all income and schooling levels, and this was more evident among women in the lowest socioeconomic levels. Absolute inequality declined, while relative inequality remained unchanged.

CONCLUSIONS FOR PRACTICE

Despite the significant reduction in the rate of episiotomy, its occurrence remains high. Women with higher income and education, therefore with lower risk for complications during childbirth, were the most frequently submitted to this procedure. Routine use of episiotomy must be reevaluated, especially among pregnant women with better socioeconomic status.

Communication Intervention Using Digital Technology to Facilitate Informed Choices at Childbirth in the Context of the COVID-19 Pandemic: Protocol for a Randomized Controlled Trial

BACKGROUND

In Brazil and other low- and middle-income countries, excess interventions in childbirth are associated with an increase in preterm and early-term births, contributing to stagnant morbidity and mortality of mothers and neonates. The fact that women often report a negative experience with vaginal childbirth, with physical pain and feelings of unsafety, neglect, or abuse, may explain the high acceptability of elective cesarean sections. The recognition of information needs and of the right to informed choice during childbirth can help change this reality. The internet has been the main source of health information, but its quality is highly variable.

OBJECTIVE

This study aimed to develop and evaluate an information and communication strategy through a smartphone app with respect to childbirth, to facilitate informed choices for access to safer and evidence-based care in the context of the COVID-19 pandemic.

METHODS

A randomized controlled trial, with 2 arms (intervention and control) and a closed, blind, parallel design, will be conducted with a smartphone app designed for behavior and opinion research in Brazil, with women of reproductive age previously registered on the app. After completing an entry questionnaire to verify the eligibility criteria and obtaining ethical consent, approximately 20,000 participants will be randomly allocated to the intervention and control groups at a 1:1 ratio. Participants allocated to the intervention group will be invited to engage in a digital information and communication strategy, which is designed to expand evidence-based knowledge on the advantages and disadvantages of options for labor and childbirth and the safety of the care processes. The information is based on the guidelines of the Ministry of Health and the World Health Organization for a positive childbirth experience and has been updated to include the new challenges and disruptions in maternity care within the context of the COVID-19 pandemic. The control group will receive information regarding disposable and reusable diapers as a placebo intervention. The groups will be compared in their responses in generating the birth plan and the entry and exit questionnaires, regarding responses less or more aligned with the guidelines for a positive childbirth experience. A qualitative component to map information needs is included.

RESULTS

The digital trial started recruiting participants in late October 2020, and data collection has been projected to be complete by December 2020.

CONCLUSIONS

This study will evaluate an innovative intervention that has the potential to promote better communication between women and providers, such that they can make better choices using an approach suitable for use during the COVID-19 pandemic.

TRIAL REGISTRATION

The Brazilian Clinical Trials Registry U1111-1255-8683; http://www.ensaiosclinicos.gov.br/rg/RBR-3g5f9f/.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/25016.

Electronic Tools to Bridge the Language Gap in Health Care for People Who Have Migrated: Systematic Review

BACKGROUND

People who have migrated or with a language barrier may face significant hurdles in accessing health care. Some apps have been specifically developed to facilitate the dialogue between health care professionals and people who have migrated who have low-level language proficiency or to promote health among people who have migrated.

OBJECTIVE

We conducted a systematic review to investigate development, acceptability, and effectiveness of these types of apps.

METHODS

We conducted a search of PubMed, Scopus, and Embase databases. We included all study designs (qualitative, quantitative, mixed) reporting development, evaluation of efficacy, or acceptability of apps facilitating dialogue with a health professional or promoting health for people who have migrated, minorities, or tourists with a language barrier, using any outcome. Two researchers selected the studies independently. We collected general information about the app, information about health literacy and cultural adaptation, information about the development of the app, evidence on acceptability or efficacy, and information on app use. Data were collected by 2 researchers independently and results were reviewed to verify agreement and reported according to PRISMA (Preferred Reporting Items for Systematic Review and Meta-analysis).

RESULTS

Positive results for translation apps included better communication, but with possible limitations, and reduced consultation time. Positive results for health promotion apps included improved quality of life and better management of chronic illnesses.

CONCLUSIONS

Overall, the apps had good levels of acceptability, though only half had their efficacy evaluated. In those evaluations, the endpoints were mostly related to reported behavior change and knowledge improvement, which is common for evaluations of health promotion programs. In the future, as more health apps are created, it is essential that apps that claim to have a public health objective undergo a rigorous evaluation of their acceptability, efficacy, and actual use. Indicators of outcomes beyond changes in behavior and knowledge should be reported; change in health status or access to care should also be reported. This systematic review has helped us note the characteristics associated with improved acceptability and efficacy, which can be helpful for the development of future apps.

"Study Natural" without Drugs: An Exploratory Study of Theory-Guided and Tailored Health Campaign Interventions to Prevent Nonmedical Use of Prescription Stimulants in College Students

Nonmedical use of prescription stimulants (NMUPS) among college students continues to rise. While some anti-NMUPS campaigns are available, little is known about the campaign development process and how well college students evaluate these messages. To bridge this gap, we developed theory-guided anti-NMUPS campaign interventions that are tailored to college students’ characteristics and evaluated students’ response towards them. A total of 445 college students (74.4% female; Mean_age of 20; 18 to 35 years old) reviewed the campaign interventions and offered their evaluation via an online survey. Findings indicate that students responded to the campaigns positively. Results also indicate that female students are more likely to perceive the campaigns as effective than their male counterparts. Overall, the findings of this study suggest that theory-guided and tailored anti-NMUPS campaigns have great potential in changing students’ attitudes and behavior towards NMUPS. While this study fills critical gaps in the literature, considering the progress needed to strengthen the research field, more research is needed to further identify effective strategies that could prevent college students’ participation in NMUPS activities.