Barriers and enablers in the implementation of a program to reduce cesarean deliveries

Pregnancy Outcomes in Survivors of Adolescent and Young Adult Breast Cancer: A Population-Based Cohort Study

OBJECTIVES

To evaluate the association between adolescent and young adult (AYA) breast cancer (BC) and the adverse pregnancy outcomes of preterm birth, small for gestational age birth, cesarean delivery, and preeclampsia, and the effect of fertility treatment on this association.

METHODS

Population-based cohort study with universal coverage health data for Ontario, Canada. BC was identified from the Ontario Cancer Registry. All births >220 weeks gestation between April 2006 to March 2018 were included. Modified Poisson regression generated risk ratios between AYA BC and adverse pregnancy outcomes, adjusted for maternal characteristics. Models were stratified by fertility treatment.

RESULTS

Among 1 189 980 deliveries, 474 mothers had AYA BC history (exposed), while 1 189 506 had no cancer history (unexposed). AYA BC was associated with cesarean delivery (adjusted risk ratio [aRR] 1.26; 95% CI 1.14-1.39). There was no association between AYA BC and other adverse outcomes. Modelling cesarean delivery subtypes, AYA BC was associated with increased risk of planned (aRR 1.27; 95% CI 1.08-1.49) and unplanned cesarean delivery (aRR 1.41; 95% CI 1.20-1.66). An increased risk of cesarean delivery in exposed persisted among singleton pregnancies (aRR 1.27; 95% CI 1.15-1.41), but not in models stratified by mode of conception (fertility treatment: aRR 1.07; 95% CI 0.84-1.36; unassisted conception: aRR 1.30; 95% CI 1.16-1.46).

CONCLUSIONS

A history of AYA BC did not confer an elevated risk of adverse pregnancy outcomes, except for planned and unplanned cesarean delivery. The risk of adverse pregnancy outcomes does not appear to be an indication for delayed pregnancy after AYA BC diagnosis.

Behavioural factors associated with fear of litigation as a driver for the increased use of caesarean sections: a scoping review

OBJECTIVE

To explore the behavioural drivers of fear of litigation among healthcare providers influencing caesarean section (CS) rates.

DESIGN

Scoping review.

DATA SOURCES

We searched MEDLINE, Scopus and WHO Global Index (1 January 2001 to 9 March 2022).

DATA EXTRACTION AND SYNTHESIS

Data were extracted using a form specifically designed for this review and we conducted content analysis using textual coding for relevant themes. We used the WHO principles for the adoption of a behavioural science perspective in public health developed by the WHO Technical Advisory Group for Behavioural Sciences and Insights to organise and analyse the findings. We used a narrative approach to summarise the findings.

RESULTS

We screened 2968 citations and 56 were included. Reviewed articles did not use a standard measure of influence of fear of litigation on provider's behaviour. None of the studies used a clear theoretical framework to discuss the behavioural drivers of fear of litigation. We identified 12 drivers under the three domains of the WHO principles: (1) cognitive drivers: availability bias, ambiguity aversion, relative risk bias, commission bias and loss aversion bias; (2) social and cultural drivers: patient pressure, social norms and blame culture and (3) environmental drivers: legal, insurance, medical and professional, and media. Cognitive biases were the most discussed drivers of fear of litigation, followed by legal environment and patient pressure.

CONCLUSIONS

Despite the lack of consensus on a definition or measurement, we found that fear of litigation as a driver for rising CS rates results from a complex interaction between cognitive, social and environmental drivers. Many of our findings were transferable across geographical and practice settings. Behavioural interventions that consider these drivers are crucial to address the fear of litigation as part of strategies to reduce CS.

The cost of preterm birth and cesarean section as a result of infertility and its treatment: A review

Infertility, irrespective of receipt of fertility treatment, is associated with an increased risk of adverse pregnancy outcomes, including cesarean section (CS) and preterm birth (PTB). These complications are associated with significant physical, mental, emotional, social, and financial costs to individuals, healthcare systems, and society at large. Although multiple pregnancy is one of the most significant contributors to the elevated CS and PTB rates in women receiving fertility treatment, singleton pregnancy is also at an increased risk of these outcomes. Single embryo transfer policies through publicly funded in vitro fertilization programs have demonstrated beneficial health outcomes and cost savings. Low-dose aspirin prophylaxis may be considered for PTB reduction in patients with infertility. Finally, upstream prevention strategies such as lifestyle modification and social policies to address the underlying needs for fertility treatment may also beneficially impact both CS and PTB rates.

An impact evaluation of the strategy for normal birth care on caesarean section rates and perinatal mortality in Spain

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.

Rapid Cycle Implementation and Retrospective Evaluation of a SARS-CoV-2 Checklist in Labor and Delivery

Background

Preparedness efforts for a COVID-19 outbreak required redesign and implementation of a perioperative workflow for the management of obstetric patients. In this report we describe factors which influenced rapid cycle implementation of a novel comprehensive checklist for the perioperative care of the COVID-19 parturient.

Methods

Within our labour and delivery unit, implementation of a novel checklist for the COVID-19 parturient requiring perioperative care was accomplished through rapid cycling, debriefing and on-site walkthroughs. Post-implementation, consistent use of the checklist was reported for all obstetric COVID-19 perioperative cases (100% workflow checklist utilization). Retrospective analysis of the factors influencing implementation was performed using a group deliberation approach, mapped against the Consolidated Framework for Implementation Research (CFIR).

Results

Analysis of factors influencing implementation using CFIR revealed domains of process implementation and innovation characteristics as overwhelming facilitators for success. Constructs within the outer setting, inner setting, and characteristic of individuals (external pressures, baseline culture, and personal attributes) were perceived to act as early barriers. Constructs such as communication culture and learning climate, shifted in influence over time.

Conclusion

We describe the influential factors of implementing a novel comprehensive obstetric workflow for care of the COVID-19 perioperative parturient during the first surge of the pandemic using the CFIR framework. Early workflow adoption was facilitated primarily by two domains, namely thoughtful innovation design and careful implementation planning in the setting of a long-standing culture of improvement. Factors initially assessed as barriers such as communication, culture and learning climate, transitioned into facilitators once a perceived benefit was experienced by healthcare teams. These results provide important information for the implementation of rapid change during a time of crisis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06787-5.

Nurses and midwives' experiences with peer-group clinical supervision intervention: A pilot study

AIM

This study aimed to evaluate differences in supervisees' understanding of clinical supervision and their perceptions of organisational functioning before and after engaging in peer-group clinical supervision.

BACKGROUND

Protected reflective time allows discussion of complex issues affecting health care. Peer-group clinical supervision is one model of clinical supervision that could facilitate this, but it is poorly understood.

METHODS

A pre-post intervention pilot study was performed. The intervention was delivered over a 12-month period. Data were collected using surveys on demographic and work-related factors and experience of clinical supervision pre- and post intervention.

RESULTS

Adaptability increased significantly between the pre- and post surveys. The post survey data showed finding time for clinical supervision scoring lowest with open-ended comments reinforcing this. The supervisees found the sessions to offer a safe place despite initial concerns.

CONCLUSION

The peer-group model of clinical supervision allowed supervisees to build a rapport and trust with their colleagues and share experiences.

IMPLICATIONS FOR NURSING MANAGEMENT

The benefits to participating in peer-group clinical supervision traversed the individual and organisation. These data support the implementation of such sessions while addressing workload and time pressures to aid participation.

Caesarean section in pregnancies conceived by assisted reproductive technology: a systematic review and meta-analysis

Background

Caesarean section rates are higher among pregnancies conceived by assisted reproductive technology (ART) compared to spontaneous conceptions (SC), implying an increase in neonatal and maternal morbidity. We aimed to compare caesarean section rates in ART pregnancies versus SC, overall, by indication (elective versus emergent), and by type of ART treatment (in-vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), fresh embryo transfer, frozen embryo transfer) in a systematic review and meta-analysis.

Methods

We searched Medline, EMBASE and CINAHL databases using the OVID Platform from 1993 to 2019, and the search was completed in January 2020. The eligibility criteria were cohort studies with singleton conceptions after in-vitro fertilization and/or intracytoplasmic sperm injection using autologous oocytes versus spontaneous conceptions. The study quality was assessed using the Newcastle Ottawa Scale and GRADE approach. Meta-analyses were performed using odds ratios (OR) with a 95% confidence interval (CI) using random effect models in RevMan 5.3, and I-squared (I²) test > 75% was considered as high heterogeneity.

Results

One thousand seven hundred fifty studies were identified from the search of which 34 met the inclusion criteria. Compared to spontaneous conceptions, IVF/ICSI pregnancies were associated with a 1.90-fold increase of odds of caesarean section (95% CI 1.76, 2.06). When stratified by indication, IVF/ICSI pregnancies were associated with a 1.91-fold increase of odds of elective caesarean section (95% CI 1.37, 2.67) and 1.38-fold increase of odds of emergent caesarean section (95% CI 1.09, 1.75). The heterogeneity of the studies was high and the GRADE assessment moderate to low, which can be explained by the observational design of the included studies.

Conclusions

The odds of delivering by caesarean section are greater for ART singleton pregnancies compared to spontaneous conceptions. Preconception and pregnancy care plans should focus on minimizing the risks that may lead to emergency caesarean sections and finding strategies to understand and decrease the rate of elective caesarean sections.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03711-x.

The Albertina Sisulu Executive Leadership Programme enhancing the competencies and performance of public health service managers in South Africa

Purpose

The purpose of this paper is to evaluate the effect of the Albertina Sisulu Executive Leadership Programme in Health (ASELPH) in improving the competencies and performance of public healthcare managers in South Africa (SA).

Design/methodology/approach

This study used a quasi-experimental study design, with pre-post assessments to assess the performance and competencies of students participating in a public health leadership programme. Students were assessed using a 360° assessment of 14 competencies and 56 performance indicators.

Findings

Students improved significantly in 11 competencies and 44 performance indicators; they perceived improvements in their own performance. The assessors observed the same improvements, which confirmed performance change at the students’ workplaces. The study showed the positive effect of the ASELPH Fellowship in improving the competencies and performance of public healthcare managers in SA.

Originality/value

The ASELPH Fellowship enhanced the leadership competencies and the performance of South African public healthcare managers. South African public healthcare managers face significant challenges and concerns have been raised regarding the competencies of healthcare managers to deal with these challenges. This study shows that leadership programmes can improve competencies and performance of managers to have an impact on the South African healthcare system

The impact of the "Health Transformation Plan" and related policies on the prevalence rate of cesarean section in Iran: Insights from an interrupted time series analysis

BACKGROUND

The high prevalence of cesarean section represents a major public health challenge worldwide. In 2014, the Iranian Health Transformation Plan (HTP) included programs promoting vaginal delivery.

AIM

The aim of this study was to investigate the effect of the HTP on the rate of cesarean section in Iran.

METHOD

The interrupted time series analysis (ITSA) was used. Cesarean section- and vaginal delivery-related monthly data were collected from eight public hospitals affiliated with the Lorestan University of Medical Sciences, from March 2012 to February 2019. The autocorrelation plots and the Durbin-Watson test were used for evaluating the autocorrelation between data points in the generalized least squares regression model.

RESULTS

The ITSA showed that the rate of cesarean section decreased immediately after the HTP, by -0.002 per 1000 persons (95% CI, -0.004 to -0.001; P = .069). After the HTP, a significant decreasing trend of cesarean section per month was computed (-0.003; 95% CI, -0.005 to 0.012; P = .043).

CONCLUSION

The present study showed that the implementation of the HTP policy was effective in reducing the rate of cesarean section. This policy should continue, involving relevant stakeholders, raising mothers' awareness and motivation, and providing financial support.

Prevalence, Related Factors, and Levels of Burnout Syndrome Among Nurses Working in Gynecology and Obstetrics Services: A Systematic Review and Meta-Analysis

BACKGROUND

Although burnout levels and the corresponding risk factors have been studied in many nursing services, to date no meta-analytical studies have been undertaken of obstetrics and gynecology units to examine the heterogeneity of burnout in this environment and the variables associated with it. In the present paper, we aim to determine the prevalence, levels, and related factors of burnout syndrome among nurses working in gynecology and obstetrics services.

METHODS

A systematic review and meta-analysis of the literature were carried out using the following sources: CINAHL (Cumulative Index of Nursing and Allied Health Literature), LILACS (Latin American and Caribbean Health Sciences Literature), Medline, ProQuest (Proquest Health and Medical Complete), SciELO (Scientific Electronic Library Online), and Scopus.

RESULTS

Fourteen relevant studies were identified, including, for this meta-analysis, n = 464 nurses. The following prevalence values were obtained: emotional exhaustion 29% (95% CI: 11-52%), depersonalization 19% (95% CI: 6-38%), and low personal accomplishment 44% (95% CI: 18-71%). The burnout variables considered were sociodemographic (age, marital status, number of children, gender), work-related (duration of the workday, nurse-patient ratio, experience or number of miscarriages/abortions), and psychological (anxiety, stress, and verbal violence).

CONCLUSION

Nurses working in obstetrics and gynecology units present high levels of burnout syndrome. In over 33% of the study sample, at least two of the burnout dimensions considered are apparent.