Effect of a two-stage intervention package on the cesarean section rate in Guangzhou, China: A before-and-after study

Educational interventions targeting pregnant women to optimise the use of caesarean section: What are the essential elements? A qualitative comparative analysis

BACKGROUND

Caesarean section (CS) rates are increasing globally, posing risks to women and babies. To reduce CS, educational interventions targeting pregnant women have been implemented globally, however, their effectiveness is varied. To optimise benefits of these interventions, it is important to understand which intervention components influence success. In this study, we aimed to identify essential intervention components that lead to successful implementation of interventions focusing on pregnant women to optimise CS use.

METHODS

We re-analysed existing systematic reviews that were used to develop and update WHO guidelines on non-clinical interventions to optimise CS. To identify if certain combinations of intervention components (e.g., how the intervention was delivered, and contextual characteristics) are associated with successful implementation, we conducted a Qualitative Comparative Analysis (QCA). We defined successful interventions as interventions that were able to reduce CS rates. We included 36 papers, comprising 17 CS intervention studies and an additional 19 sibling studies (e.g., secondary analyses, process evaluations) reporting on these interventions to identify intervention components. We conducted QCA in six stages: 1) Identifying conditions and calibrating the data; 2) Constructing truth tables, 3) Checking quality of truth tables; 4) Identifying parsimonious configurations through Boolean minimization; 5) Checking quality of the solution; 6) Interpretation of solutions. We used existing published qualitative evidence synthesis to develop potential theories driving intervention success.

RESULTS

We found successful interventions were those that leveraged social or peer support through group-based intervention delivery, provided communication materials to women, encouraged emotional support by partner or family participation, and gave women opportunities to interact with health providers. Unsuccessful interventions were characterised by the absence of at least two of these components.

CONCLUSION

We identified four key essential intervention components which can lead to successful interventions targeting women to reduce CS. These four components are 1) group-based delivery, 2) provision of IEC materials, 3) partner or family member involvement, and 4) opportunity for women to interact with health providers. Maternal health services and hospitals aiming to better prepare women for vaginal birth and reduce CS can consider including the identified components to optimise health and well-being benefits for the woman and baby.

Leadership Driven Persistent Reduction in Cesarean Trends: An Interventional Study for Quality Improvement

Background

This is a quality improvement study in North India undertaken to observe the efficacy and safety of a proposed set of interventions along Quality Improvement guidelines to reduce cesarean rates.

Materials and Methods

It was a retrospective cross-sectional study conducted in New Delhi. Measures were iteratively introduced from 2017 and improved using multiple PDSA (Plan, Do, Study, Act) cycles to note the overall reduction in cesarean rates. Chi square tests were done with subanalysis based on the Robsons classification.

Results

There was a significant reduction of annual cesarean rates from 36.35 to 22.87% over four years (p < 0.01) and in neonatal nursery admissions (p < 0.01). Covid outbreak saw a comparatively increased cesarean rate in 2020, for which it was excluded from the detailed study. The relative risk of cesarean delivery in the postintervention period was 0.62. Maximum reductions were seen in Robsons II, VI &VII.

Conclusion

Devising multipronged interventions and their implementation through PDSA cycles are essential. Such measures in moderate resources are replicable elsewhere as well.

Interventions targeting healthcare providers to optimise use of caesarean section: a qualitative comparative analysis to identify important intervention features

BACKGROUND

Rapid increases in caesarean section (CS) rates have been observed globally; however, CS rates exceeding 15% at a population-level have limited benefits for women and babies. Many interventions targeting healthcare providers have been developed to optimise use of CS, typically aiming to improve and monitor clinical decision-making. However, interventions are often complex, and effectiveness is varied. Understanding intervention and implementation features that likely lead to optimised CS use is important to optimise benefits. The aim of this study was to identify important components that lead to successful interventions to optimise CS, focusing on interventions targeting healthcare providers.  METHODS: We used Qualitative Comparative Analysis (QCA) to identify if certain combination of important intervention features (e.g. type of intervention, contextual characteristics, and how the intervention was delivered) are associated with a successful intervention as reflected in a reduction of CS. We included 21 intervention studies targeting healthcare providers to reduce CS, comprising of 34 papers reporting on these interventions. To develop potential theories driving intervention success, we used existing published qualitative evidence syntheses on healthcare providers' perspectives and experiences of interventions targeted at them to reduce CS.

RESULTS

We identified five important components that trigger successful interventions targeting healthcare providers: 1) training to improve providers' knowledge and skills, 2) active dissemination of CS indications, 3) actionable recommendations, 4) multidisciplinary collaboration, and 5) providers' willingness to change. Importantly, when one or more of these components are absent, dictated nature of intervention, where providers are enforced to adhere to the intervention, is needed to prompt successful interventions. Unsuccessful interventions were characterised by the absence of these components.

CONCLUSION

We identified five important intervention components and combinations of intervention components which can lead to successful interventions targeting healthcare providers to optimise CS use. Health facility managers, researchers, and policy-makers aiming to improve providers' clinical decision making and reduce CS may consider including the identified components to optimise benefits.

Potential resolution of placenta previa from the 28th-to the 36th-week of pregnancy: A retrospective longitudinal cohort study

INTRODUCTION

Placenta previa greatly contributes to severe antenatal and post-partum hemorrhage. Previous studies have mainly focused on the risk factors of placenta previa, with very few studies reporting which factors may affect the potential resolution of 28th-week previa. This study aimed to investigate the impact of maternal characteristics on potential resolution of placenta previa from the 28th-to the 36th-week of pregnancy.

METHODS

A retrospective longitudinal sub-cohort investigation was carried out among 368 pregnant women with 28th-week previa from the Longitudinal Placenta Previa Study (LoPPS). Logistic regression analysis was used to discover the connections between maternal covariates and the placental potential resolution. Multivariable linear regression analysis was used to detect the associations between perioperative characteristics and volume of intraoperative bleeding.

RESULTS

Among pregnant women whose placenta completely or partially covered the internal os at the 28th-week of pregnancy, 37.5% were without placenta previa at the 36th-week and 25.8% converted into marginal placenta previa. There were significant correlation between placenta previa type and GHD (Beta: 2.808, 95% CI: 1.642, 7.138; p = 0.041), type of 28th-week previa (Beta: 6.767, 95% CI: 1.592, 18.767; p < 0.001), and number of prior cesarean sections (Beta: 3.326, 95% CI: 1.580, 9.081; p < 0.001).

DISCUSSION

62.5% of the pregnant women with 28th-week placenta previa were still with previa at the 36 weeks of gestation (25.8% with marginal and 36.7% with partial/complete placenta previa). This proportion is even higher for 28th-week complete placenta previa.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2100054068, December 8, 2021.

Pregnancy complications and risk of uterine rupture among women with singleton pregnancies in China

BACKGROUND

The goal of this study was to investigate whether pregnancy complications are associated with an increased risk of uterine rupture (UR) and how that risk changes with gestational age.

METHODS

We obtained all data from China's National Maternal Near Miss Surveillance System (NMNMSS) between 2012 and 2018. Poisson regression analysis was used to assess the risk of UR with pregnancy complications (preeclampsia, gestational diabetes mellitus, placental abruption, placenta previa and placenta percreta) among 9,454,239 pregnant women. Furthermore, we analysed the risks of UR with pregnancy complications in different gestational age groups.

RESULTS

The risk of UR was increased 2.0-fold (1.2-fold to 2.7-fold) in women with pregnancy complications (except for preeclampsia). These associations also persisted in women without a previous caesarean delivery. Moreover, an increased risk of UR before term birth was observed among women with gestational diabetes mellitus, placental abruption and placenta percreta. The risk of UR was slightly higher in women with gestational diabetes mellitus who had a large for gestational age (LGA) foetus, especially at 32 to 36 weeks gestation.

CONCLUSIONS

The risk of UR is associated with gestational diabetes mellitus, placental abruption, placenta previa and placenta percreta, but varies in different gestational ages.

Multi-Indicator Intelligent Monitoring of Clinical Observations to Reduce Cesarean Section

In order to analyze multi-index monitoring and the effect of reducing cesarean section, this paper selects March 2018 and March 2019 in two obstetrics and gynecology hospitals, referred to as hospital A and hospital B. As research objects, 313 pregnant women were divided into multi-index group and conventional group, while analyzing various indicators of each group of cesarean collection. The results show that the total CNAXE rate was 48.10% and 39.29%, respectively, for 2018 and 2019, respectively, and the cesarean section of the conventional group was 65.75% and 63.64%. By contrasting data of multi-index group and conventional group, hospital B differences were significant (P < 0.05), and hospital A difference was extremely significant (P < 0.01). In Cesarean section, obstetric sectors can help maternal treatment strategies by monitoring a series of related indicators for maternal to reduce Cesarean section and improve prognosis.

Physical activity and sleep duration during pregnancy have interactive effects on caesarean delivery: a population-based cohort study in Tianjin, China

Background

There were inconsistent findings in the literature regarding the associations of physical activity and sleep duration during pregnancy with caesarean delivery for different reasons. It was also unknown whether physical activity and sleep duration during pregnancy had interactive effects on the risks of different types of caesarean delivery. The study aimed to investigate the effects of physical activity, sleep duration and their interactions on the risk of caesarean delivery for medical reasons and non-medical reasons.

Methods

From October 2010 to August 2012, a prospective population-based cohort of 13,015 pregnant women was established in six central urban districts of Tianjin, China. Pregnancy outcomes were retrieved from an electronic database and caesarean delivery was divided into caesarean delivery for medical reasons and caesarean delivery for non-medical reasons. Physical activity and sleep status were collected at 24–28 weeks of gestation using self-reported questionnaires. Logistic regression and additive interaction were used to examine physical activity, sleep duration and their interactive effects on risk of caesarean delivery.

Results

In the cohort, 5692 (43.7%) and 2641 (20.3%) of women had caesarean delivery for medical reasons and non-medical reasons, respectively. Low physical activity increased the risk of caesarean delivery for medical reasons (adjusted OR: 1.13, 95%CI 1.04–1.23) but not caesarean delivery for non-medical reasons. Sleep duration < 7 h/day and poor sleep quality were not associated with caesarean delivery. Sleep duration ≥9 h/day increased the risk of caesarean delivery for medical reasons (1.12, 1.02–1.22) and caesarean delivery for non-medical reasons (1.16, 1.05–1.29). Co-presence of low physical activity and sleep duration ≥9 h/day increased risk of caesarean delivery (1.25, 1.12–1.41), and their additive interaction was statistically significant for caesarean delivery for medical reasons but not for caesarean delivery for non-medical reasons.

Conclusions

Low physical activity and excessive sleep duration during pregnancy each increased the risk of caesarean delivery, and they had an interactive effect on the risk of caesarean delivery for medical reasons but not on the risk of caesarean delivery for non-medical reasons. Increasing physical activity and maintaining recommended sleep duration during pregnancy may have benefits for perinatal health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03788-4.

The rates and medical necessity of cesarean delivery in China, 2012-2019: an inspiration from Jiangsu

BACKGROUND

The World Health Organization (WHO) in 2015 stated that every effort should be made to provide cesarean delivery (CD) for women in need. In China, the two-child policy largely prompts the number of advanced age childbirth, which raises the possibility of an increasing number of women who need a c-section. The aim of this study was to assess the trends in the overall and medical indication-classified CD rates in the era of the two-child policy in Jiangsu, China.

METHODS

A retrospective cross-sectional study of 291,448 women who delivered in 11 hospitals in Jiangsu province between 2012 and 2019 was conducted. Medical cesarean indication for each woman was ascertained by manually reviewing the medical records. The 291,448 women were divided into two subgroups according to the presence of the indications: the indicated group (7.80%) and the non-indicated group (92.20%). We then fitted joinpoint regression and log-binomial regression models to estimate trends in the CD rates across the study period.

RESULTS

The overall CD rate was observed with a declining trend from 52.51% in 2012-2015 to 49.76% in 2016-2019 (adjusted RR, 0.92; 95% CI, 0.91-0.93; P < 0.001), along with an annual percentage change (APC) to be - 1.0 (95% CI, - 2.1 to 0.0) across the period. The participants were then divided into two subgroups according to the presence of medical CD indications: the indicated group (7.80%) and the non-indicated group (92.20%).We found the declining trend was most pronounced in the non-indicated group, with the CD rates decreased from 50.02% in 2012-2015 to 46.27% in 2016-2019 (adjusted RR, 0.90; 95% CI, 0.89-0.90; P < 0.001). By contrast, we observed a steady trend in the CD rate of the indicated group, which maintained from 87.47% in 2012-2015 to 86.57% in 2016-2019 (P = 0.448). In the indicated group, a higher risk of adverse pregnancy outcomes was revealed for those women who delivered vaginally as compared with those who received c-section. We further investigated that women with following specific indications had a higher proportion of vaginal delivery, i.e., pregnancy complications, fetal macrosomia, and pregnancy complicated with tumor (34.70%, 10.84%, and 16.34%, respectively). Women with the above 3 indications were observed with a higher risk of adverse pregnancy outcomes if delivered vaginally. The incidence rates of the medical indications among the general population increased considerably over the 8-year period (P < 0.001).

CONCLUSIONS

Although the overall CD rate apparently decreased in the recent years, along with the decline of the unnecessary CD rate, a considerable proportion of indicated women were not provided with CD service in Jiangsu, China. Instead of targeting the overall CD rate, we need to take actions to reduce unnecessary CD rate and provide adequate c-section service for women with indications, particularly for those with underlying diseases and suspected fetal macrosomia.

Does delivery in private hospitals contribute largely to Caesarean Section births? A path analysis using generalised structural equation modelling

BACKGROUND

The rate of Caesarean Section (CS) deliveries has shown an alarming rise in recent years. CS is a surgical procedure used when there is apprehension of risk to the life of mother or baby in case of vaginal delivery, but its rates higher than 10-15 per cent are not justifiable. It is well recognised that a CS delivery could have a large number of adverse impacts on women and infants. Several studies, especially in developing countries, have revealed that delivery in private hospitals is one of the most contributing factors in CS deliveries. The present study conceptualises a causal pathway in which the possible risk factors, socio-economic, maternal and pregnancy-related, as well as institutional, influence the chances of CS delivery. It is hypothesised that certain factors would contribute to CS deliveries largely indirectly through the place of delivery, that is, either a public or private institution.

METHODS AND FINDINGS

To test the hypotheses, this study analysed 146,280 most recent live births delivered in hospitals during the five years preceding the fourth round of India's National Family Health Survey (NFHS-4), carried out during 2015-2016. The analysis, using generalised structural equation modelling (GSEM), revealed that many exogenous variables considered in the path models influence CS deliveries significantly, directly and/or indirectly through the place of delivery factor. Prominent among these are wealth index and receiving ANC services at only private hospitals; the total effects of these variables are even higher than the direct/total effect of place of delivery.

CONCLUSION

From this finding, it could be said that the place of delivery is a proximate determinant of a CS delivery or a mediator of other co-factors. Interventions to curb higher CS deliveries should be focused on improving the quality of public health sectors and on developing protocols for CS deliveries.

Long-term effects of the nine-item list intervention on obstetric and neonatal outcomes in Robson group 1 - A time series study

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.

Factors affecting failed trial of labor and countermeasures: A retrospective analysis

BACKGROUND

Vaginal delivery is the ideal mode of delivery for the termination of a pregnancy. However, the cesarean section rate in China is much higher than the published by the World Health Organization in the Lancet in 2010.

AIM

To retrospectively analyze the factors related to failed trial of labor and the clinical indications for cesarean section conversion, explore how to promote the trial of labor success rate, and determine the feasibility of reducing the rate of conversion to cesarean section.

METHODS

A retrospective analysis was performed on 9240 maternal women who met vaginal delivery conditions and required a trial of labor from January 2016 to December 2018 at our hospital. Among them, 8164 pregnant women who had a successful trial of labor were used as a control group, and 1076 pregnant women who had a failed trial of labor and converted to an emergency cesarean section were used as an observation group. The patients’ clinical data during hospitalization were collected for comparative analysis, the related factors of the failed trial of labor were discussed, and reasonable prevention and resolution strategies were proposed to increase the success rate of trial of labor.

RESULTS

The analysis revealed that advanced age (≥ 35 years old), macrosomia (≥ 4000 g), delayed pregnancy (≥ 41 wk), use of uterine contraction drugs, primipara, and fever during labor were associated with conversion to an emergency cesarean section in the failed trial of labor. Multivariate regression analysis showed that age, gestational age, primipara, use of uterine contraction drugs, fever during birth, and newborn weight led to a higher probability of conversion to an emergency cesarean section in the failed trial of labor. The analysis indicated that the following clinical indications were associated with the conversion to cesarean section in the failed trial of labor: Fetal distress (44.3%), social factors (12.8%), malpresentation (face presentation, persistent occipitoposterior position, and persistent occipitotransverse position) (9.4%), and cephalopelvic disproportion (8.9%).

CONCLUSION

The conversion to emergency cesarean section in failed trial of labor is affected by many factors. Medical staff should take appropriate preventive measures for the main factors, increase the trial of labor success rate, improve the quality of delivery, ensure the safety of mother and child during the perinatal period, and improve the relationship between doctors and patients.