Reducing the rate of cesarean delivery on maternal request through institutional and policy interventions in Wenzhou, China

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.

Prophylactic antibiotic use during labor and delivery in China: a nationwide, multicenter, hospital-based, cross-sectional study

BACKGROUND

Prophylactic antibiotic use during delivery is common in routine obstetric practice to prevent infection globally, especially in low- and middle-income countries. In China, however, little is currently known about the national estimates for prophylactic antibiotic use during delivery. Therefore, we aimed to describe the prevalence of prophylactic antibiotic use and guideline adherence using national data in China.

METHODS

This cross-sectional study analyzed a national dataset from the China Labor and Delivery Survey in 2015-2016. The primary outcomes were prophylactic antibiotic use and clinician adherence to WHO recommendations for the prevention and treatment of maternal peripartum infections. We estimated the weighted prevalence of the outcomes with Taylor series linearization and investigated the associated factors of the outcomes with logistic regression.

RESULTS

Of the 72,519 deliveries, the prevalence of antibiotic prophylaxis was 52.0%, varying from 92.8% in Shanxi to 17.3% in Hainan. The prevalence of clinician adherence to the WHO guideline was 79.9%, ranging from 93.4% in Shandong to 50.0% in Shanxi. Prophylactic antibiotic use was associated with cesarean delivery (AOR, 55.77; 95%CI, 25.74-120.86), operative vaginal delivery (AOR, 4.00; 95%CI, 1.64-9.78), preterm (AOR, 1.96; 95%CI, 1.60-2.41), premature rupture of membranes (PROM) (AOR, 2.80; 95%CI, 1.87-4.18), and meconium-stained amniotic fluid (AOR, 1.91; 95%CI, 1.30-2.81) in all deliveries and also episiotomy (AOR, 1.48; 95%CI, 1.02-2.16) in vaginal deliveries. Clinician adherence was positively associated with cesarean delivery (AOR, 5.72; 95%CI, 2.74-11.93) while negatively associated with operative vaginal delivery (AOR, 0.26; 95%CI, 0.11-0.61), PROM (AOR, 0.50; 95%CI, 0.35-0.70), and meconium-stained amniotic fluid (AOR, 0.66; 95%CI, 0.48-0.91) in all deliveries. In vaginal deliveries, clinician adherence was negatively associated with episiotomy (AOR, 0.67; 95%CI, 0.46-0.96) and severe perineal trauma (AOR, 0.09; 95%CI, 0.02-0.44). Besides, clinicians in general hospitals prescribed prophylactic antibiotics more likely (AOR, 2.79; 95%CI, 1.50-5.19) and had a lower adherence (AOR, 0.38; 95%CI, 0.20-0.71) than their peers in maternity hospitals.

CONCLUSIONS

We observed that about half of all deliveries in China received antibiotics for prophylaxis, and most deliveries were prescribed according to the WHO guideline. Furthermore, the two prevalence rates for prophylactic antibiotic use and clinician adherence varied widely across provinces of China.

Changes in cesarean section rates after introduction of a punitive financial policy in Georgia: A population-based registry study 2017–2019

Background

There is little research on how financial incentives and penalties impact national cesarean section rates. In January 2018, Georgia introduced a national cesarean section reduction policy, which imposes a financial penalty on hospitals that do not meet their reduction targets. The aim of this study was to assess the impact of this policy on cesarean section rates, subgroups of women, and selected perinatal outcomes.

Methods

We included women who gave birth from 2017 to 2019 registered in the Georgian Birth Registry (n = 150 534, nearly 100% of all births in the country during this time). We then divided the time period into pre-policy (January 1, 2017, to December 31, 2017) and post-policy (January 1, 2018, to December 31, 2019). An interrupted time series analysis was used to compare the cesarean section rates (both overall and stratified by parity), neonatal intensive care unit transfer rates, and perinatal mortality rates in the two time periods. Descriptive statistics were used to assess differences in maternal socio-demographic characteristics.

Results

The mean cesarean section rate in Georgia decreased from 44.7% in the pre-policy period to 40.8% in the post-policy period, mainly among primiparous women. The largest decrease in cesarean section births was found among women <25 years of age and those with higher education. There were no significant differences in the neonatal intensive care unit transfer rate or the perinatal mortality rate between vaginal and cesarean section births in the post-policy period.

Conclusion

The cesarean section rate in Georgia decreased during the 2-year post-policy period. The reduction mainly took place among primiparous women. The policy had no impact on the neonatal intensive care unit transfer rate or the perinatal mortality rate. The impact of the national cesarean section reduction policy on other outcomes is not known.

The Inconsistency Between Women's Preference and Actual Mode of Delivery in China: Findings From a Prospective Cohort Study

Background

Previous studies have found that the rates of cesarean preference were much lower than the actual rates of cesarean births in China. We aimed to observe this inconsistency between preferred and actual modes of delivery and the factors associated with the inconsistency.

Methods

We conducted a prospective cohort study at the maternity hospital with the largest number of deliveries in Beijing. We collected data through a questionnaire applied in the outpatient department, and medical records from the hospital's information system. Unconditional logistic regression was used to identify factors influencing the inconsistency between preferred and actual delivery mode.

Results

The rates of actual cesarean section and of cesarean preference were 41 and 17%, respectively (χ2 = 82.9, P < 0.0001). The overall inconsistency rate was 31%, with 119 women preferred vaginal delivery but experienced cesarean section, accounting for 67% women undergoing cesarean section. Risk factors for this inconsistency between preferred vaginal delivery and actual cesarean section included: maternal obesity, receiving assisted reproduction, having an abnormal amniotic fluid volume, and fetal distress. Pre-labor rupture of membranes was a unique factor associated with such inconsistency between cesarean section preference and vaginal delivery at delivery.

Conclusions

The inconsistent rate between preferred delivery at late pregnancy and actual delivery is high in China. Further research is needed to understand how to lower cesarean rates in China, taking maternal preferences for vaginal deliveries into account.

What is an appropriate caesarean delivery rate for China: a multicentre survey

Objective

To assess the current status of caesarean delivery (CD) in China, propose reference CD rates for China overall, and by regions, investigate the main indications for CDs and identify possible areas for safe reduction.

Design

A multicentre cross‐sectional study.

Setting

A total of 94 hospitals across 23 provinces in China.

Population

A total of 73 977 randomly selected deliveries.

Methods

We used a modified Robson classification to characterise CDs in subgroups and by regions, and the World Health Organization (WHO) C‐Model to calculate reference CD rates.

Main outcome measures

CD rates in China.

Results

In 2015–2016, the overall CD rate in China was 38.9% (95% CI 38.6–39.3%). Considering the obstetric characteristics of the population, the multivariable model‐based reference CD rate was estimated at 28.5% (95% CI 28.3–28.8%). Accordingly, an absolute reduction of 10.4% (or 26.7% relative reduction) may be considered. The CD rate varied substantially by region. Previous CD was the most common indication in all regions, accounting for 38.2% of all CDs, followed by maternal request (9.8%), labour dystocia (8.3%), fetal distress (7.7%) and malpresentation (7.6%). Overall, 12.7% of women had prelabour CDs, contributing to 32.8% of the total CDs.

Conclusions

Nearly 39% of births were delivered by caesarean in China but a reduction of this rate by a quarter may be considered attainable. Repeat CD contributed more than one‐third of the total CDs. Given the large variation in maternal characteristics, region‐specific or even hospital‐specific reference CD rates are needed for precision management of CD.

Tweetable abstract

The caesarean rate in 2015–2016 in China was 38.9%, whereas the reference rate was 28.5%.

The caesarean rate in 2015–2016 in China was 38.9%, whereas the reference rate was 28.5%.

Linked article This article is commented on by M Varner, p. 148 in this issue. To view this mini commentary visit https://doi.org/10.1111/1471-0528.16953.

The Clinical Efficacy and Safety of Enhanced Recovery After Surgery for Cesarean Section: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies

Background: Enhanced recovery after surgery (ERAS) has been adopted in some maternity units and studied extensively in cesarean section (CS) in the last years, showing encouraging results in clinic practice. However, the present evidence assessing the effectiveness of ERAS for CS remains weak, and there is a paucity in the published literature, especially in improving maternal outcomes. Our study aimed to systematically evaluate the clinical efficacy and safety of ERAS protocols for CS. Methods: A systematic literature search using Embase, PubMed, and the Cochrane Library was carried out up to October 2020. The appropriate randomized controlled trials (RCTs) and observational studies applying ERAS for patients undergoing CS were included in this study, comparing the effect of ERAS protocols with conventional care on length of hospital stay (LOS), readmission rate, incidence of postoperative complications, postoperative pain score, postoperative opioid use, and cost of hospitalization. All statistical analyses were conducted with the RevMan 5.3 software. Results: Ten studies (four RCTs and six observational studies) involving 16,391 patients were included. ERAS was associated with a decreased LOS (WMD -7.47 h, 95% CI: -8.36 to -6.59 h, p < 0.00001) and lower incidence of postoperative complications (RR: 0.50, 95% CI: 0.37 to 0.68, p < 0.00001). Moreover, pooled analysis showed that postoperative pain score (WMD: -1.23, 95% CI: -1.32 to -1.15, p < 0.00001), opioid use (SMD: -0.46, 95% CI: -0.58 to -0.34, p < 0.00001), and hospital cost (SMD:-0.54, 95% CI: -0.63 to -0.45, p < 0.00001) were significantly lower in the ERAS group than in the conventional care group. No significant difference was observed with regard to readmission rate (RR: 0.86, 95% CI: 0.48 to 1.54, p = 0.62). Conclusions: The available evidence suggested that ERAS applying to CS significantly reduced postoperative complications, lowered the postoperative pain score and opioid use, shortened the hospital stay, and potentially reduced hospital cost without compromising readmission rates. Therefore, protocols implementing ERAS in CS appear to be effective and safe. However, the results should be interpreted with caution owing to the limited number and methodological quality of included studies; hence, future large, well-designed, and better methodological quality studies are needed to enhance the body of evidence.

Research on obstetric ward planning combining lean thinking and mixed-integer programming

BACKGROUND

In recent years, there are many studies on scheduling methods of patient flow, nurse scheduling, bed allocation, operating room scheduling and other problems, but there is no report on the research methods of how to plan ward allocation from a more macroscopic perspective.

OBJECTIVE

Refine and stratify the obstetric ward to provide more accurate medical service for pregnant women and improve the work efficiency of obstetricians and midwives. The problem of how to allocate the number of each type of ward is modeled as a mixed integer programming problem, which maximizes the patient flow of pregnant women in obstetric hospitals.

METHODS

The obstetric wards are divided into observation ward, cesarean section ward and natural delivery ward according to lean thinking. CPLEX is used to solve the mixed-integer programming problem of ward allocation. In R software, multivariate Generalized Linear Models (GLM) regression model is used to analyze the influence of each factor on patient flow.

RESULTS

The maximum patient flow of each case was obtained by CPLEX, which was 19-25% higher than that of patients without refinement, stratification and planning. GLM regression analysis was carried out on the abovementioned data, and the positive and negative correlation factors were obtained.

CONCLUSION

According to lean thinking, obstetric wards are divided into three types of wards. Obstetricians and midwives work more efficiently and get more rest time. Pregnant women also enjoy more detailed medical services. By modeling the delivery ward allocation problem as a mixed-integer programming problem, we can improve the capacity of the service in obstetric hospitals from a macro perspective. Through GLM regression model analysis, it is conducive to improve the obstetric hospital capacity from the perspective of positive and negative correlation factors.

Cesarean delivery on maternal request and its influencing factors in Chongqing, China

BACKGROUND

A high rate of cesarean delivery has become a cause of global concern. Although the rate of cesarean delivery has declined over recent years, it remains at a high level largely because of cesarean delivery on maternal request (CDMR). Unnecessary cesarean delivery has limited significance in benefiting maternal and infant physical health; in some ways, it might pose potential risks instead. With the implementation of the "Two-child Policy" in China, an increasing number of women plan to have a second child. Accordingly, how to handle the CDMR rate in China remains an important issue.

METHODS

Data were collected from a longitudinal follow-up study conducted in Chongqing, China, from 2018 to 2019. A structured questionnaire was administered to subjects for data collection. Basic information, including demographic characteristics, living habits, medical history, and follow-up data of pregnant women, as well as their families and society, was collected. Additionally, delivery outcomes were recorded. Logistic regression was performed to analyze the factors influencing CDMR.

RESULTS

The rate of cesarean delivery in Chongqing, China was 36.01 %, and the CDMR rate was 8.42 %. Maternal request (23.38 %), fetal distress (22.73 %), and pregnancy complications (9.96 %) were the top three indications for cesarean delivery. Logistic regression analysis showed that older age (OR = 4.292, 95 % CI: 1.984-9.283) and being a primiparous woman (OR = 6.792, 95 % CI: 3.230-14.281) were risk factors for CDMR. In addition, CDMR was also associated with factors such as the tendency to choose cesarean delivery during late pregnancy (OR = 5.525, 95 % CI: 2.116-14.431), frequent contact with mothers who had undergone vaginal deliveries (OR = 0.547, 95 % CI: 0.311-0.961), and the recommendation of cesarean delivery by doctors (OR = 4.071, 95 % CI: 1.007-16.455).

CONCLUSIONS

"Maternal request" has become the primary indication for cesarean delivery. The occurrence of CDMR is related to both the personal factors of women during pregnancy and others. Medical institutions and obstetricians should continue popularizing delivery knowledge among pregnant women, enhancing their own professional knowledge about delivery, adhering to the standard indications for cesarean delivery, and providing pregnant women with adequate opportunities for attempting vaginal delivery.

The Effect of the No Pain Labor & Delivery-Global Health Initiative on Cesarean Delivery and Neonatal Outcomes in China: An Interrupted Time-Series Analysis

BACKGROUND

The proportion of live births by cesarean delivery (CD) in China is significant, with some, particularly rural, provinces reporting up to 62.5%. The No Pain Labor & Delivery-Global Health Initiative (NPLD-GHI) was established to improve obstetric and neonatal outcomes in China, including through a reduction of CD through educational efforts. The purpose of this study was to determine whether a reduction in CD at a rural Chinese hospital occurred after NPLD-GHI. We hypothesized that a reduction in CD trend would be observed.

METHODS

The NPLD-GHI program visited the Weixian Renmin Hospital, Hebei Province, China, from June 15 to 21, 2014. The educational intervention included problem-based learning, bedside teaching, simulation drill training, and multidisciplinary debriefings. An interrupted time-series analysis using segmented logistic regression models was performed on data collected between June 1, 2013 and May 31, 2015 to assess whether the level and/or trend over time in the proportion of CD births would decline after the program intervention. The primary outcome was monthly proportion of CD births. Secondary outcomes included neonatal intensive care unit (NICU) admissions and extended NICU length of stay, neonatal antibiotic and intubation use, and labor epidural analgesia use.

RESULTS

Following NPLD-GHI, there was a level decrease in CD with an estimated odds ratio (95% confidence interval [CI]) of 0.87 (0.78-0.98), P = .017, with odds (95% CI) of monthly CD reduction an estimated 3% (1-5; P < .001), more in the post- versus preintervention periods. For labor epidural analgesia, there was a level increase (estimated odds ratio [95% CI] of 1.76 [1.48-2.09]; P < .001) and a slope decrease (estimated odds ratio [95% CI] of 0.94 [0.92-0.97]; P < .001). NICU admissions did not have a level change (estimated odds ratio [95% CI] of 0.99 [0.87-1.12]; P = .835), but the odds (95% CI) of monthly reduction in NICU admission was estimated 9% (7-11; P < .001), greater in post- versus preintervention. Neonatal intubation level and slope changes were not statistically significant. For neonatal antibiotic administration, while the level change was not statistically significant, there was a decrease in the slope with an odds (95% CI) of monthly reduction estimated 6% (3-9; P < .001), greater post- versus preintervention.

CONCLUSIONS

In a large, rural Chinese hospital, live births by CD were lower following NPLD-GHI and associated with increased use of labor epidural analgesia. We also found decreasing NICU admissions. International-based educational programs can significantly alter practices associated with maternal and neonatal outcomes.

Evaluation of cesarean delivery rates in different levels of hospitals in Jiangsu Province, China, using the 10-Group classification system

OBJECTIVE

To compare cesarean delivery (CD) rates in referral and non-referral hospitals in Maternal Safety Collaboration in Jiangsu province, China.

METHODS

Sixteen participants (4 referral hospitals, 12 non-referral hospitals) from Drum Tower Hospital Collaboration for Maternal Safety reported CD rates in 2019 using ten-group classification system and maternal/neonatal morbidity and mortality.

RESULTS

A total of 22,676 CDs were performed among 52,499 deliveries and the average CD rate was 43.2% (range 34.8-69.6%). CD rate in non-referral hospitals (44.7%) was significantly higher than it was in referral hospitals (40.4%, p < .001). Term singleton cephalic nulliparous women with spontaneous labor (Group 1) or induced labor (Group 2a) had higher CD rates if they were cared in non-referral hospitals compared with those in referral hospitals (Group 1: 11.8% vs. 4.4%, p < .001; Group 2a: 29.1% vs. 21.3%, p < .001). In non-referral hospitals, CD rate in Group 5 and the proportion of Group 5 to the overall population were also significantly higher than those in referral hospitals (98.5% vs. 92.5%, p < .001; and 21.0% vs. 14.5%, p < .001).

CONCLUSION

To decrease the CD rate, we need to take efforts in decreasing unnecessary operations for term singleton cephalic nulliparous women and increasing the rate of trial of labor after CD.

Trends in cesarean delivery rates in primipara and the associated factors

Background

Few studies have focused on cesarean delivery (CD) trends among primipara under the one-child and the two-child policies. This study aimed to explore the trends in CD rates among primipara during 1995–2019 and the associated factors with CD risk.

Methods

This study obtained clinical data on primiparous mothers and newborns from 1995 to 2019 at a large tertiary hospital in Wuhan, China. Trends in CD rates were calculated using the joinpoint regression analysis. The Chi-square tests and log-binomial regression analyses were used to evaluate the associations between primary variables and CD risk.

Results

CD rates showed a significant upward trend with an average annual percentage change (APC) of 2.2% (95% CI: 0.6, 3.8%) during the study period. In 1995–2006, the CD rates continued to increase with an APC of 7.8% (95% CI: 4.8, 10.9%). After 2006, the CD rates started to decline by an APC of − 4.1% (95% CI: − 5.5, − 2.6%). The CD rates non-significantly increased from 36.2% in 2016 to 43.2% in 2019. Moreover, the highest CD rate during 2015–2019 was observed on August 30 (59.2%) and the lowest on September 1 (29.7%). Primipara of older age and those with >3pregnancies had higher risks of CD. Furthermore, primipara who gave birth to newborns with low birth weight and macrosomia had higher risks of CD.

Conclusions

Maternal and fetal as well as social and cultural factors may contribute to the rising trend of CD rates. Effective measures should be taken to control CD under the two-child policy, especially for primipara.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-020-03398-6.

The effect of initiating neuraxial analgesia service on the rate of cesarean delivery in Hubei, China: a 16-month retrospective study

BACKGROUND

No Pain Labor &Delivery (NPLD) is a nongovernmental project to increase access to safe neuraxial analgesia through specialized training. This study explores the change in overall cesarean delivery (CD) rate and maternal request CD(MRCD) rate in our hospital after the initiation of neuraxial analgesia service (NA).

METHODS

NA was initiated in May 1st 2015 by the help of NPLD. Since then, the application of NA became a routine operation in our hospital, and every parturient can choose to use NA or not. The monthly rates of NA, CD, MRCD, multiparous women, intrapartum CD, episiotomy, postpartum hemorrhage (PPH), operative vaginal delivery and neonatal asphyxia were analyzed from January 2015 to April 2016.

RESULTS

The rate of NA in our hospital was getting increasingly higher from 26.1% in May 2015 to 44.6% in April 2016 (p < 0.001); the rate of CD was 48.1% (3577/7360) and stable from January to May 2015 (p>0.05), then decreased from 50.4% in May 2015 to 36.3% in April 2016 (p < 0.001); the rate of MRCD was 11.4% (406/3577) and also stable from January to May 2015 (p>0.05), then decreased from 10.8% in May 2015 to 5.7% in April 2016 (p < 0.001). At the same time, the rate of multiparous women remained unchanged during the 16 month of observation (p>0.05). There was a negative correlation between the rate of NA and rate of overall CD, r = - 0.782 (95%CI [- 0.948, - 0.534], p<0.001), and between the utilization rate of NA and rate of MRCD, r = - 0.914 (95%CI [- 0.989, - 0.766], p<0.001). The rates of episiotomy, PPH, operative vaginal delivery and neonatal asphyxia in women who underwent vaginal delivery as well as the rates of intrapartum CD, neonatal asphyxia, and PPH in women who underwent CD remained unchanged, and there was no correlation between the rate of NA and anyone of those rates from January 1st 2015 to April 30th 2016 (p>0.05).

CONCLUSIONS

Our study shows that the rates of CD and MRCD in our department were significantly decreased from May 1st 2015 to April 30th 2016, which may be due to the increasing use of NA during vaginal delivery with the help of NPLD.

Global incidence of caesarean deliveries on maternal request: a systematic review and meta-regression

BACKGROUND

Caesarean delivery on maternal request (CDMR) is considered a significant contributor to the unprecedented increase in caesarean deliveries (CDs) for nonclinical reasons. Current literature lacks a reliable assessment of the rate of CDMR, which hinders the planning and delivery of appropriate interventions for reducing CDMR rates.

OBJECTIVES

To conduct a systematic review of the literature and meta-regression to explore the global incidence of CDMR.

SEARCH STRATEGY

PubMed, Embase, CINAHL, Medline, Google scholar and grey literature were searched from January 1985 to May 2019.

SELECTION CRITERIA

Observational studies that report CDMR data were included. We excluded non-English articles, case notes, editorial reviews and articles reporting elective CDs from pregnancy risk factors.

DATA COLLECTION AND ANALYSIS

Two reviewers independently conducted the screening and quality appraisal using a validated tool. The weighted average of CDMR over total deliveries (absolute proportion) and by total CDs (relative proportion) were generated. Quality-effects meta-regression was used to explain the variability of the CDMR estimates by moderators, including study methodology and demography of study participants.

MAIN RESULTS

We identified 31 articles from 14 countries that include 5 million total births. The absolute proportion of CDMR varies between 0.2 and 42.0%, with significant variations across studies and subgroups. The economic status of the country and study year together explained 84% of the absolute and 76% of the relative proportion of CDMR variation.

CONCLUSIONS

An appropriate reporting of CDMR should be a key priority in maternal health policies and practices.

TWEETABLE ABSTRACT

Globally, the proportion of maternal requested caesarean delivery has mostly been influenced by the economic status of the country.

Reducing unnecessary caesarean sections: scoping review of financial and regulatory interventions

Background

Caesarean sections (CS) are increasing worldwide. Financial incentives and related regulatory and legislative factors are important determinants of CS rates. This scoping review examines the evidence base of financial, regulatory and legislative interventions intended to reduce CS rates.

Methods

We searched MEDLINE, EMBASE, CINAHL and two trials registers in June 2019. Both experimental and observational intervention studies were eligible for inclusion. Primary outcome measures were: CS, spontaneous vaginal and instrumental birth rates. We assessed quality of evidence using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method.

Results

We identified 9057 articles and assessed 65 full-texts. We included 16 observational studies. Most of the studies were conducted in high-income countries.

Three studies assessed payment methods for health workers: equalising physician fees for vaginal and caesarean delivery reduced CS rates in one study; however, little or no difference in CS rates was found in the remaining two studies.

Nine studies assessed payment methods for health organisations:

There was no difference in CS rates between diagnosis-related group (DRG) payment system compared to fee-for-service system in one study. However, DRG system was associated with lower odds for CS in another study.

There was little or no difference in CS rates following implementation of global budget payment (GBP) system in two studies.

Vaginal birth after caesarean section (VBAC) increased after implementation of a case-based payment system in one study. Caesarean section increased while VBAC rates decreased following implementation of a cap-based payment system in another study.

Financial incentive for providers to promote vaginal delivery combined with free vaginal delivery policy was found to reduce CS rates in one study.

Studied regulatory and legislative interventions (comprising legislatively imposed practice guidelines for physicians in one study and multi-faceted strategy which included policies to control CS on maternal request in another study) were found to reduce CS rates.

The GRADE quality of evidence varied from very low to low.

Conclusions

Available evidence on the effects of financial and regulatory strategies intended to reduce unnecessary CS is inconclusive given inconsistency in effects and low quality of the available evidence. More rigorous studies are needed.

A cluster-randomized field trial to reduce cesarean section rates with a multifaceted intervention in Shanghai, China

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.

Associations Between Delivery Mode and Early Childhood Body Mass Index Z-Score Trajectories: A Retrospective Analysis of 2,685 Children From Mothers Aged 18 to 35 Years at Delivery

Objective: To investigate the association between cesarean delivery (CD) and trajectory patterns of age- and sex-specific body mass index (BMI) z-score in early childhood. Methods: A retrospective cohort study was conducted among 2,685 children whose maternal age at the time of birth was between 18 and 35 years, and birth data and anthropometric measurement data during their ages 3-60 months were collected. A group-based trajectory modeling approach was used to identify distinct BMI z-score trajectories, and multinomial logistic regressions were applied to estimate the associations among CD (both elective and non-elective combined), elective and non-selective CD, and BMI z-score trajectory classes. Results: Of the 2,685 participants, 46.5% (N = 1,248) were born by vaginal delivery (VD), 20.7% (N = 556) by elective CD, and 32.8% (N = 881) by non-elective CD. Five BMI z-score trajectory patterns were identified, and they were "increasing from moderate to high" (10.1%, n = 270), "increasing from mild to moderate" (34.2%, n = 919), "increasing from low to high" (10.5%, n = 283), "stable mild" (30.1%, n = 808), and "stable low" (15.1%, n = 405) groups. Compared with children delivered by VD, those who delivered by CD (both elective and non-elective combined), elective CD, and non-elective CD were associated with the "increasing from moderate to high" trajectory [odds ratio (OR) = 1.61, 95% confidence interval (CI): 1.13-2.29; OR = 1.64, 95%CI: 1.06-2.54; and OR = 1.59, 95%CI: 1.05-2.39, respectively] and were also associated with the "increasing from low to high" trajectory (OR = 1.60, 95%CI: 1.17-2.19, OR = 1.75, 95%CI: 1.16-2.63; and OR = 1.53, 95%CI: 1.00-2.34, respectively). Conclusion: Both elective and non-elective CD were associated with the risk of accelerated weight gain in early childhood.

Interventions to reduce the cesarean delivery rate in a tertiary hospital in China

Introduction: High cesarean delivery rate has been a global public health concern. This study assesses the effect of medical interventions and societal changes on cesarean delivery rates in a Chinese tertiary hospital.Material and methods: A retrospective study including all live births ≥34-week gestation between 2008 and 2016 from Guangzhou Women and Children's Medical Center was divided into 5 stages: (1) no interventions; (2) patient-controlled epidural analgesia; (3) episiotomy restriction; (4) new labor management; (5) universal two-child policy. An interrupted time series design was used to measure the effect of interventions on overall cesarean rate, primary cesarean rate, maternal and neonatal outcomes.Results: There were 126,609 deliveries including 49,092 cesarean deliveries and 77,517 vaginal deliveries in this period. Overall cesarean delivery rate declined after implementing patient-controlled epidural analgesia, episiotomy restriction and universal two-child policy. Primary cesarean rate decreased after implementing episiotomy restriction. Cesarean rate with previous cesarean dramatically increased, and maternal request cesarean rate decreased gradually. Low Apgar rate (score ≤7 at 5 min) increased after episiotomy restriction and maternal postpartum hemorrhage rate increased after new labor management.Conclusions: Patient-controlled epidural analgesia, episiotomy restriction and the universal two-child policy showed the most significant effects to reducing the cesarean rate.

Interventions in Reducing Caesarean Section in the World: A Systematic Review

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.

Chinese obstetricians' attitudes, beliefs, and clinical practices related to cesarean delivery on maternal request

BACKGROUND

Obstetricians' beliefs, attitudes, and clinical practices related to cesarean delivery on maternal request appears particularly important in the context of high cesarean section rate. However, few relative studies have been conducted.

AIM

To examine Chinese obstetricians' attitudes, beliefs, and clinical practices with regard to cesarean delivery on maternal request, and to explore influencing factors associated with their practices of cesarean delivery on maternal request.

METHODS

A cross-sectional design was used. Self-administered anonymous questionnaires were distributed to eligible obstetricians at the Congress of the Shanxi Society of Gynecology and Obstetrics as well as the Congress of the Hainan Society of Gynecology and Obstetrics. The overall response rate was 526/649 (81.05%). Multivariate logistic regression models were used to examine independent effects on obstetrician's clinical practices related to cesarean delivery on maternal request.

FINDINGS

Obstetricians who agreed with pregnant women's decision to choose cesarean section directly and believed the benefits of this procedure outweigh the risks had higher odds of performing cesarean delivery on maternal request. In addition, measures to decrease cesarean section at hospitals were associated with reduced likelihood to perform cesarean delivery on maternal request.

CONCLUSIONS

The present study showed a strong correlation between obstetricians' attitudes, beliefs, as well as interventions to decrease cesarean section at hospitals and their clinical practices of cesarean delivery on maternal request. Measures to enhance the training of obstetricians and reduce CS at hospitals are essential to decrease the overall cesarean section rate in China.

Elective caesarean section on maternal request prior to 39 gestational weeks and childhood psychopathology: a birth cohort study in China

BACKGROUND

The recommendation of non-indicated caesarean section (CS) after 39 gestational weeks has been announced based on evidence of maternal and infant physiological effects. The potential psychological risks have not been acknowledged. This study aims to investigate emotional and behavioral problems in pre-school children born with elective CS (ECS) on maternal request prior to 39 weeks.

METHODS

Pregnant women within 12 gestational weeks between November 2008 and October 2010 were invited to participate in the China-Anhui Birth Cohort Study (C-ABCS). They were asked to complete a self-administered questionnaire respectively in 1st and 3rd trimester of pregnancy to collect basic maternal characteristics. Pregnant complications and delivery modes were abstracted from medical notes. Their singleton live births were followed up at preschool age. Strengths and Difficulties Questionnaires (SDQ) were completed by parents to assess children's emotional and behavioral problems. A total of 3319 mother-child pairs were put into the final analysis. Descriptive analysis and binary logistic regression analysis were used to assess the impact of delivery modes on abnormalities in SDQ dimensions at various gestational ages.

RESULTS

The prevalence of ECS on maternal request prior to 39 weeks, at 39-40 weeks, and after 41 weeks was 16.6, 23.7 and 15.9%, respectively. Compared with those born vaginally, children born with ECS on maternal request were more likely to have total difficult problems (RR 1.519, 95% confidence interval 1.077 to 2.142). ECS on maternal request was the independent predictor of emotional problems (3.479, 1.676 to 7.222) and total difficult problems (2.172, 1.175 to 4.016) in children born prior to 39 gestational weeks.

CONCLUSION

Children delivered by ECS on maternal request have an increased risk to have emotional and behavioral problems prior to 39 gestational weeks at preschool age. The potential psychological implication prior to 39 weeks has been added to the roster of impacts of ECS on maternal request. Further research is needed to probe the potential biological mechanisms.

Interventions to reduce unnecessary caesarean sections in healthy women and babies

Optimising the use of caesarean section (CS) is of global concern. Underuse leads to maternal and perinatal mortality and morbidity. Conversely, overuse of CS has not shown benefits and can create harm. Worldwide, the frequency of CS continues to increase, and interventions to reduce unnecessary CSs have shown little success. Identifying the underlying factors for the continuing increase in CS use could improve the efficacy of interventions. In this Series paper, we describe the factors for CS use that are associated with women, families, health professionals, and health-care organisations and systems, and we examine behavioural, psychosocial, health system, and financial factors. We also outline the type and effects of interventions to reduce CS use that have been investigated. Clinical interventions, such as external cephalic version for breech delivery at term, vaginal breech delivery in appropriately selected women, and vaginal birth after CS, could reduce the frequency of CS use. Approaches such as labour companionship and midwife-led care have been associated with higher proportions of physiological births, safer outcomes, and lower health-care costs relative to control groups without these interventions, and with positive maternal experiences, in high-income countries. Such approaches need to be assessed in middle-income and low-income countries. Educational interventions for women should be complemented with meaningful dialogue with health professionals and effective emotional support for women and families. Investing in the training of health professionals, eliminating financial incentives for CS use, and reducing fear of litigation is fundamental. Safe, private, welcoming, and adequately resourced facilities are needed. At the country level, effective medical leadership is essential to ensure CS is used only when indicated. We conclude that interventions to reduce overuse must be multicomponent and locally tailored, addressing women's and health professionals' concerns, as well as health system and financial factors.

Placenta response of inflammation and oxidative stress in low-risk term childbirth: the implication of delivery mode

Background

Caesarean delivery rate is increasing gradually in China and there is no doubt that delivery mode is closely associated with the maternal health and infant development.This study examined the independent effect of delivery mode on placenta inflammation response and oxidative stress response.

Methods

A total of 3474 pregnant women recruited in Ma’anshan Birth Cohort Study were the initial study population. Data on maternal socio-demographic characteristics and pre-pregnancy BMI were collected at their 1st antenatal checkups. Pregnancy-specific anxiety was assessed during the three trimesters of pregnancy. Common pregnant complications were monitored in the whole pregnancy period. Delivery modes, as well as newborn characteristics were abstracted from medical records. Delivery modes included vaginal deliveries (VD), caesarean delivery with medical indications (CDMI), caesarean delivery on maternal request (CDMR) and urgent cesarean delivery (UCD). Placentas were collected during childbirth. The mRNA expression of IL-1β, TNF-a, IL-6, IFN-γ, IL-4, IL-10, IL-8, and HO-1 were assessed in the final sample of 1978 low-risk women with singleton term-births.

Results

The overall rate of caesarean delivery (CD) was 50.5% (1650/3265) in singleton term childbirths in this study. Among women who reported definite CD reasons, 56.8%of them chose the surgery without any medical indications.It shows a non-linear relationship between cytokines related with placenta inflammatory response, oxidative stress response and different delivery modes. At high percentiles of IL-1β, IFN-γ and IL-8, women with CDMR had higher expression levels compared to women with VD. Women with CDMI had higher levels at median percentiles of IL-1β, IFN-γ and IL-8. Women with CDMR had higher expression compared with VD at high percentiles of IL-6 and HO-1, and women with CDMI had higher levels of these two cytokines at their low percentiles. It is worth noting that at high percentiles, compared with normal delivery, the expression of IL-1β, IFN-γ, IL-8 and HO-1 have significantly altered in women with CDMR.

Conclusion

A high overall CD rate was found in this study, and caesarean delivery on maternal request was the major contributor to the high prevalence. Maternal placental oxidative stress and inflammatory response were closely associated with delivery mode. The effect is much amplified at high levels of expression in women who chose CD on maternal request.Such difference needs to be noticed and may have important implications for obstetricians, midwives and other perinatal health care workers.