What would reduce caesarean section rates?—Views from pregnant women and clinicians in Ireland

Healthcare professionals' perceptions of risk management on pregnancy and childbirth: An integrative review

BACKGROUND

Risk management in maternity care aims to reduce incidents and harm to women and babies, contributing to quality care. However, there is growing concern that risk management policies may lead to unnecessary interventions during pregnancy and childbirth, resulting in both short- and long-term morbidity for women and their babies.

AIM

To evaluate healthcare professionals' perceptions of the effect of risk management on pregnancy and childbirth.

METHODS

A five-stage methodological framework was utilised in this review. A comprehensive integrative review was undertaken using a computer-assisted database approach including CINAHL, EMBASE, MEDLINE (Pubmed), PsycINFO and Scopus from 2016-2024. This review is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-analysis for Scoping Reviews (PRISMA-ScR).

FINDINGS

The review identified five papers from four different countries. Two overarching themes were generated: The impact of the dominant medical model on risk management and decision-making in maternity care and the differences and similarities in healthcare professional's perceptions of risk management. The increasing medicalisation of pregnancy and childbirth shifts healthcare professionals' focus towards documentation and administrative tasks, driven by liability fears, rather than addressing clinical risks and providing woman-centred care.

CONCLUSION

Complex factors influence risk management in maternity care. Risk management is affecting the way healthcare professionals think and operate. This review reveals that the medical model significantly shapes healthcare professionals' perceptions of risk management, often undermining midwives' autonomy and impacting decision-making in pregnancy and childbirth. Education and training are essential to restore midwives' autonomous roles, ensuring that women receive the most appropriate, safest and highest quality of care.

Midwifery students and preceptors shared experiences of practice assessment: A qualitative descriptive study

BACKGROUND

Practice placement is a vital part of midwifery programs, enabling students to develop competence in caring for women and their babies under the supervision of preceptor midwives, who assess clinical skills while managing complex caseloads. Midwifery students and preceptor midwives are however contending with significant changes within the practice environment. These include changes to routes of entry to midwifery programmes, a move to a competency-based approach to assessment and increasing complexity of care required for women and their babies.

AIM

To examine the experiences of midwifery students and preceptor midwives with clinical assessment in an Irish university during a period of significant transformation in midwifery education and practice.

METHODS

A qualitative descriptive design was used to interview students (n = 32) and preceptors (n = 29). Data were analysed using content analysis.

RESULTS

Within an overarching theme of 'the context of assessment in practice', students and preceptors reported some commonalities in their experiences of practice assessment. A clear process of assessment was valued by participants, however, lack of continuity of preceptor and resource deficits, including inadequate staffing levels, affected this process. Preceptors and students highlighted the importance of support for practice assessment.

CONCLUSION

The findings emphasise the critical importance of the context of the practice environment in shaping stakeholders' experiences and is unique in eliciting the views of preceptors and students simultaneously. While resourcing midwifery services is essential, it must also encompass the resourcing of preceptorship, as safe practice depends on robust student assessment. Preceptors and students are supported in assessment by an explicit assessment process yet there are opportunities to further bolster supports, contributing to a quality practice learning environment for all. These insights hold significance for midwifery education and other practice-based professions.

Exploring the influence of medical staffing and birth volume on observed-to-expected cesarean deliveries: a panel data analysis of integrated obstetric and gynecological departments in Germany

INTRODUCTION

Cesarean deliveries account for approximately one-third of all births in Germany, prompting ongoing discussions on cesarean section rates and their connection to medical staffing and birth volume. In Germany, the majority of departments integrate obstetric and gynecological care within a single department.

METHODS

The analysis utilized quality reports from German hospitals spanning 2015 to 2019. The outcome variable was the annual risk-adjusted cesarean section ratio-a metric comparing expected to observed cesarean sections. Explanatory variables included annual counts of physicians, midwives, and births. To account for case number-related staffing variations, full-time equivalent midwife and physician staff positions were normalized by the number of deliveries. Uni- and multivariate panel models were applied, complemented by multiple instrument variable analyses, including two-stage least square and generalized method of moments models.

RESULTS

Incorporating data from 509 integrated obstetric departments and 2089 observations, representing 2,335,839 deliveries with 720,795 cesarean sections (over 60% of all inpatient births in Germany), multivariate model with fixed effects revealed a statistically significant positive association between the number of physicians per birth and the risk-adjusted cesarean section ratio (0.004, p = 0.004). Two-stage least square instrument variable analysis (0.020, p < 0.001) and a system GMM estimator models (0.004, p < 0.001) validated these results, providing compelling evidence for a causal relationship.

CONCLUSION

The study established a robust connection between the number of physicians per birth and the risk-adjusted cesarean section ratio in integrated obstetric and gynecological departments in Germany. While the cause of the effect remains unclear, one possible explanation is a lack of specialization within these departments due to the combined provision of both obstetric and gynecological care.

Evidence-Based Strategies to Minimize Unnecessary Primary Cesarean Sections: A Comprehensive Review

The increase in cesarean section (CS) rates, whether they are classified as unnecessary or elective, has globally raised significant concerns due to the associated risks involving maternal and neonatal outcomes. Although CS can be a lifesaving operation in specific medical cases, its overuse is exposing mothers and neonates to complications like hemorrhage, infections, and long-term consequences such as uterine scarring, infertility, and future pregnancy problems. The contributing factors include maternal preferences for convenience, fear of labor, and financial incentives within the healthcare systems that favor surgical interventions. Defensive medical practices and private healthcare providers further exacerbate this trend. This review discusses the prevalence of CS, highlighting variations between developing and developed regions and the complexity of addressing the rising rates. Moreover, recommendations to reduce unnecessary CS, such as enhancing antenatal education to inform mothers about the risks and benefits associated with different delivery options, promoting supportive care models (midwives), and fostering interdisciplinary cooperation among healthcare providers, will also be addressed. Healthcare systems will gain the ability to reduce the rates of unnecessary Cesarean procedures by directing the main focus on patient education, continuous monitoring, and policy reforms. This will lead to the improvement of both neonatal and maternal health outcomes in addition to lowering the costs of healthcare. In order to provide and ensure evidence-based and safe care for childbirth, a multidisciplinary approach is essential.

The significance of different intervertebral spaces in combined spinal epidural anesthesia in cesarean section

BACKGROUND

The number of cesarean sections performed is increasing every year, and obstetric anesthesia is of great interest to physicians and research scholars because of its specificity, high risk, and high complication rate.

OBJECTIVE

To investigate the effects of combined spinal epidural anesthesia (CSEA) with different intervertebral spaces during cesarean section on anesthesia effect, anesthesia onset time, anesthesia recovery time, maternal adverse reactions, and neonates.

METHODS

Ninety-two women who underwent cesarean section in our hospital from September 2022 to February 2023 were selected as the study subjects and randomly divided them into two groups (group A and group B), 46 women in each group. Group A underwent CSEA via an L2-3 gap and group B underwent CSEA via an L3-4 gap puncture. The anesthesia effect, anesthesia onset time, sensory recovery time, adverse effects, and neonatal Apgar score were compared between the two groups.

RESULTS

When CSEA was performed from L2-3, the anesthesia efficiency was higher, but the difference was not statistically significant. When anesthesia was performed by puncture from L2-3, the onset of anesthesia and recovery time was shorter, and the incidence of intraoperative maternal nausea and vomiting, hypotension, respiratory depression, and other adverse reactions was low with a statistically significant difference. However, the Apgar scores of the neonates in the two groups have no difference.

CONCLUSIONS

When CSEA is induced via L2-3 interspace, anesthesia has a rapid onset of action, shorter recovery time, and few maternal adverse effects, without affecting the final anesthetic outcome.

Global increased cesarean section rates and public health implications: A call to action

Over the years; global caesarian section (CS) rates have significantly increased from around 7% in 1990 to 21% today surpassing the ideal acceptable CS rate which is around 10%-15% according to the WHO. However, currently, not all CS are done for medical reasons with rapidly increasing rate of nonmedically indicated CS and the so-called "caesarian on maternal request." These trends are projected to continue increasing over this current decade where both unmet needs and overuse are expected to coexist with the projected global rate of 29% by 2030. CS reduces both maternal and neonatal morbidity and mortality significantly when it is done under proper indications while at the same time, it can be of harm to the mother and the child when performed contrary. The later exposes both the mother and the baby to a number of unnecessary short and long-term complications and increase the chances of developing different noncommunicable diseases and immune-related conditions among babies later in life. The implications of lowering SC rate will ultimately lower healthcare expenditures. This challenge can be addressed by several ways including provision of intensive public health education regarding public health implications of increased CS rate. Assisted vaginal delivery approaches like the use of vacuum and forceps and other methods should be considered and encouraged during delivery as long as their indications for implementation are met. Conducting frequent external review and audits to the health facilities and providing feedback regarding the rates of CS deliveries can help to keep in check the rising CS trends as well as identifying the settings with unmet surgical needs. Moreover, the public especially expectant mothers during clinic visits and clinicians should be educated and be informed on the WHO recommendations on nonclinical interventions towards reduction of unnecessary CS procedures.