A survey on the effects of husbands' education of pregnant women on knowledge, attitude, and reducing elective cesarean section

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.

Effect of "motivational interviewing" and "information, motivation, and behavioral skills" counseling interventions on choosing the mode of delivery in pregnant women: a study protocol for a randomized controlled trial

BACKGROUND

Cesarean section is an important surgical procedure, when normal vaginal delivery imposes a risk to mother and/or baby. The World Health Organization states the ideal rate for Cesarean section to be between 10 and 15% of all births. In recent decades, the rate has been increased dramatically worldwide. This paper explains the protocol of a randomized controlled trial that aims to compare the effect of "motivational interviewing" and "information, motivation, and behavioral skills" counseling interventions on choosing mode of delivery in pregnant women.

METHODS

A four-armed, parallel-design randomized controlled trial will be conducted on pregnant women. One hundred and twenty women will be randomly assigned to four groups including three intervention groups and one control group. The intervention groups included the following: (1) motivational interviewing; (2) face-to-face information, motivation, and behavioral skills model; and (3) information, motivation, and behavioral skills model provided using a mobile application. The inclusion criteria include being literate, being in gestational age from 24 to 32 weeks, being able to speak Persian, having no complications in the current pregnancy, having no indications for Cesarean section, and having enough time to participate in the intervention. The primary outcome of the study is the mode of delivery. The secondary outcomes are women's intention to undergo Cesarean section and women's self-efficacy.

DISCUSSION

The interventions of this protocol have been programmed to reduce unnecessary Cesarean sections. Findings may contribute to a rise in normal vaginal delivery, and the effective intervention may be extended for use in national Cesarean section plans.

TRIAL REGISTRATION

Iran Randomized Clinical Trial Center IRCT20151208025431N7 . Registered on December 07, 2018.

Public target interventions to reduce the inappropriate use of medicines or medical procedures: a systematic review

Background

An epidemic of health disorders can be triggered by a collective manifestation of inappropriate behaviors, usually systematically fueled by non-medical factors at the individual and/or societal levels. This study aimed to (1) landscape and assess the evidence on interventions that reduce inappropriate demand of medical resources (medicines or procedures) by triggering behavioral change among healthcare consumers, (2) map out intervention components that have been tried and tested, and (3) identify the “active ingredients” of behavior change interventions that were proven to be effective in containing epidemics of inappropriate use of medical resources.

Methods

For this systematic review, we searched MEDLINE, EMBASE, the Cochrane Library, and PsychINFO from the databases’ inceptions to May 2019, without language restrictions, for behavioral intervention studies. Interventions had to be empirically evaluated with a control group that demonstrated whether the effects of the campaign extended beyond trends occurring in the absence of the intervention. Outcomes of interest were reductions in inappropriate or non-essential use of medicines and/or medical procedures for clinical conditions that do not require them. Two reviewers independently screened titles, abstracts, and full text for inclusion and extracted data on study characteristics (e.g., study design), intervention development, implementation strategies, and effect size. Data extraction sheets were based on the checklist from the Cochrane Handbook for Systematic Reviews.

Results

Forty-three studies were included. The behavior change technique taxonomy v1 (BCTTv1), which contains 93 behavioral change techniques (BCTs), was used to characterize components of the interventions reported in the included studies. Of the 93 BCTs, 15 (16%) were identified within the descriptions of the selected studies targeting healthcare consumers. Interventions consisting of education messages, recommended behavior alternatives, and a supporting environment that incentivizes or encourages the adoption of a new behavior were more likely to be successful.

Conclusions

There is a continued tendency in research reporting that mainly stresses the effectiveness of interventions rather than the process of identifying and developing key components and the parameters within which they operate. Reporting “negative results” is likely as critical as reporting “active ingredients” and positive findings for implementation science. This review calls for a standardized approach to report intervention studies.

Trial registration

PROSPERO registration number CRD42019139537

The effect of individual counseling on attitudes and decisional conflict in the choice of delivery among nulliparous women

BACKGROUND

The most important reasons for choosing cesarean include negative attitude of pregnant women toward natural childbirth, and it is not easy for many women to make a decision about the choice of delivery, Midwives as responsible individuals, play an important role in providing maternal counseling and care during pregnancy and childbirth and the postpartum period. This study was carried out to determine the effect of individual counseling on attitudes and decisional conflict in the choice of delivery among nulliparous women.

MATERIALS AND METHODS

This clinical trial was performed on 90 nulliparous women with 28-30 weeks of gestational age, who were referred to health-care centers in Mashhad. They were divided randomly into intervention and control groups. The intervention group received the counseling program individually during three sessions, while the control group received routine care, childbirth attitudes, and decisional conflict on choice of delivery were compared on women of 34-36 weeks of pregnancy. Data collection tools included demographic details form, Childbirth Attitudes Scale and Decisional Conflict Scale; data were analyzed using Chi-square tests, Fisher's exact test, Mann-Whitney test, t-test, parried t-test, and ANCOVA in SPSS v. 16, and P < 0.05 was considered statistically significant.

RESULTS

After consultation, there was a significant difference in attitude score between the intervention group (86.577 ± 13.531) and the control group (69.955 ± 19.858) (P < 0.001), And there was a significant difference in decisional conflict score between the intervention group (0.614 ± 0.626) and the control group (1.216 ± 0.949) (P < 0.001), and there were significant differences between the two groups in terms of preferred delivery (P < 0.001).

CONCLUSION

According to the results of this randomized control trial, individual counseling in nulliparous women during pregnancy leads to a positive attitude toward natural childbirth, informed decision-making, and increase in the selection of natural childbirth.

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.

The Effect of Educational Program Based on the Extended Theory of Reasoned Action on Self-Care Behaviors in Women with Type 2 Diabetes

BACKGROUND AND OBJECTIVE

The aim of this study is to determine the effect of educational program based on the extended theory of reasoned action on self-care behaviours in women with type 2 diabetes in Fasa. This quasi-experimental study was performed on 100 women with type 2 diabetes who referred to diabetes clinics in Fasa.

MATERIALS AND METHODS

Samples were randomly divided into experimental and control groups. The data were collected using a questionnaire based on the extended theory of reasoned action and self-care behaviours that were completed by both the control and experimental groups before and 3 months after the educational intervention. Data were analysed by SPSS software version 22, descriptive statistics tests, Chi-square test, independent T-test, and paired T-test.

RESULTS

The results of the study showed that after the educational intervention, the mean scores of all constructs of the extended theory of reasoned action in the experimental group were significantly increased compared to the control group (P <0.05).

CONCLUSION

Also, the educational intervention had a significant effect on the promotion of patient's self-care behaviours in the experimental group and the HbA1c level decreased in the experimental group compared to the control group (P <0.05). In addition, it was found that the extended theory of reasoned action could be a suitable framework for designing educational interventions for promoting self-care behaviours in diabetic patients.

Women's perspectives on health facility and system levels factors influencing mode of delivery in Tehran: a qualitative study

BACKGROUND

Iran has one of the highest national caesarean section rates worldwide. Few studies explored in-depth the health-facility and health-system level factors that affect women's choices on mode of delivery in Iran. The aim of this study was to explore the health-facility and health-system level factors affecting women's preferences on mode of delivery in Tehran.

METHODS

We conducted a qualitative study using in-depth face-to-face interviews with women between October 2017 and May 2018. Study participants were sampled purposively from a range of health service settings to include women of varying experiences regarding childbirth. Eligibility criteria were Persian-speaking, women with or without childbirth experiences. All interviews were audio-recorded and lasted 30-45 min. After verbatim transcription of the interviews, we created a preliminary thematic framework to analyze the data. A combined inductive (themes emerging from the data) and deductive (key concepts across existing frameworks) approach was used during data analysis.

RESULTS

In total, 26 in-depth interviews were conducted. Five central themes influencing women's preferences on mode of delivery emerged from the analysis: (1) health system conditions (important differences between the quality of care provided at private and public hospitals; staff shortages, skills, competency, motivation and also accessibility to staff during the longer time required for a vaginal delivery; policies and protocols on vaginal birth after cesarean, pain relief for vaginal birth, and having companion during labor; (2) standards of care in facilities (physical condition in facilities; physical examinations and procedures; continuous and organized care; ethics); (3) interaction between women and providers (communicating in a supportive manner with women and communication women's partners/families); (4) preserving women's dignity (delivering high quality and respectful care); (5) provision of information (education about pregnancy and childbirth including environment in facility, labor processes/procedures, and the risks and benefits of both vaginal delivery and caesarean section).

CONCLUSIONS

Our study suggests, there are barriers to increasing demand for and satisfaction with vaginal birth, such as women's perceived sub-optimal quality of care during labor and birth, understaffed facilities that lack standard protocols and have limited physical space, and lack of privacy and dignity. The multifactorial nature of the increase of unnecessary Cesarean section calls for multicomponent interventions to revert this trend. These interventions need to address the health-systems' and health-facilities' deficiencies behind women's preference for Cesarean section.

Non-clinical interventions for reducing unnecessary caesarean section

BACKGROUND

Caesarean section rates are increasing globally. The factors contributing to this increase are complex, and identifying interventions to address them is challenging. Non-clinical interventions are applied independently of a clinical encounter between a health provider and a patient. Such interventions may target women, health professionals or organisations. They address the determinants of caesarean births and could have a role in reducing unnecessary caesarean sections. This review was first published in 2011. This review update will inform a new WHO guideline, and the scope of the update was informed by WHO's Guideline Development Group for this guideline.

OBJECTIVES

To evaluate the effectiveness and safety of non-clinical interventions intended to reduce unnecessary caesarean section.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers in March 2018. We also searched websites of relevant organisations and reference lists of related reviews.

SELECTION CRITERIA

Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series studies and repeated measures studies were eligible for inclusion. The primary outcome measures were: caesarean section, spontaneous vaginal birth and instrumental birth.

DATA COLLECTION AND ANALYSIS

We followed standard methodological procedures recommended by Cochrane. We narratively described results of individual studies (drawing summarised evidence from single studies assessing distinct interventions).

MAIN RESULTS

We included 29 studies in this review (19 randomised trials, 1 controlled before-after study and 9 interrupted time series studies). Most of the studies (20 studies) were conducted in high-income countries and none took place in low-income countries. The studies enrolled a mixed population of pregnant women, including nulliparous women, multiparous women, women with a fear of childbirth, women with high levels of anxiety and women having undergone a previous caesarean section.Overall, we found low-, moderate- or high-certainty evidence that the following interventions have a beneficial effect on at least one primary outcome measure and no moderate- or high-certainty evidence of adverse effects.Interventions targeted at women or familiesChildbirth training workshops for mothers alone may reduce caesarean section (risk ratio (RR) 0.55, 95% confidence interval (CI) 0.33 to 0.89) and may increase spontaneous vaginal birth (RR 2.25, 95% CI 1.16 to 4.36). Childbirth training workshops for couples may reduce caesarean section (RR 0.59, 95% CI 0.37 to 0.94) and may increase spontaneous vaginal birth (RR 2.13, 95% CI 1.09 to 4.16). We judged this one study with 60 participants to have low-certainty evidence for the outcomes above.Nurse-led applied relaxation training programmes (RR 0.22, 95% CI 0.11 to 0.43; 104 participants, low-certainty evidence) and psychosocial couple-based prevention programmes (RR 0.53, 95% CI 0.32 to 0.90; 147 participants, low-certainty evidence) may reduce caesarean section. Psychoeducation may increase spontaneous vaginal birth (RR 1.33, 95% CI 1.11 to 1.61; 371 participants, low-certainty evidence). The control group received routine maternity care in all studies.There were insufficient data on the effect of the four interventions on maternal and neonatal mortality or morbidity.Interventions targeted at healthcare professionalsImplementation of clinical practice guidelines combined with mandatory second opinion for caesarean section indication slightly reduces the risk of overall caesarean section (mean difference in rate change -1.9%, 95% CI -3.8 to -0.1; 149,223 participants). Implementation of clinical practice guidelines combined with audit and feedback also slightly reduces the risk of caesarean section (risk difference (RD) -1.8%, 95% CI -3.8 to -0.2; 105,351 participants). Physician education by local opinion leader (obstetrician-gynaecologist) reduced the risk of elective caesarean section to 53.7% from 66.8% (opinion leader education: 53.7%, 95% CI 46.5 to 61.0%; control: 66.8%, 95% CI 61.7 to 72.0%; 2496 participants). Healthcare professionals in the control groups received routine care in the studies. There was little or no difference in maternal and neonatal mortality or morbidity between study groups. We judged the certainty of evidence to be high.Interventions targeted at healthcare organisations or facilitiesCollaborative midwifery-labourist care (in which the obstetrician provides in-house labour and delivery coverage, 24 hours a day, without competing clinical duties), versus a private practice model of care, may reduce the primary caesarean section rate. In one interrupted time series study, the caesarean section rate decreased by 7% in the year after the intervention, and by 1.7% per year thereafter (1722 participants); the vaginal birth rate after caesarean section increased from 13.3% before to 22.4% after the intervention (684 participants). Maternal and neonatal mortality were not reported. We judged the certainty of evidence to be low.We studied the following interventions, and they either made little or no difference to caesarean section rates or had uncertain effects.Moderate-certainty evidence suggests little or no difference in caesarean section rates between usual care and: antenatal education programmes for physiologic childbirth; antenatal education on natural childbirth preparation with training in breathing and relaxation techniques; computer-based decision aids; individualised prenatal education and support programmes (versus written information in pamphlet).Low-certainty evidence suggests little or no difference in caesarean section rates between usual care and: psychoeducation; pelvic floor muscle training exercises with telephone follow-up (versus pelvic floor muscle training without telephone follow-up); intensive group therapy (cognitive behavioural therapy and childbirth psychotherapy); education of public health nurses on childbirth classes; role play (versus standard education using lectures); interactive decision aids (versus educational brochures); labourist model of obstetric care (versus traditional model of obstetric care).We are very uncertain as to the effect of other interventions identified on caesarean section rates as the certainty of the evidence is very low.

AUTHORS' CONCLUSIONS

We evaluated a wide range of non-clinical interventions to reduce unnecessary caesarean section, mostly in high-income settings. Few interventions with moderate- or high-certainty evidence, mainly targeting healthcare professionals (implementation of guidelines combined with mandatory second opinion, implementation of guidelines combined with audit and feedback, physician education by local opinion leader) have been shown to safely reduce caesarean section rates. There are uncertainties in existing evidence related to very-low or low-certainty evidence, applicability of interventions and lack of studies, particularly around interventions targeted at women or families and healthcare organisations or facilities.

Does Spousal Support Can Increase the Women's Physical Activity?

BACKGROUND

Numerous benefits of physical activity are well-known for the prevention and treatment of various diseases such as diabetes, cardiovascular disease, obesity, and cancers. However, the status of physical activities among women remains noticeably less than the recommended level. Considering the importance of the spouses' participation in the promotion of women's health, this study examined the impact of spousal support on women's physical activity.

METHODS

This semi--experimental study was done in February 2015 on 100 couples in reproductive age referred to health centers of Falavarjan city. The participants were randomly divided into intervention and control groups. The information related to women's physical activity in both groups was collected by aquestionnaire in two steps, before and three months after the intervention. The spouses of women in the intervention group were trained in the field of the importance of physical activity in women's health in two sessions. The data were analyzed by the software SPSS21 and suitable statistical tests (Independent t, paired t, and Chi-square).

RESULTS

The mean and standard deviation of women's age in the both groups were 28.76±5.51 and 30.38±5.31, respectively. The prevalence of obesity and overweight in the women under the study was generally estimated 44%. Physical activities of women in the intervention group were significantly increased after the intervention (P<0.0001). Also, the Body Mass Index in the intervention group was significantly decreased compared to before the intervention and control group (P<0.001).

CONCLUSION

Spouses could encourage women to perform physical activities. It is recommended that the health care system should implement educational sessions for men to encourage women to exercise.

The effect of an instructional program based on health belief model in decreasing cesarean rate among primiparous pregnant mothers

INTRODUCTION

Although cesarean section has saved many mothers' and infants' lives, the problem is in its increasing prevalence. According to recent statistics, the current rate of cesarean in Iran is in fact 3-4 times as more than the standard rate defined by WHO. Therefore, the present study is aimed to estimate the effect of an instructional program based on health belief model on reducing cesarean rate among primiparous pregnant women.

MATERIALS AND METHODS

In this semi-experimental research, 60 primiparous women who had visited Bandar Abbas Healthcare Centers were selected as the subjects. They were in their 26-30(th) week of pregnancy. They were selected in a multi-stage cluster sampling method (a combination of clustering and simple randomization), and were divided into two groups, subjects and control group. The data were gathered using a valid and reliable questionnaire. The instructional intervention was done after the completion of the pretest questionnaire based on the sub-constructs of the health belief model in six instructional sessions. 1 month after the intervention, posttest questionnaires were completed by the subjects in both groups. The data were analyzed using descriptive statistics, standard deviation, independent t-test, and paired t-test. The significance level was set at <0.05.

RESULTS

Two groups had a significant difference between awareness score, perceived sensitivity, intensity, benefits, barriers, self-efficacy, and the performance (P < 0.001). In the experimental group, nine subjects (30%) had a natural delivery.

CONCLUSION

According to the findings of the current research, an instructional program illuminated (designed) by the health belief model can significantly influence pregnant women's awareness, intention, and choice of delivery type.

Does Spousal Support Can Decrease Women's Premenstrual Syndrome Symptoms?

Premenstrual syndrome is a syndrome that includes behavioral and physical symptoms occurring in the second half of the menstrual cycle and this syndrome affects millions of women universal. With regard to the importance of spouse participation in promoting reproductive and women’s health, the aim of this study was to determine the effect of educational intervention for spouse on women’s premenstrual syndrome symptoms. This quasi -experimental study was down with the participation of 100 women of reproductive age with PMS were referred to health centers Falavarjan city in 2015. Women were divided randomly into two groups as intervention and control. Educational intervention about supportive behaviors to control premenstrual symptoms was performed for spouses during the three educational sessions in the intervention group. Data was obtained with self-administered questionnaire before and three months after educational intervention and were analyzed by SPSS21 and appropriate statistical tests. Three mounts after the intervention the score of spouse’s supportive behaviors was increased significantly compare to before of the educational intervention and the control group. As well as significant decrease was occurred in case of physical and psychological-behavioral symptoms of women in the intervention group compare to before the intervention and control groups (p<0.05). Spouse’s supportive behaviors can reduce PMS symptoms in women. As a result, it is recommended that the health care system organize the educational intervention to increase spouse supportive behaviors.

Comparison of childbirth training workshop effects on knowledge, attitude, and delivery method between mothers and couples groups referring to Isfahan health centers in Iran

BACKGROUND

The World Health Organization announced the acceptable level of cesarean section (CS) as 10-15%. In recent years, the rate of CS has been increasing irregularly. Lack of appropriate knowledge and attitude among couples plays a major role in this regard. This study tried to compare the effects of a childbirth training workshop on knowledge, attitude, and delivery method.

MATERIALS AND METHODS

The present study is a randomized clinical trial conducted in four stages on 180 subjects referring to Isfahan health care centers in three groups of mothers (alone), couples (mothers and their respective partners), and control. After sampling, a pre-test and intervention in the form of an educational workshop were conducted. Then, post-test was conducted immediately after, 1 month later, and in puerperium in all three groups. Data were analyzed by SPSS version 15.

RESULTS

The analysis showed that the knowledge mean was statically significant in mothers (P < 0.0001), couples (P < 0.0001), and control group (P < 0.0001) before and after intervention. Also, the attitude mean was statically significant in mothers (P < 0.0001), couples (P < 0.0001), and control groups (P < 0.0001) before and after intervention. Analysis of delivery method showed that in mothers, couples, and control groups, normal vaginal delivery was the most preferred method in that order, w hich was significant (P = 0.017).

CONCLUSIONS

Workshop education of pregnant women and their spouses was effective on encouraging them to natural delivery. Therefore, designing educational and counseling programs through collaborative methods for mothers and their spouses is suggested to reduce the rate of cesarean deliveries.

Reasons for Elective Cesarean Section amongst Pregnant Women; A Qualitative Study

BACKGROUND

A qualitative study was carried out on 200 pregnant women attending obstetric offices and Imam Ali Women's Clinic in Zahedan, Iran during January 2010 to August 2011. Twenty-nine focus group discussions (FGDs) with 5-8 participants in each group were formed. The study included women in the third trimester of pregnancy with the intention or decision to undergo elective cesarean section. The women's views were explored and analyzed in group sessions. Subsequently, the responses were divided into four major categories. The majority (50%) of the opinions expressed were psychological in origin, or stemmed from low perceived behavioral control, improper subjective norms, or wrong attitudes about vaginal delivery.

METHODS

Twenty-nine focus group discussions (FGDs) with 5-8 participants in each group were formed. The study included women in the third trimester of pregnancy with the intention or decision to undergo elective cesarean section. The women's views were explored and analyzed in group sessions.

RESULTS

The responses were divided into four major categories. The majority (50%) of the opinions expressed were psychological in origin, or stemmed from low perceived behavioral control, improper subjective norms, or wrong attitudes about vaginal delivery.

CONCLUSION

It is necessary to hold psychological skills training classes for pregnant women and their husbands to persuade them attend group discussion sessions to increase their control on perceived behavior, highlight their positive attitudes and direct them toward natural vaginal delivery.