Caesarean section or vaginal delivery for low-risk pregnancy? Helping women make an informed choice in low- and middle-income countries

Women's experiences of and satisfaction with childbirth: Development and validation of a measurement scale for low- and middle-income countries

BACKGROUND

Measuring person-centered maternity care outcomes typically consists of two types of measures: experiences of care and satisfaction with care. There are limited validated measurement tools for these measures, particularly in low- and middle-income countries (LMICs). The QUALI-DEC study aims to improve decision-making around caesarean section. We describe development of the QUALI-DEC Study Birth Experience and Satisfaction (QD-BES) scale, and scale validation in Argentina, Burkina Faso, Thailand, and Viet Nam.

METHODS

We used a three-phase scale development and validation approach: 1) item development, 2) scale development, and 3) scale evaluation. We systematically identified existing tools, and assessed them using the QUALI-DEC theory of change, study context, and psychometric qualities. We proposed the 10-item QD-BES scale to balance feasibility, theoretical coverage, and comprehensiveness. We conducted a baseline exit survey with post-partum women in 32 hospitals in 4 countries. We conducted exploratory factor analysis (EFA), and confirmatory factor analysis (CFA).

RESULTS

3127 women participated, most were multiparous (61.0%), without previous caesarean section (77.2%), and preferred vaginal birth (72.8%) despite high rates of caesarean section (39.4%). EFA identified three dimensions: emotional satisfaction (3-items), support and respect by providers (4-items), and communication with providers (3-items), with high loading coefficients (0.5-0.97). CFA confirmed the three-dimension scale, with good model fit (CFI and IFI: 0.95, Cronbach's alpha: 0.70-0.90). Criterion validity was assessed by exploring characteristics of women, obstetric histories, and birth experiences.

CONCLUSIONS

We present psychometric validation of a scale measuring women's satisfaction with care and experiences of childbirth care, using a systematic approach to development and validation in four LMICs. The 10-item QD-BES-scale is short, easily-administered, valid, and reliable. The QD-BES-scale is useful to contribute to the generation of new knowledge about quality of maternity care in LMICs, as well as help to meet the major challenge of implementing and measuring respectful care at scale.

Planning for scale: analysis of adaptations and contextual factors influencing scale-up of the QUALI-DEC intervention to optimize caesarean section use

BACKGROUND

Researchers are encouraged to plan for scale through purposeful and guided assessment of scalability of an intervention. This study analysed factors potentially influencing scale-up and synthesised early adaptations of the QUALI-DEC intervention aiming to improve the appropriate use of caesarean section. The intervention consists of opinion leader engagement, audit and feedback for caesarean section, a tool to help women make an informed decision on the mode of birth, and labour companionship.

METHODS

We conducted a framework analysis, which was guided by the scalability assessment framework by Zamboni et al., a 34-item checklist with a three-point scale. We used data from the formative research including a document review, hospital readiness assessment and qualitative interviews conducted between March 2019 and May 2020 in 32 facilities across Argentina, Burkina Faso, Thailand, and Viet Nam. Data were deductively coded based on the four dimensions of the scalability framework. Our findings were validated with implementing partners across countries.

RESULTS

We identified the perceived relevance of the intervention by women and providers and the presence of relevant key clinical guidelines as factors that may ease scalability of QUALI-DEC. Labour companionship and the decision-analysis tool were perceived as harder to scale-up and requiring additional changes to existing healthcare structures. Most of the study facilities reported high workload and time constraints as implementation barriers. Thailand was the only country with a national policy to reduce unnecessary caesarean sections. Legal disputes were common and followed a structured process in Thailand and Argentina, which may support preference of caesarean section due to fear of litigation. Early adaptations included development, revision and translation of educational material, monetary compensation of opinion leaders and reaching consensus on clinical guidelines to be used across hospitals, most of which are deemed conducive to scale up.

CONCLUSIONS

Planning for scale-up is a key feature of the QUALI-DEC intervention. Scale-up may not be guaranteed at this point of the intervention since effectiveness and cost-effectiveness are not demonstrated yet. However, the investment in studying scale-up opportunities is a core contribution to implementation research. This exercise informed implementation and scale-up strategies of the QUALI-DEC intervention.

Multi-level factors influencing caesarean section preferences among women in low- and middle- income countries: A systematic review

BACKGROUND

Women's preferences regarding caesarean section (CS) are a significant contributing factor to the increasing and widely varying rates of this procedure across countries and regions. This trend is particularly pronounced in low- and middle-income countries (LMICs), where both overuse and underuse of CS can pose significant health risks. Understanding the multi-level factors influencing CS preferences is essential for promoting the appropriate use of this procedure and ensuring optimal maternal and neonatal health outcomes.

AIM

To systematically review literature examining multi-level factors influencing CS preferences among women in LMICs through ecological systems and exploring the prevalence of CS preferences.

METHODS

A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Six electronic databases were searched: Academic Search Ultimate (EBSCO), MEDLINE (EBSCO), Nursing & Allied Health Premium (ProQuest), PubMed, ScienceDirect, and Scopus. The search included studies published from January 2014 to August 2024. The quality of each article was assessed using the Joanna Briggs Institute's critical appraisal tool.

FINDINGS

A total of 17 studies were included in this review. The proportion of CS preferences varied significantly, ranging from 8.8 % to 58 % in LMICs. The multi-level factors influencing CS preferences were summarized across four levels, based on ecological systems: microsystem level (sociodemographic factors, reproductive factors, psychological factors, and literacy-related factors), mesosystem level (healthcare influence, family and relative influence), exosystem level (healthcare environment and social media influence), and macrosystem level (socio-cultural factors).

CONCLUSION

Factors within the microsystem, mesosystem, and macrosystem levels displayed the substantial influence aligned with ecological systems. To reduce unnecessary CS, future research should comprehensively explore multi-level factors. Policymakers should implement prominent factors across the system.

Health outcomes up to 5 years in children born as a second child after a previous caesarean section in a first pregnancy: a Swedish population-based register study between 1999 and 2015

OBJECTIVE

To explore health outcomes up to 5 years of age, according to mode of birth, in a large cohort of Swedish children who were born as a second child to women who had a caesarean section (CS) in their first pregnancy.

DESIGN

Retrospective population-based register study.

POPULATION

All children (n=94 498) who were born as a second child (or children in cases of twins or higher-order multiple births) during 1999-2015 in Sweden in women who had a CS first birth. The children were followed up to 5 years of age. For inclusion, both births must have occurred in Sweden.

METHODS

A nationwide cohort study using follow-up data up to 5 years of age. Maternal factors, including age, smoking, diabetes, obesity (body mass index ≥30), mental illness, pre-eclampsia, education, income, country of birth and the neonatal factors of being a singleton and prematurity (up to week 36+6) were adjusted for in regression models.

MAIN OUTCOME MEASURES

Developmental problems, asthma, allergy, hospital care and death within 5 years of age.

RESULTS

A total of 94 498 children were included in the study. Risk for developmental problems, asthma and allergy was increased after repeat CS but not after vaginal birth. The need for hospital care was increased in all other birth modes compared with spontaneous vaginal birth. The risk of death within 5 years increased after instrumental vaginal birth and emergency repeat CS.

CONCLUSIONS

All repeat CS compared with spontaneous vaginal birth was related to increased risks for developmental problems, asthma, allergy and hospital stay, and emergency repeat CS was associated with an increased risk of death within 5 years. The results of the present study support vaginal birth as the optimal mode of birth after previous CS for longer-term child health outcomes.

Women's caesarean section preferences: A multicountry cross-sectional survey in low- and middle-income countries

OBJECTIVE

To measure the proportion of women's preferences for CS in hospitals with high caesarean section rates and to identify related factors.

DESIGN

A cross-sectional hospital-based postpartum survey was conducted. We used multilevel multivariate logistic regression and probit models to analyse the association between women's caesarean section preferences and maternal characteristics. Probit models take into account selection bias while excluding women who had no preference.

SETTING

Thirty-two hospitals in Argentina, Thailand, Vietnam and Burkina Faso were selected.

PARTICIPANTS

A total of 1,979 post-partum women with no potential medical need for caesarean section were included among a representative sample of women who delivered at each of the participating facilities during the data collection period.

FINDINGS

The overall caesarean section rate was 23.3 %. Among women who declared a preference in late pregnancy, 9 % preferred caesarean section, ranging from 1.8 % in Burkina Faso to 17.8 % in Thailand. Primiparous women were more likely to prefer a caesarean section than multiparous women (β=+0.16 [+0.01; +0.31]; p = 0.04). Among women who preferred caesarean section, doctors were frequently cited as the main influencers, and "avoid pain in labour" was the most common perceived benefit of caesarean section.

KEY CONCLUSIONS

Our results suggest that a high proportion of women prefer vaginal birth and highlight that the preference for caesarean section is linked to women's fear of pain and the influence of doctors. These results can inform the development of interventions aimed at supporting women and their preferences, providing them with evidence-based information and changing doctors' behaviour in order to reduce the number of unnecessary caesarean sections.

CLINICAL TRIAL REGISTRY

The QUALI-DEC trial is registered on the Current Controlled Trials website (https://www.isrctn.com/) under the number ISRCTN67214403.

Low Fetal Resistance to Hypoxia as a Cause of Stillbirth and Neonatal Encephalopathy

Objective: Low fetal resistance to hypoxia is a factor in stillbirth and neonatal encephalopathy. This review examines fetal movement patterns in response to hypoxia as a predictor of the likelihood of stillbirth. Monitoring the dynamics of fetal movements during maternal apnea could allow the assessment of fetal resistance to hypoxia. The goal of this study is to describe the practical application of this method by doctors and pregnant women. Mechanism: We searched relevant keywords in the international scientific literature databases Scopus and Web of Science, as well as databases for patents granted in China, India, USA, Japan, Germany, Russia and other countries. Devices, drugs and medical technologies that provide diagnosis, modeling, prevention and treatment of intrauterine fetal hypoxia, stillbirth and neonatal encephalopathy were considered. Findings in Brief: During apnea by a pregnant woman in the second half of normal pregnancy, if the maximum duration of fetal immobility exceeds 30 seconds from the onset of breath-holding, then the fetus is considered to show good resistance to hypoxia, thus preserving its health and life during vaginal delivery. On the other hand, excessive fetal movements <10 seconds after the onset of apnea in a pregnant woman indicates low fetal resistance to hypoxia. When fetal resistance to hypoxia is low, there is no alternative to immediate cesarean section for the preservation of fetal life and health. Conclusions: The monitoring of fetal movements during apnea in pregnant women allows real-time assessment of fetal resistance to intrauterine hypoxia. Obtaining timely information on fetal resistance to hypoxia is critical for determining the optimal timing and type of delivery in order to prevent encephalopathy and stillbirth.

Implementing the QUALI-DEC project in Argentina, Burkina Faso, Thailand and Viet Nam: a process delineation and theory-driven process evaluation protocol

The project 'Quality Decision-making by women and providers' (QUALI-DEC) combines four non-clinical interventions to promote informed decision-making surrounding mode of birth, improve women's birth experiences, and reduce caesarean sections among low-risk women. QUALI-DEC is currently being implemented in 32 healthcare facilities across Argentina, Burkina Faso, Thailand, and Viet Nam. In this paper, we detail implementation processes and the planned process evaluation, which aims to assess how and for whom QUALI-DEC worked, the mechanisms of change and their interactions with context and setting; adaptations to intervention and implementation strategies, feasibility of scaling-up, and cost-effectiveness of the intervention. We developed a project theory of change illustrating how QUALI-DEC might lead to impact. The theory of change, together with on the ground observations of implementation processes, guided the process evaluation strategy including what research questions and perspectives to prioritise. Main data sources will include: 1) regular monitoring visits in healthcare facilities, 2) quantitative process and output indicators, 3) a before and after cross-sectional survey among post-partum women, 4) qualitative interviews with all opinion leaders, and 5) qualitative interviews with postpartum women and health workers in two healthcare facilities per country, as part of a case study approach. We foresee that the QUALI-DEC process evaluation will generate valuable information that will improve interpretation of the effectiveness evaluation. At the policy level, we anticipate that important lessons and methodological insights will be drawn, with application to other settings and stakeholders looking to implement complex interventions aiming to improve maternal and newborn health and wellbeing.Trial registration: ISRCTN67214403.

Global inequities in cesarean section deliveries and required resources persist

OBJECTIVE

The purpose of this study was to estimate the global distribution and financial cost associated with the inequities present in the use of cesarean sections (CS) worldwide.

STUDY DESIGN

We used the latest estimates on CS rates published by WHO and we adopted 10-15 % as the range of CS rates that are considered optimal for adequate use. We calculated the cost (in USD) to achieve CS rates of 10-15 % for countries that reported rates below 10 %. We also calculated the cost of CS rates in excess (>15 % and > 20 %) by estimating how much it would cost to reduce the rates to 10-15 % for each of those countries.

RESULTS

137 countries are included in this analysis with updated data on CS rates between the years 2010 and 2018. Our analysis found that 36 countries reported CS rates < 10 %, whereas 91 countries reported CS rates > 15 % (a majority of which were > 20 %); only 10 countries reported CS rates between 10 and 15 %. The cost of CS exceeding a rate of 15 % is estimated to be $9,586,952,466 including inflation and exceeding 20 % is $7.169.248.033 (USD). The cost of achieving "needed" CS among countries with CS rates < 10 % is $612,609,418 (USD). The cost of cesarean sections exceeding 15 % has increased by 313 % between 2008 and more recent years, accruing $7 billion (USD) more in surplus since 2008. The reallocation of CS funding would save the global economy $9 billion (USD).

CONCLUSION

Global inequities in CS performed and associated costs have increased since 2008, resulting in a disproportionate number of resources allocated.