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Hoxha I, Grezda K, Udutha A, Taganoviq B, Agahi R, Brajshori N, Rising SS. Systematic review and meta-analysis examining the effects of midwife care on cesarean birth. Birth 2024; 51:264-274. [PMID: 38037256 DOI: 10.1111/birt.12801] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 10/27/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND The increasing number of unnecessary cesarean births is a cause for concern and may be addressed by increasing access to midwifery care. The objective of this review was to assess the effect of midwifery care on the likelihood of cesarean births. METHODS We searched five databases from the beginning of records through May 2020. We included observational studies that reported odds ratios or data allowing the calculation of odds ratios of cesarean birth for births with and without midwife involvement in care or presence at the institution. Standard inverse-variance random-effects meta-analysis was used to generate overall odds ratios (ORs). RESULTS We observed a significantly lower likelihood of cesarean birth in midwife-led care, midwife-attended births, among those who received instruction pre-birth from midwives, and within institutions with a midwifery presence. CONCLUSIONS Care from midwives reduces the likelihood of cesarean birth in all the analyses, perhaps due to their greater preference and skill for physiologic births. Increased use of midwives in maternal care can reduce cesarean births and should be further researched and implemented broadly, potentially as the default modality in maternal care.
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Affiliation(s)
- Ilir Hoxha
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
- Kolegji Heimerer, Prishtina, Kosovo
- Evidence Synthesis Group, Prishtina, Kosovo
| | | | - Anirudh Udutha
- Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
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Berdzuli N, Llop-Gironés A, Farcasanu D, Butu C, Grbic M, Betran AP. From evidence to tailored decision-making: a qualitative research of barriers and facilitating factors for the implementation of non-clinical interventions to reduce unnecessary caesarean section in Romania. BMJ Open 2024; 14:e065004. [PMID: 38417956 PMCID: PMC10900340 DOI: 10.1136/bmjopen-2022-065004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 01/16/2024] [Indexed: 03/01/2024] Open
Abstract
OBJECTIVE To improve understanding of the drivers of the increased caesarean section (CS) rate in Romania and to identify interventions to reverse this trend, as well as barriers and facilitators. DESIGN A formative research study was conducted in Romania between November 2019 and February 2020 by means of in-depth interviews and focus-group discussions. Romanian decision-makers and high-level obstetricians preselected seven non-clinical interventions for consideration. Thematic content analysis was carried out. PARTICIPANTS 88 women and 26 healthcare providers and administrators. SETTINGS Counties with higher and lower CS rates were selected for this research-namely Argeș, Bistrița-Năsăud, Brașov, Ialomița, Iași, Ilfov, Dolj and the capital city of București (Bucharest). RESULTS Women wanted information, education and support. Obstetricians feared malpractice lawsuits; this was identified as a key reason for performing CSs. Most obstetrics and gynaecology physicians would oppose policies of mandatory second opinions, financial measures to equalise payments for vaginal and CS births and goal setting for CS rates. In-service training was identified as a need by obstetricians, midwives and nurses. In addition, relevant structural constraints were identified: perceived lower quality of care for vaginal birth, a lack of obstetricians with expertise in managing complicated vaginal births, a lack of anaesthesiologists and midwives, and family doctors not providing antenatal care. Finally, women expressed the need to ensure their rights to dignified and respectful healthcare through pregnancy and childbirth. CONCLUSION Consideration of the views, values and preferences of all stakeholders in a multifaceted action tailored to Romanian determinants is critical to address relevant determinants to reduce unnecessary CSs. Further studies should assess the effect of multifaceted interventions.
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Affiliation(s)
- Nino Berdzuli
- Country Health Programs, World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | - Alba Llop-Gironés
- Country Health Programs, World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | - Dana Farcasanu
- Centre for Health Policies and Services, Bucharest, Romania
| | - Cassandra Butu
- World Health Organization Country Office for Romania, Copenhagen, Denmark
| | - Miljana Grbic
- World Health Organization Country Office for Romania, Bucharest, Romania
| | - Ana Pilar Betran
- Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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3
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Zaigham M, Varallo J, Thangaratinam S, Nicholson W, H. A. Visser G. Global disparities in caesarean section rates: Why indication-based metrics are needed. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002877. [PMID: 38319901 PMCID: PMC10846695 DOI: 10.1371/journal.pgph.0002877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Affiliation(s)
- Mehreen Zaigham
- Obstetrics and Gynaecology, Institution of Clinical Sciences Lund, Lund University, Lund, Sweden
| | | | - Shakila Thangaratinam
- WHO Collaborating Centre for Global Women’s Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
| | - Wanda Nicholson
- Department of Prevention and Community Health, George Washington Milken Institute of Public Health and the Department of Obstetrics and Gynaecology, George Washington School of Medicine, Washington, DC, United States of America
| | - Gerard H. A. Visser
- Department of Obstetrics, University Medical Center, Utrecht, The Netherlands
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Kearney L, Nugent R, Maher J, Shipstone R, Thompson JM, Boulton R, George K, Robins A, Bogossian F. Factors associated with spontaneous vaginal birth in nulliparous women: A descriptive systematic review. Women Birth 2024; 37:63-78. [PMID: 37704535 DOI: 10.1016/j.wombi.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 08/25/2023] [Accepted: 08/26/2023] [Indexed: 09/15/2023]
Abstract
PROBLEM Spontaneous vaginal birth (SVB) rates for nulliparous women are declining internationally. BACKGROUND There is inadequate understanding of factors affecting this trend overall and limited large-scale responses to improve women's opportunity to birth spontaneously. AIM To undertake a descriptive systematic review identifying factors associated with spontaneous vaginal birth at term, in nulliparous women with a singleton pregnancy. METHODS Quantitative studies of all designs, of nulliparous women with a singleton pregnancy and cephalic presentation, who experienced a SVB at term were included. Nine databases were searched (inception to October 2022). Two reviewers undertook quality appraisal; Randomised Controlled Trials (RCTs) with high risk of bias (ROB 2.0) and other designs with (QATSDD) scoring ≤ 50% were excluded. FINDINGS Data were abstracted from 90 studies (32 RCTs, 39 cohort, 9 cross-sectional, 4 prevalence, 5 case control, 1 quasi-experimental). SVB rates varied (13%-99%). Modifiable factors associated with SVB included addressing fear of childbirth, low impact antenatal exercise, maternal positioning during second-stage labour and midwifery led care. Complexities arising during pregnancy and regional analgesia were shown to decrease SVB and other interventions, such as routine induction of labour were equivocal. DISCUSSION Antenatal preparation (low impact exercise, childbirth education, addressing fear of childbirth) may increase SVB, as does midwifery continuity-of-care. Intrapartum strategies to optimise labour progression emerged as promising areas for further research. CONCLUSION Declining SVB rates may be improved through multi-factorial approaches inclusive of maternal, fetal and clinical care domains. However, the variability of SVB rates testifies to the complexity of the issue.
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Affiliation(s)
- Lauren Kearney
- School of Nursing, Midwifery and Social Work, University of Queensland, Australia; Women's and Newborn Services, Royal Brisbane and Women's Hospital, Metro North Health, Australia.
| | - Rachael Nugent
- Department of Obstetrics and Gynaecology, Sunshine Coast Hospital and Health Service, Australia
| | - Jane Maher
- Department of Obstetrics and Gynaecology, Sunshine Coast Hospital and Health Service, Australia
| | | | - John Md Thompson
- School of Health, University of the Sunshine Coast, Australia; Faculty of Medicine, University of Auckland, New Zealand
| | - Rachel Boulton
- Department of Obstetrics and Gynaecology, Sunshine Coast Hospital and Health Service, Australia
| | - Kendall George
- Women's and Newborn Services, Townsville Hospital and Health Service, Australia
| | - Anna Robins
- School of Health, University of the Sunshine Coast, Australia
| | - Fiona Bogossian
- School of Health, University of the Sunshine Coast, Australia
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Symum H, Zayas-Castro JL. A Multistate Decomposition Analysis of Cesarean Rate Variations, Associated Health Outcomes, and Financial Implications in the United States. Am J Perinatol 2023; 40:1473-1483. [PMID: 34666396 DOI: 10.1055/s-0041-1736538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Cesarean rates vary widely across the U.S. states; however, little is known about the causes and implications associated with these variations. The objectives of this study were to quantify the contribution of the clinical and nonclinical factors in explaining the difference in cesarean rates across states and to investigate the associated health outcome of cesarean variations. STUDY DESIGN Using the Hospital Cost and Utilization Project State Inpatient Databases, this retrospective study included all nonfederal hospital births from Wisconsin, Florida, and New York. A nonlinear extension of the Oaxaca-Blinder method was used to decompose the contributions of differences in characteristics to cesarean variations between these states. The risk factors for cesarean delivery were identified using separate multivariable logistic regression analysis for each State. RESULTS The difference in clinical and nonclinical factors explained a substantial (~46.57-65.45%) proportion of cesarean variations between U.S. states. The major contributors of variation were patient demographics, previous cesareans, hospital markup ratios, and social determinants of health. Cesarean delivery was significantly associated with higher postpartum readmissions and unplanned emergency department visits, greater lengths of stay, and hospital costs across all states. CONCLUSION Although a proportion of variations in cesarean rates can be explained by the differences in risk factors, the remaining unexplained variations suggest differences in practice patterns and imply potential quality concerns. Since nonclinical factors are likely to play an important role in cesarean variation, we recommend targeted initiatives increasing access to maternal care and improving maternal health literacy. KEY POINTS · Cesarean rates vary widely almost two folds within U.S. states.. · The difference in risk factors explained substantial (~46.57-65.45%) of the cesarean variations.. · Mother race, hospital factors, and social determinants comprised major proportion of explained variation.. · Adverse outcomes and increased expenditures were associated with cesarean than vaginal delivery.. · Significant potential cost savings for Medicaid if the unnecessary cesarean deliveries are reduced..
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Affiliation(s)
- Hasan Symum
- Department of Industrial and Management Systems Engineering, University of South Florida, Tampa, Florida
| | - José L Zayas-Castro
- Department of Industrial and Management Systems Engineering, University of South Florida, Tampa, Florida
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Zahroh RI, Sutcliffe K, Kneale D, Vazquez Corona M, Betrán AP, Opiyo N, Homer CSE, Bohren MA. Educational interventions targeting pregnant women to optimise the use of caesarean section: What are the essential elements? A qualitative comparative analysis. BMC Public Health 2023; 23:1851. [PMID: 37741979 PMCID: PMC10517530 DOI: 10.1186/s12889-023-16718-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 09/07/2023] [Indexed: 09/25/2023] Open
Abstract
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.
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Affiliation(s)
- Rana Islamiah Zahroh
- Gender and Women's Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia.
| | - Katy Sutcliffe
- EPPI Centre, UCL Social Research Institute, University College London, London, UK
| | - Dylan Kneale
- EPPI Centre, UCL Social Research Institute, University College London, London, UK
| | - Martha Vazquez Corona
- Gender and Women's Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Ana Pilar Betrán
- Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Newton Opiyo
- Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Caroline S E Homer
- Maternal, Child, and Adolescent Health Programme, Burnet Institute, Melbourne, VIC, Australia
| | - Meghan A Bohren
- Gender and Women's Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
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Vila Ortiz M, Gialdini C, Hanson C, Betrán AP, Carroli G, Mølsted Alvesson H. A bit of medical paternalism? A qualitative study on power relations between women and healthcare providers when deciding on mode of birth in five public maternity wards of Argentina. Reprod Health 2023; 20:122. [PMID: 37605278 PMCID: PMC10440876 DOI: 10.1186/s12978-023-01661-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 08/07/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Whether women should be able to decide on mode of birth in healthcare settings has been a topic of debate in the last few decades. In the context of a marked increase in global caesarean section rates, a central dilemma is whether pregnant women should be able to request this procedure without medical indication. Since 2015, Law 25,929 of Humanised Birth is in place in Argentina. This study aims at understanding the power relations between healthcare providers, pregnant women, and labour companions regarding decision-making on mode of birth in this new legal context. To do so, central concepts of power theory are used. METHODS This study uses a qualitative design. Twenty-six semi-structured interviews with healthcare providers were conducted in five maternity wards in different regions of Argentina. Participants were purposively selected using heterogeneity sampling and included obstetrician/gynaecologists (heads of department, specialists working in 24-h shifts, and residents) and midwives where available. Reflexive thematic analysis was used to inductively develop themes and categories. RESULTS Three themes were developed: (1) Healthcare providers reconceptualize decision-making processes of mode of birth to make women's voices matter; (2) Healthcare providers feel powerless against women's request to choose mode of birth; (3) Healthcare providers struggle to redirect women's decision regarding mode of birth. An overarching theme was built to explain the power relations between healthcare providers, women and labour companions: Healthcare providers' loss of beneficial power in decision-making on mode of birth. CONCLUSIONS Our analysis highlights the complexity of the healthcare provider-woman interaction in a context in which women are, in practice, allowed to choose mode of birth. Even though healthcare providers claim to welcome women being an active part of the decision-making processes, they feel powerless when women make autonomous decisions regarding mode of birth. They perceive themselves to be losing beneficial power in the eyes of patients and consider fruitful communication on risks and benefits of each mode of birth to not always be possible. At the same time, providers perform an increasing number of CSs without medical indication when it is convenient for them, which suggests that paternalistic practices are still in place.
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Affiliation(s)
- M Vila Ortiz
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
- Centro Rosarino de Estudios Perinatales, Rosario, Argentina.
| | - C Gialdini
- Facultad de Ciencias de la Salud Blanquerna, Universidad Ramón Llull, Barcelona, Spain
- Centro Rosarino de Estudios Perinatales, Rosario, Argentina
| | - C Hanson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - A P Betrán
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - G Carroli
- Centro Rosarino de Estudios Perinatales, Rosario, Argentina
| | - H Mølsted Alvesson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Johansson M, Alvan J, Pettersson A, Hildingsson I. Conflicting attitudes between clinicians and women regarding maternal requested caesarean section: a qualitative evidence synthesis. BMC Pregnancy Childbirth 2023; 23:210. [PMID: 36978038 PMCID: PMC10044365 DOI: 10.1186/s12884-023-05471-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/27/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Caesarean section (CS) can be a life-saving operation but might also negatively affect the health of both the woman and the baby. The aim of this study was to synthesize and contrast women's and clinicians' attitudes toward maternal-requested CS, and their experiences of the decision-making process around CS. METHODS The databases of CINAHL, MEDLINE, PsycInfo and Scopus were screened. All qualitative studies that answered the study question and that were assessed to have minor or moderate methodological limitations were included. Synthesised findings were assessed using GRADE-CERQual. RESULTS The Qualitative Evidence Synthesis included 14 qualitative studies (published 2000-2022), involving 242 women and 141 clinicians. From the women's perspectives, two themes arose: women regarded CS as the safest mode of birth; and women's rights to receive support and acceptance for a CS request. From the clinicians' perspectives, four themes emerged: clinicians were concerned about health risks associated with CS; demanding experience to consult women with a CS request; conflicting attitudes about women's rights to choose a CS; and the importance of respectful and constructive dialogue about birthing options. CONCLUSION Women and clinicians often had different perceptions regarding the right of a woman to choose CS, the risks associated with CS, and the kind of support that should be part of the decision-making process. While women expected to receive acceptance for their CS request, clinicians perceived that their role was to support the woman in the decision-making process through consultation and discussion. While clinicians thought it was important to show respect for a woman's birth preferences, they also felt the need to resist a woman's request for CS and encourage her to give birth vaginally due to the associated increases in health risks.
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Affiliation(s)
- Margareta Johansson
- Department of Women’s and Children’s Health, Uppsala University, Akademiska University Hospital, SE- 751 85 Uppsala, Sweden
| | - Jonatan Alvan
- Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm, Sweden
| | - Agneta Pettersson
- Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm, Sweden
| | - Ingegerd Hildingsson
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
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Zahroh RI, Kneale D, Sutcliffe K, Vazquez Corona M, Opiyo N, Homer CSE, Betrán AP, Bohren MA. Interventions targeting healthcare providers to optimise use of caesarean section: a qualitative comparative analysis to identify important intervention features. BMC Health Serv Res 2022; 22:1526. [PMID: 36517885 PMCID: PMC9753390 DOI: 10.1186/s12913-022-08783-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 11/02/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Rapid increases in caesarean section (CS) rates have been observed globally; however, CS rates exceeding 15% at a population-level have limited benefits for women and babies. Many interventions targeting healthcare providers have been developed to optimise use of CS, typically aiming to improve and monitor clinical decision-making. However, interventions are often complex, and effectiveness is varied. Understanding intervention and implementation features that likely lead to optimised CS use is important to optimise benefits. The aim of this study was to identify important components that lead to successful interventions to optimise CS, focusing on interventions targeting healthcare providers. METHODS: We used Qualitative Comparative Analysis (QCA) to identify if certain combination of important intervention features (e.g. type of intervention, contextual characteristics, and how the intervention was delivered) are associated with a successful intervention as reflected in a reduction of CS. We included 21 intervention studies targeting healthcare providers to reduce CS, comprising of 34 papers reporting on these interventions. To develop potential theories driving intervention success, we used existing published qualitative evidence syntheses on healthcare providers' perspectives and experiences of interventions targeted at them to reduce CS. RESULTS We identified five important components that trigger successful interventions targeting healthcare providers: 1) training to improve providers' knowledge and skills, 2) active dissemination of CS indications, 3) actionable recommendations, 4) multidisciplinary collaboration, and 5) providers' willingness to change. Importantly, when one or more of these components are absent, dictated nature of intervention, where providers are enforced to adhere to the intervention, is needed to prompt successful interventions. Unsuccessful interventions were characterised by the absence of these components. CONCLUSION We identified five important intervention components and combinations of intervention components which can lead to successful interventions targeting healthcare providers to optimise CS use. Health facility managers, researchers, and policy-makers aiming to improve providers' clinical decision making and reduce CS may consider including the identified components to optimise benefits.
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Affiliation(s)
- Rana Islamiah Zahroh
- Gender and Women’s Health Unit, Centre for Health Equity, School of Population and Global Health, The University of Melbourne, Melbourne, VIC Australia
| | - Dylan Kneale
- EPPI-Centre, UCL Social Research Institute, University College London, London, UK
| | - Katy Sutcliffe
- EPPI-Centre, UCL Social Research Institute, University College London, London, UK
| | - Martha Vazquez Corona
- Gender and Women’s Health Unit, Centre for Health Equity, School of Population and Global Health, The University of Melbourne, Melbourne, VIC Australia
| | - Newton Opiyo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Caroline S. E. Homer
- Maternal, Child, and Adolescent Health Program, Burnet Institute, Melbourne, VIC Australia
| | - Ana Pilar Betrán
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Meghan A. Bohren
- Gender and Women’s Health Unit, Centre for Health Equity, School of Population and Global Health, The University of Melbourne, Melbourne, VIC Australia
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Factors Associated with the Quality and Transparency of National Guidelines: A Mixed-Methods Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19159515. [PMID: 35954872 PMCID: PMC9367745 DOI: 10.3390/ijerph19159515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 02/04/2023]
Abstract
We assessed the methodological quality and transparency of all the national clinical practice guidelines that were published in Croatia up until 2017 and explored the factors associated with their quality rating. An in-depth quantitative and qualitative analysis was performed using rigorous methodology. We evaluated the guidelines using a validated AGREE II instrument with four raters; we used multiple linear regressions to identify the predictors of quality; and two focus groups, including guideline developers, to further explore the guideline development process. The majority of the guidelines (N = 74) were developed by medical societies. The guidelines’ quality was rated low: the median standardized AGREE II score was low, 36% (IQR 28–42), and so were the overall-assessments. The aspects of the guidelines that were rated best were the “clarity of presentation” and the “scope and purpose” (median ≥ 59%); however, the other four domains received very low scores (15–33%). Overall, the guideline quality did not improve over time. The guidelines that were developed by medical societies scored significantly worse than those developed by governmental, or unofficial working groups (12–43% per domain). In focus group discussions, inadequate methodology, a lack of implementation systems in place, a lack of awareness about editorial independence, and broader expertise/perspectives in working groups were identified as factors behind the low scores. The factors identified as affecting the quality of the national guidelines may help stakeholders who are developing interventions and education programs aimed at improving guideline quality worldwide.
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Colomar M, Colistro V, Sosa C, de Francisco LA, Betrán AP, Serruya S, De Mucio B. Cesarean section in Uruguay from 2008 to 2018: country analysis based on the Robson classification. An observational study. BMC Pregnancy Childbirth 2022; 22:471. [PMID: 35672663 PMCID: PMC9175367 DOI: 10.1186/s12884-022-04792-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 05/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of caesarean section has steadily increased, with Latin America being the region with the highest rates. Multiple factors account for that increase and the Robson classification is appropriate to compare determinants at the clinical level for caesarean section rates over time. The purpose of this study is to describe the evolution of caesarean section rates by Robson groups in Uruguay from 2008 to 2018 using a country level database. METHODS We included the records of all women giving birth in Uruguay (pregnancies ≥22 weeks and weights ≥500 g) with valid data in the mode of childbirth recorded in the Perinatal Information System database between 2008 and 2018. Caesarean section rates were calculated by Robson groups for each of the years included, disaggregated by care sector (public/private) and by geographical area (Capital City/Non-Capital), with time trends and their significance analyzed using linear regression models. RESULTS Of the total 485,263 births included in this research, the overall caesarean section rate was 43,1%. In 2018, among the groups at lower risk of caesarean section (1 to 4), the highest rates were seen in women in group 2B (98,8%), followed by those in group 4B (97,9%). A significant increase in the number of caesarean sections was seen in groups 2B (97,9 to 98,8%), 3 (8,36 to 11,1%) and 4 (A (22,7 to 26,9%) and B (95,4 to 97,9%) Significant growth was also observed in groups 5 (74,3 to 78,1%), 8 (90,6 to 95,5%), and 10 (39,1 to 46,7%). The private sector had higher rates of caesarean section for all groups throughout the period, except for women in group 9. The private sector in Montevideo presented the highest rates in the groups with the lowest risk of caesarean section (1, 2A, 3 and 4A), followed by the private sector outside of the capital. CONCLUSION Uruguay is no exception to the increasing caesarean section trend, even in groups of women who have lower risk of requiring caesarean section. The implementation of interventions aimed at reducing caesarean section in the groups with lower obstetric risk in Uruguay is warranted.
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Affiliation(s)
- Mercedes Colomar
- Montevideo Clinical and Epidemiological Research Unit, Montevideo, Uruguay.
- Latin American Center for Perinatology, Women and Reproductive Health (CLAP/WR), PAHO/WHO, Montevideo, Uruguay.
| | - Valentina Colistro
- Department of Quantitative Methods, School of Medicine, Universidad de la República (UdelaR), Montevideo, Uruguay
| | - Claudio Sosa
- Department of Obstetrics and Gynecology, Pereira Rossell Hospital, School of Medicine, Universidad de la República (UdelaR), Montevideo, Uruguay
| | - Luis Andres de Francisco
- Family, Health Promotion and Life Course, Pan American Health Organization, World Health Organization, Washington, United States
| | - Ana Pilar Betrán
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Suzanne Serruya
- Latin American Center for Perinatology, Women and Reproductive Health (CLAP/WR), PAHO/WHO, Montevideo, Uruguay
| | - Bremen De Mucio
- Latin American Center for Perinatology, Women and Reproductive Health (CLAP/WR), PAHO/WHO, Montevideo, Uruguay
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Wender MCO, Duarte RG, Muller GC, Cavalheiro RR, Silva YALC, Carboni C, Valério EG. Factors Associated with the Chance of Carrying out a Primary Cesarean in a University Hospital. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRICIA : REVISTA DA FEDERACAO BRASILEIRA DAS SOCIEDADES DE GINECOLOGIA E OBSTETRICIA 2022; 44:640-645. [PMID: 35667378 PMCID: PMC9948062 DOI: 10.1055/s-0042-1748976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The present study seeks to identify the associated factors that increased primary cesarean delivery rates. METHODS This was a cross-sectional study that evaluated the number of primary cesarean sections performed in the years 2006 and 2018 at the Hospital de Clínicas de Porto Alegre (HCPA, in the Portuguese acronym), through the collection of data from the medical records of the patients. RESULTS Advanced maternal age, twin pregnancy, and higher body mass index (BMI) became more frequent in 2018 in comparison with 2006. To mitigate the impact of confounding in comparisons among groups, we made an adjustment by propensity scores and detected significant differences when comparing both age groups on twin pregnancy rates, gestational diabetes mellitus, and thyroid disease. CONCLUSION Data from the present study can be used to prevent and improve the management of morbidities, impacting on better outcomes in obstetrical practice.
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Affiliation(s)
- Maria Celeste Osório Wender
- Postgraduate Program in Health Sciences: Gynecology and Obstetrics, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.,Department of Gynecology and Obstetrics, Faculty of Medicine (FAMED), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.,Service of Obstetrics and Gynecology, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil
| | - Rafaela Girardi Duarte
- Faculty of Medicine (FAMED), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Gabriel Cardozo Muller
- Postgraduate Program in Epidemiology, Department of Social Medicine, Faculty of Medicine (FAMED), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Rosaura Rolim Cavalheiro
- Service of Obstetrics and Gynecology, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil
| | - Yanick Adolfo Leal Correia Silva
- Postgraduate Program in Health Sciences: Gynecology and Obstetrics, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Cristiane Carboni
- Postgraduate Program in Health Sciences: Gynecology and Obstetrics, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Edimárlei Gonsales Valério
- Postgraduate Program in Health Sciences: Gynecology and Obstetrics, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.,Department of Gynecology and Obstetrics, Faculty of Medicine (FAMED), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.,Service of Obstetrics and Gynecology, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil
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Symum H, Zayas-Castro J. Impact of Statewide Mandatory Medicaid Managed Care (SMMC) Programs on Hospital Obstetric Outcomes. Healthcare (Basel) 2022; 10:healthcare10050874. [PMID: 35628011 PMCID: PMC9141169 DOI: 10.3390/healthcare10050874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/24/2022] [Accepted: 05/01/2022] [Indexed: 11/16/2022] Open
Abstract
The state of Florida implemented mandatory managed care for Medicaid enrollees via the Statewide Medicaid Managed Care (SMMC) program in April of 2014. The objective of this study was to examine the impact of the implementation of the SMMC program on the access to care and quality of maternal care for Medicaid enrollees, as measured by several hospital obstetric outcomes. The primary data source for this retrospective observational study was the Hospital Cost and Utilization Project (HCUP) all-payer State ED (SED) visit and State Inpatient Databases (SIDs) from 2010 to 2017. The primary health outcomes for obstetric care were primary cesarean, preterm birth, postpartum preventable ED visits, postpartum preventable readmissions, and vaginal delivery after cesarean (VBAC) rates. Using difference-in-differences (DID) estimation, selected health outcomes were examined for Florida residents with Medicaid beneficiaries (treatment) and the commercially insured population (comparison), before and after the implementation of SMMC. Improvement in disparities for racial/ethnic minority Medicaid enrollees was estimated relative to whites, compared to the relative change among commercially insured patients. From the DID estimation, the findings showed that SMMC is statistically significantly associated with a higher reduction in primary cesarean rates, preterm births, preventable postpartum ED visits, and readmissions among Medicaid beneficiaries relative to their commercially insured counterparts. However, this study did not find any significant reduction in racial/ethnic disparities in obstetric outcomes. In general, this study highlights the impact of SMMC implementation on obstetric outcomes in Florida and provides important insights and potential scope for improvement in obstetric care quality and associated racial/ethnic disparities.
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Varnakioti D, Sarantaki A, Gourounti K, Lykeridou A. Identifying factors associated with adolescents' Intention for childbirth. JOURNAL OF MOTHER AND CHILD 2022; 26:93-103. [PMID: 36803945 PMCID: PMC10032313 DOI: 10.34763/jmotherandchild.20222601.d-22-00022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 12/02/2022] [Indexed: 02/23/2023]
Abstract
BACKGROUND Around the world, caesarean section rates have steadily increased over the past few decades. The World Health Organization (WHO) guidelines on nonclinical interventions to reduce caesarean section rates emphasize educational interventions and support programs. MATERIAL AND METHODS In this study, we have determined factors associated with adolescents' intention regarding childbirth options using the Theory of Planned Behavior (TPB). The sample was comprised of 480 high school students in Greece who were invited to complete a questionnaire consisting of three sections: a section on sociodemographic data; a section featuring the Adolescents' Intentions towards Birth Options (AIBO) scale, a recently developed instrument that accesses attitudes and intentions regarding vaginal birth and caesarean section; and a section detailing participants' awareness regarding reproduction and birth. RESULTS Multiple logistic regression found that participants' impressions of vaginal birth and the TPB constructs were significantly associated with intention towards caesarean section. In particular, participants with a negative impression of vaginal birth had a 2.20-fold higher probability of reporting their preference for caesarean section, compared to participants with neither a negative nor a positive impression. Furthermore, participants with higher scores on the "Attitudes towards vaginal birth," "Subjective norms," and "Perceived behavior control over vaginal birth" subscales had a significantly lower probability of reporting preference for caesarean section. CONCLUSION Our study demonstrates the effectiveness of the TPB to identify factors that influence adolescents' preference for childbirth. We highlight the necessity to implement nonclinical interventions to reduce the preference for caesarean section, providing evidence for developing school-based educational programs for a timely and consistency implementation.
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Affiliation(s)
- Dimitra Varnakioti
- Faculty of Health and Caring Sciences, Midwifery Department, University of West Attica, Athens, Greece
| | - Antigoni Sarantaki
- Faculty of Health and Caring Sciences, Midwifery Department, University of West Attica, Athens, Greece
| | - Kleanthi Gourounti
- Faculty of Health and Caring Sciences, Midwifery Department, University of West Attica, Athens, Greece
| | - Aikaterini Lykeridou
- Faculty of Health and Caring Sciences, Midwifery Department, University of West Attica, Athens, Greece
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Perrotta C, Romero M, Sguassero Y, Straw C, Gialdini C, Righetti N, Betran AP, Ramos S. Caesarean birth in public maternities in Argentina: a formative research study on the views of obstetricians, midwives and trainees. BMJ Open 2022; 12:e053419. [PMID: 35078842 PMCID: PMC8796244 DOI: 10.1136/bmjopen-2021-053419] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES To explore obstetricians', midwives' and trainees' perceptions of caesarean section (CS) determinants in the context of public obstetric care services provision in Argentina. Our hypothesis is that known determinants of CS use may differ in settings with limited access to essential obstetric services. SETTING We conducted a formative research study in 19 public maternity hospitals in Argentina. An institutional survey assessed the availability of essential obstetric services. Subsequently, we conducted online surveys and semistructured interviews to assess the opinions of providers on known CS determinants. RESULTS Obstetric services showed an adequate provision of emergency obstetric care but limited services to support women during birth. Midwives, with some exceptions, are not involved during labour. We received 680 surveys from obstetricians, residents and midwives (response rate of 63%) and interviewed 26 key informants. Six out of 10 providers (411, 61%) indicated that the use of CS is associated with the complexities of our caseload. Limited pain management access was deemed a potential contributing factor for CS in adolescents and first-time mothers. Providers have conflicting views on the adequacy of training to deal with complex or prolonged labour. Obstetricians with more than 10 years of clinical experience indicated that fear of litigation was also associated with CS. Overall, there is consensus on the need to implement interventions to reduce unnecessary CS. CONCLUSIONS Public maternity hospitals in Argentina have made significant improvements in the provision of emergency services. The environment of service provision does not seem to facilitate the physiological process of vaginal birth. Providers acknowledged some of these challenges.
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Affiliation(s)
- Carla Perrotta
- School of Public Health, Physiotherapy and Sport Sciences, University College Dublin, Dublin, Ireland
| | - Mariana Romero
- Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), Buenos Aires, Argentina
- Health, Economy and Society Department, CEDES, Buenos Aires, Argentina
| | | | - Cecilia Straw
- School of Social Sciences, University of Buenos Aires, CEDES, Buenos Aires, Argentina
| | | | - Natalia Righetti
- Health, Economy and Society Department, CEDES, Buenos Aires, Argentina
| | - Ana Pilar Betran
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneve, Switzerland
| | - Silvina Ramos
- Health, Economy and Society Department, CEDES, Buenos Aires, Argentina
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Hirsh-Yechezkel G, Glasser S, Farhi A, Levitan G, Shachar Y, Zaslavsky-Paltiel I, Boyko V, Ezra Y, Lerner-Geva L. Cesarean delivery on maternal request in Israel: Maternity department policies and obstetricians' perspectives. WOMEN'S HEALTH (LONDON, ENGLAND) 2022; 18:17455057221125366. [PMID: 36366970 PMCID: PMC9661554 DOI: 10.1177/17455057221125366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 07/25/2022] [Accepted: 08/24/2022] [Indexed: 09/08/2024]
Abstract
OBJECTIVE This study aimed to describe Israeli maternity departments' policies regarding cesarean delivery on maternal request, and factors associated with obstetricians' support for cesarean delivery on maternal request in specific scenarios. METHODS This multicenter cross-sectional study included 22 maternity department directors and 222 obstetricians from the majority of Israeli hospitals. Directors were interviewed and completed a questionnaire about their department's cesarean delivery on maternal request policy, and obstetricians responded to a survey presenting case scenarios in which women requested cesarean delivery on maternal request. The scenarios represented profiles referring to the following factors: maternal age, poor obstetric history, pregnancy complications, and psychological problems. The survey also included the obstetricians' socio-demographic information and questions about other issues associated with cesarean delivery on maternal request. The main outcome measures were department policies regarding cesarean delivery on maternal request and obstetricians' support for cesarean delivery on maternal request in specific cases. RESULTS Policies were divided between allowing and prohibiting cesarean delivery on maternal request (n = 10 and 12, respectively), and varied regarding issues such as informed consent and pre-surgery consultation. Most of the obstetricians (96.5%) did not support cesarean delivery on maternal request in the "reference scenario" describing a young woman with no obstetric complications. Additional factors increased the rate of support. Support was greater among obstetricians aged > 45 (odds ratio = 2.11; 95% confidence intervals 1.33-3.36) and lower among females (odds ratio = 0.58; 95% confidence intervals 0.39-0.86). Obstetricians whose department policy was less likely to allow cesarean delivery on maternal request reported lower rates of support for cesarean delivery on maternal request in most cases. CONCLUSION Policies and obstetricians' support for cesarean delivery on maternal request vary broadly depending on clinical profiles and physician characteristics. Department policy has an impact on obstetricians' support for cesarean delivery on maternal request. Health policy will benefit from a framework in which the organizations, physicians, and patients are consulted.
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Affiliation(s)
- Galit Hirsh-Yechezkel
- Women and Children’s Health Research Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center affiliated with Tel Aviv University, Ramat Gan, Israel
| | - Saralee Glasser
- Women and Children’s Health Research Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center affiliated with Tel Aviv University, Ramat Gan, Israel
| | - Adel Farhi
- Women and Children’s Health Research Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center affiliated with Tel Aviv University, Ramat Gan, Israel
| | - Gila Levitan
- Women and Children’s Health Research Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center affiliated with Tel Aviv University, Ramat Gan, Israel
| | - Yael Shachar
- Women and Children’s Health Research Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center affiliated with Tel Aviv University, Ramat Gan, Israel
| | - Inna Zaslavsky-Paltiel
- Women and Children’s Health Research Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center affiliated with Tel Aviv University, Ramat Gan, Israel
| | - Valentina Boyko
- Women and Children’s Health Research Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center affiliated with Tel Aviv University, Ramat Gan, Israel
| | - Yossef Ezra
- Department of Obstetrics and Gynaecology, Hadassah University Hospital, Jerusalem, Israel
| | - Liat Lerner-Geva
- Women and Children’s Health Research Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center affiliated with Tel Aviv University, Ramat Gan, Israel
- School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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17
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Colomar M, Gonzalez Mora F, Betran AP, Opiyo N, Bohren MA, Torloni MR, Siaulys M. Collaborative model of intrapartum care: qualitative study on barriers and facilitators to implementation in a private Brazilian hospital. BMJ Open 2021; 11:e053636. [PMID: 34916321 PMCID: PMC8679125 DOI: 10.1136/bmjopen-2021-053636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION A collaborative (midwife-obstetrician) model of intrapartum care (CMIC) is associated with lower caesarean section (CS) rates than physician-led models. In 2019, the largest private maternity hospital in Latin America (14.000 deliveries/year, 89% CS) created a quality improvement initiative to optimise intrapartum care and safely reduce CS in low-risk women managed by its internal team of healthcare providers (HCP). We conducted formative research to identify potential barriers and facilitators to the implementation of a CMIC. METHODS Three groups of stakeholders participated in focus groups and interviews: hospital managers and clinical coordinators, HCP working in labour/delivery wards and pregnant women intending to give birth in the hospital. We explored participants' views about the acceptability of implementing a CMIC where a nurse-midwife (NM) on shift would be the main intrapartum HCP, with continuous support/supervision of a dedicated, in-house, obstetrician-gynaecologist (OB-GYN). A thematic analysis approach was used. RESULTS 12 HCPs, 5 clinical coordinators, 2 hospital managers and 7 women participated. OB-GYNs, coordinators and managers highlighted health system, organisational and structural factors (NMs' limited experience/skills, professional roles, financial reimbursement) as potential barriers. NMs identified logistical and human resources as additional barriers. Women viewed the CMIC with perplexity and insecurity because of cultural beliefs about the dominant role of OB-GYNs, and limited information about NM's capabilities. All professionals agreed that women's acceptance of a CMIC will require educational interventions and communication strategies to inform potential users about the advantages and safety of this model. CONCLUSION There are important barriers and facilitators to implement a CMIC in a private Brazilian maternity hospital. Factors related to health system structure and organisation may have the greatest impact. A CMIC is more likely to succeed if stakeholders' concerns about responsibilities, power and financial revenues are addressed, and educational interventions targeted at users are deployed prior to its implementation.
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Affiliation(s)
- Mercedes Colomar
- Montevideo Clinical and Epidemiological Research Unit, Montevideo, Uruguay
| | - Franco Gonzalez Mora
- Health Sociology Unit, University of the Republic of Uruguay Faculty of Medicine, Montevideo, Uruguay
| | - Ana Pilar Betran
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Newton Opiyo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Meghan A Bohren
- Gender and Women's Health Unit, Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
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Negrini R, D'Albuquerque IMSC, de Cássia Sanchez E Oliveira R, Ferreira RDDS, De Stefani LFB, Podgaec S. Strategies to reduce the caesarean section rate in a private hospital and their impact. BMJ Open Qual 2021; 10:e001215. [PMID: 34385187 PMCID: PMC8362699 DOI: 10.1136/bmjoq-2020-001215] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 08/03/2021] [Indexed: 12/02/2022] Open
Abstract
There is a concern around the world of an increasing caesarean section rate. It was estimated that between 2010 and 2015, caesarean section rates increased by almost 50%. There are several implications for this, considering that caesarean sections are associated with higher costs and worse clinical outcomes. In this context, several interventions have been considered to increase vaginal delivery rates, including the Adequate Childbirth Project (PPA) in Brazil. This study aimed to verify the impact of the strategies adopted internally in the Hospital Israelita Albert Einstein (HIAE) located in São Paulo, Brazil, regarding the reduction of caesarean sections and their perinatal results. Actions to support our study were implemented in two phases based on the PPA schedule. These actions involved three axes: a multidisciplinary team, pregnant women and facility improvements. All pregnant women admitted for childbirth at the HIAE between 2014 and 2019 were included in this study. The overall rate of vaginal delivery in this study population and among primiparous women and the percentage of admissions to the neonatal intensive care unit (NICU) were analysed in three periods: before the implementation of PPA actions (period A), after the first phase of the project (period B) and after its second phase (period C). The results showed an increase in the average vaginal delivery rate from 23.57% in period A to 27.88% in period B, and to 30.06% in period C (AxB, p<0.001; BxC, p=0.004). There was a decrease in the average of NICU admissions over the periods (period A 19.22%, period B 18.71% and period C 13.22%); a significant reduction was observed when periods B and C (p<0.001) were compared.
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Affiliation(s)
- Romulo Negrini
- Departamento Materno Infantil, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | | | - Rita de Cássia Sanchez E Oliveira
- Departamento Materno Infantil, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Consultorio, TAGIDES - Unidade de Ultrassonografia, São Paulo, Brazil
| | | | | | - Sergio Podgaec
- Saúde da Mulher, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
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19
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Betran AP, Ye J, Moller AB, Souza JP, Zhang J. Trends and projections of caesarean section rates: global and regional estimates. BMJ Glob Health 2021; 6:bmjgh-2021-005671. [PMID: 34130991 PMCID: PMC8208001 DOI: 10.1136/bmjgh-2021-005671] [Citation(s) in RCA: 430] [Impact Index Per Article: 143.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/20/2021] [Indexed: 11/24/2022] Open
Abstract
Background The caesarean section (CS) rate continues to increase across high-income, middle-income and low-income countries. We present current global and regional CS rates, trends since 1990 and projections for 2030. Methods We obtained nationally representative data on the CS rate from countries worldwide from 1990 to 2018. We used routine health information systems reports and population-based household surveys. Using the latest available data, we calculated current regional and subregional weighted averages. We estimated trends by a piecewise analysis of CS rates at the national, regional and global levels from 1990 to 2018. We projected the CS rate and the number of CS expected in 2030 using autoregressive integrated moving-average models. Results Latest available data (2010–2018) from 154 countries covering 94.5% of world live births shows that 21.1% of women gave birth by caesarean worldwide, averages ranging from 5% in sub-Saharan Africa to 42.8% in Latin America and the Caribbean. CS has risen in all regions since 1990. Subregions with the greatest increases were Eastern Asia, Western Asia and Northern Africa (44.9, 34.7 and 31.5 percentage point increase, respectively) while sub-Saharan Africa and Northern America (3.6 and 9.5 percentage point increase, respectively) had the lowest rise. Projections showed that by 2030, 28.5% of women worldwide will give birth by CS (38 million caesareans of which 33.5 million in LMIC annually) ranging from 7.1% in sub-Saharan Africa to 63.4% in Eastern Asia. Conclusion The use of CS has steadily increased worldwide and will continue increasing over the current decade where both unmet need and overuse are expected to coexist. In the absence of global effective interventions to revert the trend, Southern Asia and sub-Saharan Africa will face a complex scenario with morbidity and mortality associated with the unmet need, the unsafe provision of CS and with the concomitant overuse of the surgical procedure which drains resources and adds avoidable morbidity and mortality. If the Sustainable Development Goals are to be achieved, comprehensively addressing the CS issue is a global priority.
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Affiliation(s)
- Ana Pilar Betran
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneve, Switzerland
| | - Jiangfeng Ye
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ann-Beth Moller
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneve, Switzerland
| | - João Paulo Souza
- Department of Social Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - Jun Zhang
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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20
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Austad K, Juarez M, Shryer H, Hibberd PL, Drainoni ML, Rohloff P, Chary A. Improving the experience of facility-based delivery for vulnerable women through obstetric care navigation: a qualitative evaluation. BMC Pregnancy Childbirth 2021; 21:425. [PMID: 34116648 PMCID: PMC8193958 DOI: 10.1186/s12884-021-03842-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 04/30/2021] [Indexed: 11/14/2022] Open
Abstract
Background Global disparities in maternal mortality could be reduced by universal facility delivery. Yet, deficiencies in the quality of care prevent some mothers from seeking facility-based obstetric care. Obstetric care navigators (OCNs) are a new form of lay health workers that combine elements of continuous labor support and care navigation to promote obstetric referrals. Here we report qualitative results from the pilot OCN project implemented in Indigenous villages in the Guatemalan central highlands. Methods We conducted semi-structured interviews with 17 mothers who received OCN accompaniment and 13 staff—namely physicians, nurses, and social workers—of the main public hospital in the pilot’s catchment area (Chimaltenango). Interviews queried OCN’s impact on patient and hospital staff experience and understanding of intended OCN roles. Audiorecorded interviews were transcribed, coded, and underwent content analysis. Results Maternal fear of surgical intervention, disrespectful and abusive treatment, and linguistic barriers were principal deterrents of care seeking. Physicians and nurses reported cultural barriers, opposition from family, and inadequate hospital resources as challenges to providing care to Indigenous mothers. Patient and hospital staff identified four valuable services offered by OCNs: emotional support, patient advocacy, facilitation of patient-provider communication, and care coordination. While patients and most physicians felt that OCNs had an overwhelmingly positive impact, nurses felt their effort would be better directed toward traditional nursing tasks. Conclusions Many barriers to maternity care exist for Indigenous mothers in Guatemala. OCNs can improve mothers’ experiences in public hospitals and reduce limitations faced by providers. However, broader buy-in from hospital staff—especially nurses—appears critical to program success. Future research should focus on measuring the impact of obstetric care navigation on key clinical outcomes (cesarean delivery) and mothers’ future care seeking behavior. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03842-1.
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Affiliation(s)
- Kirsten Austad
- Wuqu' Kawoq
- Maya Health Alliance, 2da Avenida 3-48 Zona 3, Barrio Patacabaj, Tecpán, Chimaltenango, Guatemala. .,Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, 850 Harrison Avenue, Dowling 5, Boston, MA, 02118, USA.
| | - Michel Juarez
- Wuqu' Kawoq
- Maya Health Alliance, 2da Avenida 3-48 Zona 3, Barrio Patacabaj, Tecpán, Chimaltenango, Guatemala
| | - Hannah Shryer
- Wuqu' Kawoq
- Maya Health Alliance, 2da Avenida 3-48 Zona 3, Barrio Patacabaj, Tecpán, Chimaltenango, Guatemala
| | - Patricia L Hibberd
- Department of Global Health, Boston University School of Public Health, 715 Albany Street, Boston, MA, 02118, USA
| | - Mari-Lynn Drainoni
- Section of Infectious Disease, Department of Medicine, Boston University School of Medicine, 801 Massachusetts Avenue, Boston, MA, 02118, USA.,Department of Health Law Policy & Management, Boston University School of Public Health, Boston, USA.,Evans Center for Implementation and Improvement Sciences, Department of Medicine, Boston University School of Medicine, Boston, USA
| | - Peter Rohloff
- Wuqu' Kawoq
- Maya Health Alliance, 2da Avenida 3-48 Zona 3, Barrio Patacabaj, Tecpán, Chimaltenango, Guatemala.,Division of Global Health Equity, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Anita Chary
- Wuqu' Kawoq
- Maya Health Alliance, 2da Avenida 3-48 Zona 3, Barrio Patacabaj, Tecpán, Chimaltenango, Guatemala.,Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
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Colomar M, Opiyo N, Kingdon C, Long Q, Nion S, Bohren MA, Betran AP. Do women prefer caesarean sections? A qualitative evidence synthesis of their views and experiences. PLoS One 2021; 16:e0251072. [PMID: 33951101 PMCID: PMC8099111 DOI: 10.1371/journal.pone.0251072] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 04/19/2021] [Indexed: 11/19/2022] Open
Abstract
Background Caesarean sections (CS) continue to increase worldwide. Multiple and complex factors are contributing to the increase, including non-clinical factors related to individual women, families and their interactions with health providers. This global qualitative evidence synthesis explores women’s preferences for mode of birth and factors underlying preferences for CS. Methods Systematic database searches (MEDLINE, EMBASE, CINAHL, PsycINFO) were conducted in December 2016 and updated in May 2019 and February 2021. Studies conducted across all resource settings were eligible for inclusion, except those from China and Taiwan which have been reported in a companion publication. Phenomena of interest were opinions, views and perspectives of women regarding preferences for mode of birth, attributes of CS, societal and cultural beliefs about modes of birth, and right to choose mode of birth. Thematic synthesis of data was conducted. Confidence in findings was assessed using GRADE-CERQual. Results We included 52 studies, from 28 countries, encompassing the views and perspectives of pregnant women, non-pregnant women, women with previous CS, postpartum women, and women’s partners. Most of the studies were conducted in high-income countries and published between 2011 and 2021. Factors underlying women preferences for CS had to do mainly with strong fear of pain and injuries to the mother and child during labour or birth (High confidence), uncertainty regarding vaginal birth (High confidence), and positive views or perceived advantages of CS (High confidence). Women who preferred CS expressed resoluteness about it, but there were also many women who had a clear preference for vaginal birth and those who even developed strategies to keep their birth plans in environments that were not supportive of vaginal births (High confidence). The findings also identified that social, cultural and personal factors as well as attributes related to health systems impact on the reasons underlying women preferences for various modes of birth (High confidence). Conclusions A wide variety of factors underlie women’s preferences for CS in the absence of medical indications. Major factors contributing to perceptions of CS as preferable include fear of pain, uncertainty with vaginal birth and positive views on CS. Interventions need to address these factors to reduce unnecessary CS.
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Affiliation(s)
- Mercedes Colomar
- Montevideo Clinical and Epidemiological Research Unit, Montevideo, Uruguay
- * E-mail:
| | - Newton Opiyo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Carol Kingdon
- School of Community Health and Midwifery, University of Central Lancashire, Preston, United Kingdom
| | - Qian Long
- Global Health Research Center, Duke Kunshan University, Kunshan, Jiangsu Province, China
| | - Soledad Nion
- Faculty of Social Sciences, Sociology Department, Universidad de la República (UdelaR), Montevideo, Uruguay
| | - Meghan A. Bohren
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
- Gender and Women’s Health Unit, Centre for Health Equity, School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Ana Pilar Betran
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Doraiswamy S, Billah SM, Karim F, Siraj MS, Buckingham A, Kingdon C. Physician-patient communication in decision-making about Caesarean sections in eight district hospitals in Bangladesh: a mixed-method study. Reprod Health 2021; 18:34. [PMID: 33563303 PMCID: PMC7871368 DOI: 10.1186/s12978-021-01098-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 01/31/2021] [Indexed: 11/10/2022] Open
Abstract
Background Caesarean sections (CS) in Bangladesh have risen eight-fold in the last 15 years. Few studies have explored why. Anecdotally, physicians suggest maternal request for CS is a reason. Women and families suggest physicians influence their decision-making. The aim of this research was to understand more about the decision-making process surrounding CS by exploring physician–patient communication leading to informed-consent for the operation. Methods We conducted a mixed-method study using structured observations with the Option Grid Collaborative’s OPTION5 tool and interviews with physicians and women between July and December 2018. Study participants were recruited from eight district public-sector hospitals. Eligibility criteria for facilities was ≥ 80 births every month; and for physicians, was that they had performed CSs. Women aged ≥ 18 years, providing consent, and delivering at a facility were included in the observation component; primigravid women delivering by CS were selected for the in-depth interviews. Quantitative data from observations were analysed using descriptive statistics. Following transcription and translation, a preliminary coding framework was devised for the qualitative data analysis. We combined both inductive and deductive approaches in our thematic analysis. Results In total, 306 labour situations were observed, and interviews were conducted with 16 physicians and 32 women who delivered by CS (16 emergency CS; 16 elective CS). In 92.5% of observations of physician–patient communication in the context of labour situations, the OPTION5 mean scores were low (5–25 out of 100) for presenting options, patient partnership, describing pros/cons, eliciting patient preferences and integrating patient preferences. Interviews found that non-clinical factors prime both physicians and patients in favour of CS prior to the clinical encounter in which the decision to perform a CS is documented. These interactions were both minimal in content and limited in purpose, with consent being an artefact of a process involving little communication. Conclusions Insufficient communication between physicians and patients is one of many factors driving increasing rates of caesarean section in Bangladesh. While this single clinical encounter provides an opportunity for practice improvement, interventions are unlikley to impact rates of CS without simultaneoulsy addressing physician, patient and health system contextual factors too.
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Affiliation(s)
| | - Sk Masum Billah
- Maternal and Child Health Division, icddr,b, Dhaka, Bangladesh.,Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Camperdown, NSW, Australia
| | - Farhana Karim
- Maternal and Child Health Division, icddr,b, Dhaka, Bangladesh
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Abstract
A Caesarean section can be a life-saving intervention in case of pregnancy complications or difficult labour. The prevalence of Caesarean section continues to increase, especially in sub-Saharan Africa, yet the reasons for this remain largely unexplored. This study investigated risk factors contributing to the decision to perform Caesarean sections in Ghana using data from 8645 women aged 15-49 years from the 2017 Ghana Maternal Health Survey. The data were analysed by applying complementary log-log and logit models. The majority of Ghanaian women (about 87%) reported preferring vaginal delivery to Caesarean section. Of those who had undergone a Caesarean section for their most recent birth, about 55% had an elective rather than an emergency section. Women with labour complications (prolonged/obstructed labour) were significantly more likely to have a Caesarean section (OR=4.09, 95% CI=3.10-5.41). Furthermore, women with maternal complications, particularly prolonged/obstructed labour, were less likely to have an elective Caesarean section than those who had no such complications (OR=0.25, 95% CI=0.14-0.46). Compared with poorer women, wealthy women were significantly more likely to have an elective Caesarean section (OR=1.84, 95% CI=1.08-3.14). The findings suggest that beyond maternal complications, women's socioeconomic and demographic characteristics are important risk factors for undergoing a Caesarean section in Ghana.
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24
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Sk R. Does delivery in private hospitals contribute largely to Caesarean Section births? A path analysis using generalised structural equation modelling. PLoS One 2020; 15:e0239649. [PMID: 33031397 PMCID: PMC7544137 DOI: 10.1371/journal.pone.0239649] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 09/11/2020] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND The rate of Caesarean Section (CS) deliveries has shown an alarming rise in recent years. CS is a surgical procedure used when there is apprehension of risk to the life of mother or baby in case of vaginal delivery, but its rates higher than 10-15 per cent are not justifiable. It is well recognised that a CS delivery could have a large number of adverse impacts on women and infants. Several studies, especially in developing countries, have revealed that delivery in private hospitals is one of the most contributing factors in CS deliveries. The present study conceptualises a causal pathway in which the possible risk factors, socio-economic, maternal and pregnancy-related, as well as institutional, influence the chances of CS delivery. It is hypothesised that certain factors would contribute to CS deliveries largely indirectly through the place of delivery, that is, either a public or private institution. METHODS AND FINDINGS To test the hypotheses, this study analysed 146,280 most recent live births delivered in hospitals during the five years preceding the fourth round of India's National Family Health Survey (NFHS-4), carried out during 2015-2016. The analysis, using generalised structural equation modelling (GSEM), revealed that many exogenous variables considered in the path models influence CS deliveries significantly, directly and/or indirectly through the place of delivery factor. Prominent among these are wealth index and receiving ANC services at only private hospitals; the total effects of these variables are even higher than the direct/total effect of place of delivery. CONCLUSION From this finding, it could be said that the place of delivery is a proximate determinant of a CS delivery or a mediator of other co-factors. Interventions to curb higher CS deliveries should be focused on improving the quality of public health sectors and on developing protocols for CS deliveries.
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Affiliation(s)
- Rayhan Sk
- Centre for the Study of Regional Development, School of Social Sciences, Jawaharlal Nehru University, New Delhi, India
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25
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Vink MDH, de Bekker PJGM, Koolman X, van Tulder MW, de Vries R, Mol BWJ, van der Hijden EJE. Design characteristics of studies on medical practice variation of caesarean section rates: a scoping review. BMC Pregnancy Childbirth 2020; 20:478. [PMID: 32819308 PMCID: PMC7441547 DOI: 10.1186/s12884-020-03169-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 08/11/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Medical practice variation in caesarean section rates is the most studied type of practice variation in the field of obstetrics and gynaecology. This has not resulted in increased homogeneity of treatment between geographic areas or healthcare providers. Our study aim was to evaluate whether current study designs on medical practice variation of caesarean section rates were optimized to identify the unwarranted share of practice variation and could contribute to the reduction of unwarranted practice variation by meeting criteria for audit and feedback. METHODS We searched PubMed, Embase, EBSCO/CINAHL and Wiley/Cochrane Library from inception to March 24th, 2020. Studies that compared the rate of caesarean sections between individuals, institutions or geographic areas were included. Study design was assessed on: selection procedure of study population, data source, case-mix correction, patient preference, aggregation level of analysis, maternal and neonatal outcome, and determinants (professional and organizational characteristics). RESULTS A total of 284 studies were included. Most studies (64%) measured the caesarean section rate in the entire study population instead of using a sample (30%). (National) databases were most often used as information source (57%). Case-mix correction was performed in 87 studies (31%). The Robson classification was used in 20% of the studies following its endorsement by the WHO in 2015. The most common levels of aggregation were hospital level (35%) and grouped hospitals (35%) e.g. private versus public. The percentage of studies that assessed the relationship between variation in caesarean section rates and maternal outcome was 9%, neonatal outcome 19%, determinants (professional and organizational characteristics) 21% and patient preference 2%. CONCLUSIONS Study designs of practice variation in caesarean sections varied considerably, raising questions about their appropriateness. Studies focused on measuring practice variation, rather than contributing to the reduction of unwarranted practice variation. Future studies should correct for differences in patient characteristics (case-mix) and patient preference to identify unwarranted practice variation. Practice variation studies could be used for audit and feedback if results are presented at lower levels of aggregation, and appeal to intrinsic motivation of physicians, for example by including the health effects on mother and child.
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Affiliation(s)
- Maarten D H Vink
- Department Health Sciences, Faculty of Science & Talma Institute, Vrije Universiteit, De Boelelaan 1085, 1081 HV, Amsterdam, the Netherlands.
- Department of Obstetrics and Gynaecology, University Medical Center Groningen, Groningen, the Netherlands.
| | - Piet J G M de Bekker
- Department Health Sciences, Faculty of Science & Talma Institute, Vrije Universiteit, De Boelelaan 1085, 1081 HV, Amsterdam, the Netherlands
| | - Xander Koolman
- Department Health Sciences, Faculty of Science & Talma Institute, Vrije Universiteit, De Boelelaan 1085, 1081 HV, Amsterdam, the Netherlands
| | - Maurits W van Tulder
- Department Health Sciences, Faculty of Science & Talma Institute, Vrije Universiteit, De Boelelaan 1085, 1081 HV, Amsterdam, the Netherlands
| | - Ralph de Vries
- Medical Library, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ben Willem J Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Eric J E van der Hijden
- Department Health Sciences, Faculty of Science & Talma Institute, Vrije Universiteit, De Boelelaan 1085, 1081 HV, Amsterdam, the Netherlands
- Zilveren Kruis Health Insurance, Leusden, The Netherlands
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A Quality Improvement Initiative to Increase the Frequency of Vaginal Delivery in Brazilian Hospitals. Obstet Gynecol 2020; 135:415-425. [PMID: 31923054 PMCID: PMC7012340 DOI: 10.1097/aog.0000000000003619] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A quality improvement initiative for low-risk women in Brazilian hospitals was associated with a 62% increase in the frequency of vaginal delivery. OBJECTIVE: To evaluate a quality improvement (QI) initiative designed to increase the frequency of vaginal delivery in Brazilian hospitals. METHODS: Twenty-eight hospitals enrolled in a 20-month (May 2015–December 2016) Breakthrough Series Collaborative that used QI methods to increase implementation of obstetric approaches with potential to increase the frequency of vaginal delivery. All hospitals contributed qualitative data for iterative redesign. Thirteen intervention hospitals with complete data contributed to an analysis of changes in vaginal delivery in a targeted population over time. Hospitals from the São Paulo region (five intervention and eight nonintervention) contributed to a comparator analysis of changes in vaginal delivery for all deliveries over time. INTERVENTION: Most hospitals targeted low-risk pregnancies in primiparous women, delivered by hospital-employed obstetricians or admitted through emergency departments, and some included all pregnant women. The collaborative tested four interventions to increase vaginal delivery: 1) coalition building of stakeholders with the common purpose of ensuring “appropriate delivery,” 2) empowering pregnant women to choose their preferred mode of delivery, 3) implementation of new care models favoring physiologic birth, and 4) improved information systems for continuous learning by health care providers. RESULTS: For 119,378 targeted deliveries (36% of all deliveries) in 13 intervention hospitals, vaginal delivery increased from 21.5% in 2014 to 34.8% in 2016, a relative increase of 1.62 (95% CI 1.27–2.07, P<.001). In the comparator analysis, vaginal delivery for all deliveries in the five São Paulo intervention hospitals increased from 16.1% to 23% (RI 1.43, P<.001) and from 11.0% to 13.0% (relative rate ratio 1.18, P<.001) in the eight nonintervention São Paulo hospitals. The relative increase in vaginal delivery between the São Paulo intervention and nonintervention groups was 1.21 (95% CI 1.05–1.41, P=.01). The rate of maternal adverse events and neonatal intensive care unit admissions for newborns who weighed at least 2,500 g did not differ significantly during the observation period. CONCLUSIONS: Key interventions implemented with QI methods were associated with increased vaginal delivery. This approach may help address the global cesarean delivery epidemic.
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Fernandes LMM, Lansky S, Oliveira BJ, Friche AAL, Bozlak CT, Shaw BA. Changes in perceived knowledge about childbirth among pregnant women participating in the Senses of Birth intervention in Brazil: a cross-sectional study. BMC Pregnancy Childbirth 2020; 20:265. [PMID: 32370737 PMCID: PMC7201865 DOI: 10.1186/s12884-020-02874-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 03/12/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Senses of Birth (SoB) is a health education intervention in Brazil that aims to reduce unnecessary cesareans in the country by providing information on reproductive rights, benefits and risks of childbirth, and use of intrapartum evidence-based practices (EBP) which are recommended by the World Health Organization (WHO) to improve childbirth outcomes and satisfaction. This study evaluates the impact of the SoB on pregnant women's perceived knowledge about normal birth (NB), cesarean, and use of EBP. METHODS 1287 pregnant women answered a structured survey immediately after their visit to the intervention, between March 2015 and March 2016. To estimate the potential impact of the intervention on women's perceived knowledge, and possible associations between sociodemographic characteristics and perceived knowledge, statistical analyses were performed, including paired T-tests, ANOVA, and logistic and linear regressions. RESULTS The mean score (MS) of perceived knowledge after the intervention was higher than the MS before experiencing the intervention for all three knowledge domains: Normal Birth (MS Before = 3.71 x MS After = 4.49), Cesarean (MS Before = 3.54 x MS After = 4.26) and EBPs (MS Before = 3.14 x MS After = 4.14). The results suggest that perceived knowledge increased more for low-income women (B = 0.206; p < 0.001 for EBP), women without private health insurance (OR 2.47, 95% CI: 1.49-4.09 for NB), with private prenatal care (OR 2.42, 95% CI: 1.59-3.66 for NB), experiencing their first pregnancy (OR 1.92, 95% CI: 1.31-2.82 for EBP; OR 1.37, 95% CI: 1.03-1.84 for NB; OR 1.37, 95% CI: 1.03-1.84 for cesarean), and in their first or second trimester (OR 1.64, 95% CI: 1.13-2.39 for EBP; OR 1.48, 95% CI: 1.11-1.97 for NB; OR 1.85, 95% CI: 1.40-2.41 for cesarean). CONCLUSION The study showed that participation in the SoB was associated with an increase in perceived knowledge among Brazilian pregnant women. The intervention gains relevance considering the lack of evidence of the impact of non-clinical interventions to reduce unnecessary cesareans in middle and low-income countries.
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Affiliation(s)
- Luísa M M Fernandes
- Department of Health Policy, Management, and Behavior, School of Public Health, University at Albany, State University of New York, One University Place, Rensselaer, NY, 12144, USA.
| | - Sônia Lansky
- Department of Health, City Hall, Belo Horizonte, Minas Gerais, Brazil
| | - Bernardo J Oliveira
- School of Education, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Amélia A L Friche
- School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Christine T Bozlak
- Department of Health Policy, Management, and Behavior, School of Public Health, University at Albany, State University of New York, One University Place, Rensselaer, NY, 12144, USA
| | - Benjamin A Shaw
- Department of Health Policy, Management, and Behavior, School of Public Health, University at Albany, State University of New York, One University Place, Rensselaer, NY, 12144, USA
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Negrini R, Ferreira RDDS, Albino RS, Daltro CAT. Reducing caesarean rates in a public maternity hospital by implementing a plan of action: a quality improvement report. BMJ Open Qual 2020; 9:e000791. [PMID: 32381595 PMCID: PMC7223294 DOI: 10.1136/bmjoq-2019-000791] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 04/07/2020] [Accepted: 04/12/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Caesarean rates increased in different parts of the world, rising from 20% to 33% in the USA and from 40% to 55% in Brazil between 1996 and 2011; however, there was no reduction in morbimortality rates. Several factors have been suggested as responsible for this increase, such as health judicialisation, fear of the painful process on the patients' part and reduction of medical training in vaginal delivery and labour complications. It is urgent to reverse this process and, therefore, a model of actions was created with the intention of engaging the team in order to reduce caesarean rates in a Brazilian hospital. METHODOLOGY The model was based on the following actions: encouragement of labour analgesia; execution of written reports of any cardiotocographic examination; plan-do-study-act cycles for nursing orientations about the positions that favour pregnant women during labour; creation of a birth induction form; monthly feedback with physicians and nurses on caesarean rates achieved; verification of the caesarean rate by medical staff with individual feedback; daily round of medical coordination for case discussions; disclosure of caesarean rates on hospital posters; and constant dissemination of literature with strategies to reduce caesarean delivery. This plan of action started in January 2016. The mean caesarean section rate in the 31 months preceding the interventions (period A) was then compared with the 31 subsequent months (period B). RESULTS Both periods presented caesarean rates with normal distribution. The mean caesarean rate was 29.24% (range: 38.69%-23.89%, SD 3.24%) vs 25.84% (range: 17.96%-34.97%, SD 3.92%, p<0.05), respectively, for periods A and B. CONCLUSION After the implementation of the plan of action, there was a reduction in caesarean rates in this hospital.
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Affiliation(s)
- Romulo Negrini
- Maternal Fetal Department, Hospital Israelita Albert Einstein, Sao Paulo, São Paulo, Brazil
- Hospital Geral de Itapecerica da Serra, Secretaria da Saúde do Estado de São Paulo, Sao Paulo, São Paulo, Brazil
| | - Raquel Domingues da Silva Ferreira
- Maternal Fetal Department, Hospital Israelita Albert Einstein, Sao Paulo, São Paulo, Brazil
- Hospital Geral de Itapecerica da Serra, Secretaria da Saúde do Estado de São Paulo, Sao Paulo, São Paulo, Brazil
| | - Renata Silva Albino
- Hospital Geral de Itapecerica da Serra, Secretaria da Saúde do Estado de São Paulo, Sao Paulo, São Paulo, Brazil
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Pfeifer E, Lozovatsky M, Abraham J, Kannampallil T. Effect of an Alternative Newborn Naming Strategy on Wrong-Patient Errors: A Quasi-Experimental Study. Appl Clin Inform 2020; 11:235-241. [PMID: 32236916 DOI: 10.1055/s-0040-1705175] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVES Newborns are often assigned temporary names at birth. Temporary newborn names-often a combination of the mother's last name and the newborn's gender-are vulnerable to patient misidentification due to similarities with other newborns or between a mother and her newborn. We developed and implemented an alternative distinct naming strategy, and then compared its effectiveness on reducing the number of wrong-patient orders with the standard distinct naming strategy. METHODS This study was conducted over a 14-month period in the newborn nursery and neonatal intensive care units of three hospitals that were part of the same health care system. We used a quasi-experimental study design using interrupted time series analysis to compare the differences in wrong-patient orders (an indicator of patient misidentification) before and after the implementation of the alternative distinct naming strategy. RESULTS Overall, there were 25 wrong-patient errors per 10,000 orders during entire study period (36.8 per 10,000 before and 19.6 per 10,000 after). However, there was no statistically significant change in the rate of wrong-patient ordering errors after the transition from the distinct to the alternative distinct naming strategy (β = 0.832, 95% confidence interval [CI] = -0.83 to 2.49, p = 0.326). We also found that, overall, 1.7% of the clinicians contributed to 62% of the wrong-patient errors. CONCLUSION Although we did not find statistically significant differences in wrong-patient errors, the alternative distinct naming approach provides pragmatic advantages over its predecessors. In addition, the localization of wrong-patient errors within a small set of clinicians highlights the potential for developing strategies for delivering training to clinicians.
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Affiliation(s)
- Ethan Pfeifer
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri, United States.,Institute for Informatics, Washington University School of Medicine, St Louis, Missouri, United States
| | - Margaret Lozovatsky
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri, United States
| | - Joanna Abraham
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri, United States.,Institute for Informatics, Washington University School of Medicine, St Louis, Missouri, United States
| | - Thomas Kannampallil
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri, United States.,Institute for Informatics, Washington University School of Medicine, St Louis, Missouri, United States
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30
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Kc A, Axelin A, Litorp H, Tinkari BS, Sunny AK, Gurung R. Coverage, associated factors, and impact of companionship during labor: A large-scale observational study in six hospitals in Nepal. Birth 2020; 47:80-88. [PMID: 31765037 DOI: 10.1111/birt.12471] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 10/29/2019] [Accepted: 11/04/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Companionship at the time of birth is a nonclinical intervention that has been proven to improve the quality of intrapartum care. This study aims to evaluate the coverage, associated factors, and impact of companionship during labor at public hospitals in Nepal. METHODS We conducted a cross-sectional observational study in six public hospitals in Nepal. The study was conducted from July 2018 to August 2018. Data were collected on sociodemographic, maternal, obstetric, and neonatal characteristics from patient case notes and through predischarge interviews. Coverage of companionship during labor and its association with intrapartum care was analyzed. Bivariate and multivariate analyses were done to assess the association between companionship during labor and demographic, obstetric, and neonatal characteristics. RESULTS A total of 63 077 women participated in the study with 19% of them having a companion during labor. Women aged 19-24 years had 65% higher odds of having a companion during labor compared with women aged 35 years and older (aOR 1.65 [95% CI, 1.40-1.94]). Women who were from an advantaged ethnic group (Chhetri/Brahmin) had fourfold higher odds of having a companion than women from a disadvantaged group (aOR 3.84; [95% CI, 3.24-4.52]). Women who had companions during labor had fewer unnecessary cesarean births than those who had no companions (5.2% vs 6.8%, P < .001). CONCLUSIONS In Nepal, sociodemographic factors affect women's likelihood of having a companion during labor. As companionship during labor is associated with improved quality of care, health facilities should encourage women's access to birth companions.
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Affiliation(s)
- Ashish Kc
- Department of Women and Children, International Maternal and Child Health, Uppsala University, Uppsala, Sweden.,Society of Public Health Physician's Nepal, Kathmandu, Nepal
| | - Anna Axelin
- Department of Nursing Science, University of Turku, Turku, Finland
| | - Helena Litorp
- Department of Women and Children, International Maternal and Child Health, Uppsala University, Uppsala, Sweden.,Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Bhim Singh Tinkari
- Society of Public Health Physician's Nepal, Kathmandu, Nepal.,Department of Health Services, Ministry of Health and Population, Kathmandu, Nepal
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Zhang L, Zhang L, Li M, Xi J, Zhang X, Meng Z, Wang Y, Li H, Liu X, Ju F, Lu Y, Tang H, Qin X, Ming Y, Huang R, Li G, Dai H, Zhang R, Qin M, Zhu L, Zhang J. A cluster-randomized field trial to reduce cesarean section rates with a multifaceted intervention in Shanghai, China. BMC Med 2020; 18:27. [PMID: 32054535 PMCID: PMC7020498 DOI: 10.1186/s12916-020-1491-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 01/07/2020] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Lulu Zhang
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lin Zhang
- Department of Obstetrics and Gynecology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Meng Li
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Jiao Tong University School of Public Health, Shanghai, China
| | - Jie Xi
- Department of Obstetrics, Jiading District Maternal and Child Health Hospital, Shanghai, China
| | - Xiaohua Zhang
- Department of Maternal Health Care, Minhang District Maternal and Child Health Hospital, Shanghai, China
| | - Zhenni Meng
- Department of Obstetrics, First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ying Wang
- Department of Obstetrics, Songjiang District Maternal and Child Health Hospital, Shanghai, China
| | - Huaping Li
- Department of Obstetrics and Gynecology, Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaohua Liu
- Department of Obstetrics, First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Obstetrics, China Welfare Association International Peace Maternal and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Feihua Ju
- Department of Obstetrics and Gynecology, Pudong New District Maternal and Child Health Hospital, Shanghai, China
| | - Yuping Lu
- Department of Obstetrics and Gynecology, Pudong New Area People's Hospital, Shanghai, China
| | - Huijun Tang
- Department of Obstetrics, Putuo District Maternal and Child Health Hospital, Shanghai, China
| | - Xianju Qin
- Department of General Surgery, Eighth People's Hospital, Shanghai, China
| | - Yanhong Ming
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Rong Huang
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guohong Li
- Shanghai Jiao Tong University School of Public Health, Shanghai, China.,Center for HTA, China Hospital Development Institute, Shanghai Jiao Tong University, Shanghai, China
| | - Hongying Dai
- Nursing College, Shanghai University of Medicine & Health Sciences, Shanghai, China
| | - Rong Zhang
- Shanghai Maternal and Child Health Center, Shanghai, China
| | - Min Qin
- Shanghai Maternal and Child Health Center, Shanghai, China.
| | - Liping Zhu
- Shanghai Maternal and Child Health Center, Shanghai, China.
| | - Jun Zhang
- Ministry of Education-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Opiyo N, Kingdon C, Oladapo OT, Souza JP, Vogel JP, Bonet M, Bucagu M, Portela A, McConville F, Downe S, Gülmezoglu AM, Betrán AP. Non-clinical interventions to reduce unnecessary caesarean sections: WHO recommendations. Bull World Health Organ 2019; 98:66-68. [PMID: 31902964 PMCID: PMC6933434 DOI: 10.2471/blt.19.236729] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/22/2019] [Accepted: 08/23/2019] [Indexed: 11/30/2022] Open
Affiliation(s)
- Newton Opiyo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Carol Kingdon
- School of Community Health and Midwifery, University of Central Lancashire, Preston, England
| | - Olufemi T Oladapo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland
| | - João Paulo Souza
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Joshua P Vogel
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Mercedes Bonet
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Maurice Bucagu
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Anayda Portela
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Frances McConville
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Soo Downe
- School of Community Health and Midwifery, University of Central Lancashire, Preston, England
| | - Ahmet Metin Gülmezoglu
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Ana Pilar Betrán
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland
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Bohren MA, Opiyo N, Kingdon C, Downe S, Betrán AP. Optimising the use of caesarean section: a generic formative research protocol for implementation preparation. Reprod Health 2019; 16:170. [PMID: 31744493 PMCID: PMC6862737 DOI: 10.1186/s12978-019-0827-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 10/18/2019] [Indexed: 01/21/2023] Open
Abstract
Background Caesarean section rates are rising across all geographical regions. Very high rates for some groups of women co-occur with very low rates for others. Both extremes are associated with short and longer term harms. This is a major public health concern. Making the most effective use of caesarean section is a critical component of good quality, sustainable maternity care. In 2018, the World Health Organization published evidence-based recommendations on non-clinical interventions to reduce unnecessary caesarean section. The guideline identified critical research gaps and called for formative research to be conducted ahead of any interventional research to define locally relevant determinants of caesarean birth and factors that may affect implementation of multifaceted optimisation strategies. This generic formative research protocol is designed as a guide for contextual assessment and understanding for anyone planning to take action to optimise the use of caesarean section. Methods This formative protocol has three main components: (1) document review; (2) readiness assessment; and (3) primary qualitative research with women, healthcare providers and administrators. The document review and readiness assessment include tools for local mapping of policies, protocols, practices and organisation of care to describe and assess the service context ahead of implementation. The qualitative research is organized according to twelve identified interventions that may optimise use of caesarean section. Each intervention is designed as a “module” and includes a description of the intervention, supporting evidence, theory of change, and in-depth interview/focus group discussion guides. All study instruments are included in this protocol. Discussion This generic protocol is designed to underpin the formative stage of implementation research relating to optimal use of caesarean section. We encourage researchers, policy-makers and ministries of health to adapt and adopt this design to their context, and share their findings as a catalyst for rapid uptake of what works.
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Affiliation(s)
- Meghan A Bohren
- Gender and Women's Health Unit, Centre for Health Equity, University of Melbourne School of Population and Global Health, 207 Bouverie St, Carlton, VIC, Australia. .,UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, 20 Avenue Appia, Genève, Switzerland.
| | - Newton Opiyo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, 20 Avenue Appia, Genève, Switzerland
| | - Carol Kingdon
- School of Community Health and Midwifery, Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - Soo Downe
- School of Community Health and Midwifery, Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - Ana Pilar Betrán
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, 20 Avenue Appia, Genève, Switzerland
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34
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Elnakib S, Abdel-Tawab N, Orbay D, Hassanein N. Medical and non-medical reasons for cesarean section delivery in Egypt: a hospital-based retrospective study. BMC Pregnancy Childbirth 2019; 19:411. [PMID: 31703638 PMCID: PMC6842224 DOI: 10.1186/s12884-019-2558-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 10/14/2019] [Indexed: 12/17/2022] Open
Abstract
Background Caesarean section (CS) is an important lifesaving intervention that can reduce maternal and newborn morbidity and mortality. The dramatic increase in CS rates globally has prompted concerns that the procedure may be overused or used for inappropriate indications. In Egypt, CS rates are alarmingly high, accounting for 52% of all deliveries. This study sought to (1) explore indications and risk factors for CS in public hospitals in four governorates in Egypt and (2) examine health care provider factors impacting the decision to perform a CS. Methods We reviewed medical records for all deliveries that took place during April 2016 in 13 public hospitals situated in four governorates in Egypt (Cairo, Alexandria, Assiut and Behera), and extracted information pertaining to medical indications and women’s obstetric characteristics. We also interviewed obstetricians in the study hospitals to explore factors associated with the decision to perform CS. Results A total of 4357 deliveries took place in the study hospitals during that period. The most common medical indications were previous CS (50%), an “other” category (13%), and fetal distress (9%). Multilevel analysis revealed that several obstetric risk factors were associated with increased odds of CS mode of delivery – including previous CS, older maternal age, and nulliparity – while factors such as partograph completion and oxytocin use were associated with reduced odds of CS. Interviews with obstetricians highlighted non-medical factors implicated in the high CS rates, including a convenience incentive, lack of supervision and training in public hospitals, as well as absence of or lack of familiarity with clinical guidelines. Conclusion A combination of both medical and non-medical factors drives the increase in CS rates. Our analysis however suggests that a substantial number of CS deliveries took place in the absence of strong medical justification. Health care provider factors seem to be powerful factors influencing CS rates in the study hospitals.
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Affiliation(s)
- Shatha Elnakib
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
| | | | | | - Nevine Hassanein
- Independent Consultant, Reproductive Health Consultant, Cairo, Egypt
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35
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The effectiveness of financial intervention strategies for reducing caesarean section rates: a systematic review. BMC Public Health 2019; 19:1080. [PMID: 31399068 PMCID: PMC6688325 DOI: 10.1186/s12889-019-7265-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 06/30/2019] [Indexed: 01/08/2023] Open
Abstract
Background The increasing trend of Caesarean section (CS) in childbirth has become a global public health challenge. Previous studies have proposed financial intervention strategies for reducing CS rates by limiting caesarean delivery on maternal request (CDMR). This study synthesizes such strategies while evaluating their effectiveness. Methods The sources of data for this study are Cochrane Library, PubMed, EMBASE, and CINAHL. The publication period included in this study is from January 1991 to November 2018. The financial intervention strategies are divide into two categories: healthcare provider interventions and patient interventions. Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) was employed to assess the risk of bias of included studies. The outcome of each study was evaluated with Grades of Recommendation, Assessment, Development and Evaluation (GRADE) through the GRADEpro Guideline Development Tool software. Results Nine studies were included in this systematic review: five with high certainty evidence (HCE), three with moderate certainty evidence (MCE), and one with low certainty evidence (LCE). Of the nine studies, seven are centered on the effect of provider-side interventions. Three of the HCE studies found that the diagnosis-related group payment system, risk-adjusted capitation, and equalizing fee for both facilities and physicians were effective intervention strategies. One HCE and one MCE study showed that only equalizing facility fees between vaginal and CS deliveries in healthcare service settings had no significant effect on reducing the CS rate. The MCE study showed that case payment had a negative effect on reducing the CS rates. One LCE study revealed that the effect of a global budget system was uncertain, and one HCE and one MCE study focused on combining both provider and patient-side interventions. However, equalizing fees for vaginal and CS deliveries and a co-payment policy for CDMRs failed to reduce the CS rate. Conclusions The effectiveness of risk-adjusted payment methods appears promising and should be the subject of further research. Financial interventions should consider stakeholders’ characteristics, especially the personal interests of doctors. Finally, high-quality randomized control trials and comparative studies on different financial intervention methods are needed to confirm or refute previous studies’ outcomes. Electronic supplementary material The online version of this article (10.1186/s12889-019-7265-4) contains supplementary material, which is available to authorized users.
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36
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Kingdon C, Downe S, Betran AP. Interventions targeted at health professionals to reduce unnecessary caesarean sections: a qualitative evidence synthesis. BMJ Open 2018; 8:e025073. [PMID: 30559163 PMCID: PMC6303601 DOI: 10.1136/bmjopen-2018-025073] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 10/10/2018] [Accepted: 10/15/2018] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To establish the views and experiences of healthcare professionals in relation to interventions targeted at them to reduce unnecessary caesareans. DESIGN Qualitative evidence synthesis. SETTING Studies undertaken in high-income, middle-income and low-income settings. DATA SOURCES Seven databases (CINAHL, MEDLINE, PsychINFO, Embase, Global Index Medicus, POPLINE and African Journals Online). Studies published between 1985 and June 2017, with no language or geographical restrictions. We hand-searched reference lists and key citations using Google Scholar. STUDY SELECTION Qualitative or mixed-method studies reporting health professionals' views. DATA EXTRACTION AND SYNTHESIS Two authors independently assessed study quality prior to extraction of primary data and authors' interpretations. The data were compared and contrasted, then grouped into summary of findings (SoFs) statements, themes and a line of argument synthesis. All SoFs were Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) assessed. RESULTS 17 papers were included, involving 483 health professionals from 17 countries (nine high-income, six middle-income and two low-income). Fourteen SoFs were identified, resulting in three core themes: philosophy of birth (four SoFs); (2) social and cultural context (five SoFs); and (3) negotiation within system (five SoFs). The resulting line of argument suggests three key mechanisms of effect for change or resistance to change: prior beliefs about birth; willingness or not to engage with change, especially where this entailed potential loss of income or status (including medicolegal barriers); and capacity or not to influence local community and healthcare service norms and values relating to caesarean provision. CONCLUSION For maternity care health professionals, there is a synergistic relationship between their underpinning philosophy of birth, the social and cultural context they are working within and the extent to which they were prepared to negotiate within health system resources to reduce caesarean rates. These findings identify potential mechanisms of effect that could improve the design and efficacy of change programmes to reduce unnecessary caesareans. PROSPERO REGISTRATION NUMBER CRD42017059455.
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Affiliation(s)
- Carol Kingdon
- School of Community Health and Midwifery, Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - Soo Downe
- School of Community Health and Midwifery, Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - Ana Pilar Betran
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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37
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Betrán AP, Temmerman M, Kingdon C, Mohiddin A, Opiyo N, Torloni MR, Zhang J, Musana O, Wanyonyi SZ, Gülmezoglu AM, Downe S. Interventions to reduce unnecessary caesarean sections in healthy women and babies. Lancet 2018; 392:1358-1368. [PMID: 30322586 DOI: 10.1016/s0140-6736(18)31927-5] [Citation(s) in RCA: 303] [Impact Index Per Article: 50.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 08/06/2018] [Accepted: 08/09/2018] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Ana Pilar Betrán
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
| | - Marleen Temmerman
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya; Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Carol Kingdon
- School of Community Health and Midwifery, Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - Abdu Mohiddin
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya
| | - Newton Opiyo
- Review Production and Quality Unit, Cochrane, London, UK
| | - Maria Regina Torloni
- Postgraduate Program on Evidence-Based Healthcare, São Paulo Federal University, São Paulo, Brazil
| | - Jun Zhang
- MOE-Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Othiniel Musana
- Uganda Martyrs University, St Francis Hospital Nsambya, Kampala, Uganda
| | - Sikolia Z Wanyonyi
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya
| | - Ahmet Metin Gülmezoglu
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Soo Downe
- School of Community Health and Midwifery, Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
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