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Do non-clinical interventions reduce unnecessary caesarean section rates?

There has been an increase in caesarean section rates globally. As much as caesarean sections might be life saving, some are unnecessary, they predispose the mother to potential harms, such as haemorrhage, and they have high costs. Non clinical interventions may reduce unnecessary caesarean section. This includes interventions such as providing education to health pro-fessionals and mothers, mandatory second opinions, financial in-terventions, and other guideline implementation strategies.

 

Key messages

 

  • Interventions that may reduce unnecessary caesarean sections include: nurse-led relaxation training, birth preparation classes, education of local opinion leaders, and review of each delivery that does not meet guideline criteria + a 24-hour in house coverage system.
  • A mandatory second opinion and post caesarean section presentation of cases may reduce repeat caesarean section rates.
  • Interventions that may have little or no overall effect on caesarean section rates include: a prenatal education support programme for vaginal birth after caesarean sections, intensive group therapy for women with fear of childbirth, deci-sion aids, a mandatory second opinion and post caesarean section presentation of cases, audit and feedback, childbirth education classes for primary care nurses, changes in fees for vaginal deliveries or caesarean sections, and mandatory peer review.
  • To the extent that reducing unnecessary caesarean sections is a priority, interventions to achieve this goal should be evaluated in randomised trials or interrupted time series studies and the cost effectiveness of effective interventions should be evaluated.

 

 

There has been an increase in caesarean section rates globally. As much as caesarean sections might be life-saving, some are unnecessary, they predispose the mother to potential harms, such as haemorrhage, and they have high costs. Non-clinical interventions may reduce unnecessary caesarean section. This includes interventions such as providing education to health professionals and mothers, mandatory second opinions, financial interventions, and other guideline implementation strategies.

 

Key messages

è Interventions that may reduce unnecessary caesarean sections include: nurse-led relaxation training, birth preparation classes, education of local opinion leaders, and review of each delivery that does not meet guideline criteria + a 24-hour in-house coverage system.

è A mandatory second opinion and post-caesarean section presentation of cases may reduce repeat caesarean section rates.

è Interventions that may have little or no overall effect on caesarean section rates include: a prenatal education support programme for vaginal birth after caesarean sections, intensive group therapy for women with fear of childbirth, decision aids, a mandatory second opinion and post-caesarean section presentation of cases, audit and feedback, childbirth education classes for primary care nurses, changes in fees for vaginal deliveries or caesarean sections, and mandatory peer review.

è To the extent that reducing unnecessary caesarean sections is a priority, interventions to achieve this goal should be evaluated in randomised trials or interrupted time series studies and the cost-effectiveness of effective interventions should be evaluated.


Background

Caesarean section is a medical procedure to reduce complications related to child birth. However, not all caesarean sections are necessary. Unnecessary caesarean sections include those performed in the absence of medical indications such as substantial maternal risk factors, fetal anomalies and pregnancy complications. Non-clinical interventions (those applied independent of a clinical encounter between provider and patient) can be used to reduce unnecessary caesarean sections. These include mandatory second opinion by an obstetrician on caesarean section decisions, health professional education, patient and community education, audit and feedback, clinical practice guidelines, quality improvement strategies, and financial incentives.


About the systematic review underlying this summary

Review objectives: To determine the effectiveness and safety of non-clinical interventions for reducing unnecessary caesarean section rates
Type of What the review authors searched for What the review authors found
Study designs & interventions Randomised trials, quasi experimental studies, non randomised trials, controlled before after studies, and interrupted time series studies that evaluated interventions targeting patients, interventions targeting healthcare providers; financial, organisational and regulatory interventions 16 studies, including cluster randomised trials (5), patient randomised trials (6), and interrupted time series studies (5) targetting patients (6) and healthcare providers (10), of which 2 were financial interventions and 3 were regulatory interventions.
Participants Pregnant women and their families, healthcare providers who work with expectant mothers, communities and advocacy groups Pregnant women (6), physicians/obstetricians (6), public health nurses (1), hospitals or departments (3)
Settings Healthcare settings in low, middle and high-income countries North America (6), Latin America (1), Taiwan (2), Iran (2), UK (1), Nether-lands (1), Australia (1), Finland (2)
Outcomes

Primary outcomes: the rate of caesarean sections and the rate of unnecessary caesarean sections

Other outcomes: maternal, fetal or neonatal complications, cost and financial benefits, patient and provider satisfaction

Caesarean section rates (16 studies) and complications (11 studies)
Date of most recent search: March 2010
Limitations:This is a well-conducted systematic review with only minor limitations, but the last search for studies was conducted in 2010.

Khunpradit S, Tavender E, Lumbiganon P, et al. Non-clinical interventions for reducing unnecessary caesarean section. Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD005528.

Khunpradit S, Tavender E, Lumbiganon P, et al. Non-clinical interventions for reducing unnecessary caesarean section. Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD005528.

Summary of findings

This review found sixteen studies that assessed the effects of interventions to reduce unnecessary caeserean sections. A variety of interventions were used in the sixteen studies. Six studies evaluated interventions targetting patients and ten studies targetted healthcare professionals. Thirteeen of the sixteen studies were from high-income settings and three were from middle-income settings.

 1) Interventions targetting pregnant women to reduce unnecessary caesarean sections

 

  • Nurse-led relaxation training may reduce caesarean section and low birth weight rates. The certainty of this evidence is low.
  • Birth preparation classes may reduce caesarean section rates and the number of women with back or pelvic pain, but may increase the number of women with headache. The certainty of this evidence is low.
  • A prenatal education support programme for vaginal birth after caesarean section, intensive group therapy for women with fear of childbirth, and decision aids may have little or no effect on caesarean section rates. The certainty of this evi-dence is low.

Interventions to reduce unnecessary caesarean sections targeted at pregnant women

People:  Pregnant women
Settings:  Hospitals and community settings in high and middle-income countries
Intervention: Interventions targetting pregnant women
Comparison: Standard care
Outcomes Impact Number of Participants
(studies)
Certainty of the evidence
(GRADE)
Caesarean section and vaginal births after previous caesarean section rates

One small study of a nurse led relaxation training programme for primagravid women in Iran reported a reduction in caesarean section rates (15 per 100 versus 40 per 100, difference = 25 fewer caesarean section per 100 women; 95% CI: 42 to 8 fewer).

 

Another study of birth preparation sessions also reported a reduction in caesarean section rates (3 per 100 versus 10 per 100, difference = 7 fewer caesarean sections per 100 women; 95% CI: 14 to 0 fewer).

 

Studies that evaluated a prenatal education support programme for vaginal birth after caesarean section (1 study), intensive group therapy (1 study), decision aids (2 studies) reported little or no difference in caesarean section rates.

 

6 studies

Low

Maternal and neonatal complications

The study of a nurse led relaxation training programme for primagravid women in Iran reported a reduction in low birth rates (6 per 100 versus 27 per 100, difference = 21 fewer newborns with a low birth weight per 100 births; 95% CI: 35 to 8 fewer), but little or no difference in preterm birth rates or gestational age.

 

The study of birth preparation sessions reported a reduction in maternal back or pelvic pain (46 per 100 versus 66/100 per 100, difference = 20 fewer women with back or pelvic pain per 100 women; 95% CI: 33 to 7 fewer), but an increase in women with headache (12 per 100 versus 3 per 100, difference = 9 more women with headache per 100 women: 95% CI: 2 to 16 more) and little or no difference in other complications.

 

The study that evaluated prenatal education support programme for vaginal birth after caesarean section reported little or no difference in maternal and neonatal complications.

 


3 studies

Low

GRADE: GRADE Working Group grades of evidence (see above and last page)

2) Interventions targetting healthcare professionals to reduce unnecessary caesarean sections

  • Education of local opinion leaders or review of each delivery that does not meet guideline criteria + a 24 hour in house coverage system may reduce caesarean section rates. The certainty of this evidence is low.
  • A mandatory second opinion and post caesarean section presentation of cases may have little or no effect on overall caesarean section rates, but may decrease repeat cae-sarean sections. The certainty of this evidence is low.
  • Audit and feedback or childbirth education classes for primary care nurses may have little or no effect on caesarean section rates. The certainty of this evidence is low.

Interventions to reduce unnecessary caesarean sections targeted at pregnant women

People:  Healthcare providers who work with expectant mothers, communities and advocacy 
Settings:  groups
Intervention: Hospitals and community settings in high and middle-income settings
Comparison: Interventions targetting health professionals standard care 
Outcomes Impact Number of Participants
(studies)
Certainty of the evidence
(GRADE)
Caesarean section and vaginal births after previous caesarean section (VBAC) rates

A study of a mandatory second opinion for emergency caesarean sections reported a small reduction in caesarean section rates (RD = 19 fewer caesarean sections per 1000 women; 95% CI: 38 to 1 fewer).

A 3 arm study of audit and feedback and local opinion leader education reported an increase of 168 more VBACs per 1000 women (95% CI not reported) compared to both audit and feedback and routine care.

A study of a mandatory second opinion and post caesarean section presentation of cases reported little or no change overall in caesarean section rates, but a decrease in repeat caesarean sections (64 fewer repeat caesarean sections per 1000 women after 2 years of follow up (95% CI: 97 to 31 fewer).

A study of implementation of labour management and caesarean delivery guidelines with review of each delivery that did not meet guideline criteria + a 24-hour in house coverage system reported a reduction of 66 caesarean sections per 1000 women after 2 years of follow up (95% CI: 101 to 32).

A study of childbirth education classes for primary care nurses reported a small increase in caesarean section rates (3 more per 100; 95% CI not reported).

 

5 studies

Low

Maternal and neonatal comp

Financial and regulatory interventions

Standard care

 

tions

The reported complication rates were low in all of these studies and there was little or no difference in maternal and perinatal mortality or morbidity. 

 


4 studies

Low

GRADE: GRADE Working Group grades of evidence (see above and last page)

3) Financial and regulatory interventions

 

  • Changes in fees for vaginal deliveries or caesarean sections may have little or no effect on caesarean section rates. The certainty of this evidence is low.
  • Mandatory peer review may have little or no effect on caesarean section rates. The certainty of this evidence is low.

 

Financial and regulatory interventions to reduce unnecessary caesarean sections 

People:  Healthcare providers who work with expectant mothers, communities and advocacy 
Settings:  groups
Intervention: Hospitals and community settings in high-income settings
Comparison: Interventions targetting health professionals standard care 
Outcomes Impact Number of Participants
(studies)
Certainty of the evidence
(GRADE)
Caesarean section and vaginal births after previous caesarean section (VBAC) rates

A study of a small reduction (2%) in fees for caesarean sections reported little or no overall difference in caesarean section rates.

Another study of an increase in fees for vaginal births to that for caesarean sections (90%) also reported little or no overall difference in caesarean section rates.

A state wide peer review programme to reduce caesarean section rates reported little or no overall difference in caesarean section rates.

Another study of mailed peer review in formation also reported little or no differ-ence in caesarean section rates.

A third study of legislation mandating dissemination of caesarean section practice guidelines to obstetric physicians and establishment of peer review boards also reported little or no difference in caesarean section rates.

 

5 studies

Low

Maternal and neonatal complications

The study of mailed peer review information  reported little or no difference in neonatal neurological examination rates.

 


1 study

Low

GRADE: GRADE Working Group grades of evidence (see above and last page)

 

Hospitals and community settings in high-income settings

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY
The included studies were conducted in high (13 studies) and middle-income countries (3 studies). 

Education of local opinion leaders, and review of each delivery that does not meet guideline criteria + a 24 hour in house coverage system might be more difficult to implement and consequently less effective in low income countries.

 

  • Changes in fees might be more effective in low income countries due to differences in economic circumstances.

 

 


EQUITY
No data were reported regarding differential effects for disadvantaged populations. It is uncertain what if any effect interventions to reduce unnecessary caesarean sections might have on inequities. However, given the high cost of caesarean section, to the extent that interventions reduce unnecessary caesarean sections in low income populations, they might reduce inequities.
ECONOMIC CONSIDERATIONS
None of the included studies reported data on costs or cost-effectiveness. Some interventions, such as mandatory second opinions, entail costs that might be more or less than any savings from a reduction in caesarean sections.
MONITORING & EVALUATION
None of the included studies was conducted in a low-income country and the certainty of the evidence was low for all of the interventions evaluated in the included studies.

To the extent that reducing unnecessary caesarean sections is a priority, interventions to achieve this goal should be evaluated in randomised trials or interrupted time series studies and the cost-effectiveness of effective interventions should be evaluated.


*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm

 

Some interventions, such as mandatory second opinions, entail costs that might be more or less than any savings from a reduction in caesarean sections.

Additional information

Related literature

Nair M, Yoshida S, Lambrechts T, et al. Facilitators and barriers to quality of care in maternal, newborn and child health: a global situational analysis through metareview. BMJ Open 2014; 4(5):e004749.

 

Chaillet N, Dumont A. Evidence-based strategies for reducing cesarean section rates: a meta-analysis. Birth 2007; 34:53-64.

 

Walker R, Turnbull D, Wilkinson C. Strategies to address global cesarean section rates: a review of the Evidence. Birth 2002; 29:28–39.

 

Althabe F, Belizan JM, Villar J, et al. Mandatory second opinion to reduce rates of unnecessary caesarean sections in Latin America: a cluster randomised control trial. Lancet 2004; 363:1934–40.

 

Bastani F, Hidarnia A, Montgomery KS, et al. Does relaxation education in anxious primigravid Iranian women in-fluence adverse pregnancy outcomes? A randomised controlled trial. Journal of Perinatal & Neonatal Nursing 2006; 20:138–46.

 

Mehdizadeh A, Roosta F, Chaichian S, Alaghehbandan R. Evaluation of the im-pact of birth preparation courses on the health of the mother and the newborn. American Journal of Perinatology 2005; 22:7–9.

 

This summary was prepared by

Mercy N Mulaku, School of Pharmacy, University of Nairobi, Kenya.

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: Emma Tavender and Clara Bermudez-Tamayo.

 

This review should be cited as

Khunpradit S, Tavender E, Lumbiganon P, et al. Non-clinical interventions for re-ducing unnecessary caesarean section. Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD005528.

 

The summary should be cited as

Mulaku N M. Do non-clinical interventions reduce unnecessary caesarean sec-tions rates? A SUPPORT Summary of a systematic review. December 2016. www.supportsummaries.org

 

Keywords

evidence-informed health policy, evidence-based, systematic review, health sys-tems research, health care, low and middle-income countries, developing coun-tries, primary health care, caesarean section or birth, education, pregnant wom-en, vaginal birth, health care professionals

 

 

 

 



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