Abstract
BackgroundIn Burkina Faso, facility-based caesarean delivery rates have markedly increased since the national subsidy policy for deliveries and emergency obstetric care was implemented in 2006. Effective and safe strategies are needed to prevent unnecessary caesarean deliveries.MethodsWe conducted a cluster-randomized controlled trial of a multifaceted intervention at 22 referral hospitals in Burkina Faso. The evidence-based intervention was designed to promote the use of clinical algorithms for caesarean decision-making using in-site training, audits and feedback of caesarean indications and SMS reminders. The primary outcome was the change in the percentage of unnecessary caesarean deliveries. Unnecessary caesareans were defined on the basis of the literature review and expert consensus. Data were collected daily using a standardized questionnaire, in the same way at both the intervention and control hospitals. Caesareans were classified as necessary or unnecessary in the same way, in both arms of the trial using a standardized computer algorithm.ResultsA total of 2138 and 2036 women who delivered by caesarean section were analysed in the pre and post-intervention periods, respectively. A significant reduction in the percentage of unnecessary caesarean deliveries was evident from the pre- to post-intervention period in the intervention group compared with the control group (18.96 to 6.56% and 18.27 to 23.30% in the intervention and control groups, respectively; odds ratio [OR] for incremental change over time, adjusted for hospital and patient characteristics, 0.22; 95% confidence interval [CI], 0.14 to 0.34; P < 0.001; adjusted risk difference, − 17.02%; 95% CI, − 19.20 to − 13.20%).The intervention did not significantly affect the rate of maternal death (0.75 to 0.19% and 0.92 to 0.40% in the intervention and control groups, respectively; adjusted OR 0.32; 95% CI 0.04 to 2.23; P = 0.253) or intrapartum-related neonatal death (4.95 to 6.32% and 5.80 to 4.29% in the intervention and control groups, respectively, adjusted OR 1.73; 95% CI 0.82 to 3.66; P = 0.149). The overall perinatal mortality data were not available.ConclusionPromotion and training on clinical algorithms for decision-making, audit and feedback and SMS reminders reduced unnecessary caesarean deliveries, compared with usual care in a low-resource setting.Trial registrationThe DECIDE trial is registered on the Current Controlled Trials website: ISRCTN48510263.
Highlights
Despite long-standing international concern and debate, the number of births by caesarean section continues to increase worldwide [1, 2]
Cost was an important barrier to accessing caesarean sections prior to the fee subsidy policy, and addressing this barrier is necessary to ensure women who need a caesarean receive one; there are concerns that such policies may increase unnecessary caesareans [9]
We included public hospitals with a functioning operating room, at least 200 caesarean sections performed in the year before the initiation of the study, no previously implemented audits of caesarean indications, and signed consent forms from the director of the hospital and the head of the maternity ward to participate
Summary
Despite long-standing international concern and debate, the number of births by caesarean section continues to increase worldwide [1, 2]. The increase in the use of caesarean section is not limited to high-resource settings but affects low-income countries and their public hospitals [3]. In these settings, the increased use is likely to contribute to the worsening of maternal and perinatal outcomes [4, 5]. In some tertiary hospitals in Burkina Faso, the caesarean delivery rate may rise up to 40% with unclear medical justification [7]. In this country, user fees for caesarean delivery were reduced by 80% since 2006 in all public hospitals [8], and totally eliminated in April 2016. Effective and safe strategies are needed to prevent unnecessary caesarean deliveries
Sign-in/Register to view highlights & summary Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
