Optimising the use of caesarean section: a generic formative research protocol for implementation preparation

Meghan A Bohren,Newton Opiyo,Soo Downe,Carol Kingdon,Ana Pilar Betrán

doi:10.1186/s12978-019-0827-1

Meghan A Bohren, Newton Opiyo + Show 3 more

Open Access

https://doi.org/10.1186/s12978-019-0827-1

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Abstract

BackgroundCaesarean 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.MethodsThis 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.DiscussionThis 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.

Highlights

Caesarean section rates are rising across all geographical regions
Rapid rises in caesarean section without concurrent decreases in maternal or perinatal morbidity or mortality suggest that a large proportion of caesarean sections are unnecessary
We suggest that all three main groups of participants are included, though specific sub-groups may vary depending on who is most likely to influence the use of caesarean section locally

Summary

Introduction

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. 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. As with all surgical procedures, caesarean section is associated with short and long-term risks for women, children, and future pregnancies, as well as substantial healthcare costs [2,3,4,5]. These risks are higher in settings where women have limited access to comprehensive obstetric and post-surgical care. The global caesarean section rate increased by 12.4% (from 6.7 to 19.1%) from 1990 to 2014 [6]

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