Reduction In Caesarean Section Rates Research Articles

Reduction in Cesarean Section Rates in Developing Countries

Reduction in Cesarean Section Rates in Developing Countries

The Impact of Continuous Labor Support on Cesarean Section Rates among Nulliparous Women: A Randomized Controlled Trial

Cesarean section (CS) rates are increasing globally, raising concerns about maternal and neonatal morbidity. Continuous labor support (CLS) has been shown to reduce CS rates in some settings, but its impact in Indonesia remains understudied. This study aimed to evaluate the effect of CLS on CS rates among nulliparous women in Purwakarta Regency, Indonesia. A randomized controlled trial was conducted at the Purwakarta Regional Hospital from January 2022 to December 2023. Eligible nulliparous women in labor were randomized to receive either CLS (n=210) from a trained midwife or standard care (n=205). The primary outcome was the rate of CS. Secondary outcomes included duration of labor, use of analgesia, maternal satisfaction, and neonatal outcomes. The CS rate was significantly lower in the CLS group (18.1%) compared to the standard care group (29.3%) (p=0.02). Women in the CLS group also reported higher satisfaction with their birth experience. No significant differences were found in other secondary outcomes. Continuous labor support provided by a trained midwife significantly reduces CS rates among nulliparous women in Purwakarta Regency, Indonesia. Implementing CLS as a routine practice may help address the rising CS rates and improve maternal birth experiences in this setting.

Effect of acidic vaginal pH on the efficacy of dinoprostone (PGE2) vaginal tablet for labor induction in full term pregnant women: a randomized controlled trial.

There is controversial evidence that acidification of vaginal pH may increase the efficacy of vaginal prostaglandins in labor induction, with research being mainly focused on misoprostol. This study aims to evaluate the impact of this intervention on the progress of labor induction with dinoprostone (PGE2) vaginal tablet. This double-blind, parallel-group, randomized study was conducted between October 2021 and December 2022 at Alexandra General Hospital, Athens, Greece. A total of 230 women with singleton, full term pregnancy that were scheduled for labor induction were randomly divided into two groups: Group A, who received acidic vaginal wash (5 % acetic acid) and Group B, who received a normal saline vaginal wash. Afterwards, participants received a vaginal tablet of 3 mg dinoprostone every 6 h (maximum two doses). There were no statistically significant differences in mode of delivery, duration of different labor stages, Bishop score changes and possible complications. Participants in the acidification group needed less often labor augmentation with oxytocin and epidural anesthesia (p=0.03). Vaginal acidification seems to have no effect on the efficacy of the dinoprostone vaginal tablet. Even though it may reduce the need for oxytocin augmentation, there is no apparent benefit on clinical outcomes, such as reduction in cesarean section rates or shorter labor duration. Future research is necessary in order to validate these findings.

Outcomes of the MAMA Training: A Simulation and Experiential Learning Intervention for Labor and Delivery Providers to Improve Respectful Maternity Care for Women Living with HIV in Tanzania.

Respectful maternity care (RMC) for women living with HIV (WLHIV) improves birth outcomes and may influence women's long-term commitment to HIV care. In this study, we evaluated the MAMA training, a team-based simulation training for labor and delivery (L&D) providers to improve RMC and reduce stigma in caring for WLHIV. The study was conducted in six clinical sites in the Kilimanjaro Region of Tanzania. 60 L&D providers participated in the MAMA training, which included a two-and-a-half-day workshop followed by a half-day on-site refresher. We assessed the impact of the MAMA training using a pre-post quasi-experimental design. To assess provider impacts, participants completed assessments at baseline and post-intervention periods, measuring RMC practices, HIV stigma, and self-efficacy to provide care. To evaluate patient impacts, we enrolled birthing women at the study facilities in the pre- (n = 229) and post- (n = 214) intervention periods and assessed self-reported RMC and perceptions of provider HIV stigma. We also collected facility-level data on the proportion of patients who gave birth by cesarean section, disaggregated by HIV status. The intervention had a positive impact on all provider outcomes; providers reported using more RMC practices, lower levels of HIV stigma, and greater self-efficacy to provide care for WLHIV. We did not observe differences in self-reported patient outcomes. In facility-level data, we observed a trend in reduction in cesarean section rates for WLHIV (33.0% vs. 24.1%, p = 0.14). The findings suggest that the MAMA training may improve providers' attitudes and practices in caring for WLHIV giving birth and should be considered for scale-up.

Intravenous fluid rate of 250 mL/h versus 125 mL/h in nulliparous women: A systematic review and meta-analysis of randomized controlled trials.

Evidence regarding the type and rate of intravenous (IV) fluid administration during labor is still inconclusive and the studies assessing the impact of IV fluids had mixed results. To evaluate the effects of IV fluids at an infusion rate of 250 mL/h as compared with 125 mL/h on labor outcomes in nulliparous women. We searched six databases for relevant studies through a search strategy containing the relevant keywords "IV hydration", "IV fluids", and "labor" from the inception of these databases to May 1, 2023, without any applied restrictions. Search results were imported to Covidence for screening of eligible articles for this review. Randomized controlled trials (RCTs) assessing the impact of IV fluids at 250 mL/h on the outcomes of labor in nulliparous women at term (>37 weeks) as compared with 125 mL/h were included only. Data regarding the characteristics of included studies, participant's baseline characteristics, and concerned outcomes were collected in an Excel spreadsheet and all the concerned outcomes were pooled as risk ratios (RR) or mean difference (MD) with 95% confidence interval (CI) in the meta-analysis models using RevMan 5.4. Pooled data from 11 RCTs with 1815 patients showed that 250 mL/h infusion rate had a significant reduction in cesarean section rate (RR 0.70, 95% CI 0.56-0.88, P = 0.002), the first stage of labor duration (MD -46.97, 95% CI -81.79 to -12.14, P = 0.008), the second stage of labor duration (MD -2.69, 95% CI -4.34 to -1.05, P = 0.001), prolonged labor incidence (RR 0.72, 95% CI 0.58-0.89, P = 0.003), as compared with 125 mL/h. Also, the vaginal delivery rate (RR 1.07, 95% CI 1.02-1.12, P = 0.009) was higher with a 250 mL/h infusion rate. IV fluids at an infusion rate of 250 mL/h during labor in nulliparous women decreased the cesarean delivery rate, increased the vaginal delivery rate, shortened the first and second-stage labor duration, decreased the incidence of prolonged labor as compared with 125 mL/h. These findings suggest enhanced labor progression and a lower risk of labor complications with higher infusion rates. However, future research involving a more diverse population and exploring the potential benefits of combining IV infusion rates with other interventions, such as adding dextrose or less restrictive oral intake during labor, is needed.

Reducing primary cesarean delivery rate through implementation of a smart intrapartum surveillance system

The rapid changes in clinical maternity situations that occur in a labor and delivery unit can lead to unpredictable maternal and newborn morbidities. Cesarean section (CS) rate is a key indicator of the accessibility and quality of a labor and delivery unit. This retrospective cross-sectional study assesses the nulliparous, term, singleton, vertex (NTSV) cesarean delivery rates before and after the implementation of a smart intrapartum surveillance system. Research data were collected from the electronic medical records of a labor and delivery unit. The primary outcome was the CS rate of the NTSV population. The data of 3648 women admitted for delivery were analyzed. Of the studied deliveries, 1760 and 1888 occurred during the preimplementation and postimplementation periods, respectively. The CS rate for the NTSV population was 31.0% and 23.3% during the preimplementation and postimplementation periods, respectively, indicating a significant 24.7% (p = 0.014) reduction in CS rate after the implementation of the smart intrapartum surveillance system (relative risk, 0.75; 95% confidence interval, 0.71–0.80). In the NTSV population, the vaginal and CS birth groups, no significant difference in terms of newborn weight, neonatal Apgar scores, composite neonatal adverse outcome indicator, and the occurrence of the following: neonatal intensive care unit admission, neonatal meconium aspiration, chorioamnionitis, shoulder dystocia, perineal laceration, placental abruption, postpartum hemorrhage, maternal blood transfusion, and hysterectomy before and after the implementation of the smart intrapartum surveillance system. This study reveals that the use of the smart intrapartum surveillance system can effectively reduce the primary CS rate for low-risk NTSV pregnancies without significantly affecting perinatal outcomes.

Talking about the Influence of the New Obstetric Nursing Model on the Reduction of Cesarean Section Rate

Talking about the Influence of the New Obstetric Nursing Model on the Reduction of Cesarean Section Rate

The effect of the two-child policy on cesarean section in China: Identification using difference-in-differences techniques

BackgroundChina has one of the highest rates of cesarean section in the world. One of the possible reasons for such high rates was China's one-child policy. Relaxation of the one-child policy might be associated with a reduction in the rate of cesarean section. ObjectivesTo assess the effect of China's universal two-child policy on cesarean section rates using patient-level data from one large municipal-level obstetrics and gynecology hospital in Shanghai, East China. Data sourcesThe study used inpatient hospital records data on all infants delivered between January 1, 2013 and May 31, 2018 at the Shanghai First Maternity and Infant Hospital, which is one of the largest obstetrical hospitals in China. Study designA quantitative study design with difference-in-differences (DID) estimation techniques were used to control for socio-economic and health-related factors in order to identify the impact of the universal two-child policy on cesarean section rates in China. Moreover, DID analysis stratified by maternal migrant status and age were conducted. ResultsAnalysis of 133,358 deliveries suggests that China's universal two-child policy resulted in a statistically significant reduction in cesarean section rates from 49.5 to 43.3 per 100 deliveries over the study period. ConclusionOur findings suggest that the significant reduction in cesarean section rates may be due to a shift in health risk perceptions resulting from the relaxation of the one-child policy when mothers consider the possibility of having a second child. Health education on the risk of repeat cesarean section in pregnant women should be enhanced.

Evaluating the effects of maternal positions in childbirth: An overview of Cochrane Systematic Reviews.

INTRODUCTIONThe purpose of this study is to conduct an overview of Cochrane systematic reviews (SRs) evaluating the effects of maternal positions in childbirth in order to compile existing evidence for relevant research questions that have been addressed by more than one review, to provide a succinct summary of the up-to-date evidence and to identify areas for future research.METHODSAn electronic search was conducted in the Cochrane database. Two primary outcomes were the duration of labor and birth, and operative birth. The quality of included reviews was assessed using the AMSTAR criteria, and the quality of the evidence was rated using the GRADE criteria.RESULTSWe included 3 Cochrane SRs. There was a significant mean difference (MD) found in the duration of the first stage by 1 hour and 22 minutes (MD= -1.21; 95% CI: -2.35 – -0.07, I2=94%) and reduction in caesarean section rates (RR=0.71; 95% CI: 0.54–0.94, I2=0%) in the upright birth position group compared with the horizontal. Also, there was a statistically significant difference in the duration (minutes) of the second stage of labor (MD= -6.16; 95% CI: -9.74 – -2.59, I2=91%) and a reduction in assisted vaginal birth rates (RR=0.75, 95% CI: 0.66–0.86, I2=29%) in the upright group compared with the horizontal without epidural analgesia. The quality of evidence within the reviews was very low to moderate.CONCLUSIONSThere is currently a limited body of evidence to clearly assess the benefits and risks of assuming upright positions during childbirth. The overview highlights the need for high-quality research studies, involving better definition and comprehensive assessment of the effects of squatting during childbirth.

Impact of maternal nationality on caesarean section rate variation in a high-income country.

Background: Caesarean section (CS) rates have been reported to differ between immigrants and native-born women in high-income countries.Objective: We assessed the CS rate and its relationship with the CS rate in country of nationality and other explanatory factors among women of different nationalities including Qatari women who underwent deliveries at our hospital to generate evidence that will quantify and help explain the observed CS rates in our hospital.Methods: In this retrospective cross-sectional study conducted at the second-largest public maternity hospital in Qatar, Al-Wakra Hospital (AWH), data for all births delivered in 2019 were retrieved from the hospital's electronic medical records. The CS rates and the crude and adjusted risks of Caesarean delivery for mothers from each nationality were determined, and the common indications for CS were analyzed based on nationality. The association between nationality and Caesarean delivery was examined using binomial logistic regression analysis, with Qatari women as the reference group. The correlation between CS rate in country of nationality and observed CS rates in Qatar was also examined using Pearson's correlation.Results: The study population consisted of 4816 births by women of 68 nationalities, of which 4513 births were by women from 25 countries. The highest proportion of deliveries (n-1247, 25.9%) was by Indian women. The frequency of CS was the highest and lowest among Egyptian (49.6%) and Yemeni women (17.9%), respectively. Elective CS was predominantly performed in women of Arab nationalities; the most common indication was a history of previous multiple CSs. Emergency CS was primarily performed in women of Asian and Sub-Saharan African nationalities; the most common indications were failure to progress and fetal distress. For most nationalities, the CS rate in Qatar was associated with those of the countries of nationality.Conclusions: The observed CS rates varied widely among women of different nationalities. The variation was influenced by maternal factors and medical indications as well as the CS rates in the country of nationality. We posit that cultural preferences, acculturation, and patient expectations influenced observed findings. More efforts are required to reduce primary CS rates and to help women make the most informed decisions regarding modes of delivery.Key Message: CS rates varied widely among women of different nationalities. The variation was influenced by medical indications, maternal preferences, and CS rate in countries of nationality. The solution to reducing CS rates should be a culturally informed response.

The Project Appropriate Birth and a reduction in caesarean section rates: an analysis using the Robson classification system

The objective of this study was to assess caesarean section (CS) rates before and after the implementation of the Project Appropriate Birth (PPA), based on the Robson ten group classification system. A before-and-after study. Maternity hospital in South Brazil. All pregnant women attending from April 2016 to April 2017 (period 1, pre-implementation of PPA) and from June 2017 to June 2018 (period 2, post-implementation of PPA). Maternal and obstetric characteristics were evaluated, including Robson's classification, based on the characteristics of pregnancy and childbirth. A chi-square test and crude and adjusted relative rates were used to analyse the study variables. The significance level was set at 5%. The CS rate for each group, their contribution to the overall CS rate and the differences in these contributions before and after PPA implementation. The CS rates decreased from 62.4 to 55.6%, which represented a 10.9% reduction after the implementation of the PPA. Pregnant women in Robson classification groups 1-4 had a 21.4% reduction in CS rates, ranging from 49.1 to 38.6%. The greatest contributors to the overall CS rates were group 5 and group 2, accounting for more than 60% of the CS deliveries. The study results suggest that Project Appropriate Birth had an impact on the reduction of CS rates, especially in Robson classification groups 1 through 4, which indicates that providing mothers with evidence-based interventions for labour and childbirth assistance contributed to reduce CS rates. The Project Appropriate Birth is an innovative project that has demonstrated promising results, suggesting that interventions based on scientific evidence can lead to real changes in childbirth care, contributing to reduce CS rates. The aim of the PPA is to promote activities to improve childbirth care and encourage vaginal delivery. In this study, 6238 pregnant women admitted to the hospital for delivery were included and classified into one of the Robson 10-group classification. Findings revealed a 10.9% reduction in the overall CS rate and a 21.4% reduction for pregnant women in Robson classification groups 1 through 4, after the implementation of the PPA.

OPTIMIZING CLINICAL APPROACH TO THE FORM OF DELIVERY DURING PREGNANCY IN PATIENTS WITH CARDIAC DISEASE; A REVIEW OF THE EFFECTS OF PRACTICE CHANGE BY CONCURRING TO INTERNATIONAL GUIDELINES

Objective: To assess if adherence to international guidelines for pregnant cardiac patients’ mode of delivery is achievable with available local resources.
 Study Design: Prospective quasi experimental descriptive study.
 Place and Duration of Study: All Pregnant patients with cardiac disease reporting to Armed Forces Institute of Cardiac Disease/National Institute of Heart Disease (AFIC/NIHD) who were admitted for and were delivered from Oct 2009 to Sep 2011 were included in the study.
 Methodology: International guidelines and recommendations for mode of delivery for cardiac patients with pregnancy were followed for patients. Caesarean sections were reserved only for obstetrical reasons and absolute cardiac indications. The patients with first trimester miscarriage were not included. Data was collected on a personal computer Microsoft excel sheet. Frequency was calculated from the data entered. The reduction in caesarean section rate and increase in vaginal delivery rate as per guidelines without an increase in maternal mortality, was the main outcome.
 Results: Total of 221 patients were delivered in the 2 year period between October 2009 to September 2011 at AFIC/NIHD. The caesarean section rate the year before 2008-2009 had been 48.6%. After the change in practice by concurring to international guidelines, the caesarean section rate for the 2 year period dropped to 26.7%. The hospital maternal deaths were 5. This was slightly better to the year 2008-2009 which had 3 maternal deaths.
 Conclusion: It’s possible to adhere to international recommendations and protocols for pregnant cardiac patients and achieve internationally comparable outcome in terms of mode of delivery without increasing current institutional maternal mortality rate with local hospital resources.

Gestational Risk as a Determining Factor for Cesarean Section according to the Robson Classification Groups.

To analyze and compare the frequency of cesarean sections and vaginal deliveries through the Robson Classification in pregnant women attended at a tertiary hospital in two different periods. Cross-sectional, retrospective study of birth records, comprising 4,010 women, conducted from January 2014 to December 2015 in the only public regional referral hospital for the care of high- risk pregnancies, located in Southern Brazil. The overall cesarean section rate reached 57.5% and the main indication was the existence of a previous uterine cesarean scar. Based on the Robson Classification, groups 5 (26.3%) and 10 (17.4%) were the most frequent ones. In 2015, there was a significant increase in the frequency of groups 1 and 3 (p < 0.001), when compared with the previous year, resulting in an increase in the number of vaginal deliveries (p < 0.0001) and a reduction in cesarean section rates. The Robson Classification proved to be a useful tool to identify the profile of parturients and the groups with the highest risk of cesarean sections in different periods in the same service. Thus, it allows monitoring in a dynamic way the indications and delivery routes and developing actions to reduce cesarean rates according to the characteristics of the pregnant women attended.

Maternal birth trauma: how imaging can (and should) change clinical practice.

Maternal birth trauma: how imaging can (and should) change clinical practice.

Estimated Treatment Effects of Tight Glycaemic Targets in Mild Gestational Diabetes Mellitus: A Multiple Cut-Off Regression Discontinuity Study Design.

Background: We investigated the treatment effects of tight glycaemic targets in a population universally screened according to the International Association of Diabetes and Pregnant Study Groups (IADPSG)/World Health Organisation (WHO) gestational diabetes mellitus (GDM) guidelines. As yet there, have been no randomized control trials evaluating the effectiveness of treatment of mild GDM diagnosed under the IADPSG/WHO diagnostic thresholds. We hypothesize that tight glycaemic control in pregnant women diagnosed with GDM will result in similar clinical outcomes to women just below the diagnostic thresholds. Methods: A multiple cut-off regression discontinuity study design in a retrospective observational cohort undergoing oral glucose tolerance tests (OGTT) (n = 1178). Treatment targets for women with GDM were: fasting capillary blood glucose (CBG) of ≤5.0 mmol/L and the 2-h post-prandial CBG of ≤6.7 mmol/L. Regression discontinuity study designs estimate treatment effects by comparing outcomes between a treated group to a counterfactual group just below the diagnostic thresholds with the assumption that covariates are similar. The counterfactual group was selected based on a composite score based on OGTT plasma glucose categories. Results: Women treated for GDM had lower rates of newborns large for gestational age (LGA), 4.6% versus those just below diagnostic thresholds 12.6%, relative risk 0.37 (95% CI, 0.16–0.85); and reduced caesarean section rates, 32.2% versus 43.0%, relative risk 0.75 (95% CI, 0.56–1.01). This was at the expense of increases in induced deliveries, 61.8% versus 39.3%, relative risk 1.57 (95% CI, 1.18–1.9); notations of neonatal hypoglycaemia, 15.8% versus 5.9%, relative risk 2.66 (95% CI, 1.23–5.73); and high insulin usage 61.1%. The subgroup analysis suggested that treatment of women with GDM with BMI ≥30 kg/m2 drove the reduction in caesarean section rates: 32.9% versus 55.9%, relative risk 0.59 (95%CI, 0.4–0.87). Linear regression interaction term effects between non-GDM and treated GDM were significant for LGA newborns (p = 0.001) and caesarean sections (p = 0.015). Conclusions: Tight glycaemic targets reduced rates of LGA newborns and caesarean sections compared to a counterfactual group just below the diagnostic thresholds albeit at the expense of increased rates of neonatal hypoglycaemia, induced deliveries, and high insulin usage.

Impact of clinical audits on cesarean section rate in a Spanish hospital: Analysis of 6 year data according to the Robson classification

ObjectivesThe aim of this study is to analyze the impact of the introduction of an internal clinical audit on the cesarean section (CS) rate, evaluated according to the Robson Ten Group Classification System (TGCS), and to identify the main contributors to the overall CS rate in order to plan further interventions. Study DesignIn 2014, an internal clinic audit committee was established in our center. Modifications of clinical management protocols were also implemented.A retrospective review of clinical records was conducted and pre-audit (2011−2014) results were compared against audit (2015−2018) results. Patients were clustered according to the Robson TGCS and the analyzed outcomes were CS rate and maternal and neonatal results. ResultsBetween January 2011 and December 2018, 12,766 women gave birth at our institution among which 2,281 CS were analyzed. After the establishment of the clinical audit, the overall CS rate decreased from 20.27% to 14.82 % (p < 0.01). The major contribution to the overall CS rate in both periods were made by Group 2a (nulliparous with a single cephalic pregnancy at term who underwent labor induction: 4.86 % of all cases), followed by Group 5 (patients with a previous C-section: 3.26 %) and Group 1 (nulliparous with a single cephalic pregnancy at term with spontaneous labor: 2.39 %), representing 59.6 % of all CS.The group that showed the greatest reduction to the overall Cs rate was Group 2 (5.77 % vs 3.96 %, OR 1.48 (p < 0.01).No differences in perinatal and maternal results were found between preaudit and audit group. ConclusionAudit, feedback, and modification of clinical management protocols may be effective in changing clinical practice and reducing CS rates without worsening maternal and neonatal morbimortality. Robson TGCS allowed us to identify which groups had the greatest impact on CS rate in order to establish new strategies that may lead us to optimize the use of this intervention. It seems that efforts to reduce the overall CS rate should be directed on increasing vaginal birth after CS and reducing CS rates in nulliparous women with single cephalic full-term pregnancy.

Economic implications of reducing caesarean section rates - Analysis of two health systems.

Caesarean section (CS) rates throughout Europe have risen significantly over the last two decades. As well as being an important clinical issue, these changes in mode of birth may have substantial resource implications. Policy initiatives to curb this rise have had to contend with the multiplier effect of women who had a CS for their first birth having a greater likelihood of requiring one during subsequent births, thus making it difficult to decrease CS rates in the short term. Our study examines the long-term resource implications of reducing CS rates among first-time mothers, as well as improving rates of vaginal birth after caesarean section (VBAC), among an annual cohort of women over the course of their most active childbearing years (18 to 44 years) in two public health systems in Europe. We found that the economic benefit of improvements in these two outcomes is considerable, with the net present value of the savings associated with a five-percentage-point change in nulliparous CS rates and VBAC rates being €1.1million and £9.8million per annual cohort of 18-year-olds in Ireland and England/Wales, respectively. Reductions in CS rates among first-time mothers are associated with a greater payoff than comparable increases in VBAC rates. The net present value of achieving CS rates comparable to those currently observed in the best performing Scandinavian countries was €3.5M and £23.0M per annual cohort in Ireland and England/Wales, respectively.

System Level Barriers in Early Initiation of BreastfeedingFinding from a Cross-sectional Survey in Khagaria District of State Bihar, India

Purpose: Despite 55% children aged 0-6 months being exclusively breastfed in India, 0.26 million children die each year from diarrhoea and pneumonia that can be prevented through early initiation of and exclusive breastfeeding (EIBF). A study was conducted to assess the factors associated with EIBF in 20 villages from the District Khagaria (State Bihar). Method: The cross-sectional study was carried out from Jan-March 2017 with a sample of 288 married women who had delivered in last 1 year. Bivariate and multivariate logistic regression analyses were performed to identify associated factors of EIBF. Results: Analyses show that institutional delivery (aOR: 2.69; CI 1.22 to 5.93; p<0.05) and delivery with normal mode (aOR: 4.61; CI 1.74 to 12.18; p<0.01) were significant contributors of EIBF. Additionally, likelihoods of EIBF were lower when the delivery was performed in a private institution (OR 0.28, CI 0.14 to 0.59; p<0.001) and by a doctor (OR 0.33, CI 0.18 to 0.60; p<0.001). Besides, higher birth order (OR 2.00, CI 0.98 to 4.10; p<0.05) was also found to be significantly associated with EIBF. Conclusion: System level efforts are needed to promote EIBF, along with improved training and reinforcement in doctors for breastfeeding. Reduction in caesarean section rates can positively contribute to EIBF.

Caesarean section trends in Catalonia between 2013 and 2017 based on the Robson classification system: A cross-sectional study.

In Catalonia caesarean rates have always been analysed as a single percentage. The objective is to estimate caesarean section rates using the Robson classification in publicly funded hospitals in Catalonia between 2013 and 2017, considering sociodemographic, institutional and obstetric characteristics. Cross-sectional population-based study in Catalonia including all women delivering within publicly funded hospitals between 2013-2017 (n = 210 020). The modified Robson classification distribution was estimated, the caesarean rate and the overall contribution, analysed for each year, and by confounders, through logistic regression models. CS rates decreased steadily between 2013 and 2017 in Catalonia within publicly funded hospitals from 24.3% to 22.8% (cOR 0.92, 95% CI; 0.89 to 0.95). Once adjusted for changes in sociodemographic, institutional and obstetric characteristics the observed decline was even more pronounced (aOR 0.87, 95% CI; 0.84 to 0.90). Within the different groups of Robson once adjusted for confounders, groups 1+2 (aOR 0.88, 95% CI; 0.83 to 0.93), 3+4 (aOR 0.83, 95% CI; 0.78 to 0.89) and 10 (aOR 0.78, 95% CI; 0.68 to 0.90) presented a reduction in caesarean section rates, whereas group 5 showed no significant decrease (aOR 0.95, 95% CI; 0.87 to 1.03%). The decrease in caesarean section rates in Catalonia is more pronounced when adjusted for known confounders, suggesting retrospective overutilization of caesarean section and percentages of (in)adequacy in the past. In any case, it remains above the recommended by experts. Further efforts should be made to achieve optimum rates, including improvement on obstetric data collection.

Assessment of Strategies for the Reduction of Cesarean Section Rate in Iranian and Foreign Studies: A Narrative Review

Objectives: This study was conducted aiming at exploring strategies for reducing cesarean section (C-section) in Iranian and foreign studies. Materials and Methods: The present study was carried out using a matrix approach and searching keywords including "Cesarean", "Effective Intervention", and "Cesarean Section Reduction Strategy" to find studies (2000-2019) in databases such as PubMed, SID, Science Direct, Google Scholar, and WHO. Results: CS reduction strategies were classified into 3 categories of psychological, clinical, and structural-policy interventions. The first category supports women throughout labor and childbirth by the midwife, doula, coping skills with fear and pain of labor, changes in the attitudes of service providers and pregnant women. Clinical interventions include vaginal birth after CS, vaginal breech delivery, external cephalic version (ECV) for breech presentation, encouragement of service providers into intermittent auscultation for the fetal heart rate instead of continuous electronic fetal monitoring (EFM), and training of service providers, pregnant woman, and her family. The last category encompassed managing insurance and financial services, receiving one-to-one care and midwifery care throughout active labor, and updating policy of labor induction in post-term pregnancy, as well as women’s admission policy with cervical dilatation of more than 4 cm with regular uterine contractions, active team care in labor, and auditing and feedback. Conclusions: It seems that multi-dimensional interventions are required to reduce the CS rate. Concerning some of the strategies (e.g., ECV), it is suggested that further research should be performed by addressing the limitations and drawbacks of previous studies before applying clinical procedures due to contradictory results.