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

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

Maternal and perinatal mortality and complications associated with caesarean section in low and middle-income countries: A systematic review of 12 million pregnancies

Background Universal access to caesarean section is a key requirement for safe childbirth. We determined the burden of maternal and perinatal mortality and morbidity, and their risk factors following caesarean sections in low and middle-income countries (LMIC) by a systematic review. Methods We searched electronic databases until November 2017 without language restrictions for observational studies on maternal or perinatal outcomes following caesarean section in LMIC. We used random effects model to synthesise the rate data, and reported the association between risk factors and outcomes using odds ratios (OR) with 95% confidence intervals (CI). Findings We included 196 studies from 67 LMIC. The risk of maternal death in women undergoing caesarean section (116 studies, 2,933,456 caesarean section) was 7·6 per 1000 procedures (95% CI 6.6-8.5, Tau2=0.81); the highest burden was in sub-Saharan Africa (10·9/1000; 95% CI 9·5-12·5, Tau2=0·81). A quarter of all mothers who died in LMIC (72 studies, 27,651 deaths) had undergone caesarean section (23·8%, 95% CI 21·0-26·7). The rates of stillbirths and perinatal deaths in caesarean section births were 56.6 (95% CI 46.1-68.1, Tau2 = 1.33) and 84.7 / 1000 procedures (95% CI 70.5-100.2, Tau2 = 1.61) respectively. The odds of maternal death were increased for caesarean sections performed in the second vs. first stage of labour (OR 12·3; 95% CI 2·9 - 52·5, Tau2=0·0), and for emergency vs. elective caesarean section (OR 2·2; 95% CI 1·1 - 4·1, Tau2=0·91). Maternal mortality did not vary according to the type or experience of the operator. Interpretation: Maternal deaths and perinatal deaths following caesareans sections are disproportionately high in LMIC. The timing and urgency of caesarean section are major risk factors. Funding: Ammalife Charity (Registered UK Charity: 1120236) and ELLY Appeal, Barts Charity (Registered UK Charity: 212563), NIHR UK.Ammalife CharityELLY AppealBarts CharityUK National Institute for Health Research

Socio-demographic factors of cesarean births in Nha Trang city, Vietnam: a community-based survey

Background: The cesarean section rate in Vietnam has been increasing especially in urban area. However, limited evidence identified regarding socio-demographic factors of the cesarean section birth. The objective of this study was to determine the current cesarean birth rate and the associated socio-demographic factors among mothers in Nha Trang city, south-central Vietnam. Methods: A community-based cross-sectional study was conducted between October and November in 2016 as part of a Streptococcus pneumoniae carriage survey conducted in 27 communes of Nha Trang city. From each commune, 120 mothers and their children less than 2 years old were randomly selected. Mothers were asked to answer standardized questions regarding socio-demographic information and mode of birth. Multivariate logistic regression was adopted to examine associations between socio-demographic variables and mode of birth. Results: Of 3148 participants, the number of cesarean births was 1396 (44.3 %). Older maternal age (? 30 years old), having another child going to school or kindergarten, monthly income more than 644 USD, gestational weeks at birth over 42 weeks, and low (< 2500 g) or high (? 3500 g) birth weight were associated with higher likelihood of cesarean births. Conclusion: The CS rate obtained in this study was more than twice of what is recommended by the World Health Organization, which is consistent with the previous nation-wide study in Viet Nam. Further monitoring is suggested to examine the non-medical reason for the increased CS rate