Non-Clinical Interventions to reduce overall cesarean sections
- Implementation of the recommendations
The necessary steps for implementing a guideline are:
1) Analyze local needs and priorities.
2) Identify all potential barriers and facilitating factors.
3) Determine available resources.
4) Design a strategy to support the adoption of the recommendations and to make the overall context favorable to the proposed changes.
Several barriers may constitute a bottleneck for the effective implementation and scale-up of the recommendations in this guideline. These factors may be related to the behaviors of patients (women or families), the behavior of health-care professionals, to the organization of care, health service delivery or to financial arrangements. The barriers were identified from focus group discussion. The barriers include:
1. Maternal request for CS
2. Financial incentives
3. Medicolegal threats in the absence of clear and explicit support and protection
4. Lack of human resources with the necessary expertise and skills to implement, supervise and support recommended practices (e.g. senior clinicians to provide second opinion for cesarean section indication).
5. Lack of health information management systems designed to document and monitor recommended practices (e.g. electronic records, registers).
➡️Monitoring and evaluation
The implementation and the impact of the recommendations will be monitored at the health-service levels based on clearly defined criteria and indicators that are associated with locally agreed targets. The WHO Standards for improving quality of maternal and newborn care in health facilities provide lists of prioritized input, output, and outcome measures, which can be used to define quality-of-care criteria and indicators with locally agreed targets.
Suggested indicators:
1. Overall Cesarean sections
a. Denominator: women with a livebirth.
b. Numerator: women in the denominator who had cesarean sections
2. NTSV Cesarean sections measure
a. Denominator: Nulliparous with a livebirth term singleton in vertex presentation.
b. Numerator: women in the denominator who had cesarean sections
The recommendations included in this guideline will be regularly reviewed and prioritized as needed by the National Steering Group. The W.H.O recommends a minimum of two years and a maximum of five, but it is essential to take into consideration the pace of change of research on the topic.
The National Steering Group will continue to follow the research developments in cesarean section, particularly those relating to questions for which no evidence was found and those that are supported by evidence of very low or low certainty, where new recommendations or a change in the published recommendations may be warranted. Decisions to make updates will also be informed by data on ongoing studies identified from trial registry searches. Following the publication and dissemination of the guideline, any appropriate concern about the validity of any recommendation will be promptly communicated to the guideline implementers in addition to informing plans to update the recommendation.
Where there are concerns about the validity of a recommendation based on new evidence, the systematic review addressing the primary question will be updated. Any new questions identified following the scoping exercise at the end of five years will undergo a similar process of evidence retrieval, synthesis and grading in accordance with the standards for guideline development.
In conjunction with the Steering Group, there will be periodic assessment of the currency of the recommendations and the need for new or updated guidance on the topic. This will be achieved by performing a scoping exercise among technical experts, health-care professionals, and research and service users to identify controversial or priority areas where evidence-based guidance may be needed.
➡️Dissemination
This guideline is available online and as a printed publication. Technical meetings will be held within the national maternity hospitals to share the recommendations and derivative products with the teams responsible for policy and program implementation.
The executive summary and recommendations will be translated into Arabic for mainstream media and the public. A policy brief summarizing the recommendations and implementation-related issues will be developed for policymakers and program managers. To increase awareness of the guideline, the recommendations will also be published in a peer-reviewed journal.
➡️Research implications
The GDG and Steering Group identified areas where further studies are needed based on four broad considerations:
1. uncertainty in the effects of the interventions due to evidence of very low or low certainty.
2. concerns with the applicability of the evidence (particularly as most interventions were assessed in single studies; the interventions would benefit from replication).
3. lack of studies for predefined guideline questions.
4. promising interventions not specifically designed to reduce cesarean births that would benefit from examination in areas with high cesarean section rates (e.g. continuous one-to-one intrapartum support).
Additional research questions were proposed by the GDG during the face-to-face meeting. In particular, the GDG emphasized that future intervention trials should be preceded with formative research to define locally relevant determinants of cesarean births. Prioritized research gaps include:
1) Local evidence namely qualitative assessment of patient's values and preferences and studies of resources utilization: Evidence regarding patient’s values and preferences, utilization of resources involving the interventions, and feasibility is mandatory to elaborate the recommendations. This is crucial to successfully adapt an international document to the local context.
2) Interventions that need rigorous controlled trials include Decision analysis tools, Audit and feedback, Information dissemination, Antenatal education on natural childbirth with training in breathing and relaxation techniques, nurse‐led applied relaxation training program, Psychosocial couple‐based prevention program, childbirth training workshop, Pelvic floor muscle training exercises, laborist model of obstetric care, psychoeducation (face to face or by telephone), education of public health nurses on childbirth classes, Prenatal education for husbands, cognitive behavioral therapy and childbirth psychotherapy, midwife-led continuity model of care, continuous one-to-one intrapartum support, simulation-based obstetrics and neonatal emergency training, physical activity-based interventions.