- Acknowledgements

The Egyptian Guideline Development Group gratefully acknowledge the contributions that many individuals and organizations have made to the development of this guideline.

The members of the Steering Group who managed the guideline development process were: Mohamed Hamed Salama, Hamdy Bakry Alqenawy, Asmaa Fahmy Kassem, Yasmeen Nashaat, Essam Eldin Abdelrehim, and Ashraf Fawzy Nabhan. Ashraf Nabhan coordinated the guideline development project and chaired the GDG.

We would also like to thank the following National advisers for their contributions: Mohamed Mourad Youssef.

We would also like to thank External Review Group members who provided valuable comments and suggestions to improve the guideline.

Funding for this guideline: None.

Acronyms and abbreviations

DECIDE	Developing and Evaluating Communication strategies to support Informed Decisions and practice based on Evidence
EtD	Evidence to Decision
GDG	Guideline Development Group
GRADE-ADOLPMENT	GRADE Evidence to Decision frameworks for adoption, adaptation, and de novo development of trustworthy recommendations
GRADE	Grading of Recommendations Assessment, Development and Evaluation
GREAT	Guideline-driven, Research priorities, Evidence synthesis, Application of evidence and Transfer of knowledge
NTSV	Nulliparous women with a term, singleton baby in a vertex position
PICO	Population, Intervention, Comparator, Outcome
WHO	World Health Organization

General scope of the guideline

Title	Non-clinical interventions to reduce cesarean sections
Purpose	to reduce cesarean sections
Perspective	an individual patient, community
Target population	low-risk pregnancy
Key coexisting conditions	prior cesarean section should be considered when making recommendations
Setting	health care level providing labor and delivery services
Types of interventions	Preventive
Key stakeholders and users	obstetricians, nurses, general medical practitioners, managers of maternal and child health programs and public health policy-makers
Key resources to consider	need for adequate human resources, appropriate infrastructure, and supportive system changes (financial, legislative)
Key issues for implementation	Several barriers may hinder the effective implementation and scale-up of the recommendations in this guideline. These factors include behaviors of patients (women or families), the behavior of health-care professionals, to the organization of care, health service delivery or to financial arrangements.
Existing guideline that has been adapted	WHO recommendations non-clinical interventions to reduce unnecessary cesarean sections. Geneva: World Health Organization; 2018.

- Executive summary

➡️Introduction

The number of women who deliver by Cesarean section has increased steadily in Egypt over the last three decades, from 4.6% in 1992 (1) to 51.8% in 2014 (2).

Cesarean birth is associated with short- and long-term risks that can extend many years beyond the current delivery and affect the health of the woman, the child, and future pregnancies. High rates of cesarean section are associated with substantial health-care costs (3).

The factors contributing to the rise in cesarean section rates are complex, and identifying interventions to address them is challenging. Factors associated with cesarean births include changes in the characteristics of the population such as increase in the prevalence of multiple pregnancies, assisted reproduction, and increase in the proportion of nulliparous women with advanced age. Other non-clinical factors such as women increasingly wanting to determine how and when their child is born, generational shifts in work and family responsibilities, physician factors, increasing fear of medical litigation, as well as organizational, economic and social factors have all been implicated in this increase (4).

The sustained, unprecedented rise in cesarean section rates in Egypt is a major public health concern. There is an urgent need for evidence-based guidance to address the trend. This is the national guideline on non-clinical interventions (defined as interventions applied independently of a clinical encounter between a health-care provider and a patient in the context of patient care).

The objective of this guideline is to provide evidence-based recommendations on non-clinical interventions specifically designed to reduce cesarean sections. Clinical interventions that could help to reduce cesarean section rates are being prepared in a second guideline.

➡️Target audience

The primary audience for this guideline includes health-care professionals including obstetricians, midwives, nurses, and general medical practitioners, as well as managers of maternal and child health programs and public health policymakers in Egypt.

➡️Guideline development methods

We used the GRADE-Adolopment methodology for the guideline adaptation process (5). Briefly, this included, identifying and training guideline panelists, prioritizing questions and outcomes, identifying existing guideline (6), assessing quality and adaptability of the identified guideline, reviewing GRADE evidence tables and EtD frameworks, and formulating and grading strength of recommendations.

The identified existing guideline was developed by the WHO in accordance with standard procedures set out in the WHO handbook for guideline development (7). The evidence, in the identified guideline, on the effectiveness of interventions was derived from an updated Cochrane review of 29 studies (8). 

- Recommendations

The recommendations are intended to inform national and subnational policies and protocols to reduce cesarean births. They should be implemented alongside the clinical recommendations for intrapartum care to improve the quality of care for mothers and newborns during childbirth. The recommendations are:

Recommendation 1

Implementation of evidence-based clinical practice guidelines (on-site training, facilitation by a local opinion leader [obstetrician-gynaecologist], supervision) plus audits of indications for cesarean delivery and provision of feedback to healthcare professionals are recommended to reduce overall cesarean sections.

(Recommended, High-certainty evidence).

Recommendation 2

Healthcare professionals’ education by a local opinion leader [obstetrician-gynaecologist] to promote implementation of evidence-based clinical practice guidelines is recommended to reduce repeat cesarean sections.

(Recommended, High-certainty evidence).

Recommendation 3

Implementation of evidence-based clinical practice guidelines combined with structured, mandatory second opinion for cesarean section indication is recommended to reduce cesarean births only with targeted monitoring and evaluation in settings with an on-site senior clinician able to provide mandatory second opinion for cesarean section indication. (Context-specific recommendation, moderate-certainty evidence).

Recommendation 4

For the sole purpose of reducing cesarean sections, peer review plus mandatory second opinion are recommended only in the context of rigorous research.

(Context-specific recommendation, very low-certainty evidence).

Recommendation 5

For the sole purpose of reducing cesarean sections, audit and feedback plus financial incentive for health-care professionals or health-care organizations are recommended only in the context of rigorous research.

(Context-specific recommendation, very low-certainty evidence).

Recommendation 6

For the sole purpose of reducing cesarean sections, audit and feedback using Robson classification is recommended only in the context of rigorous research.

(Context-specific recommendation, very low-certainty evidence).

- Introduction

➡️Background

Significant improvements in clinical obstetric care and increased safety in surgical procedures have been observed over the past three decades. This appears an increase in cesarean sections in Egypt, like a global trend. The number of women who deliver by Cesarean section has increased steadily in Egypt over the last three decades, from 4.6% in 1992 (1) to 51.8% in 2014 (2).

Cesarean birth is associated with short- and long-term risks that can extend many years beyond the current delivery and affect the health of the woman, the child, and future pregnancies. As with any surgery, cesarean section is associated with short- and long-term risks. These can extend many years beyond the current delivery and affect the health of the woman, the child, and future pregnancies. Cesarean section increases the likelihood of requiring a blood transfusion, the risks of anesthesia complications, organ injury, infection, thromboembolic disease, and neonatal respiratory distress, among other short-term complications. Cesarean section has been associated in the long term with an increased risk of asthma and obesity in children, and complications in subsequent pregnancies, such as uterine rupture, placenta accreta, placenta previa, hysterectomy, and intra-abdominal adhesions, with the risk of these morbidities progressively increasing as the number of previous cesarean deliveries increases. These risks are higher in women with limited access to comprehensive obstetric care, and they require careful consideration in settings that lack the facilities and capacity to conduct surgery safely or to treat surgical complications. High rates of cesarean section are associated with substantial health-care costs (3).

The factors contributing to the rise in cesarean section rates are complex, and identifying interventions to address them is challenging. Factors associated with cesarean births include changes in the characteristics of the population such as increase in the prevalence of multiple pregnancies, assisted reproduction, and increase in the proportion of nulliparous women with advanced age. Other non-clinical factors such as women increasingly wanting to determine how and when their child is born, generational shifts in work and family responsibilities, physician factors, increasing fear of medical litigation, as well as organizational, economic and social factors have all been implicated in this increase (4).

For nearly 30 years, the international health-care community has considered the ideal rate for cesarean section to be between 10% and 15%.  WHO released a statement summarizing the results of systematic reviews and analysis of the available data on cesarean births. Considering the evidence, the panel of experts convened by WHO concluded in the statement that, at population level, cesarean section rates higher than 10% were not associated with reductions in rates of maternal and newborn mortality. The statement notes, however, that the association between cesarean section rates and other relevant outcomes such as stillbirths, maternal and perinatal morbidity, pediatric outcomes and psychological or social well-being could not be determined due to the lack of data on these outcomes at the population level. The scarcity of data is a limitation of this evidence that needs to be borne in mind when interpreting the WHO statement (9).

The ideal or optimal cesarean rate is unknown, yet cesarean section is effective in saving maternal and infant lives, but only when it is used for medically indicated reasons. Ultimately, every effort

should be made to provide cesarean sections to women in need, rather than striving to achieve a specific rate.

This is the first national guideline on non-clinical interventions to reduce cesarean sections – i.e. those performed in the absence of medical indications. Non-clinical interventions in this guideline refer to those interventions applied independently of a clinical encounter between a particular provider and patient in the context of patient care.

➡️Why this guideline is needed

The rise in cesarean section rates is a national problem. The causes of the increase are multiple. Changes in the characteristics of the population, such as the increase in assisted reproduction, advanced maternal age, and multifetal gestation, have been cited to contribute to the rise. Other factors such as differences in style of professional practice, increasing fear of medical litigation, and organizational, economic, social, and cultural factors have all been implicated in this rising tide.

We expect this guideline to help clinicians and other health-care professionals to reduce rates of cesarean sections. Effective implementation of this guideline will contribute to achievement of the United Nation’s Sustainable Development Goal 3 (“Ensure healthy lives and promote well-being for all at all ages”) by improving the quality of care during childbirth and reducing complications, disability and death associated with cesarean births, particularly in settings that lack the facilities and/or capacity to properly conduct safe surgery (10).

➡️Target audience

The primary audience for this guideline includes health-care professionals namely obstetricians, midwives, nurses, and general medical practitioners, as well as managers of maternal and child health programs and public health policymakers in Egypt.

- Methods

The GDG followed the GRADE-Adolopment methodology to develop this guideline (6)

1)  Topic prioritization and need for a guideline: has been decided by the Supreme Health Council based on the importance of the topic and the potential impact of the guideline when implemented.

2)  The intention of the guideline is to improve practice and to change health policies. The target audience and scope of the document were explicitly defined at the outset.

3)  Setting up the guideline development group. All members signed a COI statement.

4)  Identification and assessment of existing guidelines: The GDG screened potentially relevant guidelines. The development group assessed the relevance, timeliness, and quality of these reports. The GDG identified only one comprehensive, high-quality, and up-to-date guideline (6).

5)  The identified guideline Assessment of the methodological quality of the guideline using the AGREE GRS instrument (11). AGREE GRS includes:

b)   Adaptability assessment: The GDG assessed the adaptability of the original document. Among the adaptability assessment, the GDG focused on the evidence profiles, the evidence to decision tables, and the inclusion of the pre-specified critical outcomes.

c)  Decision: After the guideline assessment, the GDG decided to adapt the original document, taking into consideration the resources required for the process.

d)  Evidence profiles

e) Evidence to decision tables: The chair of the GDG presented the evidence profiles and the EtD tables in the face-to-face meeting and the group discussed the final recommendations. The GDG determined the direction and strength of the final recommendations using the GRADE methodology, based on four key factors presented in the evidence profiles and EtD tables: the balance between benefits and harms, certainty of evidence, patients' preferences and values, and resources considerations (including equity and feasibility). The panel decided the final redaction of the recommendations.

f) Final draft: The GDG collaborated in writing the final draft of the clinical guideline.

g) External revision: The guideline underwent peer review before final publication. Experts that are not in the development group performed the external revision.

- Priority questions and outcomes

The population of interest comprised:

▪️ women seeking antenatal, labour and delivery care in health-care facilities (term, singleton, in vertex presentation with or without a prior cesarean);

▪️ families of pregnant women;

▪️ health-care professionals who work with expectant mothers (midwives, nurses and obstetricians); and

▪️ health-care facilities that provide maternity care; and

Interventions:

Comparator: usual care

Critical outcome:

➡️Related guidelines

This guideline is a companion to the guideline intended to provide recommendations on the best intrapartum care.

➡️Focus and approach

The focus of this guideline is non-clinical interventions for reducing cesareans.

- Formulation of the recommendations

The DECIDE framework was used to guide the formulation of recommendations. DECIDE is an evidence-to-decision tool that allows explicit and systematic consideration of evidence on interventions in terms of six domains: effects, values, resources, equity, acceptability and feasibility. For each priority question, judgements are made on the impact of the intervention against each of these domains, to inform guideline recommendations.

Using the DECIDE framework, members of the GDG prepared evidence-to-decision tables for each priority question, covering evidence on each of these six domains. At the face-to-face meeting (held in July 2023), GDG members collectively reviewed the evidence-to-decision tables and the draft recommendations, and reached consensus on each recommendation, based on explicit consideration of domains within the evidence-to-decision tables. The GDG also identified important considerations for guideline implementation, monitoring and evaluation, and research gaps.

The GDG made three types of recommendation:

1. Recommended: The benefits of implementing this option outweigh the possible harms. This option can be implemented.

2. Context-specific recommendation

3.  No recommendation: The reasons for deciding “No recommendation” are either:

➡️Decision-making during the GDG meeting

The GDG meeting was held in July 2023. The GDG members discussed the evidence summarized in the evidence-to-decision tables for each guideline question and then considered the relevant draft recommendation. After discussing each question, the draft recommendation and justification were revised as needed. The final set of recommendations was made by consensus.

➡️Document preparation and peer review

Following the final GDG meeting, a draft of the full guideline document was prepared. The document was sent to the External Review Group for peer review. The External Review Group members were asked to review the final draft guideline to identify errors of fact, comment on clarity of language, and consider issues of implementation, adaptation and context. The Steering Group evaluated the input of the peer reviewers for inclusion in the guideline document and made further revisions to the guideline draft as needed. After the GDG meetings and external peer review, further modifications to the guideline by the Steering Group were limited to corrections of factual error and improvements in language to address any lack of clarity. The revised final version was returned to the GDG for the final approval.

- Evidence and recommendations

Recommendation 1

Implementation of evidence-based clinical practice guidelines (on-site training, facilitation by a local opinion leader [obstetrician-gynaecologist], supervision) plus audits of indications for cesarean

delivery and provision of feedback to healthcare professionals are recommended to reduce overall cesarean sections.

(Recommended, High-certainty evidence).

Evidence-base

◾ Effects of interventions

▶️  One cluster RCT (12) assessed the effectiveness of standard of care versus multifaceted intervention comprising implementation of evidence-based clinical practice guidelines (on-site training, facilitation by a local opinion leader [obstetrician-gynecologist], supervision), audits of indications for caesarean delivery and provision of feedback to HCP. High certainty evidence indicates that the multi-faceted intervention reduced overall cesarean sections (RR 0.929 [95% CI 0.900 to 0.959]).

◾ Values

▶️  No direct local research evidence was identified on the values and preferences of women on the implementation of evidence-based clinical practice guidelines, audits and, feedback.

◾ Resources

▶️  No direct local research evidence was identified on the impact on resource use (costs) of implementation of evidence-based clinical practice guidelines, audits and, feedback.

◾ Cost-effectiveness

▶️ No local research evidence was identified on the cost-effectiveness of implementation of evidence-based clinical practice guidelines, audits and, feedback.

◾ Equity

▶️  No direct local evidence was identified on the impact on equity of implementation of evidence-based clinical practice guidelines, audits and, feedback.

◾  Acceptability

▶️  No local research evidence was identified on the acceptability of implementation of evidence-based clinical practice guidelines, audits and, feedback.

◾  Feasibility

▶️  No local research evidence was identified on the Feasibility of implementation of evidence-based clinical practice guidelines, audits and, feedback.

Recommendation 2

Healthcare professionals’ education by a local opinion leader [obstetrician-gynaecologist] to promote implementation of evidence-based clinical practice guidelines is recommended to reduce repeat cesarean sections.

(Recommended, High-certainty evidence).

Evidence-base

 ◾ Effects of interventions

▶️  One cluster RCT (13) assessed the effectiveness of standard of care versus HCP education by a local opinion leader to promote compliance with guidelines that recommended clinical action to increase trial of labour and vaginal birth rates in women who have had previous caesarean sections. There was high certainty evidence that the multi-faceted intervention reduced repeat cesarean sections (RR 0.879 [95% CI 0.838 to 0.921]).

◾  Values

▶️   No direct local research evidence was identified on the values and preferences of women on education by a local opinion leader to promote compliance with guidelines that recommended clinical action to increase trial of labour and vaginal birth rates in women who have had previous caesarean sections.

◾ Resources

▶️   No direct local research evidence was identified on the impact on resource use (costs) of education by a local opinion leader to promote compliance with guidelines that recommended clinical action to increase trial of labour and vaginal birth rates in women who have had previous caesarean sections.

◾ Cost-effectiveness

▶️   No local research evidence was identified on the cost-effectiveness of education by a local opinion leader to promote compliance with guidelines that recommended clinical action to increase trial of labour and vaginal birth rates in women who have had previous caesarean sections.

◾ Equity

▶️   No direct local evidence was identified on the impact on equity of education by a local opinion leader to promote compliance with guidelines that recommended clinical action to increase trial of labour and vaginal birth rates in women who have had previous caesarean sections.

◾ Acceptability

▶️   No local research evidence was identified on the acceptability of education by a local opinion leader to promote compliance with guidelines that recommended clinical action to increase trial of labour and vaginal birth rates in women who have had previous caesarean sections.

◾ Feasibility

▶️ No local research evidence was identified on the feasibility of education by a local opinion leader to promote compliance with guidelines that recommended clinical action to increase trial of labour and vaginal birth rates in women who have had previous caesarean sections.

Recommendation 3

Implementation of evidence-based clinical practice guidelines combined with structured, mandatory second opinion for cesarean section indication is recommended to reduce cesarean births only with targeted monitoring and evaluation in settings with an on-site senior clinician able to provide mandatory second opinion for cesarean section indication. (Context-specific recommendation, moderate-certainty evidence).

Evidence-base

◾ Effects of interventions

▶️  One cluster RCT (14) assessed the effectiveness of standard of care versus Implementation of clinical practice guidelines combined with mandatory second opinion for cesarean section indication. Moderate certainty evidence suggests that Implementation of clinical practice guidelines combined with mandatory second opinion probably reduce overall cesarean sections (RR 0.992 [95% CI 0.968 to 1.017]).

◾ Values

▶️   No direct local research evidence was identified on the values and preferences of women on the implementation of evidence-based clinical practice guidelines, combined with structured, mandatory second opinion.

◾ Resources

▶️   No direct local research evidence was identified on the impact on resource use (costs) of implementation of evidence-based clinical practice guidelines, combined with structured, mandatory second opinion.

◾ Cost-effectiveness

▶️   No local research evidence was identified on the cost-effectiveness of implementation of evidence-based clinical practice guidelines, combined with structured, mandatory second opinion.

◾ Equity

▶️   No direct local evidence was identified on the impact on equity of implementation of evidence-based clinical practice guidelines, combined with structured, mandatory second opinion.

◾ Acceptability

▶️   No local research evidence was identified on the acceptability of implementation of evidence-based clinical practice guidelines, combined with structured, mandatory second opinion.

◾ Feasibility

▶️  No local research evidence was identified on the feasibility of implementation of evidence-based clinical practice guidelines, combined with structured, mandatory second opinion.

Recommendation 4

For the sole purpose of reducing cesarean sections, peer review plus mandatory second opinion are recommended only in the context of rigorous research.

(Context-specific recommendation, very low-certainty evidence).

Evidence-base

◾ Effects of interventions

▶️   One before-after study (15) assessed the effectiveness of standard of care versus peer review plus mandatory second opinion for reducing the overall cesarean sections. The effect of intervention is uncertain because of very low certainty evidence (RR 0.830 [95% CI 0.796 to 0.866]).

◾ Values

▶️   No direct local research evidence was identified on the values and preferences of women on peer review plus mandatory second opinion.

◾ Resources

▶️   No direct local research evidence was identified on the impact on resource use (costs) of peer review plus mandatory second opinion.

v Cost-effectiveness

▶️   No local research evidence was identified on the cost-effectiveness of peer review plus mandatory second opinion.

◾ Equity

▶️   No direct local evidence was identified on the impact on equity of peer review plus mandatory second opinion.

◾ Acceptability

▶️   No local research evidence was identified on the acceptability of peer review plus mandatory second opinion.

◾ Feasibility

▶️   No local research evidence was identified on the feasibility of peer review plus mandatory second opinion.

Recommendation 5

For the sole purpose of reducing cesarean sections, audit and feedback plus financial incentive for health-care professionals or health-care organizations are recommended only in the context of rigorous research.

(Context-specific recommendation, very low-certainty evidence).

Evidence-base

◾ Effects of interventions

▶️ One before-after study (16) assessed the effectiveness of standard of care versus audit and feedback plus financial incentive for reducing the overall cesarean sections. The effect of intervention is uncertain because of very low certainty evidence (RR 0.828 [95% CI 0.758 to 0.904]).

◾ Values

▶️   No direct local research evidence was identified on the values and preferences of women on the audit and feedback plus financial incentive.

◾ Resources

▶️   No direct local research evidence was identified on the impact on resource use (costs) of audit and feedback plus financial incentive.

◾ Cost-effectiveness

▶️   No local research evidence was identified on the cost-effectiveness of audit and feedback plus financial incentive.

◾ Equity

▶️   No direct local evidence was identified on the impact on equity of audit and feedback plus financial incentive.

◾ Acceptability

▶️   No local research evidence was identified on the acceptability of audit and feedback plus financial incentive.

◾ Feasibility

▶️   No local research evidence was identified on the feasibility of audit and feedback plus financial incentive.

Recommendation 6

For the sole purpose of reducing cesarean sections, audit and feedback using Robson classification is recommended only in the context of rigorous research.

(Context-specific recommendation, very low-certainty evidence).

Evidence-base

◾ Effects of interventions

▶️   One before-after study (17) assessed the effectiveness of standard of care versus audit and feedback using Robson classification for reducing the overall cesarean sections. The effect of intervention is uncertain because of very low certainty evidence (RR 0.862 [95% CI 0.765 to 0.972]).

◾ Values

▶️   No direct local research evidence was identified on the values and preferences of women on audit and feedback using Robson classification.

◾ Resources

▶️   No direct local research evidence was identified on the impact on resource use (costs) of audit and feedback using Robson classification.

◾ Cost-effectiveness

▶️   No local research evidence was identified on the cost-effectiveness of audit and feedback using Robson classification .

◾ Equity

▶️   No direct local evidence was identified on the impact on equity of audit and feedback using Robson classification.

◾ Acceptability

▶️   No local research evidence was identified on the acceptability of audit and feedback using Robson classification.

◾ Feasibility

▶️   No local research evidence was identified on the feasibility of audit and feedback using Robson classification

- 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:

➡️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

2.  NTSV Cesarean sections measure

➡️Updating the guideline

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:

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:

- References

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2.  Ministry of Health and Population/Egypt, El-Zanaty and Associates/Egypt, ICF International. Egypt Demographic and Health Survey 2014 [Internet]. Cairo, Egypt: Ministry of Health and Population and ICF International; 2015. Available from: http://dhsprogram.com/pubs/pdf/FR302/FR302.pdf

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14.  Althabe F, Belizán JM, Villar J, Alexander S, Bergel E, Ramos S, et al. Mandatory second opinion to reduce rates of unnecessary caesarean sections in Latin America: a cluster randomised controlled trial. The Lancet. 2004 Jun;363(9425):1934–40.

15.  Liang WH, Yuan CC, Hung JH, Yang ML, Yang MJ, Chen YJ, et al. Effect of peer review and trial of labor on lowering cesarean section rates. J Chin Med Assoc JCMA. 2004 Jun;67(6):281–6.

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17.  Scarella A, Chamy V, Sepúlveda M, Belizán JM. Medical audit using the Ten Group Classification System and its impact on the cesarean section rate. Eur J Obstet Gynecol Reprod Biol. 2011 Feb;154(2):136–40.