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).