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