Interventions Targeting Health Care Providers to Optimise the Use of Caesarean Section: A Qualitative Comparative Analysis to Identify Important Intervention Features

Rapid increases in caesarean section (CS) rates have been observed globally; however, CS rates exceeding 15% at a population level have limited benefits for women and babies. Many interventions targeting health care providers have been developed to optimise use of CS, typically aiming to improve and monitor clinical decision-making. However, interventions are often complex, and effectiveness is varied. Understanding intervention and implementation features that likely lead to optimised CS use is important to optimise benefits. The aim of this study was to identify important components that lead to successful interventions to optimise CS, focusing on interventions targeting health care providers.

An Example of Too Much Too Soon? A Review of Caesarean Sections Performed in the First Stage of Labour in Kenya 

Caesarean section (CS) is the most commonly performed major surgical procedure, with global rates rising. When performed for appropriate indications, CS can be life-saving for mothers and babies. However, the procedure has potential short- and long-term complications, with reported rates of caesarean-associated death in sub-Saharan Africa at 10.9 per 1,000 procedures. In many health facilities, decisions to perform CS are made by nonspecialist doctors, without support from experienced obstetricians. This can result in suboptimal decision-making and inappropriate surgery. Our study assesses decision-making in CS performed in the first stage of labour.

ReJudge: Development and Testing of an Intervention to Reduce Cesarean Section (CS) Carried Out Due to Fear of Litigation 

Obstetrics is a leading area for litigation worldwide, which can result in defensive health care practices including the use of interventions to protect against litigation. Caesarean section (CS) rates are over 80% in some regions of India, which is likely to result in medically generated harms. Existing interventions that aim to reduce unnecessary CS include educational interventions and clinical guidelines. Fear of litigation is recognised as a factor that stimulates unnecessary CS. We were unaware of an existing intervention specifically targeted to this driver of unnecessary CS. The ReJudge project was designed to develop an intervention to reduce CS carried out due to fear of litigation.

Implementing the Robson Ten Group Classification System (TGCS) to Monitor Hospital Cesarean Section Rates in Nepal: Some Early Lessons 

Nepal's population-based caesarean section (CS) rate has increased over the years but the (CS) rate of 9% (2016) is still within the World Health Organization (WHO) reference of 5–15%. Observed rates at the facility level vary due to case-mix, and their appropriateness is difficult to assess as they could reflect either overuse or unmet need for CS. Unsafe provision of CS quality of care endangers patient outcomes. The Family Welfare Division (FWD) adapted the WHO Robson Ten Group Classification System (TGCS) Guideline 2017, piloted it in four hospitals, and has recently rolled it out to 33 hospitals across the country.