interventions in reducing caesarean section review in the ...€¦ · reduce caesarean section. in...

Malays J Med Sci. Sep–Oct 2019; 26(5): 21–37www.mjms.usm.my © Penerbit Universiti Sains Malaysia, 2019

This work is licensed under the terms of the Creative Commons Attribution (CC BY) (http://creativecommons.org/licenses/by/4.0/).

21

To cite this article: Moradi F, Aryankhesal A, Heidari M, Soroush A, Rahimi Sadr S. Interventions in reducing caesarean section in the world: a systematic review. Malays J Med Sci. 2019;26(5):21–37. https://doi.org/10.21315/mjms2019.26.5.3

To link to this article: https://doi.org/10.21315/mjms2019.26.5.3

AbstractCaesarean section without medical indication imposes many problems to families,

personnel and medical equipment causing some side effects to pregnant woman and foetus, compared to natural childbirth. The present study aimed to evaluate the interventions in reducing caesarean section in the world. This study was a systematic review using Embase, PubMed, Scopus, Web of Science, Science Direct, Magiran and SID databases and grey literature. All studies conducted during 2000–2018 were reviewed and finally the studies with inclusion and exclusion criteria were selected. A total of 19 studies were selected among 5,559 studies. The interventions conducted for reducing caesarean section included training the specialists and women by using Six Sigma method, changing the guidelines, reviewing the definition of natural childbirth various stages, encouraging the natural childbirth and expanding painless childbirth. All interventions were divided into educational strategy and managerial strategy. The interventions can be implemented to change the behaviour of physicians and attitude of pregnant women in order to reduce caesarean section. In this regard, the authorities are recommended to make more efforts.

Keywords: pregnant women, caesarean section, childbirth

Interventions in Reducing Caesarean Section in the World: A Systematic Review

Farideh Moradi1,2, Aidin Aryankhesal2, Mohammad Heidari3, Ali Soroush1, Sara Rahimi Sadr1

1 LifeStyleModificationResearchCenter,ImamRezaHospital,KermanshahUniversityofMedicalSciences,Kermanshah,Iran

2 DepartmentofHealthServicesManagement,SchoolofHealthManagementandInformationSciences,IranUniversityofMedicalSciences,Tehran,Iran

3 Community-OrientedNursingMidwiferyResearchCenter,ShahrekordUniversityofMedicalSciences,Shahrekord,Iran

Submitted: 2 Jan 2019Accepted: 21 Apr 2019Online: 4 Nov 2019

Review Article

Introduction

Childbirth is one of the most sensitive and important services of the health system in all societies and caesarean section is considered as one of the main concerns in this regard (1). Caesarean section refers to the removal of the placenta, embryo and membranes by cutting the abdominal wall and uterus (2). Although caesarean section has played a significant role in reducing the mortality and morbidity of high-

risk natural childbirth in the last century, its high level is a challenging issue during the recent decades (3).

Caesarean section, without medical indication, creates a lot of troubles on families, medical personnel and medical equipment which can lead to side effects for pregnant women and foetus compared to natural childbirth including the problems related to anaesthesia, post-operative infection, high haemorrhage and thromboembolism (4–6). In addition, caesarean

Malays J Med Sci. Sep–Oct 2019; 26(5): 21–37

www.mjms.usm.my22

i) caesarean or caesarean section or repeat caesarean section or pregnancy or pregnant woman or parturition or birth or labour; and

ii) intervention or policy or plan or programme or, strategy or strategic planning; and

iii) decrease or change or impact or health impact assessment.

Eligibility Criteria

The inclusion criteria for selecting the studies related to the field of research included: i) the studies published during 2000–2018 ii) the studies in English or Persian and iii) the studies referring to at least one aspect of policy interventions to reduce caesarean section. The exclusion criteria included the letter to the editor, commentaries and the articles presented at the conferences.

Quality Assessment

After extracting the articles from the above-mentioned databases, they were evaluated using the descriptive-analytical, Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist and the articles without any good quality of reporting were excluded.

Results

A total of 5,559 articles were reviewed, among which 2,778 articles were repetitive. A total of 2,781 articles were screened of which 2,680 articles were eliminated in the review of the title and abstract. Then, the full text of 101 articles was studied among which 82 articles were excluded (62 articles due to inadequate results and 20 articles due to poor quality). Finally, 19 articles were included. The above-mentioned items are listed in Figure 1.

Data Extraction

After reviewing the quality of articles, 19 articles were eventually reviewed by three individuals. The information obtained from the articles were included in Word software and in the table containing the author’s name, year of publication, sample size, analysis method, type of intervention, method of investigation, the most important results and conclusion.

section can have some side effects for infant such as respiratory problems, hospitalisation at the NICU, the possibility of infection, asthma in childhood and reduced breastfeeding (7). Some studies indicated that the reduction of caesarean section affects the maternal and neonatal mortality (8–10).

Further, caesarean section leads to more costs than natural childbirth (11, 12). Douangvichit et al., in their study, at two public hospitals in Latos indicated that the average cost for caesarean section and natural childbirth is 270 and 59 dollars, respectively (13). Based on the World Health Organization (WHO) statistics in different countries, the expected caesarean section should be 10%–15% and it is announced that there is no reason to increase the caesarean section (14). Based on the latest reports from 150 countries in the world, 18.6% of childbirths in the world are performed by caesarean section which is from 6.6% in developed countries and 27.2% in less developed countries (15).

Considering its effects on maternal health and reducing the cost of treatment and the economy of the family and country, most governments adopted some measures to reduce this problem. Such policies and interventions include the changes in the steps of natural childbirth leading to some caesarean section decisions and free natural childbirth (16). Since no study has been conducted on the interventions and policies implemented in different countries to reduce caesarean section, this study aimed to review the policies adopted in this area and evaluate their effectiveness.

Methods

Study Design

This systematic review study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (17). The present systematic review study aimed to examine the interventions to reduce caesarean section in the world during 2000–2018 through searching in Embase, PubMed, Scopus, Web of Science, Science Direct, Magiran, SID and grey literature.

Search Strategy

The key words and search strategy were as follows:

www.mjms.usm.my 23

Review Article | Interventions in reducing caesarean section

places. Most studies were conducted after the year 2010 (76%). Asia (67%) allocated the most studies. In terms of research methodology, most of the studies were interventional (67%) and 21% were retrospective studies related to the evaluation programmes, which were already conducted while 12% of the studies were combined. The context of other studies is shown in Table 1.

Summary of Reviewed Articles

A total of 19 articles conducted in different parts of the world during the year 2000–2018 were evaluated after screening in terms of quality and relevance. The processes of reviewing the studies are presented in Figure 1.

Regarding to the target population of the studies, 11 studies were conducted in hospital, 6 studies in health centres and 2 studies in other

Figure 1. Review selection process and results based on the PRISMA guidelines


www.mjms.usm.my24

Table 1. Countries that studied

Country Number of studies

Iran 10 studies

China 2 studies

US 2 studies

France 1 study

India 1 study

Pakistan 1 study

Taiwan 1 study

Argentina, Brazil, Cuba, Guatemala, Mexico

1 study

The strategies obtained from the results of the studies were divided into managerial and educational strategies.

Educational Strategy

This strategy is a collection of methods and tools for raising the awareness of pregnant women, their families and specialists. Based on the current studies, this strategy has the following sub-categories:

i) Training the pregnant women and their families

ii) Training the specialists

iii) Applying an experienced person to accompany and train pregnant women in the hospital

iv) Training the benefits of natural childbirth and side effects of caesarean section to the husbands of pregnant women

Managerial Strategy

i) Performing natural childbirth as free

ii) Encouraging natural childbirth with the spread of painless childbirth

iii) Studying and making decision for caesarean section by experienced physicians in the hospital

iv) Having confidential correspondence with surgeons for conducting caesarean section in the hospital and the surgeon himself

v) Using the Six Sigma method

vi) Changing the guidelines and defining the various stages of childbirth

www.mjms.usm.my 25


Tab

le 2

. Su

mm

ary

of d

ata

extr

acti

on o

f the

sel

ecte

d ar

ticl

es to

inve

stig

ate

inve

stig

atin

g th

e in

terv

enti

ons

in r

educ

ing

caes

area

n se

ctio

n in

the

wor

ld

(200

0–20

18)

Con

clu

sion

Res

ult

Met

hod

sS

tati

stic

al a

nal

ysis

Sam

ple

siz

eIn

terv

enti

onse

ttin

gA

uth

ors

&

Yea

r

The

theo

ry o

f re

ason

ed a

ctio

n ca

n be

eff

ecti

ve in

cre

atin

g an

d in

crea

sing

the

inte

nt o

f pre

gnan

t w

omen

to c

hoos

e na

tura

l chi

ldbi

rth

Aft

er th

e in

terv

enti

on,

seve

n (1

5.6%

) sub

ject

s in

the

case

gro

up h

ad

the

inte

nt to

cho

ose

natu

ral c

hild

birt

h bu

t it

did

not

hap

pen

in th

e co

ntro

l gro

up

The

stud

y ty

pe w

as s

emi-

expe

rim

enta

l, pr

ospe

ctiv

e an

d ca

se-c

ontr

ol. T

he in

clus

ion

crit

eria

incl

uded

in th

e th

ird

trim

este

r of

ges

tati

on w

ith

a ge

stat

iona

l age

of 2

8–24

wee

ks,

wit

hout

a h

isto

ry o

f chi

ldbi

rth,

w

ith

a hi

gh te

nden

cy to

cae

sare

an

sect

ion

and

wit

hout

a m

edic

al

avoi

danc

e fo

r na

tura

l chi

ldbi

rth-

spec

ial t

rain

ing

in th

e ca

se

grou

p an

d no

rmal

trai

ning

in th

e co

ntro

l gro

up, t

he s

ampl

ing

was

co

nduc

ted

in th

ree

area

s of

dow

n,

cent

re a

nd to

p of

the

city

and

se

lect

ing

15 p

eopl

e in

eac

h ar

ea

Usi

ng s

tati

stic

al

soft

war

e (S

PSS

vers

ion

16) a

nd c

hi-s

quar

e,

Man

n-W

hitn

ey,

Wilc

oxon

, t-t

est a

nd

pair

ed t-

test

s

90Tr

aini

ng b

y qu

esti

on a

nd a

nsw

er

met

hod,

vid

eo p

rese

ntat

ion

and

lect

ure

for

60 m

in in

the

form

of

grou

p m

eeti

ngs

wit

h at

leas

t div

e pr

egna

nt w

omen

who

inte

nded

to

perf

orm

cae

sare

an s

ecti

on, h

oldi

ng

a se

ssio

n w

ith

the

pres

ence

of

phys

icia

ns a

nd in

fluen

tial

peo

ple

incl

udin

g th

e le

arne

rs’ h

usba

nds,

di

stri

buti

on o

f a b

ook

enti

tled

“R

epro

duct

ive

Hea

lth”

to r

emin

d th

e co

nten

ts to

the

lear

ners

Iran

Asa

di e

t al.

(201

4) (3

6)

Plac

ing

a co

here

nt

curr

icul

um a

long

wit

h ot

her

soci

al s

uppo

rt

met

hods

can

be

effe

ctiv

e in

red

ucin

g ca

esar

ean

sect

ion

The

rate

of c

aesa

rean

se

ctio

n w

as 4

1.41

%

in th

e ca

se g

roup

and

74

.8%

in th

e co

ntro

l gr

oup

and

the

over

all

inci

denc

e w

as 5

9.8%

. Th

e ca

esar

ean

sect

ion

was

60.

5% in

the

cont

rol g

roup

and

16

.7%

in th

e ca

se g

roup

, an

d th

is d

iffer

ence

was

st

atis

tica

lly s

igni

fican

t (P

≤ 0

.001

)

The

stud

y ty

pe w

as c

ase-

cont

rol

and

inte

rven

tion

al, t

he c

ase

grou

p in

clud

ed 1

87 s

ubje

cts

and

cont

rol

grou

p in

clud

ed 2

23 s

ubje

cts.

Pr

ovid

ing

spec

ial t

rain

ing

to th

e ca

se g

roup

and

reg

ular

trai

ning

to

the

cont

rol g

roup

Chi

-squ

are

test

410

Trai

ning

the

case

gro

up in

clud

ing

the

use

of s

lides

and

vid

eo ta

pes

abou

t the

ana

tom

y an

d ph

ysio

logy

of

pre

gnan

cy, p

repa

rati

on fo

r na

tura

l chi

ldbi

rth

and

caes

area

n se

ctio

n, m

etho

d of

red

ucin

g pa

in,

form

atio

n of

a g

roup

dis

cuss

ion

abou

t the

sen

ses

and

atti

tude

s of

the

pati

ent i

n co

nnec

tion

wit

h ch

ildbi

rth,

invi

tati

on o

f the

hus

band

s of

the

preg

nant

wom

en, t

rain

ing

them

abo

ut p

ostp

artu

m p

robl

ems

and

appr

opri

ate

solu

tion

s to

them

, di

stri

buti

on o

f edu

cati

onal

pam

phle

ts

on p

ostp

artu

m e

duca

tion

, thr

ee

trai

ning

ses

sion

s fo

r tw

o ho

urs:

The

in

clus

ion

crit

eria

incl

uded

: i) t

he

last

thre

e m

onth

s of

pre

gnan

cy, i

i).

first

or

seco

nd p

regn

ancy

, iii)

. no

hist

ory

of il

lnes

s an

d de

pres

sion

, iv)

. no

t hav

ing

a ch

ild, v

). a

ge b

etw

een

17 a

nd 3

4 ye

ars,

vi)

. hav

ing

at le

ast

the

mid

dle

scho

ol d

egre

e, v

ii).

confi

rmat

ion

of th

e he

alth

of t

he

foet

us in

ult

raso

und

exam

inat

ion

Iran

Azh

and

Yo

ones

ian

(201

4) (3

7)

(continuedonnextpage)


www.mjms.usm.my26

Con

clu

sion

Res

ult

Met

hod

sS

tati

stic

al a

nal

ysis

Sam

ple

siz

eIn

terv

enti

onse

ttin

gA

uth

ors

&

Yea

r

Prov

idin

g th

e ne

cess

ary

trai

ning

du

ring

pre

gnan

cy

was

eff

ecti

ve in

en

cour

agin

g pr

egna

nt

wom

en to

hav

e na

tura

l chi

ldbi

rth

Aft

er th

e in

terv

enti

on,

the

mea

n sc

ore

of

child

birt

h in

the

inte

rven

tion

gro

up

decr

ease

d an

d th

e m

ean

scor

e of

wai

ting

fo

r ch

ildbi

rth

and

the

effic

ienc

y of

chi

ldbi

rth

incr

ease

d. 7

1.4%

of t

he

preg

nant

wom

en o

f the

in

terv

enti

on g

roup

and

53

.8%

of t

he p

regn

ant

wom

en o

f the

con

trol

gr

oup

wer

e gi

ven

natu

ral c

hild

birt

h

The

stud

y ty

pe w

as q

uasi

-ex

peri

men

tal.

The

popu

lati

on

incl

uded

pre

gnan

t wom

en

Pair

ed a

nd

inde

pend

ent t

-tes

t, ch

i-sq

uare

and

var

ianc

e an

alys

is.

130

Trai

ning

the

preg

nant

wom

en in

th

ree

sess

ions

of 6

0 m

in-9

0 m

in.

Sess

ion

1: g

roup

dis

cuss

ion

of

preg

nant

wom

en w

ith

one

anot

her

on

the

caus

e of

fear

of d

eliv

ery.

Ses

sion

2:

pre

sent

atio

n of

the

succ

essf

ul

natu

ral p

regn

ancy

exp

erie

nce

by

preg

nant

wom

en a

nd e

duca

tion

on

the

anxi

ety

of p

regn

ant m

othe

rs o

n th

e em

bryo

, cae

sare

an s

ecti

on, a

nd

Keg

el e

xerc

ise.

Ses

sion

3: r

epet

itio

n of

the

trai

ning

Iran

Tahe

ri e

t al.

(201

4) (3

8)

Find

ings

indi

cate

d th

at fi

nanc

ial

ince

ntiv

es a

ffec

t the

se

lect

ion

of c

hild

birt

h ty

pe

In th

e st

ate

of M

adha

ya,

the

rate

of c

aesa

rean

se

ctio

n in

crea

sed

from

26.

6% in

200

7 to

40

.7%

in 2

010,

whi

le

the

rate

for

caes

area

n se

ctio

n w

as 4

.9%

be

fore

the

prog

ram

w

as im

plem

ente

d. I

n G

ujar

at, t

he r

ate

of

caes

area

n se

ctio

n w

as

redu

ced

4.3%

than

in

2004

whi

ch w

as 0

.8%

The

stud

y co

mpa

red

two

publ

ic

and

priv

ate

fund

ing

prog

ram

s in

two

Indi

an s

tate

s w

hich

wer

e co

nduc

ted

for

incr

easi

ng th

e nu

mbe

r of

chi

ldbi

rth

Des

crip

tive

sta

tist

ics

anal

ysis

.80

5,00

0Pa

ying

som

e m

oney

to m

ater

nity

sp

ecia

list t

o en

cour

age

child

birt

h.

In th

e st

ate

of M

adha

ya, t

he fe

e pa

id fo

r ca

esar

ean

rate

s w

as h

ighe

r th

an n

atur

al c

hild

birt

h an

d th

e fe

e w

as a

scen

dant

whi

le in

the

stat

e of

Guj

arat

, a fi

xed

fee

was

pai

d to

sp

ecia

lists

bas

ed o

n th

e ch

ildbi

rth

type

Indi

aB

ogg

et a

l. (2

016)

(39)

Six

Sigm

a is

an

effe

ctiv

e ap

proa

ch

to r

educ

e ca

esar

ean

sect

ion

The

defe

ct r

ate

decl

ined

fr

om 4

1.83

% to

32%

an

d th

e Si

x Si

gma

scor

e in

crea

sed

from

1.

706

to 1

.967

aft

er

impr

ovem

ent m

easu

res

(P <

0.0

1)

The

stud

y ty

pe w

as

inte

rven

tion

al-s

ampl

ing

and

extr

acti

ng in

form

atio

n fr

om

arch

ival

file

s, d

eter

min

ing

the

caus

es o

f cae

sare

an s

ecti

on u

sing

fis

h bo

ne c

hart

s as

one

of t

he

Six

sigm

a st

ages

, det

erm

inin

g in

terv

enti

on b

ased

on

caes

area

n se

ctio

n

Usi

ng M

init

ab

soft

war

e X

2 te

st to

co

mpa

re c

lass

ifica

tion

in

form

atio

n.

1,01

6M

onit

orin

g an

d fin

al d

ecis

ion

mak

ing

for

seni

or r

esid

ent c

aesa

rean

, di

abet

es s

cree

ning

and

pre

vent

ion

educ

atio

n fo

r pr

even

ting

dia

bete

s an

d fe

tal e

nlar

gem

ent a

nd r

educ

ing

caes

area

n se

ctio

n, tr

aini

ng o

n ne

onat

al r

esus

cita

tion

and

nat

ural

ch

ildbi

rth,

pos

tpar

tum

hae

mor

rhag

e,

child

birt

h us

ing

forc

eps

by m

idw

ives

as

mon

thly

Chi

naC

hai e

t al.

(201

7) (4

0)


Tab

le 2

. (continued)

www.mjms.usm.my 27


Con

clu

sion

Res

ult

Met

hod

sS

tati

stic

al a

nal

ysis

Sam

ple

siz

eIn

terv

enti

onse

ttin

gA

uth

ors

&

Yea

r

In s

ome

case

s of

he

alth

pro

blem

s su

ch

as c

aesa

rean

sec

tion

w

hich

is r

oote

d in

the

cult

ure

and

belie

fs

of th

e pe

ople

, the

m

obili

sati

on o

f gro

ups

of p

eopl

e in

sol

ving

th

e pr

oble

m, a

long

w

ith

the

prom

otio

n of

rel

ated

hea

lth

serv

ices

, can

hav

e be

nefic

ial e

ffec

ts

In

this

stu

dy, 7

0%

of p

regn

ant w

omen

w

ere

sati

sfied

wit

h th

e pr

ovid

ed tr

aini

ng. T

he

freq

uenc

y of

cae

sare

an

sect

ion

decr

ease

d fr

om 6

3% b

efor

e th

e im

plem

enta

tion

to 5

2%

afte

r in

terv

enti

on

(P <

0.0

5)

The

stud

y w

as fi

eld

type

and

the

rese

arch

pop

ulat

ion

incl

uded

th

e pr

egna

nt w

omen

hav

ing

no

prev

ious

his

tory

of c

aesa

rean

se

ctio

n an

d le

ss th

an th

ree

tim

es

of p

regn

ancy

who

wer

e ra

ndom

ly

sele

cted

and

giv

en th

e ne

cess

ary

trai

ning

Pair

ed t-

test

and

M

cNem

ar te

st17

1Tr

aini

ng th

e pr

egna

nt w

omen

on

the

bene

fits

of n

atur

al c

hild

birt

h an

d co

mpl

icat

ions

of c

aesa

rean

sec

tion

by

the

heal

th c

are

team

incl

udin

g m

idw

ives

, hea

lth

clin

ic p

hysi

cian

s,

and

non-

sani

tary

sta

ff

Iran

Gan

jee

and

Kho

srav

i (2

008)

(41)

Edu

cati

onal

pr

ogra

mm

e ba

sed

on

heal

th b

elie

f mod

el is

ef

fect

ive

in in

crea

sing

th

e kn

owle

dge

and

atti

tude

s of

pre

gnan

t w

omen

in c

hild

birt

h

Ther

e w

as a

sig

nific

ant

diff

eren

ce in

the

mea

n sc

ore

of a

war

enes

s

(P ≤

0.0

01),

Per

ceiv

ed

sens

itiv

ity

(P ≤

0.

001)

, Per

ceiv

ed

seve

rity

(P ≤

0.0

01),

Pe

rcei

ved

bene

fits

(P ≤

0.

001)

and

Per

ceiv

ed

self-

effic

acy

(P =

0.

02).

The

re w

as n

o si

gnifi

cant

cor

rela

tion

be

twee

n w

omen

in

the

case

gro

up th

an

in th

e co

ntro

l gro

up

afte

r in

terv

enti

on. I

n th

e ca

se o

f per

ceiv

ed

barr

ier

stru

ctur

es

(P =

0.0

9), t

here

was

no

sign

ifica

nt d

iffer

ence

in

the

choi

ce o

f chi

ldbi

rth

type

(P =

0.7

3) a

nd

perf

orm

ance

(P =

0. 2

4)

The

stud

y ty

pe w

as s

emi-

expe

rim

enta

l, th

e re

sear

ch

popu

lati

on in

clud

ed p

regn

ant

wom

en d

eliv

erin

g th

eir

first

chi

ld

who

wer

e at

the

20–

30 w

eeks

of

gest

atio

n. T

he in

stru

men

t of t

his

stud

y w

as a

que

stio

nnai

re b

ased

on

the

stru

ctur

e of

the

heal

th

belie

f mod

el, i

nter

vent

ion

in th

e ca

se g

roup

and

com

plet

ion

of th

e qu

esti

onna

ire

4–8

wee

ks a

fter

in

terv

enti

on in

bot

h gr

oups

Usi

ng S

PSS

14 a

nd

inde

pend

ent-

t and

t-

pair

ed te

sts,

chi

-sq

uare

, and

Man

n–W

hitn

ey te

st

100

Edu

cati

onal

pro

gram

me

was

un

ders

tood

dur

ing

six

sess

ions

ac

cord

ing

to th

e he

alth

bel

ief m

odel

, in

clud

ing

awar

enes

s, p

erce

ived

se

nsit

ivit

y, p

erce

ived

sev

erit

y,

perc

eive

d ba

rrie

rs, p

erce

ived

be

nefit

s, a

nd s

elf-

effic

acy.

The

in

form

atio

n w

as p

rovi

ded

by fi

lm a

nd

lect

ure

Iran

Gha

ffar

i et a

l. (2

011)

(42)


Tab

le 2

. (continued)


www.mjms.usm.my28

Con

clu

sion

Res

ult

Met

hod

sS

tati

stic

al a

nal

ysis

Sam

ple

siz

eIn

terv

enti

onse

ttin

gA

uth

ors

&

Yea

r

Alt

houg

h th

e ra

te o

f ca

esar

ean

sect

ion

decl

ined

in th

e fir

st

mon

th a

fter

the

impl

emen

tati

on o

f the

he

alth

pla

n, it

s ra

te

incr

ease

d du

ring

the

stud

y. T

his

sugg

ests

th

at n

atur

al c

hild

birt

h in

Ira

n ha

s no

t bee

n in

crea

sed

as o

ne o

f th

e go

als

set b

efor

e th

e im

plem

enta

tion

of

the

plan

Cae

sare

an s

ecti

on

decr

ease

d to

0.1

1 in

th

e fir

st m

onth

aft

er

the

inte

rven

tion

s bu

t it

incr

ease

d m

onth

ly to

0.

17 (P

≤ 0

01)

The

stud

y ty

pe w

as r

etro

spec

tive

an

d qu

asi-

expe

rim

enta

l. Th

e st

atis

tica

l pop

ulat

ion

incl

uded

th

e ho

spit

als

affil

iate

d to

K

erm

ansh

ah U

MS

and

the

num

ber

of c

aesa

rean

sec

tion

was

ev

alua

ted

25 m

onth

s be

fore

and

28

mon

ths

afte

r th

e in

terv

enti

on

Dis

cont

inue

d ti

me

seri

es.

Fift

een

hosp

ital

s af

filia

ted

to

Ker

man

shah

U

nive

rsit

y of

M

edic

al S

cien

ces

Nat

ural

chi

ldbi

rth

as fr

ee, t

he

enco

urag

emen

t of n

atur

al c

hild

birt

h w

ith

the

spre

ad o

f pai

nles

s ch

ildbi

rth,

th

e re

cons

truc

tion

of c

hild

birt

h bl

ocks

by

crea

ting

spe

cial

spa

ces

for

the

plea

sant

ness

of t

he n

atur

al

child

birt

h en

viro

nmen

t

Iran

Kar

ami e

t al.

(201

7) (4

3)

Inte

rven

tion

of u

sing

th

e se

cond

phy

sici

an’s

op

inio

n w

as e

ffec

tive

in

red

ucin

g th

e nu

mbe

r of

cae

sare

an

sect

ion

In th

e ho

spit

als

whe

re

inte

rven

tion

was

pe

rfor

med

, the

rat

e of

cae

sare

an s

ecti

on

decr

ease

d (1

.9%

to 1

%

P =

0.0

44).

87%

of

phys

icia

ns b

elie

ved

that

th

is w

as a

n ef

fect

ive

stra

tegy

in p

ublic

ho

spit

als

and

41%

be

lieve

d th

at th

ey w

ere

effe

ctiv

e in

pri

vate

ho

spit

als

This

stu

dy w

as a

ran

dom

ised

, co

ntro

lled

clus

ter

clin

ical

tria

l st

udy.

The

pop

ulat

ion

incl

uded

th

e ho

spit

als

in L

atin

Am

eric

a w

ith

caes

area

n se

ctio

n ra

te a

s hi

gh a

s 15

% p

er 1

000

case

s pe

r ye

ar

36 h

ospi

tals

The

indi

cati

ons

wer

e ex

amin

ed u

sing

ex

isti

ng e

vide

nce

from

phy

sici

ans

bein

g hi

gher

or

at th

e sa

me

leve

l in

term

s of

the

clin

ical

exp

erie

nce

and

qual

ity

and

the

final

dec

isio

n w

as

mad

e by

the

phys

icia

ns b

y dr

awin

g th

e flo

wch

art

Arg

enti

na,

Bra

zil,

Cub

a,

Gua

tem

ala,

M

exic

o

Maw

son

(200

4) (4

4)

For

the

mid

dle

clas

s w

omen

wor

king

w

ith

the

supp

ort

of th

eir

husb

and,

th

e co

ntin

uous

at

tend

ance

of a

m

idw

ife in

the

hosp

ital

red

uces

th

e lik

elih

ood

of

caes

area

n se

ctio

n an

d th

e ne

ed fo

r ep

idur

al

anes

thes

ia

In th

e in

terv

enti

on

grou

p, th

e nu

mbe

r of

cae

sare

an s

ecti

ons

decr

ease

d co

mpa

red

to th

e co

ntro

l gro

up

(13.

4% v

ersu

s 25

%,

P =

0.0

02).

In

the

wom

en w

ith

indu

ctio

n ch

ildbi

rth,

the

supp

orte

d gr

oup

had

low

er th

an c

aesa

rean

se

ctio

n (1

2.5%

ver

sus

58.8

%, P

= 0

.007

) an

d le

ss n

umbe

r of

pr

egna

nt w

omen

in

the

inte

rven

tion

gro

up

rece

ived

epi

dura

l an

esth

esia

than

the

cont

rol g

roup

(64.

7%

vers

us 7

6% ,

P =

0.0

02)

This

stu

dy w

as a

con

trol

led

clin

ical

tria

l. Th

e re

sear

ch

popu

lati

on in

clud

ed th

e pr

egna

nt

wom

en d

urin

g th

eir

thir

d tr

imes

ter.

A to

tal o

f 420

pre

gnan

t w

omen

wer

e in

clud

ed in

the

stud

y of

who

m 1

96 w

omen

wer

e in

the

cont

rol g

roup

and

224

w

omen

wer

e ra

ndom

ly a

ssig

ned

to th

e in

terv

enti

on g

roup

Des

crip

tive

ana

lysi

s,

anal

ytic

al a

naly

sis

for

com

pari

ng in

terv

enti

on

and

cont

rol g

roup

s - C

hi-s

quar

e te

st fo

r di

scre

te v

aria

bles

an

alys

is.

420

Inte

rven

tion

invo

lved

the

use

of a

tr

aine

d an

d ex

peri

ence

d pe

rson

to

acco

mpa

ny a

nd s

uppo

rt p

regn

ant

wom

en a

fter

adm

issi

on to

the

hosp

ital

. Thi

s su

ppor

t is

prov

ided

in

the

phys

ical

pro

xim

ity,

eye

con

tact

an

d co

mm

unic

atio

n, tr

aini

ng,

assu

ranc

e an

d in

sura

nce,

and

en

cour

agem

ent o

f pre

gnan

t wom

en

and

thei

r hu

sban

ds

US

McG

rath

and

K

enne

ll (2

008)

(45)

Tab

le 2

. (continued)


www.mjms.usm.my 29


Con

clu

sion

Res

ult

Met

hod

sS

tati

stic

al a

nal

ysis

Sam

ple

siz

eIn

terv

enti

onse

ttin

gA

uth

ors

&

Yea

r

The

foun

d th

at o

ur

wor

king

pla

n fo

r m

anag

emen

t of l

abor

an

d de

liver

y yi

elde

d an

d m

aint

aine

d a

succ

essf

ul d

eclin

e in

th

e ce

sare

an d

eliv

ery

rate

s w

itho

ut a

ny

nega

tive

eff

ect o

n ne

onat

al o

r m

ater

nal

mor

talit

y ra

tes

The

rate

of c

aesa

rean

se

ctio

n ra

nged

from

16

.59%

to 1

0.92

% a

nd

the

init

ial c

aesa

rean

w

as fr

om 9

.22

to 7

.11

whi

le th

e re

peat

ed

caes

area

n se

ctio

n ra

nged

from

7.3

7%

to 3

.81%

. The

rat

e of

nat

ural

chi

ldbi

rth

afte

r ca

esar

ean

sect

ion

incr

ease

d fr

om 3

5.6

to 5

4.5

(P <

0.0

01).

Th

e us

e of

oxy

toci

n in

crea

sed

from

38.

8 to

63

.4 (P

< 0

.001

)

The

stud

y ty

pe w

as r

etro

spec

tive

ev

alua

ting

the

rate

of c

aesa

rean

st

atis

tics

ove

r te

n ye

ars

(198

9 to

19

98) a

nd th

e fa

ctor

s re

duci

ng

this

rat

e

The

stat

isti

cs w

ere

divi

ded

into

ten

peri

ods

of o

ne y

ear,

usi

ng th

e X

2 tes

t wit

h a

fact

or o

f 2

at 1

0

Usi

ng o

xyto

cin

and

its

inje

ctio

n un

der

the

supe

rvis

ion

of a

phy

sici

an,

exam

inat

ion

of th

e co

ndit

ion

and

fetu

s of

the

fetu

s be

fore

the

inje

ctio

n of

oxy

toci

n, im

plem

enta

tion

of t

he

prot

ocol

for

high

-ris

k ch

ildbi

rth

by e

xper

ienc

ed m

idw

ives

, use

of

intr

aute

rine

cat

hete

r by

doc

tors

if th

e do

se o

f oxy

toci

n is

mor

e th

an 2

0

US

Nai

den

and

Des

hpan

de

(200

1) (4

6)

Clin

ical

aud

it is

an

effe

ctiv

e st

rate

gy fo

r re

duci

ng c

aesa

rean

de

liver

y

Cae

sare

an s

ecti

on d

ue

to D

ysto

cia

9.6

vers

us

2.6

(P ≤

0.0

01) w

as

sign

ifica

ntly

less

in th

e cl

inic

al a

udit

gro

up

than

in th

e pr

e-au

dit

grou

p. H

owev

er, t

here

w

as n

o si

gnifi

cant

di

ffer

ence

in th

e va

gina

l de

liver

y ra

te a

mon

g th

e gr

oups

; of 1

95 c

ases

, 16

aud

ited

cae

sare

an

sect

ions

did

not

req

uire

ca

esar

ean

sect

ion.

In

non

-del

iver

ed

wom

en (2

148

case

s),

mul

tiva

riat

e an

alys

is

indi

cate

d th

at c

linic

al

exam

inat

ion

(OR

=

0.78

), m

ater

nal (

OR

=

1.10

), g

esta

tion

al a

ge a

t de

liver

y (O

R =

0.8

0),

and

embr

yo b

irth

w

eigh

t (O

R =

0.0

05)

wer

e in

depe

nden

t of

caes

area

n se

ctio

n by

de

faul

t P ≤

0.0

05)

This

stu

dy w

as a

ret

rosp

ecti

ve

stud

y. 3

,781

indi

vidu

als

who

w

ere

give

n tr

eatm

ent f

rom

Ja

nuar

y 20

08 to

Jan

uary

201

1 w

ere

stud

ied

Mot

hers

who

had

gi

ven

birt

h fr

om J

anua

ry 2

008

to J

anua

ry 2

009

wer

e pa

rt o

f th

e pr

e-au

dit g

roup

(1,5

92)

whi

le th

ose

who

had

giv

en b

irth

af

ter

Aug

ust 2

009

wer

e pa

rt o

f th

e po

st-a

udit

gro

up. T

hen,

the

rate

of c

aesa

rean

sec

tion

was

ev

alua

ted

in tw

o gr

oups

Wilc

oxon

test

, log

isti

c re

gres

sion

2,18

9E

valu

atin

g th

e ca

uses

and

the

need

fo

r ca

esar

ean

sect

ion

by a

team

of

8 ex

pert

s an

d pr

esen

ting

res

ults

at

mon

thly

con

fere

nces

Taiw

anPe

ng e

t al.

(201

6) (4

7)

Tab

le 2

. (continued)



www.mjms.usm.my30

Con

clu

sion

Res

ult

Met

hod

sS

tati

stic

al a

nal

ysis

Sam

ple

siz

eIn

terv

enti

onse

ttin

gA

uth

ors

&

Yea

r

Aft

er im

plem

enti

ng

the

heal

th c

are

refo

rm p

lan,

the

rate

of

cae

sare

an s

ecti

on

0.10

dec

reas

ed in

co

mpa

riso

n to

bef

ore

the

impl

emen

tati

on

14.0

2% o

f the

rat

e of

cae

sare

an s

ecti

on

decr

ease

d af

ter

the

impl

emen

tati

on o

f the

he

alth

sys

tem

ref

orm

pl

an

The

type

of r

etro

spec

tive

and

lo

ngit

udin

al s

tudy

was

the

stud

y po

pula

tion

of a

ll ho

spit

als

in

Kur

dist

an p

rovi

nce

havi

ng a

m

ater

nity

war

d, r

esea

rch

tool

is

chec

k lis

t

Freq

uenc

y in

dice

s,

perc

enta

ge, m

ean

and

chi-

squa

re te

st

1,15

5N

atur

al c

hild

birt

h fo

r fr

ee, t

he

enco

urag

emen

t of n

atur

al c

hild

birt

h w

ith

the

spre

ad o

f pai

nles

s la

bor,

th

e re

cons

truc

tion

of d

eliv

ery

bloc

ks

by c

reat

ing

spec

ial s

pace

s fo

r th

e pl

easu

rabl

e ch

ildbi

rth

envi

ronm

ent,

rew

ardi

ng th

e de

liver

y te

am

Iran

Piro

ozi e

t al.

(201

6) (4

8)

Supe

rvis

ion

and

cont

rol o

f the

au

thor

itie

s is

re

quir

ed fo

r th

e ra

te

of c

aesa

rean

sec

tion

, an

d it

is b

ette

r fo

r ot

her

orga

nisa

tion

s to

co-

oper

ate

wit

h th

e tr

eatm

ent d

epar

tmen

t to

red

uce

caes

area

n de

liver

y

Dur

ing

the

stud

y,

2,17

1 ch

ildbi

rths

w

ere

cond

ucte

d in

th

e ca

se h

ospi

tal a

nd

980

child

birt

hs w

ere

cond

ucte

d in

Sha

hed

Hos

pita

l and

44.

8% o

f ch

ildbi

rths

wer

e in

the

case

gro

up a

nd 4

6.6%

of

the

child

birt

hs w

ere

in th

e co

ntro

l gro

up

by c

aesa

rean

sec

tion

. Th

e te

st in

dica

ted

that

th

e in

terv

enti

on d

id

not a

ffec

t the

rat

e of

ca

esar

ean

sect

ion,

but

th

e ra

te o

f cae

sare

an

sect

ion

decr

ease

d in

the

case

and

con

trol

gro

ups

afte

r in

terv

enti

on

(P <

0.0

01)

Type

of c

linic

al tr

ial,

the

rese

arch

po

pula

tion

incl

udin

g tw

o se

lect

ed

hosp

ital

s in

Maz

anda

ran

prov

ince

(o

ne h

ospi

tal i

n ca

se o

f a c

ontr

ol

hosp

ital

), 1

0-m

onth

inte

rven

tion

, co

mpa

riso

n of

dat

a be

fore

and

af

ter

inte

rven

tion

in e

ach

hosp

ital

Des

crip

tive

sta

tist

ics

(fre

quen

cy, m

ean,

st

anda

rd d

evia

tion

) an

d in

fere

ntia

l (m

ean

com

pari

sons

and

X2 )

Con

fiden

tial

cor

resp

onde

nce

wit

h su

rgeo

ns r

egar

ding

the

rate

of

caes

area

n se

ctio

n pe

rfor

med

in th

e ho

spit

al a

nd th

e ra

te o

f cae

sare

an

sect

ion

perf

orm

ed b

y ea

ch s

urge

on

Iran

Kha

ni(2

004)

(49)

Tab

le 2

. (continued)


www.mjms.usm.my 31


Con

clu

sion

Res

ult

Met

hod

sS

tati

stic

al a

nal

ysis

Sam

ple

siz

eIn

terv

enti

onse

ttin

gA

uth

ors

&

Yea

r

The

desi

gn a

nd

impl

emen

tati

on o

f sy

stem

atic

trai

ning

pr

ogra

ms

by h

ealt

h w

orke

rs h

as a

si

gnifi

cant

rol

e in

en

cour

agin

g pr

egna

nt

mot

hers

to u

nder

go

natu

ral c

hild

birt

h an

d re

duce

cae

sare

an

sect

ion

A s

igni

fican

t diff

eren

ce

was

obs

erve

d be

twee

n th

e aw

aren

ess

scor

es

(P <

0.0

01) a

nd s

elf-

effic

acy

(P <

0.0

01)

afte

r ed

ucat

iona

l in

terv

enti

on in

the

two

grou

ps. A

fter

th

e ed

ucat

iona

l in

terv

enti

on in

the

inte

rven

tion

gro

up,

16 (4

.45%

) wom

en

sele

cted

nat

ural

ch

ildbi

rth

as th

e pr

efer

red

met

hod.

Aft

er

tele

phon

e fo

llow

ups

, 11

(42.

31%

) wom

en

sele

cted

nat

ural

ch

ildbi

rth

The

stud

y ty

pe w

as in

terv

enti

onal

w

ith

two

inte

rven

tion

and

con

trol

gr

oups

. The

stu

dy p

opul

atio

n in

clud

ed a

ll p

regn

ant w

omen

ha

ving

thei

r fir

st c

hild

(w

ith

caes

area

n se

ctio

n in

tent

ion)

si

mpl

e ra

ndom

sam

plin

g,

incl

usio

n cr

iter

ia in

bot

h gr

oups

, th

e pr

egna

nt w

omen

hav

ing

thei

r fir

st c

hild

w

ante

d ca

esar

ean

sect

ion

duri

ng 2

5–30

wee

ks o

f ge

stat

ion,

no

clea

r ba

rrie

rs to

na

tura

l chi

ldbi

rth,

exc

lusi

on

crit

eria

in b

oth

inte

rven

tion

an

d co

ntro

l gro

ups,

incl

udin

g th

e ab

senc

e of

pre

gnan

t wom

en

duri

ng tr

aini

ng s

essi

ons

(abs

ence

m

ore

than

two

sess

ions

), th

e un

avai

labi

lity

of p

regn

ant w

omen

, in

com

plet

e qu

esti

onna

ire,

and

te

rmin

atio

n of

pre

gnan

cy fo

r an

y re

ason

, dat

a co

llect

ion

is a

st

ruct

ured

que

stio

nnai

re b

ased

on

the

rese

arch

obj

ecti

ves

and

the

use

of s

cien

tific

sou

rces

Des

crip

tive

sta

tist

ics,

in

fere

ntia

l sta

tist

ics

(ind

epen

dent

t-te

st a

nd

pair

ed t-

test

)

70 (3

5 su

bjec

ts in

the

inte

rven

tion

gr

oup

and

35

subj

ects

in th

e co

ntro

l gro

up)

Trai

ning

bas

ed o

n pr

e-te

st

anal

ysis

on

the

mat

erna

l fea

r fr

om n

atur

al c

hild

birt

h, c

aesa

rean

se

ctio

n di

sadv

anta

ges

and

natu

ral

child

birt

h ad

vant

ages

, in

seve

ral

50-6

0 m

in tr

aini

ng s

essi

ons

(num

ber

of s

essi

ons

depe

ndin

g on

the

char

acte

rist

ics

of th

e ta

rget

gr

oup)

, lec

ture

, gro

up d

iscu

ssio

n,

ques

tion

and

ans

wer

, Pow

erPo

int

soft

war

e fo

r th

e in

terv

enti

on g

roup

. A

t the

fina

l ses

sion

, the

film

on

two

type

s of

nat

ural

chi

ldbi

rth

and

caes

area

n se

ctio

n w

ere

show

n to

the

part

icip

ants

Iran

Safa

ri

Mor

adab

adi e

t al

. (20

14) (

50)

Trai

ning

the

husb

and

of p

regn

ant w

omen

ca

n be

eff

ecti

ve in

th

e kn

owle

dge

and

posi

tive

att

itud

e of

sp

ouse

s fo

r na

tura

l ch

ildbi

rth

and

redu

ctio

n of

sel

ecti

ve

caes

area

n se

ctio

n

Cae

sare

an s

ecti

on in

th

e ca

se g

roup

was

m

uch

less

than

the

cont

rol g

roup

(29.

5%

vers

us 5

0%)

The

stud

y ty

pe w

as e

xper

imen

tal

and

the

rese

arch

pop

ulat

ion

incl

uded

the

preg

nant

wom

en a

t 28

–32

wee

ks a

nd 4

wee

ks a

fter

tr

aini

ng, t

he k

now

ledg

e an

d aw

aren

ess

of th

e st

udie

d gr

oup

(cas

e an

d co

ntro

l gro

up) w

as

eval

uate

d

inde

pend

ent t

-tes

t, pa

ired

t-te

st, c

hi-

squa

re te

st, A

NO

VA

88 p

regn

ant

wom

enD

ivid

ing

the

husb

ands

of t

he c

ase

grou

p in

to th

ree

grou

ps o

f 13–

15

subj

ects

, dur

atio

n of

trai

ning

for

90 m

inut

es, e

duca

tion

al c

onte

nt

of th

e m

echa

nism

of n

atur

al

child

birt

h an

d ca

esar

ean

sect

ion,

th

eir

disa

dvan

tage

s an

d ad

vant

ages

, tr

aini

ng m

etho

d (l

ectu

re a

nd Q

& A

se

ssio

ns)

Iran

Shar

ifira

d et

al.

(201

3) (5

1)

Impl

emen

ting

the

stan

dard

chi

ldbi

rth

man

agem

ent c

an

redu

ce p

rim

ary

caes

area

n se

ctio

ns

wit

hout

hur

ting

the

mat

erna

l and

feta

l sa

fety

The

rate

of c

aesa

rean

se

ctio

n de

crea

sed

from

16%

to 1

2%. T

he

exer

cise

of e

xam

inin

g th

e fe

tal c

ord

bloo

d an

d m

aint

enan

ce o

f pa

ram

eter

s im

prov

ed

and

ther

e w

as n

o m

ater

nal a

nd p

erin

atal

co

nseq

uenc

e

This

stu

dy w

as a

com

preh

ensi

ve

eval

uati

on o

f all

prim

ary

caes

area

n se

ctio

ns fr

om

Janu

ary

1 to

Mar

ch 3

1 du

ring

20

03–

2004

and

the

resu

lts

of

the

eval

uati

on w

ere

pres

ente

d in

the

form

of a

gui

delin

e. T

hen,

th

e ra

te o

f cae

sare

an s

ecti

on a

nd

mat

erna

l and

feta

l sta

tus

wer

e ch

ecke

d be

fore

and

aft

er th

e im

plem

enta

tion

of t

he g

uide

line

No

stat

isti

cal t

est w

as

perf

orm

edN

o sa

mpl

ing

was

con

duct

ed.

Eva

luat

ion

of c

aesa

rean

sec

tion

and

pr

esen

tati

on o

f res

ults

in fo

rm o

f in

stru

ctio

ns to

rel

evan

t dep

artm

ents

. E

valu

atio

n ch

eckl

ist i

nclu

ding

m

ater

nal a

ge, d

eliv

ery

stat

us, d

eliv

ery

peri

od [b

egin

ning

of d

eliv

ery,

em

erge

ncy

leve

l, ne

cess

ity

and

need

for

post

oper

ativ

e m

onit

orin

g,

post

oper

ativ

e co

mpl

icat

ions

, etc

.]

Paki

stan

Shei

kh e

t al.

(200

8) (5

2)

Tab

le 2

. (continued)



www.mjms.usm.my32

Con

clu

sion

Res

ult

Met

hod

sS

tati

stic

al a

nal

ysis

Sam

ple

siz

eIn

terv

enti

onse

ttin

gA

uth

ors

&

Yea

r

Cha

ngin

g th

e pr

otoc

ol r

esul

ted

in a

de

crea

se in

cae

sare

an

sect

ion

wit

hout

any

co

mpl

icat

ion

in th

e in

fant

s

The

rate

of c

aesa

rean

se

ctio

n de

crea

sed

sign

ifica

ntly

from

9.4

%

to 6

.9%

. In

the

peri

od

afte

r th

e ch

ange

in th

e gu

idel

ines

(P <

0.0

1),

the

rate

of c

aesa

rean

se

ctio

n in

the

first

sta

ge

was

less

than

hal

f, 1.

8 to

0.0

9. I

t dec

reas

ed

in th

e se

cond

pha

se

but w

as n

ot s

igni

fican

t be

twee

n pe

riod

s. I

n ad

diti

on, t

he d

urat

ion

of th

e de

cisi

on to

pe

rfor

m c

aesa

rean

se

ctio

n w

ith

rega

rd to

th

e ce

rvic

al p

osit

ion

was

sig

nific

antl

y lo

nger

in

the

first

chi

ldbi

rth

The

stud

y ty

pe w

as b

efor

e-an

d-af

ter

coho

rt. T

he s

tudy

pop

ulat

ion

incl

uded

the

preg

nant

wom

en

havi

ng th

eir

first

chi

ld w

ith

a ge

stat

iona

l age

of m

ore

than

37

wee

ks. T

he s

tudy

pla

ce w

as o

ne o

f th

e un

iver

sity

affi

liate

d ho

spit

als

Stat

isti

cal a

naly

sis

usin

g R

stu

dio

vers

ion

0.99

.896

(CR

AN

) so

ftw

are,

X2 t

ests

, Fi

sher

test

, odd

s ra

tio

and

inde

pend

ent T

The

part

icip

ants

w

ere

3,28

3 pe

ople

bef

ore

inte

rven

tion

and

3,

068

peop

le

wer

e af

ter

inte

rven

tion

Cha

ngin

g th

e gu

idel

ines

or

chan

ging

th

e de

finit

ion

of th

e va

riou

s st

ages

of

natu

ral c

hild

birt

h

Fran

ceTh

uilli

er e

t al.

(16)

Org

anis

atio

nal a

nd

polic

y in

terv

enti

ons

can

redu

ce th

e am

ount

of p

ropo

sed

caes

area

n se

ctio

n an

d th

is in

dex

shou

ld

be c

onsi

dere

d as

on

e of

the

indi

cato

rs

for

asse

ssin

g th

e ho

spit

als

Aft

er a

pply

ing

orga

nisa

tion

al

inte

rven

tion

s, th

e ra

te

of c

aesa

rean

sec

tion

de

crea

sed

by 1

2%.

The

aver

age

annu

al

grow

th o

f thi

s in

dex

decr

ease

d fr

om 2

0.11

to

-4.3

0. A

fter

pol

icy

inte

rven

tion

s, th

e ov

eral

l cae

sare

an

sect

ion

rate

and

ann

ual

prob

abili

ty d

ecre

ased

A b

efor

e-an

d-af

ter

stud

y th

at w

as

cond

ucte

d du

ring

200

6–20

14 in

th

ree

clin

ical

clin

ics

in C

hina

Chi

-squ

are

test

and

pr

edic

ted

mod

el31

2,13

1Po

licy

inte

rven

tion

s in

clud

ing

the

Impl

emen

tati

on o

f eva

luat

ion

prog

ram

s su

ch a

s th

e in

dica

tors

of

cont

rol a

nd q

ualit

y m

anag

emen

t fo

r co

mpr

ehen

sive

hos

pita

ls, a

nd

ulti

mat

ely

the

impa

ct o

f the

se

polic

ies

on e

ncou

ragi

ng m

othe

rs to

ca

rry

out n

atur

al c

hild

birt

h by

the

heal

th c

are

team

. Org

anis

atio

nal

inte

rven

tion

s in

clud

e ed

ucat

ion

for

mot

hers

and

thei

r fa

mili

es b

y ph

ysic

ians

and

nut

riti

onis

ts o

nce

or tw

ice

a w

eek,

trai

ning

thro

ugh

billb

oard

s, c

aesa

rean

sec

tion

by

spec

ialis

t tea

ms,

par

tici

pati

on o

f m

idw

ives

in e

duca

tion

al c

lass

es

annu

ally

, use

of p

ainl

ess

child

birt

h in

th

e ho

spit

al

Chi

naYu

et a

l. (2

017)

(53)

Tab

le 2

. (continued)

www.mjms.usm.my 33


Discussion

The results of this study indicated that education is effective in reducing caesarean section. The results of this study are consistent with studies of Spinelli et al. (18) and Ferguson et al. (19) but inconsistent with the studies of Artieta-Pinedo et al. (20) and, Bostani and Rafat (21).

It seems that the differences in the studied population such as the level of education, attitude of people and the readiness of people to attend educational classes are not affected by the difference between the results obtained from these studies. Other factors affecting the outcomes of education includes the skills and experiences of the trainer, the extent he addressed all the aspects of the subject and whether he was able to transfer it to the learners. In addition, the number of learners and their interest in learning, the time and number of hours spent in the classroom are influential in this regard.

The findings of this study indicated that training the husbands is effective in reducing caesarean section. Noghaee and Hadizadeh indicated that implementing the educational programme and raising the awareness of men can be effective in social protection of women (22).

Considering that men are one of the important pillars of reproductive health services, their role as the closest person to their spouse was confirmed in supporting the women and running family planning programmes. Thus, it is suggested that men should be trained and justified to transfer the learned knowledge to their spouses, which results in increasing women’s awareness and reducing caesarean section.

Sharghi et al. indicated a significant relationship between the opinion of the spouse and the desire to choose caesarean section (23). In another study, Faraji Darkhaneh and Farjad Bastani indicated that 64% of women considered the role of the spouse in choosing the method of childbirth (24).

The results of this study indicated that using a midwife is effective in reducing caesarean section. As a result, the presence of a midwife after the childbirth, facilitates the pregnant women readiness for infants and postpartum affairs. Furthermore, the results of Kozhimannil et al.’s study indicated that the presence of a

midwife is effective in reducing caesarean section (25).

Considering the role of midwife in the care of pregnant women before, during and after childbirth, as well as preventing the complications and risks of pregnancy by this group of people, it is recommended to pay more attention to this issue and provide special conditions and facilities for using pregnant women including the easy and inexpensive access.

The results of this study indicated that the evaluation and indication of caesarean section as well as using the feedback to specialists had a slight effect on the rate of caesarean section. The results of Khunpradit et al.’s review study (26) are in line with the results of this study. The results of Tavarez et al.’s study indicated that the feedback of performance to pediatric emergency physicians over a three-month period is ineffective in the management of patients with diarrhea and vomiting (27). In another study, Tu et al. confirmed that the announcement of hospital indicators is ineffective in improving the indices (28). The results of these studies were inconsistent with those in the present study.

Based on the results of a meta-analysis study, feedback and evaluation were effective at a rate of 13% in reducing the caesarean section (29). In addition, the results of some studies are not in line with those in the present study (30–33).

It seems that the underlying characteristics of the environment where feedback is performed including the amount of personnel’s attention and belief in feedback is not ineffective in the obtained results. Sargeant et al. indicated that the reaction and perception of physicians to multi-stage feedbacks can affect their performance (34). However, the characteristics of service providers, the way of providing feedback and the extent of real feedback to personnel may not be ineffective in their feedback.

Physician-patient relationship culture in Iran indicates that medical team can play an important role in controlling or stimulating caesarean statistics. It is suggested that physicians should always be given the necessary feedback in this regard. Obviously, this control has a moral value physically and economically. The findings of this study stated the level of tariffs on caesarean section reduction. The results of the study by Fabri and Murta confirmed this finding (35).


www.mjms.usm.my34

Interventions in the developed countries (change in guidelines) were more systematic in this study and involved a wide range of women, leading to the better process of natural childbirth and caesarean section reduction. However, the interventions in developing countries including Iran had a personal dimension including only a few people who are learners. The lack of transparency in the research method in a limited number of studies was one of the limitations encountered by the researchers in this study. It is suggested that future studies should include the interventions, which are more systematic and functional.

Conclusion

Finally, the researcher believed that modifying the referral system for childbirth is considered as the most important method for reducing the caesarean section. All the patients should first be examined by midwife and referred to a specialist in case of necessity and the need for the indications of caesarean section. Further, training the pregnant women and their husbands, performing natural childbirth as free, studying and making decision for caesarean section by experienced physicians in the hospital, encouraging natural childbirth with the spread of painless childbirth are considered as effective.

Acknowledgements

The researchers would like to thank the Clinical Research Development Unit of the Educational Treatment Center of Imam Reza (PBUH).

Conflict of Interest

None.

Funds

None.

Authors’ Contributions

Conception and design: FMAnalysis and interpretation of the data: FM, ASDrafting of the article: FM, MHCritical revision of the article for important intellectual content: MHFinal approval of the article: FM, AS, MHProvision of study materials or patients: SRSStatistical expertise: ASObtaining of funding: FMAdministrative, technical, or logistic support: FM, MH, AA, AS, SRSCollection and assembly of data: FM, AA, AS, MH, SRS

Correspondence

Dr Ali SoroushLife Style Modification Research Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran.Tel: +989 1883 09157Fax: +083 3427 6301E-mail: [email protected]

References

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