Implementation and evaluation of nonclinical interventions for appropriate use of cesarean section in low- and middle-income countries: protocol for a multisite hybrid effectiveness-implementation type III trial

Bohren, Meghan A.; Mac, Quoc Nhu Hung; Escuriet, Ramón; Hanson, Claudia; Hansen, Claudia; Mölsted-Alvesson, Helle; Annerstedt, Kristi Sidney; Robson, Michael; Betrán, Ana Pilar; Opiyo, Newton; Bohren, Meghan A; Carroli, Guillermo; Campodónico, Liana; Gialdini, Celina; Carroli, Berenise; Camacho, Gabriela Garcia; Giordano, Daniel; Gamerro, Hugo; Romero, Mariana; Lumbiganon, Pisake; Boriboonhirunsarn, Dittakarn; Jampathong, Nampet; Kongwattanakul, Kiattisak; Ratinthorn, Ameporn; Musigavong, Olarik; Escuriet, Ramón; Canet, Olga; Kaboré, Charles; Fadima, Yaya Bocoum; Tiendrébéogo, Simon; Roger, Zerbo; Hung, Mac Quoc Nhu; Truong, Thao; Ngo, Tran Minh Thien; Toan, Bui Duc; Trang, Huynh Nguyen Khanh; Tuyet, Hoang Thi Diem; Dumont, Alexandre; Lombard, Laurence; Loenzien, Myriam de; Ravit, Marion; Visan, Delia; Hermann, Angela; Ridde, Valéry

doi:10.1186/s13012-020-01029-4

Cited by 19 publications

(34 citation statements)

References 44 publications

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“…We plan to use opinion leaders (influential and respected healthcare leaders who are effective communicators and identified by their colleagues or local authorities) at each study hospital to help support implementation. 7 We plan to engage with the opinion leaders during an intensive, 5-day pre-study training workshop, where we will present the results of this formative research and engage to design strategies to optimise implementation. 7 Engaging with the opinion leaders about the benefits of labour companionship and codesigning strategies to address barriers to implementation that are feasible and acceptable in their clinical settings will be critical.…”

Section: Discussionmentioning

confidence: 99%

“… 7 We plan to engage with the opinion leaders during an intensive, 5-day pre-study training workshop, where we will present the results of this formative research and engage to design strategies to optimise implementation. 7 Engaging with the opinion leaders about the benefits of labour companionship and codesigning strategies to address barriers to implementation that are feasible and acceptable in their clinical settings will be critical. For example, we will explore how to assuage healthcare providers’ fears that introducing companions will result in higher workloads, potentially through training solutions to help healthcare providers understand benefits of companions and how to integrate them in their care—a similar approach to Kabakian-Khasholian and colleagues.…”

Section: Discussionmentioning

confidence: 99%

“…The QUALI-DEC strategy is designed to combine four key components: (1) opinion leaders to implement evidencebased clinical guidelines; (2) caesarean audits and feedback to help providers identify potentially avoidable caesarean sections; (3) a Decision Analysis Tool to help women make an informed decision on mode of birth and (4) implementation of WHO recommendations on companionship during labour and childbirth. 7 Labour companionship is included as a QUALI-DEC intervention component given the association between continuous support and increased chance of vaginal birth 5 as well as due to emerging evidence that companionship may improve women's experience of care and reduce mistreatment during childbirth. 8 9 The QUALI-DEC strategy supports the woman to choose any person to act as her labour companion.…”

Section: Context Of Labour Companionship In Thailandmentioning

confidence: 99%

“…In the context of sustained growing caesarean section rates in Thailand, the Ministry of Health and other stakeholders are examining factors underlying the increase and interventions to optimise its use. The QUALI-DEC study: ‘Appropriate use of caesarean section through QUAL i ty DEC ision-making by women and providers’ 7 aims to design, adapt and evaluate a multifaceted strategy, for the appropriate use of caesarean section in Argentina, Burkina Faso, Thailand and Viet Nam. The QUALI-DEC strategy is designed to combine four key components: (1) opinion leaders to implement evidence-based clinical guidelines; (2) caesarean audits and feedback to help providers identify potentially avoidable caesarean sections; (3) a Decision Analysis Tool to help women make an informed decision on mode of birth and (4) implementation of WHO recommendations on companionship during labour and childbirth.…”

Section: Introductionmentioning

confidence: 99%

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Factors influencing the implementation of labour companionship: formative qualitative research in Thailand

et al. 2022

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IntroductionWHO recommends that all women have the option to have a companion of their choice throughout labour and childbirth. Despite clear benefits of labour companionship, including better birth experiences and reduced caesarean section, labour companionship is not universally implemented. In Thailand, there are no policies for public hospitals to support companionship. This study aims to understand factors affecting implementation of labour companionship in Thailand.MethodsThis is formative qualitative research to inform the ‘Appropriate use of caesarean section through QUALIty DECision-making by women and providers’ (QUALI-DEC) study, to design, adapt and implement a strategy to optimise use of caesarean section. We use in-depth interviews and readiness assessments to explore perceptions of healthcare providers, women and potential companions about labour companionship in eight Thai public hospitals. Qualitative data were analysed using thematic analysis, and narrative summaries of the readiness assessment were generated. Factors potentially affecting implementation were mapped to the Capability, Opportunity, and Motivation behaviour change model (COM-B).Results127 qualitative interviews and eight readiness assessments are included in this analysis. The qualitative findings were grouped in four themes: benefits of labour companions, roles of labour companions, training for labour companions and factors affecting implementation. The findings showed that healthcare providers, women and their relatives all had positive attitudes towards having labour companions. The readiness assessment highlighted implementation challenges related to training the companion, physical space constraints, overcrowding and facility policies, reiterated by the qualitative reports.DiscussionIf labour companions are well-trained on how to best support women, help them to manage pain and engage with healthcare teams, it may be a feasible intervention to implement in Thailand. However, key barriers to introducing labour companionship must be addressed to maximise the likelihood of success mainly related to training and space. These findings will be integrated into the QUALI-DEC implementation strategies.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Context Of Labour Companionship In Thailandmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Factors influencing the implementation of labour companionship: formative qualitative research in Thailand

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“…According to the Ottawa Decision Support framework, decision aids can improve decisionmaking by informing patients about the risks and benefits of different options for their health [15]. We developed implementation research to design and evaluate a strategy, called Quality Decision-Making by Women and Providers (QUALI-DEC), to implement interventions targeted simultaneously at women, health care providers, and health systems in order to improve decision-making for planned modes of birth in Argentina, Burkina Faso, Thailand, and Vietnam [16]. The QUALI-DEC strategy combines four active components: (1) opinion leaders to carry out evidence-based clinical guidelines; (2) caesarean audits and feedback to help providers identify potentially avoidable caesarean sections; (3) a decision-analysis tool (DAT) to help women make an informed decision on mode of birth; and (4) companionship during labour to support women during this time, as well as vaginal delivery.…”

Section: Introductionmentioning

confidence: 99%

Caesarean section or vaginal delivery for low-risk pregnancy? Helping women make an informed choice in low- and middle-income countries

Dumont

Loenzien²,

Nhu³

et al. 2022

PLOS Glob Public Health

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Women’s fear and uncertainty about vaginal delivery and lack of empowerment in decision-making generate decision conflict and is one of the main determinants of high caesarean section rates in low- and middle-income countries (LMICs). This study aims to develop a decision analysis tool (DAT) to help pregnant women make an informed choice about the planned mode of delivery and to evaluate its acceptability in Vietnam, Thailand, Argentina, and Burkina Faso. The DAT targets low-risk pregnant women with a healthy, singleton foetus, without any medical or obstetric disorder, no previous caesarean scarring, and eligibility for labour trials. We conducted a systematic review to determine the short- and long-term maternal and offspring risks and benefits of planned caesarean section compared to planned vaginal delivery. We carried out individual interviews and focus group discussions with key informants to capture informational needs for decision-making, and to assess the acceptability of the DAT in participating hospitals. The DAT meets 20 of the 22 Patient Decision Aid Standards for decision support. It includes low- to moderate-certainty evidence-based information on the risks and benefits of both modes of birth, and helps pregnant women clarify their personal values. It has been well accepted by women and health care providers. Adaptations have been made in each country to fit the context and to facilitate its implementation in current practice, including the development of an App. DAT is a simple method to improve communication and facilitate shared decision-making for planned modes of birth. It is expected to build trust and foster more effective, satisfactory dialogue between pregnant women and providers. It can be easily adapted and updated as new evidence emerges. We encourage further studies in LMICs to assess the impact of DAT on quality decision-making for the appropriate use of caesarean section in these settings.

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Low-Value Surgical Procedures in Low- and Middle-Income Countries

Albarqouni,

Abukmail,

MohammedAli

et al. 2023

JAMA Netw Open

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ImportanceOveruse of surgical procedures is increasing around the world and harms both individuals and health care systems by using resources that could otherwise be allocated to addressing the underuse of effective health care interventions. In low- and middle-income countries (LMICs), there is some limited country-specific evidence showing that overuse of surgical procedures is increasing, at least for certain procedures.ObjectivesTo assess factors associated with, extent and consequences of, and potential solutions for low-value surgical procedures in LMICs.Evidence ReviewWe searched 4 electronic databases (PubMed, Embase, PsycINFO, and Global Index Medicus) for studies published from database inception until April 27, 2022, with no restrictions on date or language. A combination of MeSH terms and free-text words about the overuse of surgical procedures was used. Studies examining the problem of overuse of surgical procedures in LMICs were included and categorized by major focus: the extent of overuse, associated factors, consequences, and solutions.FindingsOf 4276 unique records identified, 133 studies across 63 countries were included, reporting on more than 9.1 million surgical procedures (median per study, 894 [IQR, 97-4259]) and with more than 11.4 million participants (median per study, 989 [IQR, 257-6857]). Fourteen studies (10.5%) were multinational. Of the 119 studies (89.5%) originating from single countries, 69 (58.0%) were from upper-middle–income countries and 30 (25.2%) were from East Asia and the Pacific. Of the 42 studies (31.6%) reporting extent of overuse of surgical procedures, most (36 [85.7%]) reported on unnecessary cesarean delivery, with estimated rates in LMICs ranging from 12% to 81%. Evidence on other surgical procedures was limited and included abdominal and percutaneous cardiovascular surgical procedures. Consequences of low-value surgical procedures included harms and costs, such as an estimated US $3.29 billion annual cost of unnecessary cesarean deliveries in China. Associated factors included private financing, and solutions included social media campaigns and multifaceted interventions such as audits, feedback, and reminders.Conclusions and RelevanceThis systematic review found growing evidence of overuse of surgical procedures in LMICs, which may generate significant harm and waste of limited resources; the majority of studies reporting overuse were about unnecessary cesarean delivery. Therefore, a better understanding of the problems in other surgical procedures and a robust evaluation of solutions are needed.

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Implementation and evaluation of nonclinical interventions for appropriate use of cesarean section in low- and middle-income countries: protocol for a multisite hybrid effectiveness-implementation type III trial

Cited by 19 publications

References 44 publications

Factors influencing the implementation of labour companionship: formative qualitative research in Thailand

Factors influencing the implementation of labour companionship: formative qualitative research in Thailand

Caesarean section or vaginal delivery for low-risk pregnancy? Helping women make an informed choice in low- and middle-income countries

Low-Value Surgical Procedures in Low- and Middle-Income Countries

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