Women’s and communities’ views of targeted educational interventions to reduce unnecessary caesarean section: a qualitative evidence synthesis

Abstract

BackgroundThere is continued debate about the role of women and communities in influencing rising rates of caesarean section (CS). In settings where CS rates exceed recommended levels, mothers and babies are exposed to potential harms that may outweigh the potential benefits. There is therefore a need to understand how educational interventions targeted at women and communities to reduce unnecessary CS are perceived and used. This qualitative evidence synthesis aimed to explore what women and communities say about the barriers and facilitators to intervention effectiveness for these important groups.MethodSeven electronic databases were searched using predefined search terms. Studies reporting qualitative data pertaining to interventions, published between 1985 and March 2017, with no language restriction were sought. Study quality was independently assessed by two authors before qualitative evidence synthesis was undertaken using an interpretive, meta-ethnography approach. Resulting Statements of Findings were assessed using GRADE-CERQual, and summarised thematically.ResultsTwelve studies were included. They were published between 2001 and 2016. Eleven were from high-income countries. Twelve Summaries of Findings encompassed the data, and were graded (moderate or high) on CerQual. The Statements of Findings are reported under three final themes: 1) Mutability of women’s and communities’ beliefs about birth; 2) Multiplicity of individual information needs about birth; 3) Interactions with health professionals and influence of healthcare system on actual birth method. Women and communities value educational interventions that include opportunities for dialogue, are individualised (including acknowledgement of previous birth experiences), and are consistent with available clinical care and the advice of the health professional they come into contact with.ConclusionWomen’s values and preferences for birth, and for information format and content, vary across populations, and evolves in individual women over time. Interactions with health professionals and health system factors can partly be responsible for changes in views. Educational interventions should take into account these dynamic interactions, as well as the women’s need for emotional support and dialogue with professionals alongside information about birth. Further research is required to test these findings and the utility of their practical application, particularly in medium and low income settings.Systematic review registration numberPROSPERO 2017 CRD42017059453.Electronic supplementary materialThe online version of this article (10.1186/s12978-018-0570-z) contains supplementary material, which is available to authorized users.

Interventions to reduce unnecessary caesarean sections in healthy women and babies

“…Pregnant women tend to identify health providers as the most important influence on their decision about mode of birth. 24,45,46 In contrast, health providers report women´s request as an important driver for performing non-medically indicated CS deliveries. A pan-European survey of 1530 obstetricians found compliance with a hypothetical women's request for CS without medical indications to be lowest in Spain (15%) and highest in the UK (79%).…”

“…65 Recent WHO recommendations on this topic (web appendix Table 1) drew on an updated Cochrane review (29 included studies), 12 and three qualitative evidence syntheses on women's and providers' views, values, beliefs and perceptions about CS, and factors related to organisations, facilities and systems (49 studies reported in 52 papers). 45,87,88 Below we present a summary of the findings of these reviews.…”

“…12 The qualitative evidence synthesis was based on 12 studies published between 2001 and 2016, undertaken in Australia, Brazil, Canada, Norway, Taiwan, UK and USA, in mostly urban settings. 45 The studies encompassed both highly motivated women who expressed an intense desire for engagement, and those who wanted the provider to make relevant decisions. Across all groups, pregnant women welcomed educational interventions.…”

Changes in perceived knowledge about childbirth among pregnant women participating in the Senses of Birth Intervention in Brazil: A cross-sectional study

“…Discussing the use of EBP might be an essential aspect to achieve a positive childbirth experience, contributing to change women's perception of fear of normal birth and believe that a cesarean is the safest type of birth. Women's voices and values need to be incorporated into a comprehensive childbirth model to reduce unnecessary C-sections (15,77).…”

A cluster-randomized field trial to reduce cesarean section rates with a multifaceted intervention in Shanghai, China

“…Despite that the rate has declined to 47.9% in 2016, it remains high [15]. Given that the causes of the high CS rate are multifactorial, previous studies suggested that multifaceted interventions be used to decrease the CS rate [5,6,[16][17][18][19][20][21][22]. However, evidence concerning effective approaches to reduce unnecessary CS is limited [23,24], especially in China and other lowand mid-income countries.…”