Elsevier

The Lancet

Volume 392, Issue 10155, 13–19 October 2018, Pages 1358-1368
The Lancet

Series
Interventions to reduce unnecessary caesarean sections in healthy women and babies

https://doi.org/10.1016/S0140-6736(18)31927-5Get rights and content

Summary

Optimising the use of caesarean section (CS) is of global concern. Underuse leads to maternal and perinatal mortality and morbidity. Conversely, overuse of CS has not shown benefits and can create harm. Worldwide, the frequency of CS continues to increase, and interventions to reduce unnecessary CSs have shown little success. Identifying the underlying factors for the continuing increase in CS use could improve the efficacy of interventions. In this Series paper, we describe the factors for CS use that are associated with women, families, health professionals, and health-care organisations and systems, and we examine behavioural, psychosocial, health system, and financial factors. We also outline the type and effects of interventions to reduce CS use that have been investigated. Clinical interventions, such as external cephalic version for breech delivery at term, vaginal breech delivery in appropriately selected women, and vaginal birth after CS, could reduce the frequency of CS use. Approaches such as labour companionship and midwife-led care have been associated with higher proportions of physiological births, safer outcomes, and lower health-care costs relative to control groups without these interventions, and with positive maternal experiences, in high-income countries. Such approaches need to be assessed in middle-income and low-income countries. Educational interventions for women should be complemented with meaningful dialogue with health professionals and effective emotional support for women and families. Investing in the training of health professionals, eliminating financial incentives for CS use, and reducing fear of litigation is fundamental. Safe, private, welcoming, and adequately resourced facilities are needed. At the country level, effective medical leadership is essential to ensure CS is used only when indicated. We conclude that interventions to reduce overuse must be multicomponent and locally tailored, addressing women's and health professionals' concerns, as well as health system and financial factors.

Introduction

There is no debate about the need to increase access to safe caesarean sections (CSs) where the procedure is underused. However, there is no evidence of a benefit at the population level of CS for women and babies who do not require the procedure,1, 2 and, as for any surgery, there are short-term and long-term risks to CS that have been outlined in the second paper of this Series on Optimising Caesarean Section Use.3 Additionally, surgery overuse might constrain resources that could be used to address underuse.4

Consensus among the scientific and medical communities about the optimal population-level frequency of CS has not been reached.5 Even the intent to develop a global standard is contested in the scientific literature. However, there is an almost universal consensus that, in many settings, the current frequency of CS cannot be medically justified.2, 6, 7, 8 Underuse of CS has been a focus of medical literature, research, policy, and funding efforts for decades, since increasing access to CS is a priority to reduce maternal and perinatal mortality and morbidity. Overuse, however, is a more recent and less well understood phenomenon that can even coexist with underuse in many countries.9 There might be the potential, therefore, to redistribute resources in such countries to address underuse. This paper is the third in a Series on Optimising Caesarean Section Use,2, 3 and we focus here on interventions to reduce unnecessary CSs, which we define as CSs used in the absence of medical (including psychological) indications.10, 11, 12

We begin with an overview of the drivers of increasing CS use. We then examine the nature and effects of both clinical and non-clinical (behavioural, educational, and psychosocial) interventions that have been tested in studies specifically designed to safely reduce the use of births by CS. We discuss the degree to which these interventions target the underlying drivers and the mechanisms of their effect that might underpin successful reduction strategies. Finally, we propose research priorities for the future.

Section snippets

Drivers of excessive CS use

Many decisions to use CS are driven by the clinical or psychological needs of the mother or by the clinical needs of the baby, or by both. However, where frequency of use is greater than needed, the drivers fall into three broader, interconnected, and sometimes overlapping categories. These categories relate to childbearing women, families, communities, and the broader society; health professionals; and health-care systems, financing, and organisational design and cultures.

Interventions to reduce unnecessary caesareans

Interventions to reduce unnecessary CSs can be broadly conceptualised as clinical and non-clinical, although there is overlap between the two. Clinical interventions tend to target a specific clinical practice for an individual woman (eg, vaginal birth after CS [VBAC]). Such interventions might only slightly reduce CS use because CS for clinical indications represents a shrinking proportion of the overall increasing use of this operation, as reported in the first paper in this Series.2

Strategies for successful implementation of interventions

The data we have presented suggest that few interventions (clinical or non-clinical) are targeted to the several drivers of high CS use and their interactions (Kingdon et al, unpublished),45, 68, 93 which are complex, dynamic, and partly context-specific. Consequently, few of these interventions have been effective in reducing the frequency of unnecessary CSs.8, 12 For example, addressing preparedness and knowledge of pregnant women while ignoring health-care providers' demand for skill

Future research priorities

With some exceptions, interventions tested thus far to reduce unnecessary CSs have been single faceted, targeted to one group (eg, women or health-care providers), tested in a single site or country with a relatively small number of participants, and have provided low-quality or very low-quality evidence. Women's views and experiences were often not included, and medium-term and long-term follow-up was not done. Studies have rarely considered the qualitative evidence of what might work for a

Conclusions

Although there is almost universal consensus that current CS use has transgressed reasonable justification of need, effective interventions to optimise the frequency of births by CS by increasing use in settings with underuse and reducing overuse in areas where this is a key problem have proven elusive. The poor effect of these interventions in optimising the frequency of CS use might be due to the complexity of the factors that drive underuse and overuse of CS worldwide and to the prevalent

Search strategy and selection criteria

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases and two trial registries (International Clinical Trials Registry Platform and ClinicalTrials.gov) for studies published between March 29, 2010 (ie, the date of the previous version of the Cochrane review), and Aug 6, 2014. We updated our search on Feb 17, 2017, and March 8, 2018, for studies published until these dates. We searched for

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