Cesarean Delivery Prevention Efforts Should Target Clinicians

Norra MacReady

June 15, 2011

June 15, 2011 — To reduce the number of unnecessary Cesarean deliveries, the focus should be on clinicians, a new meta-analysis suggests.

Mandatory second opinions, peer review feedback, postcesarean surveillance to prevent repeat cesarean deliveries, and guidelines endorsed and supported by local opinion leaders were among the most effective interventions identified in the analysis. In addition, "nurse-led relaxation and birth preparation classes may reduce cesarean section rates in low-risk pregnancies," the authors state.

Cesarean delivery can save the lives of mother and baby in high-risk pregnancies, but it is rarely indicated in a low-risk pregnancy and carries its own risk for complications, such as maternal infections, hemorrhage, need for transfusions, other organ injuries, and anesthetic or psychological complications, the authors explain.

Yet the number of cesarean deliveries is rising in developed and developing countries alike. For example, in various European countries, cesarean delivery rates have jumped from 4% to 5% in 1970 to 20% to 22% in 2001, and more than half of all Latin American countries report rates in excess of 15%.

"While there may be medical reasons for this increase, many believe that non-medical factors are at least partly responsible," write the authors, led by Suthit Khunpradit, MD, from the Department of Obstetrics and Gynecology, Lamphun Hospital, Thailand. In their review, they examined the safety and efficacy of nonmedical strategies, such as educating mothers and health professionals or requiring a second opinion, designed to reduce the rate of unnecessary cesarean deliveries. The findings were published online June 15 in the Cochrane Database of Systematic Reviews.

A search of 6 databases yielded 16 eligible studies. Of the 6 studies that targeted pregnant women, only 2 were associated with lower cesarean delivery rates: a nurse-led training program for women who were anxious about childbirth and birth preparation classes. Both studies were randomized clinical trials, but they "were small in size and targeted younger mothers with their first pregnancies," the authors point out.

They add that there is still "insufficient evidence that prenatal education and support programs, computer patient decision aids, decision-aid booklets and intensive group therapy are effective."

Of 10 studies that focused on health professionals, only 3 showed any effect on reducing cesarean delivery rates: one evaluating a guideline that included a mandatory second opinion, a second involving a mandatory second opinion as well as peer review feedback, and a third looking at the implementation of a guideline with support from local opinion leaders. There was insufficient evidence to support the efficacy of audit and feedback, training of public health nurses, insurance reform, external peer review, and legislative measures.

Eleven of the studies were randomized or cluster-randomized controlled trials and were of a quality the authors deemed "reasonably good." The other 5 studies were interrupted time series analyses. "The results of these studies should be interpreted cautiously," the authors warn.

They also point out that "[t]hese conclusions are based on individual studies and caution should be exercised applying them to very different populations or with substantially different interventions."

More research is needed, they maintain, on broadly generalizable interventions, especially on low-risk pregnancies and in areas with high baseline rates of cesarean deliveries. Women considering vaginal birth after cesarean delivery are another potential target group.

The authors have disclosed no relevant financial relationships.

Cochrane Database Syst Rev. Published online June 15, 2011. Full text

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