The Best Start - caesarean section rates: review report

Evidence-informed actions to address non clinically indicated caesarean section

The World Health Organisation published guidance, in 2018 focussed on non-clinical interventions for reducing unnecessary caesarean sections.^[96] The recommendations are grouped according to the target of the intervention:

• Interventions targeted at women
• Interventions targeted at healthcare professionals
• Interventions targeted at health organisations or systems.

Interventions targeted at women

Evidence on non-clinical interventions targeted at women mostly comprises of educational interventions and support programmes. Findings of a systematic review of qualitative studies recommend that women want educational tools such as childbirth training workshops, booklets and decision aids. The content of educational materials should not provoke anxiety and needs to be consistent with advice from health-care professionals.^[97] Women also found that information from their consultant and midwife that was tailored to their personal situation would be more helpful when making a decision about their mode of birth.^[98] This recommendation from the WHO echoes many of the findings highlighted in the studies references above, particularly to tailored information provision.

Interventions targeted at healthcare professionals

Evidence on non-clinical interventions targeted at health care professionals is focussed on the effect of a policy of a second opinion for caesarean section indications. Evidence suggests that health care professionals can have differing beliefs on what constitutes a definite clinical indication for caesarean across time^[99] and often have differing methods and confidence levels of communicating information to women.^[100] Evidence from a randomised trial suggests that women who received a second opinion felt better about their decision, the findings also found that 91% of obstetricians would recommend that second opinion should be used.^[101]

Evidence also suggests that audits of indications for caesarean delivery and the provision of feedback to healthcare professionals involved in the decision making process were effective interventions. Studies have suggested that using the Robson classification system and applying this to historical data can help in analysing, screening, auditing, and comparing caesarean rates across different hospitals, countries, or regions and can help to create and implement effective strategies to address specific areas of concern or anomaly^[102],[103].

Interventions targeted at health organisations or systems

Evidence on interventions targeted at health organisations or systems is focused on collaborative midwifery-obstetrician model of care and midwife led models of care. Evidence suggests that women allocated to primarily midwife-led care (with collaborative and supportive access to obstetricians where required) throughout pregnancy were less likely to experience a caesarean section.^[104]

Evidence suggests that organisational factors such as inter-professional conflicts, dominant medical models of birth, time pressures and a culture of 'busyness' are perceived barriers to delivering midwife-led care.^[105] Studies have also shown that alternative institutional settings such as bedroom-like rooms and ambient rooms increase the likelihood of spontaneous vaginal birth, labour and birth without analgesia/anaesthesia, satisfaction with care, and decreased likelihood of assisted vaginal birth and caesarean birth.^[106] There is a growing body of research which has demonstrated the independent effects of physical attributes of the hospital room on caregivers' behaviour and patients' health outcomes.

A recent data linkage study from Australia which aimed to quantify the hospital resource savings that could occur if all low‐risk women in Australia gave birth at home or in birth centres found that caesarean section rates would have reduced from 13.4% to 3.7% if all low‐risk women gave birth at home and to 2.3% if they gave birth in a free-standing birth centre in 2017 in Australia.^[107] However, further research would be required to understand women's preferences on place of birth and also to relate these findings to births in Scotland and the UK.