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Non-Clinical Interventions To Reduce Unnecessary Caesarean Sections PowerPoint Presentation

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Published on : Jun 20, 2023 | Views : 1197 | Downloads : 0

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Slide 1-

The guideline recommendations are available at
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METHODS 02 EVIDENCE BASE 03 RECOMMENDATIONS 04 IMPLEMENTATION OF THE RECOMMENDATIONS RESEARCH PRIORITIES 06 Table of contents 01 BACKGROUND 05
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Background Caesarean section as a mode of delivery Caesarean section increasing worldwide Non-clinical factors contributing to rising caesarean section rates Non-clinical interventions for reducing unnecessary caesarean sections Scope of the guideline Target audience
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Caesarean section as a mode of delivery Caesarean section is a surgical procedure that can effectively prevent maternal and newborn mortality when used for medically indicated reasons. There is no evidence showing the benefits of caesarean delivery for women or infants who do not require the procedure. As with any surgery, caesarean sections are associated with short and long term risk which can extend many years beyond the current delivery and affect the health of the woman, her child, and future pregnancies. These risks are higher in women with limited access to comprehensive obstetric care. Every effort should be made to provide caesarean sections to women in need, rather than striving to achieve a specific rate
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Caesarean section rates increasing worldwide The optimal caesarean section rate is unknown but it varies between facilities because of differences in the obstetric populations attended. Over the last decades birth by caesarean section has increased in a sustainable and continuous manner to unprecedented levels worldwide Governments and clinicians have expressed concern about the rise in the numbers of caesarean section births and the potential negative consequences for maternal and infant health. Source: Betrán AP, Ye J, Moller AB, Zhang J, Gülmezoglu AM, Torloni MR. The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990-2014. PLoS One. 2016 Feb 5;11(2):e0148343.
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Non-clinical factors contributing to rising caesarean section rates Factors associated with caesarean births include: changes in the characteristics of the population such as increase of obesity, of multiple pregnancies, of nulliparous women or of older women. These changes are unlikely, however, to explain the large increases and wide variations in caesarean section rates across countries. Other non-clinical factors have all been implicated in this increase: women increasingly wanting to determine how and when their child is born generational shifts in work and family responsibilities physician factors increasing fear of medical litigation organizational, economic and social factors
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SCOPE OF THE GUIDELINE The guideline recommendations relate to the use of CS in women with low-risk pregnancies, (specifically, healthy women with term, singleton, cephalic pregnancies), which represents majority of the obstetrical population. The guideline specifically considered those settings with high rates of caesarean section, where large numbers of caesareans are assumed to be unnecessary. Women with complications or particular obstetric risk factors (such as breech or multiple pregnancy) are not considered within the guideline. The guideline does not specify what clinical indications constitute a medically necessary CS, as the decision regarding medical necessity is according to the judgement of the treating clinician.
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Primary audience of this guideline Target audience include: health-care professionals responsible for developing regional, national and local health protocols and policies obstetricians, midwives, nurses, general medical practitioners managers of maternal and child health programmes public health policy-makers
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Methods Guideline development methods Technical groups involved in developing guideline Priority questions and outcomes Quality assessment and synthesis of evidence
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GUIDELINE DEVELOPMENT METHODS Development of a guideline proposal for the WHO Guidelines Review Committee Formation of technical groups Declaration and management of interests Formulating priority questions and outcomes Retrieval and synthesis of evidence Grading of the quality of the evidence Formulating the recommendations Planning for dissemination, implementation, evaluation and updating of the guideline A systematic evidence-based approach
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Technical groups involved in developing guideline WHO Steering Group This comprises staff members from the WHO Departments of Reproductive Health and Research (RHR); Maternal, Newborn, Child and Adolescent Health (MCA), who managed the guideline development process. Guideline Development Group This consists of external experts and stakeholders from the six WHO regions. Members were identified in a way that ensured geographic representation and gender balance, and they had no important conflicts of interest. The group examined and interpreted the evidence and formulated the final recommendations at a face-to-face meeting, September 2017. Technical Working Group This comprises guideline methodologists and systematic review team leads, who worked closely with WHO Steering Group to synthesize the evidence and other considerations for development of the recommendations. External Review Group These are external experts and stakeholders from the six WHO regions, who peer-reviewed the final guideline document to identify any factual errors and comment on clarity of the language, contextual issues and implications for implementation. External partners and observers Representatives of FIGO, ICM, RCOG, UNFPA and USAID
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Priority guideline questions
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Priority guideline questions
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Priority guideline outcomes Critical outcomes Rate of caesarean section and rate of all other modes of delivery (spontaneous vaginal birth, caesarean section before labour, emergency caesarean section, instrumental vaginal birth) Perineal/vaginal trauma (e.g. vaginal tears, episiotomy) Birth trauma (e.g. fractured skull, haematoma, cerebral haemorrhage) Perinatal asphyxia (e.g. low Apgar score at 5 minutes, cord blood acidosis, needed major resuscitation) Maternal birth experience (e.g. maternal satisfaction with care) Important outcomes Maternal morbidity (e.g. peripartum infection, postpartum haemorrhage) Long-term infant outcomes (e.g. breastfeeding, childhood disability) Serious maternal morbidity (e.g. organ failure, obstetric hysterectomy, sepsis) Long-term maternal outcomes (e.g. urinary or faecal incontinence, obstetric fistula) Health-care resource utilization (e.g. length of hospital stay, maternal readmission/rehospitalization) Full PICO questions and outcomes are presented in the full guideline (Annex 1)
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QUALITY ASSESSMENT AND SYNTHESIS OF THE EVIDENCE Confidence in the quantitative evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) benefits and harms resource requirement cost-effectiveness Confidence in the qualitative evidence was assessed using Confidence in the Evidence from Reviews of Qualitative research (CERQual) values and preferences acceptability resource requirement equity feasibility GRADE Evidence-to-Decision (EtD) Framework was used to integrate evidence on benefits and harms of interventions, values, acceptability, resource use, equity, and feasibility.
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Evidence base Systematic review of quantitative evidence Systematic reviews of qualitative evidence
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Systematic review of quantitative evidence Evidence on the effectiveness of interventions was derived from an updated Cochrane review of 29 studies: 19 randomised trials, 1 controlled before-after study and 9 interrupted time series studies. Most of the studies were conducted in high-income countries. None of the studies was done in a low-income country. The studies enrolled a mixed population of pregnant women, including nulliparous women, multiparous women, women with a fear of childbirth, women with high levels of anxiety and women having undergone a previous caesarean section.
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SYSTEMATIC REVIEWs OF QUALITATIVE EVIDENCE Judgements about values, acceptability, equity, resource implications and feasibility of interventions were informed by three systematic reviews of 49 qualitative studies.
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Recommendations Formulating recommendations Interventions targeted at women Interventions targeted at healthcare professionals Interventions targeted at health organizations or systems
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FORMULATING RECOMMENDATIONS The Guideline Development Group (GDG) convened in September 2017 in Geneva, Switzerland, to review the summarized evidence and formulate recommendations. The GDG made three types of recommendations.
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INTERVENTIONS TARGETED AT WOMEN When considering the educational interventions and support programmes, no specific format (e.g. pamphlet, videos, role play education) is recommended as more effective. (Low- to moderate-certainty evidence)
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INTERVENTIONS TARGETED AT WOMEN
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INTERVENTIONS TARGETED AT healthcare professionals
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INTERVENTIONS TARGETED AT healthcare professionals
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INTERVENTIONS TARGETED AT healthcare professionals
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INTERVENTIONS TARGETED AT HEALTH ORGANIZATIONS OR SYSTEMS
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INTERVENTIONS TARGETED AT HEALTH ORGANIZATIONS OR SYSTEMS
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INTERVENTIONS TARGETED AT HEALTH ORGANIZATIONS OR SYSTEMS
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Implementation of the recommendations Barriers to implementation and strategies to address them
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IMPLEMENTATION OF THE RECOMMENDATIONS Community-level sensitization activities should be undertaken to disseminate information about the risks of unnecessary caesarean sections and the benefits of adhering to recommended practices. Lack of understanding of the value of recommended practices among women seeking maternity care, families or communities Barrier or constraint Implementation strategy Involve local opinion leaders; identify champions to promote the implementation of the recommendation. Involve training institutions and professional bodies in the introduction of the guideline so that pre-service and in-service training curricula can be updated with the recommendations. Resistance of health-care providers to changing their entrenched caesarean section practices; lack of understanding of the value of newly recommended interventions
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IMPLEMENTATION OF THE RECOMMENDATIONS Provide tailored patient education materials. Train targeted health-care professionals to provide patient education. Patients may make demands that hinder adherence Barrier or constraint Implementation strategy Organize teams in which roles are defined and they have a shared goal. Dysfunctional teamwork among health-care professionals (e.g. lack of communication between maternity and theatre staff). Lack of human resources with the necessary expertise and skills to implement, supervise and support recommended practices (e.g. senior clinicians to provide second opinion for caesarean section indication) Redistribute health-care resources; task shifting. Pragmatic consideration of what is feasible; gradual change; shifting resources from elsewhere in the health-care budget; increasing the health-care budget. Strategic long-term planning and budgeting to provide the necessary resources.
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IMPLEMENTATION OF THE RECOMMENDATIONS Adapt implementation strategies to work within the constraints of the existing systems. Strategic long-term planning and budgeting to provide the necessary resources. Lack of physical space (e.g. a venue for birth preparation classes and counselling sessions, training workshops) Barrier or constraint Implementation strategy Devise strategies to improve supply chain management according to local requirements, such as developing protocols for obtaining and maintaining the stock of supplies. Adapt implementation strategies to work within the constraints of the existing systems. Lack of essential supplies (locally adapted information, education and communication materials to support training, and support programmes, e.g. booklets or pamphlets in local languages) Lack of health information management systems designed to document and monitor recommended practices (e.g. electronic records, registers) Provide appropriate incentives to record the needed information. Strategic long-term planning and budgeting to provide the necessary resources for health information management systems.
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RESEARCH PRIORITIES The Technical Working Group and Steering Group identified areas where further studies are needed based on four broad considerations: uncertainty in the effects of the interventions due to evidence of very low or low certainty. concerns with the applicability of the evidence (particularly as most interventions were assessed in single studies; the interventions would benefit from replication in other settings). lack of studies for predefined guideline questions. promising interventions not specifically designed to reduce caesarean births that would benefit from examination in areas with high caesarean section rates (e.g. continuous one-to-one intrapartum support).
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RESEARCH PRIORITIES Future research should focus on the following areas In particular, the guideline development group emphasized that future intervention trials should be preceded with formative research to define locally relevant determinants of caesarean births.
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RESEARCH PRIORITIES Future research should focus on the following areas
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ACKNOWLEDGEMENTs WHO Steering Group Ana Pilar Betrán, Mercedes Bonet, Maurice Bucagu, A. Metin Gülmezoglu, Frances McConville, Olufemi Oladapo, Anayda Portela, João Paulo Souza, Joshua Vogel Guideline Development Group Hany Abdel-Aleem, Fernando Althabe, Guillermo Carroli, Karen Daniels, Sylvia Deganus, Tao Duan, Alexandre Dumont, Aparajita Gogoi, Anne-Beatrice Kihara, Ana Langer, Barbara Levy, Pisake Lumbiganon, Abedini Mehrandokht, Rintaro Mori, Tomas Pantoja, Sadequa Shahrook, William Stones, Elizabeth Sullivan, Maria Regina Torloni, Petr Velebil WHO Regional Advisors Mavjuda Babamuradova, Karima Gholbzouri, Bremen De Mucio, Mari Nagai, Leopold Ouedraogo Technical Working Group Soo Downe, Carol Kingdon, Simon Lewin, Newton Opiyo External Review Group Justus Hofmeyr, Ingela Lundgren, Catherine Spong, Johanne Sundby, Jim Zhang, Agustin Zongo Observers Diogo Ayres-de-Campos [FIGO]); Mechthild M. Gross [ICM]); Petra ten Hoope-Bender [UNFPA]; Mary Ellen Stanton [USAID], Alison Wright [RCOG] Funders USAID; UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP)
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CONTACT DETAILS FOR ADDITIONAL INFORMATION You can also contact WHO: Email: Department of Reproductive Health and Research: reproductivehealth@who.int Twitter: @HRPresearch Facebook:World Health Organization