Barriers and enablers in the implementation of a program to reduce cesarean deliveries

High rates of cesarean deliveries constitute an important public health problem. Audits, implementing best practices and giving feedback to the professionals have shown considerable promise in reducing rates of cesarean deliveries and mother-child morbidity. This study aims to identify the factors that facilitate change in practice and thus reduce the use of obstetric interventions. We analyzed the experiences of ob-gyns and nurse-midwives who work in Spain’s National Healthcare System and have been involved in the program. The interviews examined factors related to policy/management, hospitals, practitioners and patients.

The barriers identified were: 1) At the management level: limited influence of institutional policy and the scant political commitment perceived. 2) At the organizational level: separation of the hierarchical structure of doctors from that of nurse-midwives, few positive incentives and the strong threat of sanctions for malpractice, inappropriate reorganization of midwife/ob-gyns competencies, 3) Healthcare staff and facility level: reluctance to change accentuated by years of professional practice. 4) Physical resources: obsolete delivery rooms with a medical view, 5) At the professional level: medical and legal pressure, cesarean deliveries considered safe in the event of a legal claim, low motivation due to decline in working conditions, convenience-based practices. 6) Woman giving birth and her family: fear of pain, impatience while waiting for process to occur, misinformation. The enablers include: 1) At the organizational level: good coordination with paediatrics and emergency departments, 2) Training: skills updates for a less-interventionist approach, increased awareness, 3) Health professionals: satisfaction for a job well done, recognition by patients. 4) Woman giving birth: information circuits for patients and their families, trust in health professionals.

These results allow a better understanding of the problems that remain latent and that emerge in the day-to-day activity of the healthcare professionals attending births in public hospitals.

High rates of cesarean deliveries constitute an important public health problem, not only because of the potential maternal and perinatal complications resulting from interventions without clinical justification, but also because of long-term complications and higher associated costs [1].

According to the World Health Organization, at the population level, caesarean section (CS) rates higher than 10% are not associated with reductions in maternal and newborn mortality rates [1]. In 2015, the rate of cesarean deliveries in Spain was 25.3% [2], considerably higher than the figure deemed acceptable [3]. In the region of Andalusia, the rates range from 16% to 25% in publicly-financed healthcare centers, with significant variations between provinces (13%–28%) and centers [1].

In response to the rise in CS rates across Spain, the Ministry of Health released in 2008 a joint policy statement aimed at reducing unnecessary CS and promoting normal childbirth whenever possible [4]. However, these recommendations have remained quite general and decisions to opt for CS continue to be discretionary and often based on non-medical factors [5].

Although evidence on the effectiveness of various strategies to reduce cesarean rates is limited [6, 7], some studies that evaluated interventions targeting health care providers (obtaining second opinions, conducting audits with feedback, having peer reviews) suggest that such interventions are promising and have brought reductions in both cesarean rates [8‐12] and mother-child morbidity [8].

In Spain, a multicenter program was implemented at the national level by the Ministry of Health, with leadership in the Balearic Islands. The aim of this program was to reduce the number of inappropriate cesarean sections in public hospitals [13]. In Andalusia, the program was introduced in 20 public hospitals. The steps taken in this program included training professionals in best practices, performing technical audits of cesarean delivery data and giving feedback to the professionals. The audit process allowed inappropriate CS practices to be identified and corrective actions to be defined [14].

The preliminary results of the program show a decrease in obstetric interventions, although rates vary considerably among hospitals [14]. Further analysis is needed to better understand which elements of the program have acted as barriers and which have acted as enablers to achieve the program goals, how the knowledge generated can best be applied, and how existing models can be transformed so as to improve childbirth practices and system performance.

Recent qualitative studies have explored the factors interacting in the childbirth care process, at the policy/management level, at the organizational level and in relation to the women giving birth [15‐20]. These factors create a complex environment of barriers and enablers that could make the reduction of the cesarean rate more difficult [15]. However, no specific studies have been found on precisely how these factors intervene, particularly in a knowledge translation project intended to reduce the rate of cesareans.

The purpose of this study was to identify the factors that have been conducive to changing practices and reducing CS, as well as the challenges faced by professionals and hospitals in their efforts to implement the program for cesarean adequacy (PCA). The factors considered relate to policy/management, hospitals, practitioners and patients. This evaluation was carried out before the end of the program, to identify the need for adjustments and to promote optimal implementation.

A qualitative exploratory study was performed in the region of Andalusia (Spain). Participating in the study were ob-gyns and nurse-midwives working at 14 hospitals where the program was being implemented. The study was performed 6 months after initiation of the program. The PCA is explained in detail in the protocol published elsewhere [14].

This study has identified different factors that have facilitated or hindered the effectiveness of the national program to reduce the rate of cesarean deliveries in Andalusia’s public hospitals. In-depth interviews were found to be a good technique for learning the opinions and perceptions of the healthcare professionals involved in the program. This dialogue has led to a better understanding of aspects of the problem that remain latent and that emerge in the day-to-day activities of healthcare professionals attending births in public hospitals.

There are limitations to this study. This analysis may not reflect the situation in other regions, which could have different problems with access, provider relationships, or medical-legal climate. Qualitative research cannot be generalized [23], but to a theory of the phenomenon being studied, in our case, programs to reduce cesarean rates.

The PCA cesarean reduction program is based on a process of audit and feedback. Audit and feedback is a common implementation intervention that has been used in a variety of clinical contexts and evaluated in three Cochrane reviews and updates over the past 30 years [24‐27]. In the field of cesarean reduction, it is a very promising methodology, although results to date have been modest [7, 8]. The results of this study can contribute to the design of more effective interventions based on overcoming obstacles, highlighting enabling factors and making an effort to (re)define the boundaries between research and practice.

In Spain, a number of transformations are taking place within the National Healthcare System and in the external factors that influence it, which in turn have an effect on the PCA. Among the healthcare policy changes that affect obstetrics departments, the reorientation of clinical practice toward the humanization of delivery has been especially significant and has brought important changes on different levels [26]. The strategy set by Spain’s healthcare system is to work towards establishing consensus regarding the naturalization of childbirth and to equip healthcare centers with the human and material resources necessary to favor vaginal deliveries.

The new focus on the humanization of perinatal care and the effort to reduce the rate of cesarean deliveries are part of the demand for a less interventionist clinical practice, which would imply a greater role for midwives and a change in the relationship between obgyns and midwives, along with a new distribution of competencies [28, 29]. This new context of relations is not free of conflict, as this study shows. The change in professional practice sought by the PCA project is one of the fruits of these developments. Two recently released, unrelated reports serve as stark reminders of how challenging it has been to change professional behavior in a sustained and purposeful way [30‐32].

The new framework also entails incorporating shared decision-making into the birth process, giving greater agency to the women, their decisions and their needs during pregnancy, delivery and puerperium. Légaré [33] notes that shared decision-making involves several essential elements. First, providers and patients must recognize that a decision is required. Next, they must have at their disposal, and understand, the best available evidence. Finally, they must incorporate the patient’s preferences into treatment decisions.

There are elements in this study that must be viewed as core issues. For example, midwives perceived themselves as more inclined than doctors, to adhere to the PCA and it points to the medical staff as being less inclined to intervention. The discourses underlying these opinions reflect a different attribution of responsibilities and recognition of the role of midwives. While some informants were aware of the importance of midwives in reaching the project’s goals, others underline that the decision to perform a cesarean is based on the doctor’s judgment alone. Some studies showed that the influence of the model of maternity care concerns (more humanised vs. more technology focused) not only the obstetric results but also the level of mother’s satisfaction. Higher mother’s satisfaction was found in a more humanised models of care compared with the biomedical one [34]. Other authors have also demonstrated that high levels of interventions in normal birth can lead to the dissatisfaction of women and their families [35]. The discourses formulated from feminist viewpoints or more egalitarian positions are inclined to defend greater empowerment for pregnant women because it will lead to monitoring of the delivery process and clinical practice. These discourses contain more criticism of the patriarchal and medicalized vision of childbirth and they highlight the characteristics of “biological patients” as being positive elements. More paternalistic discourses defend information being provided to pregnant women because it can reduce conflict and contribute to the acceptance of medical criteria, they consider “biological patients” to be conflictive and they are less critical of the caregiving activity and clinical practice of the personnel. Ensuring that women can take active part in their pregnancies and deliveries, can experience a less-medicalized birth in a setting of mutual listening and active collaboration among all parties, is to broaden the right of women to inclusive health and must be treated as a priority [1].

In future research, it would be interesting to examine the opinions and expectations of women giving birth. It would also be valuable to have a better understanding of the hierarchical relationships among different professionals working in delivery rooms, through the methodologies based, for example, on participant observation [36‐38].