Introduction
Methods
Qualitative comparative analysis (QCA)
Data sources, case selection, and defining outcomes
Developing a logic model
Identifying data sources and selecting cases
Defining outcomes
Assessing risk of bias in main intervention studies
QCA stage 1: Identifying conditions, building data tables and calibration
QCA stage 2: Constructing truth tables
QCA stage 3: Checking quality of truth tables
QCA stage 4: Identifying parsimonious configurations through Boolean minimization
QCA stage 5: Checking the quality of the solution
QCA stage 6: Interpretation of solutions
Results
Overview of included studies
Study characteristics | n (%) n = 21 | References |
---|---|---|
Setting | ||
High income countries | 12 (57.1%) | |
Middle-income countries | 8 (38.1%) | |
Low-income countries | 1(4.8%) | [35] |
Data collection period | ||
< 2000 | 7 (33.3%) | |
2000–2010 | 5 (23.8) | |
> 2010a | 9 (42.9%) | |
Study design | ||
Randomized controlled trial | 5 (23.8%) | |
Before and after | 7 (33.3%) | |
Interrupted time series | 8 (38.1%) | |
Retrospective cohort | 1 (4.8%) | [73] |
Type of women | ||
All pregnant women | 14 (66.7%) | |
Women with low-risk pregnancy | 6 (28.6%) | |
Women with previous CS | 1 (4.8%) | [67] |
Baseline CS rate | ||
< 20% | 3 (14.3%)b | |
20–39% | 7 (33.3%)b | |
30–39% | 3 (14.3%) | |
≥ 40% | 9 (42.9%) | |
Outcomes | ||
Successful interventions | 14 (66.7%) | |
Unsuccessful interventions | 7 (33.3%) |
Qualitative comparative analysis of the audit and feedback interventions
Model 1 – Implementing training to improve providers knowledge and clinical skills |
The existing qualitative evidence synthesis and intervention component analysis indicated four different themes relating to training [18, 28, 34, 44, 86]. Firstly, healthcare providers are often reluctant to implement new CS programs or to implement overall change due to perceived insufficiency of skills and knowledge on labour and vaginal birth management, especially the younger generation [28]. Secondly, healthcare providers and other stakeholders (i.e. policy makers, hospital managers) emphasised the importance of implementing various training or education for healthcare providers [18, 28, 86]. This training includes clinical skills training in labour and vaginal birth, recommendations in practice, clinical audit and program content itself [18, 28, 86]. Thirdly, both providers [28, 86] and trialists [34, 44] mentioned that the underlying factor of success lies on providers’ beliefs about CS and vaginal birth, as well as whether providers are willing to step out of their comfort zone to. Lastly, providers mentioned that they preferred the intervention to be reflective in nature, instead of dictatorial and enforcing [28] |
Model 2 – The audit and feedback process |
In relation to audit and feedback process, the existing qualitative evidence synthesis and intervention component analysis revealed three different themes [28, 86]. Firstly, the process of conducting audit and feedback was considered critical by healthcare providers, as the content, methods of delivery, and timing of audit and feedback influenced how they feel about the intervention overall [86]. Secondly, some providers were concerned that audit and feedback may pose a threat to their identities and careers [28]. Therefore, the more acceptable the structure of feedback is to the providers (i.e. feedback delivered individually instead in group), the better they respond to it, thus increasing its effectiveness [86]. Thirdly, findings by Kingdon et al. also revealed organisations which were able to reduce CS are often characterised by having healthcare providers who valued continuous quality improvements, such as clinical audits, second opinion, continuing education [28] |
Model 3 – Working relationship and environment |
In terms of working relationship and environment, existing qualitative evidence syntheses by Kingdon et al. revealed three themes [18, 28]. Firstly, multi-disciplinary collaboration between doctors, midwives, nurses and other maternity care providers was pointed as a key element in optimising CS [18, 28]. Multi-disciplinary collaboration has been observed as very poor in health facilities with high CS rates, and actively present in health facilities with low CS rates [18, 28]. Secondly, healthcare providers reported about the unequal and hierarchical power relations when caring for women. Working relationships, collaboration and communication may also be diminished through hierarchy-driven fear, which may be present when for example midwives are considered to have fewer skills than doctors [18, 28]. Thirdly, Kingdon et al. also emphasized the effectiveness of interventions to reduce unnecessary CS is strongly mediated by stakeholder commitment and organizational buy-in or, systems and policy changes that facilitate vaginal birth [18] |
Actionable recommendations: each audit and feedback cycle produced actionable recommendations that healthcare providers could act upon until next cycle |
Active dissemination of CS indications: implementation CS indications, such as clinical algorithms on when to conduct CS, through guidelines or protocol implementation, information, education and communication (IEC) materials, or reminder systems) |
Dictated nature of intervention: intervention which used top-down enforcement where mandate to reduce CS was imposed |
Frequent audit and feedback cycle: frequent audit and feedback cycle which classified either weekly or monthly |
Healthcare providers’ willingness to change: providers willingness to adopt to change and adhere to the intervention. Willingness to change was added as it becomes and overarching factor across qualitative evidence syntheses [28, 86] and discussion section of trials reports [34, 44] – where both providers and trialists mentioned that the underlying factor of success lies on providers’ beliefs about CS and vaginal birth, as well as whether providers are willing to step out of their comfort zone to change |
Individual dissemination of audit and feedback results: dissemination of audit and feedback results to providers individually instead in group settings |
Internal policies that support vaginal birth: whether internal policies that support vaginal birth or the intervention exists outside of the intervention. This include national consensus in improving CS rates where CS is nationally treated as a measure of institutional and individual practice quality [44], recommended maternity practices supporting physiologic birth [39, 41, 43, 45], national guidelines on vaginal birth after caesarean (VBAC) [67], equipment and technical support for local healthcare facilities [63], implementation of new care models favouring physiologic birth [65], additional rooms to support physiologic birth [65], hire full-time obstetricians [34], and increase staffing in the labour ward [34] |
Multidisciplinary collaboration: when the intervention involved different cadre of health workers in caring for women, which could include team of obstetricians, midwives, nurses, and doctors working together |
Reflective nature of intervention: Leveraged bottom-up approach through discussions and consultations |
Training to improve providers’ knowledge and skills: implementation of theory-based or practical education session for healthcare providers to improve their knowledge and skills on labour management |
Model 1 – Implementing training to improve providers knowledge and clinical skills (n = 15 cases)
Row | Training to improve knowledge and skills | Active dissemination of CS indications | Providers’ willingness to change | Dictated | CS outcome | Number of studies | Inclusion scorea | PRIb | Cases |
---|---|---|---|---|---|---|---|---|---|
1 | 1 | 1 | 0 | 0 | 1 | 2 | 1 | 1 | |
2 | 0 | 1 | 1 | 0 | 1 | 3 | 1 | 1 | |
3 | 1 | 0 | 1 | 0 | 1 | 3 | 1 | 1 | |
4 | 1 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | [73] |
5 | 1 | 1 | 0 | 1 | 0 | 2 | 0 | 0 | |
6 | 0 | 1 | 0 | 0 | 0 | 2 | 0 | 0 | |
7 | 0 | 1 | 0 | 1 | 0 | 1 | 0 | 0 | [46] |
8 | 1 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | [45] |
Model 2 – The audit and feedback process (n = 15 cases)
Row | Individual dissemination | Actionable recommendations | Frequency of audit and feedback cycle | Dictated | CS outcome | Number of studies | Inclusion scorea | PRIb | Cases |
---|---|---|---|---|---|---|---|---|---|
1 | 0 | 1 | 0 | 1 | 1 | 1 | 1 | 1 | [73] |
2 | 0 | 1 | 1 | 0 | 1 | 4 | 1 | 1 | |
3 | 1 | 1 | 0 | 0 | 1 | 1 | 1 | 1 | [39] |
4 | 1 | 1 | 1 | 0 | 1 | 3 | 1 | 1 | |
5 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | [45] |
6 | 0 | 1 | 1 | 1 | 0 | 2 | 0 | 0 | |
7 | 1 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | [44] |
8 | 1 | 0 | 1 | 0 | 0 | 1 | 0 | 0 | [41] |
9 | 1 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | [46] |
Model 3 – Working relationship and environment (n = 15 cases)
Row | Multidisciplinary collaboration | Providers' willingness to change | Internal policies | CS outcome | Number of studies | Inclusion scorea | PRIb | Cases |
---|---|---|---|---|---|---|---|---|
1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | [34] |
2 | 1 | 1 | 0 | 1 | 2 | 1 | 1 | |
3 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | [39] |
4 | 1 | 0 | 0 | 1 | 3 | 1 | 1 | |
5 | 0 | 1 | 0 | 1 | 2 | 1 | 1 | |
6 | 0 | 0 | 0 | 0 | 2 | 0 | 0 | |
7 | 0 | 0 | 1 | 0 | 2 | 0 | 0 | |
8 | 1 | 0 | 1 | 0 | 2 | 0 | 0 |
Consolidated model – Important conditions to prompt successful interventions targeting healthcare providers (n = 15 cases)
Row | Training to improve knowledge and skills | Active dissemination of CS indications | Providers’ willingness to change | Actionable recommendations | Multidisciplinary collaboration | Dictated | CS outcome | Number of studies | Inclusion scorea | PRIb | Cases |
---|---|---|---|---|---|---|---|---|---|---|---|
1 | 0 | 1 | 1 | 1 | 0 | 0 | 1 | 2 | 1 | 1 | |
2 | 0 | 1 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 1 | [40] |
3 | 1 | 0 | 1 | 1 | 1 | 0 | 1 | 2 | 1 | 1 | |
4 | 1 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | [73] |
5 | 1 | 0 | 1 | 1 | 0 | 0 | 1 | 1 | 1 | 1 | [38] |
6 | 1 | 1 | 0 | 1 | 1 | 0 | 1 | 2 | 1 | 1 | |
7 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | [44] |
8 | 0 | 1 | 0 | 0 | 0 | 1 | 0 | 1 | 0 | 0 | [46] |
9 | 0 | 1 | 0 | 0 | 1 | 0 | 0 | 1 | 0 | 0 | [41] |
10 | 1 | 0 | 0 | 0 | 1 | 0 | 0 | 1 | 0 | 0 | [45] |
11 | 1 | 1 | 0 | 1 | 0 | 1 | 0 | 2 | 0 | 0 |
Sub-analysis – Interventions targeting both women and healthcare providers or systems (n = 21 cases)
Row | Training to improve knowledge and skills | Active dissemination of CS indications | Providers' willingness to change | Actionable recommendations | Multidisciplinary collaboration | Dictated | Multi-target interventions | CS outcome | Number of studies | Inclusion scorea | PRIb | Cases |
---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | 0 | 1 | 1 | 1 | 0 | 0 | 0 | 1 | 2 | 1 | 1 | |
2 | 0 | 1 | 1 | 1 | 1 | 0 | 0 | 1 | 1 | 1 | 1 | [40] |
3 | 1 | 0 | 0 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 1 | [73] |
4 | 1 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 3 | 1 | 1 | |
5 | 1 | 0 | 1 | 1 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | [38] |
6 | 1 | 0 | 1 | 1 | 1 | 0 | 0 | 1 | 2 | 1 | 1 | |
7 | 1 | 1 | 0 | 1 | 0 | 1 | 1 | 1 | 2 | 1 | 1 | |
8 | 1 | 1 | 0 | 1 | 1 | 0 | 0 | 1 | 2 | 1 | 1 | |
9 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | [44] |
10 | 0 | 1 | 0 | 0 | 0 | 1 | 0 | 0 | 1 | 0 | 0 | [46] |
11 | 0 | 1 | 0 | 0 | 1 | 0 | 0 | 0 | 1 | 0 | 0 | [41] |
12 | 1 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 1 | 0 | 0 | [45] |
13 | 1 | 0 | 0 | 1 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | [68] |
14 | 1 | 1 | 0 | 1 | 0 | 1 | 0 | 0 | 2 | 0 | 0 |
Sensitivity analysis (n = 15)
Row | Training to improve knowledge and skills | Active dissemination of CS indications | Providers' willingness to change | Actionable recommendations | Multidisciplinary collaboration | Dictated | CS outcome | Number of studies | Inclusion scorea | PRIb | Cases |
---|---|---|---|---|---|---|---|---|---|---|---|
1 | 1 | 0 | 1 | 1 | 1 | 0 | 1 | 2 | 1 | 1 | |
2 | 1 | 1 | 0 | 1 | 1 | 0 | 1 | 2 | 1 | 1 | |
3 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | [46] |
4 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | [44] |
5 | 0 | 1 | 0 | 0 | 1 | 0 | 0 | 1 | 0 | 0 | [41] |
6 | 1 | 0 | 0 | 0 | 1 | 0 | 0 | 1 | 0 | 0 | [45] |
7 | 1 | 1 | 0 | 1 | 0 | 1 | 0 | 2 | 0 | 0 |
Discussion
Strength and limitations
Implications for practice, policy, and research
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1. Are trainings to improve providers’ knowledge and skills on both the intervention and labour management implemented?
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2. Are materials on CS indications actively disseminated to healthcare providers?
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3. To what extent are providers willing to change behaviours regarding CS? Have their views been assessed and addressed (e.g. as part of formative research contributing to intervention design)?
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4. Do audit and feedback cycles produce clear and actionable implementation recommendations?
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5. Is multidisciplinary collaboration between obstetricians and midwives promoted when delivering care to women?
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6. Based on questions 1–5, are dictated or reflective nature of interventions more appropriate?