When medically indicated, caesarean section can prevent deaths and other serious complications in mothers and babies. Lack of access to caesarean section may result in increased maternal and perinatal mortality and morbidity. However, rising caesarean section rates globally suggest overuse in healthy women and babies, with consequent iatrogenic damage for women and babies, and adverse impacts on the sustainability of maternity care provision. To date, interventions to ensure that caesarean section is appropriately used have not reversed the upward trend in rates. Qualitative evidence has the potential to explain why and how interventions may or may not work in specific contexts. We aimed to establish stakeholders’ views on the barriers and facilitators to non-clinical interventions targeted at organizations, facilities and systems, to reduce unnecessary caesarean section.
We undertook a systematic qualitative evidence synthesis using a five-stage modified, meta-ethnography approach. We searched MEDLINE, CINAHL, PsychINFO, EMBASE and grey literature databases (Global Index Medicus, POPLINE, AJOL) using pre-defined terms. Inclusion criteria were qualitative and mixed-method studies, investigating any non-clinical intervention to reduce caesarean section, in any setting and language, published after 1984. Study quality was assessed prior to data extraction. Interpretive thematic synthesis was undertaken using a barriers and facilitators lens. Confidence in the resulting Summaries of Findings was assessed using GRADE-CERQual.
8,219 studies were identified. 25 studies were included, from 17 countries, published between 1993–2016, encompassing the views of over 1,565 stakeholders. Nineteen Summary of Findings statements were derived. They mapped onto three distinct themes:
Health system, organizational and structural factors (6 SoFs); Human and cultural factors (7 SoFs); and Mechanisms of effect to achieve change factors (6 SoFs). The synthesis showed how inter- and intra-system power differentials, and stakeholder commitment, exert strong mechanisms of effect on caesarean section rates, independent of the theoretical efficacy of specific interventions to reduce them.
Non-clinical interventions to reduce caesarean section are strongly mediated by organisational power differentials and stakeholder commitment. Barriers may be greatest where implementation plans contradict system and cultural norms.
Citation: Kingdon C, Downe S, Betran AP (2018) Non-clinical interventions to reduce unnecessary caesarean section targeted at organisations, facilities and systems: Systematic review of qualitative studies. PLoS ONE 13(9): e0203274. https://doi.org/10.1371/journal.pone.0203274
Editor: Sharon Mary Brownie, Aga Khan University, KENYA
Received: March 28, 2018; Accepted: August 19, 2018; Published: September 4, 2018
Copyright: © 2018 Kingdon et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: The funding for this review was provided by the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP); Department of Reproductive Health and Research, World Health Organization; and the United States Agency for International Development (USAID). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Although, over recent decades, maternity care provision has resulted in improvements in maternal and infant health, there is increasing evidence of the phenomenon that has been characterised as ‘Too much, too soon, too little, too late’. [1,2] This describes the simultaneous over and underuse of interventions in pregnancy, labour and birth. Caesarean section epitomizes this situation, with substantial inequalities in caesarean section rates within and between countries. [1–3] At the same time as lack of access to caesarean section can result in increased maternal and perinatal mortality and morbidity, the global rise in caesarean section rates is associated with overuse in healthy women and babies, with consequent iatrogenic damage, and with adverse impacts on the sustainability of maternity care provision. [3–5]
Latest estimates show that rates are highest in middle-income countries and rising in most low-income countries. From 1990 to 2014, on average, caesarean section rates increased from 22.8% to 42.2% in Latin American and the Caribbean, 18.5% to 32.6% in Oceania, 22.3% to 32.3% in North America, 11.2% to 25% in Europe, 4.4% to 19.5% in Asia, and 2.9% to 7.4% in Africa.  In view of this unprecedented rise, in 2015, the World Health Organization (WHO) published a Statement on caesarean section declaring that caesarean section rates higher than 10% are not associated with reductions in maternal and newborn mortality rates, and, as for any surgical procedure, a caesarean section can result in complications, disability or death, particularly in settings that lack the facilities and/or capacity to properly conduct safe surgery.  Around the same time, the United Nation’s (UN) Sustainable Development Goals,  and calls for Right Care for health,  for every woman, every child, everywhere,  emerged as global health priorities. However, a reduction in the rate of increase in caesarean section has not yet followed these strategic intentions, with the additional hurdle that little is known about to how tackle the paradoxical over and underuse to achieve optimal caesarean section rates.  This is possibly because the reasons for excessive use of caesarean section are complex, and include non-clinical factors (such as maternal or clinician convenience, financial incentives, fear of litigation or social demands). 
In addition to the clinical and psychosocial factors that are known to affect caesarean section rates, health system, facility management and organizational factors are important aggregate-level determinants of caesarean section use.  Little is known about the influence of these agents on childbirth interventions, or about how these factors modulate the effectiveness of interventions to reduce caesarean section rates that are targeted at this level of the maternity care system. We present a qualitative evidence synthesis that aimed to add new insights into what stakeholders say are the barriers and facilitators to the implementation of non-clinical interventions to reduce unnecessary caesarean section targeted at organizations, facilities and systems (OFS).
Materials and methods
We used a modified meta-ethnography methodological approach.  (S1 Table). In our protocol  (S1 Text) we specified six objectives relating to six kinds of interventions targeted at OFS (replicating the categorization used in the Cochrane Review of non-clinical interventions to reduce unnecessary caesarean section) [11,15]. These interventions were; different types of nurse/midwife and physician staffing models; changes in the physical environment of labour; predetermined caesarean section rates set at physician-, hospital- or regional-level; financial strategies; legal liability strategies; and organisational culture.
Search strategy and selection criteria
Inclusion criteria were pre-specified as: qualitative or mixed-method studies reporting stakeholder views, undertaken in any setting where a non-clinical intervention to reduce unnecessary caesarean section targeted at OFS had been investigated or developed, published in any language, for which a full manuscript was available. Stakeholders could be anyone whose view was sought on an intervention. We surmised that stakeholders could include policy makers, healthcare managers, health professionals, women and families, but stated in our protocol that the category would be post-defined, depending on the nature of the included studies. We predefined an intervention as anything considered by the study authors as an intervention undertaken with the aim of reducing caesarean section, that was different to usual care. We, excluded clinical interventions. 
We searched CINAHL, MEDLINE, PsychINFO, EMBASE, Global Index Medicus, POPLINE and African Journals Online using MeSH and free-text terms combining up to four components: stakeholder populations; interventions of interest; caesarean section; and qualitative methods. Search strategies were informed by preliminary scoping searches, existing quantitative reviews of interventions to reduce caesarean section, [15–17], guidelines developed by the Cochrane Qualitative Research Methods Group, [18,19] and papers detailing strategies for optimising the identification of qualitative studies. [20–23] (S2 Text) A date restriction (1st January 1985 to date of last search: 22nd March 2017) was imposed to identify studies published since the WHO  consensus statement on caesarean section. We imposed no language or geographic restrictions. Back-chaining and forward checking of reference lists was undertaken. Key articles cited by multiple authors (citation pearls) were checked on Google Scholar. The authors of relevant published protocols were contacted. [25,26]
Records of included studies at the abstract stage were collated into one database and duplicates removed. Two review authors (CK,SD) independently assessed each abstract and full text to determine eligibility for inclusion against a priori inclusion and exclusion criteria. Three papers required translation and were found to be eligible for inclusion. [27–29] The view of the third author (APB) was sought before agreeing on the final list of included studies. Two studies quality assessed as C-D were excluded from the main analysis based on sampling decisions that prioritised geographical spread, and excluded lower quality studies if they were based in locations where sufficient good quality studies were already included. [30,31] These two studies and two others [32,33] investigating organisational culture in general (rather than a targeted cultural change) were used in a confirmatory capacity to test the fit of the line of argument that emerged from the study.
The analytic process followed a broad Qualitative Evidence Synthesis (QES) approach. Following the principles of meta-ethnography  data extraction and analyses were undertaken simultaneously. We did this in five stages:
- Familiarisation and quality assessment of individual studies was independently undertaken by two authors (CK,SD) using the criteria described by Walsh  and the A-D grading of Downe. 
- Data extraction whereby the characteristics of included studies, verbatim text (participant quotes) and author interpretation (themes, theories and metaphors) were entered into a form designed specifically for the purposes of the review, beginning with the earliest paper. 
- Coding with codes constructed using extracted data from the first paper and then comparing it with the findings from another until all extracted data from all included studies were coded into initial concepts.
- Interpretative synthesis was the process of grouping initial concepts into emergent themes (also termed Summary of Findings (SoFs) in QES analysis), first by looking for what was similar between the studies we had already looked at, and the one currently under review (termed ‘reciprocal analysis’), and then by looking for what might be different between the previous analysis and the paper currently under review (termed ‘refutational analysis’). This process resulted in a set of Summaries of Findings (SoFs) that explained a range of barriers and facilitators to change. The SoFs were then synthesised into final themes, and these were translated into a Line of Argument statement.
- GRADE-CERQual is an approach to assess the confidence in qualitative evidence synthesis findings. [37,38] Assessment was undertaken at the level of the SoFs, with each one assessed for four criteria: methodological quality of studies underpinning the SoF, coherence across those studies, relevance to the review question, and adequacy. Based on the GRADE approach, each SoFs was initially given a high confidence rating, and then downgraded to moderate, low or very low confidence depending on the degree to which each of these criteria were not met. (S2 Table).
Reflexive accounting allows the reader of the final research product to assess the degree to which the prior views and experiences of the researcher may have influenced the design, data collection and data interpretation of the study or in this case, the synthesis of the findings of multiple studies. This review was conceived with an informed knowledge of caesarean section and a degree of professional distance, which arguably limited bias based on the teams own experiences. APB is a medical officer with over 15 years of experience in maternal and perinatal health research and public health in general, and caesarean section in particular. CK, a medical sociologist, came to the project with prior beliefs about the complexity and interdependency of social factors driving caesarean section rates, principally informed by undertaking earlier primary research with women and health professionals in the UK. SD, a Professor of Midwifery, believed that maternity care organisations are complex adaptive systems, and that the organisational ethos can exert either toxic or enhancing effects that have real consequences for staff morale, engagement, attitudes, behaviours and performance.
Twenty-five studies (reported in 28 papers) were included, from 17 countries, published between 1993 and 2016. Sample sizes ranged from 10 to 336 participants, and the views of over 1,565 stakeholders were included. [27–29,36,39–62] Stakeholders were policy makers, managers, health professionals, women, family members and community representatives. The database searches identified 8,215 studies; from CINAHL (n = 2,225), MEDLINE (n = 644), PsychINFO (n = 330), EMBASE (n = 958), Popline (n = 1,950), Global Index Medicus (n = 1,608) and African Journals Online (n = 500). Four further studies were identified by key informants and through back-chaining reference lists. [27,29,40,61] (Fig 1) Nineteen studies were graded A or B for quality. Five were graded C, and one D. Of the 25 studies, nine were from high-income countries, five from Africa, four from Latin America, three from China, two from Iran, one from Bangladesh and one from Lebanon. Table 1 describes the characteristics of the included studies, the type of intervention used, and the quality assessment.
The studies investigated stakeholder views of different types of midwife staffing models [36,50,52–54]; financial strategies [28,29,43–44,48,58–60]; and organisational culture [27,40,42,46,47,49,51,55–57,61,62]. We also included two studies of social (doula) support during labour [39,41], with the decision for inclusion made by consensus, because of their positive effect on caesarean section rate reduction in the associated Cochrane review of effectiveness studies.  We identified no studies specifically investigating views of legal liability interventions, changes to the physical environment, or interventions where predetermined caesarean section rates were set at physician-, hospital- or regional-level, although general views on these issues were reported in the context of particular staffing models and/or organisational culture.
Nineteen SoF statements were derived. They mapped onto three distinct themes (Table 3): Health system, organizational and structural factors (6 SoFs); Human and cultural factors (7 SoFs); and Mechanisms of effect to achieve change factors (6 SoFs).
Summary theme 1. Power, place and perverse incentives: Health system, organizational and structural factors
This theme encapsulates how structural health system, facility management and organizational factors that exist at an aggregate-level impact the values of stakeholders, and shape individual views of the feasibility, or otherwise, of interventions to reduce unnecessary caesarean section.
Supporting and challenging professional power, roles and relationships (SoFs1).
The power of the medical profession was perceived as an important barrier to overcome where doctors believed their professional identity and the safety of women was compromised by relinquishing lead professional responsibility to midwives. [50,52–54] Some midwives expressed similar concerns where midwifery confidence, skills and support were low within specific organisations [46,50,52–54] and systems. [46,47,49,52–54] As explained by this midwife in Chile, “Neither midwives nor women are empowered enough to question a medical prescription.” (: p.1153). Women too reported observing the negative effects of power differentials between doctors and midwives.  In 11 studies, reported in 13 papers [42,46,47,49,50,52–54,57,58,60–62] interventions, including initiatives to promote physiological birth in Iran , hospital primary vaginal birth in the US , normal labour and birth in the UK [50,52–54] and the humanization of birth in Japan  and Chile, [49,62] challenged the structural balance of power between stakeholders. In UK organisations where a more equal balance of power did exist between women, midwives, family doctors, and obstetrician, there was some evidence that midwifery-led staffing interventions to keep birth normal and reduce caesarean section empowered midwives to work more autonomously [50,52–54] by “…sort of put[ting] a little tag on that woman as a way of saying ‘leave her alone’, which I think some doctors respect, and some don’t” (:p.232). A further perspective on power, roles and relationships between stakeholders was offered by a nurse in the US who said; “My job is to empower them [women]. I don’t need to feel powerful…” (:p.341).
Perverse incentives, fee exemption, fee reduction and health insurance reform (SoFs 2, 3).
Financial incentives, for hospitals, doctors, or women, either to reduce caesareans, or to increase access to caesarean section when needed, were not always perceived to have had the desired effect. In one study from China insurance reform was not believed to be as influential on caesarean section rates as women’s preferences for caesareans.  From low- and middle-income countries there was evidence that financing structures, in the form of fee exemption policies [28,43,44,58–60] and insurance reform, [27,29,47,48] were mediators of access to both necessary caesarean section and unnecessary caesarean section. Whether financial interventions were successful or not was mediated by local philosophies of maternity care; inter-professional and inter-personal relationships; staff motivation to work with women or with the organisation, or simply for an income; and the expectations and demands of local women, families and communities.
For example, in a study from Senegal, the intervention was government payments for each caesarean performed, with the intention of ensuring that necessary caesarean section was accessible to all. All participants in the study (including women, medical and midwifery staff) perceived all caesareanss conducted as necessary. In a highly telling interview, an administrator spoke of the increased revenue generated by this policy as the cash-cow for the hospital; the “vaches laitières des hôpitaux.” (:p216) It was seen as a source of pride for the obstetric department, providing them with power and influence in the hospital as a whole. In Iran, insurance policy change was met with scepticism by health professionals, amid concerns that women who need a caesarean section may no longer get one, or that there might be a paradoxical increase in the misreporting of indications for caesarean section to satisfy amended insurance criteria. 
Birth environment, efficiency concerns, and organisational logistics (SoFs 4).
In 16 studies, stakeholders talked about the built environment (i.e. physical space, facilities), efficiency (i.e. time constraints on labour and staff) and/or logistical concerns (i.e. availability of equipment, theatre access) as powerful mediators of barriers or facilitators to reducing unnecessary caesarean section. [28,36,39,40–42,46,47,49,51,55–58,61,62] In high-income countries where “quick win” changes had been made to labour and delivery rooms to encourage normal labour and birth, the priority an organisation gave to maintaining them was fundamental to their effectiveness in reducing caesarean section rates. [56,61] This included changes to in-room facilities for labour and guaranteed access to operating theatres when necessary. [51,56,61] One study reported midwives’ views about how birth in a home setting reduces unnecessary caesarean section, , citing the absence of restrictions on women’s movements, environmental comforts, and efficiency concerns evident in the other 15 studies of institutional birth contributing to this SoFs. In middle-income countries inadequate facilities (lighting, bathrooms, air-conditioning and shared delivery areas), or the actual conversion of delivery rooms into operating theatres, were reported as important barriers. [42,47,55,57] The need to consider the birth environment as comprising of material facilities, but also material relations between humans and systems was evident within and between studies, and across resource settings.
Role of hospital: philosophies, purpose and structures (SoFs 5).
Type of hospital, such as whether the hospital was in the public or private sector of care, a university teaching hospital and/or a regional referral centre, was perceived by stakeholders to influence the acceptability and feasibility of specific interventions to reduce caesarean section rates. [27,36,42–44,46,47,55] This could simply be a consequence of different financing structures, clinical policies, and the working environment. However, it could also be due to the power of the predominant philosophy of pregnancy and childbirth, based on perceptions of the purpose of the particular kind of unit. For example, being a University affiliated hospital was viewed by some stakeholders as a potential barrier to caesarean section rate reduction because of the lack of continuity of care and interpersonal relationships due to task and intervention orientated pressures, , or to the organisational need for medical residents to take responsibility for births, in preference to midwives . In contrast, where larger or more academic hospitals were associated with better governance structures, this was perceived to be associated with low caesarean section rates, as in the case of Lebanon, where it was reported that caesarean section were low because rigorous audit systems [are] more common in teaching hospitals. (:p.45)
Apathy to change, interdependency and complexity of system (SoFs 6).
Across settings, the complexity of the healthcare system, were clinical and non-clinical factors inevitably converge was perceived as a barrier to simple, standardised interventions to reduce unnecessary caesarean section. [28,43,46,47,52–55,57–60]. This was partly due to the powerful impact of non-clinical factors, such as management processes, rules, regulations, and conflicting strategies. [46,47] For example, the interdependency of the British National Health Service’s internal structures and workforce (midwives, obstetricians, junior doctors), and “the hugely complex series of events”, contributing to high rates of intervention in pregnancy and childbirth, meant many participants reported that achieving higher rates of normal birth and lower rates of caesarean section was unlikely to be effectively addressed by the apparently simple solution of a clinical pathway.(:p231) In Nicaragua, healthcare providers spoke of high CS rates as a way of compensating for the multi-dimensional weaknesses in their health system (including insufficient human resource, material resource, or coverage).  This was evident in other middle- and low-income countries where antenatal care was absent, communication between all levels of the system, and between the system, staff, and women, was deficient, and infrastructural and geographic challenges of reaching skilled labour care existed. [43,47,58,59]
Summary theme 2: Norms and human relationships: Human and cultural factors
This theme captures the way in which the culture in and of organisations, facilities and systems may impact stakeholder views of interventions to reduce unnecessary caesarean section. This included the forms of behaviours that are learnt across generations, and those that are characteristic of a particular time and place.
Multi-disciplinary collaboration, role demarcation and respect (SoFs 7).
In 15 studies, the strength of multi-disciplinary teamwork in an organisation or system was reported to be an important barrier to or facilitator of caesarean section rate reduction. [40,42,46,47,49–58,60–62]. The kind of teamwork that mattered was less about working directly on the caesarean section rate, and more about the general ethos and atmosphere of mutual respect. Stakeholders from organisations or systems with high caesarean section rates said working relationships between professionals were poor, with collaboration, communication, and respectful role demarcation between professionals lacking. [56,57,61] As expressed by this Iranian midwife “in many cases of care, we need to ask other colleagues to do the examination, or other things to help but unfortunately, some colleagues do not believe in helping their colleagues” (:p.1277) . In contrast, stakeholders working within organisations with low caesarean section rates valued “working together as a team, knowing that everyone’s voice will be heard, and action is taken at every level of the organization.” (:p.45) One explanation as to why respectful teamwork may contribute to lower organisational caesarean section rates was offered by a UK midwifery manager: “everybody has greater awareness; consultants, registrars, SHOs, ultrasonographers, student midwives, student nurses, anaesthetists… they all bring a different perspective and they also take credibility back to their own peer group.” (:p.337)
Whose risks, whose benefits’? Attitudes towards risks, benefits and rates of caesarean section (SoFs 8).
Important differences in stakeholder attitudes towards caesarean section were reported. [36,39,42,46,47,50–56,59,61] Within and between studies, some health professionals described a lack of knowledge about caesarean section rates, indications or outcomes [42,51,55] while other health professionals and women perceived caesarean section as “normal”.  Some health professionals acknowledged caesarean section rates were (too) high locally, and that this might increase risks, but perceived them to be less, or no more severe, than the risks associated with vaginal delivery for mother or infant. [42,47,51,55]. In one study some specialists claimed the complications secondary to C-section are ignorable (:p.6), while other health professionals reported concerns about anaesthetic risks, surgical complications, increased recovery time, cost, and longer term consequences for women. [46,47] In a US study, an obstetrician summed up how attitudes towards caesarean section are shaped by cultural context, at the same time as suggesting the potential of human agency; “People are starting to think; are we really doing the right thing? And I think the answer is clearly no … I can’t believe that evolution is pushing us into the operating room. I think we’re pushing ourselves into the operating room… it’s almost like the perfect storm. You’re going to pay me more, I get to worry less, you’re not going to sue me, and I’ll be done in an hour.” (:p.342) Women also had varied views about birth method, some of which were resonant with those of health professionals. One important difference in women’s views was the embodiment of living with the health consequences of caesarean section. For example, in the context of Ghana’s subsistence culture, one woman said “the C-section itself becomes a disease.” (:p.e123)
Beliefs about quality of care mediated by beliefs about caesarean section (SoFs 9).
Related to stakeholders’ attitudes concerning caesarean section, were their varying beliefs about whether care quality is compromised or enhanced by reducing caesareans. [27,39–42,46–55,57–62] In the UK, US and Canada in organisations where care was focused on the promotion of normal birth and reducing, or maintaining, low caesarean section rates, some health professionals viewed this as having a positive impact on women’s birth experiences and quality of care. [40,59,61] However, within these studies [59,61] where a specific facility’s organisational culture endorsed maternal request caesarean section, and across other studies from high- and middle-income countries, health professionals’ inertia to change was based on the belief that women increasingly want caesareans and are inadequately prepared for labour and vaginal birth. [27,42,46–48,51,55,57,59,61]. Twelve studies reported women’s views, [27,39,41,42,46,48,49,58–62] including their choice of caesarean section and lack of antenatal education about labour, vaginal birth and caesareans. Two studies noted that maternity service users’ views about the acceptability of caesarean section may change (positively or negatively) as increasing numbers of women undergo the procedure, and that there is a need to understand how this relates to women’s perceptions of the quality of care. [52,42]
The value of interpersonal relationships during childbirth (SoFs 10).
In 13 studies [36,39,40,41,46,47,49,52–57,61,62] stakeholders reported valuing interpersonal relationships during labour and childbirth (including emotional labour, companionship and advocacy). In twelve high- and one middle-income country, women talked about their positive experiences of labour support from doulas and/or midwives. Health professionals also talked about the importance of partner support and one-to-one midwifery/nursing care in high-income settings where these were available. In middle-income settings the value of labour support was acknowledged, but availability was limited by too few midwives and inadequate facilities for partners to accompany women during labour.
Normative culture of intervention in childbirth (SoFs 11).
Stakeholder’s concerns that there was a normative culture of intervention in childbirth, and that this acted as an important barrier to caesarean section reduction, were voiced across high- and middle income settings. [36,39,42,46,47,49,50,52–57,61,62] These stakeholders were predominantly health professionals who valued medical care when used appropriately, but who also talked about how the over-medicalisation of childbirth may limit both their opportunities to fulfil their role optimally, and the opportunities for women to experience normal pregnancy and childbirth. Some health professionals, women, and managers perceived the advantages of vaginal birth to include increased speed of recovery, improved bonding between mother and child, shorter stays at the facility, lower costs for the health system, and, as stated by a decision-maker professional at a local level in Nicaragua, “it is physiological.” [55:p.2387] In contrast, there was recognition across settings, that “some doctors’ routine prescription is intervention.” [57:1377] That quote, from a participant in Iran, is illustrative of a general culture of intervention. Other stakeholders talked about specific practices, such as shift handover, where it was the norm for some staff engage in the process of “cleaning up”, about which, a paediatrician from the USA said: “I’ll come in and the C-section fairy is on.” [61:p.341]
Widely desired in principle but not universally acceptable in practice: standardising care (SoFs 12).
In 8 studies [40,42,50–55,57,58] health professionals and policy makers reported that shifts to standardise care were widely desired, but not universally acceptable in practice. Many stakeholders said they had high expectations of guidelines, care pathways or screening tools to reduce unnecessary caesarean section. They were particularly confident about such instruments of change if they were evidence based, designed to be used by multi-professional teams, and developed by consensus. However, discrepancies between what policy makers said existed and what health professionals said they were aware of were evident.  Participants from organisations with low caesarean section rates recognised that “great effort has been made to ensure that staff are aware of national standards and guidelines.” [40:p.45] Where intervention content imitated existing practices some health professionals welcomed them as legitimising and supportive of their clinical judgement, [50,52–54] while other staff in the same studies, particularly more experienced staff, experienced them as constraining of clinical judgement suggesting they encouraged “robotic care” through a “tick-box-approach.” [53:p.232] The burden of tools to audit and record standardised processes, and the time this took away from direct hands on care was also noted in one cross-country study. 
Attitudes towards in-practice use of best-evidence (SoFs 13).
One of the issues that underpinned the theoretical acceptance of standardised care, but the resistance to it in practice, was the notion of which standards are ‘good’ and how far population based evidence should always be used for individuals. In organisations with low caesarean section rates the normative culture was described as “embracing of evidence and the drive to continually improve.” [40:p.45] In organisations where new interventions were introduced with the aim to reduce caesarean section rates, without taking account of local health cultural norms, professionals reported how the underpinning evidence may be seen as credible or not depending on the prior beliefs and values of specific stakeholder groups. This is illustrated by a midwife in the UK who said “It’s written down and because it’s coming from research, you’ve got all the references in front of you as to what type of research has been used and it sort of … just backs you up”, while her obstetric colleague said of the same evidence “We’re swapping one lot of vague-ish evidence for another lot of vague-ish evidence–and wait and see if anything goes wrong or not”. [54:p.728] The selective use of evidence was reported by participants within studies, across resource settings. [42,47,50,54,55]
Summary theme 3: Tackling too much caesarean section: Mechanisms of effect for change factors
The third summary theme comprises the components stakeholders identified as important to the implementation of interventions to reduce unnecessary caesarean section. This theme builds on the previous two, in illustrating some of the mechanisms to overcome entrenched power bases, and antagonistic cultural norms and behaviours.
Leading and following: Effective leadership, stakeholder involvement, and ownership to facilitate more positive attitudes towards changing workloads (SoFs 14 and 15).
In 14 studies from 13 countries, participants reported effective leadership, stakeholder involvement and ownership as crucial facilitators of commitment to reducing unnecessary caesarean section. [28,40,42,47,50–58,60–62] There was talk of the high priority caesarean section reduction should be given in the public domain (including media coverage) to engage women and their wider social networks. It was felt that this should be undertaken simultaneously with interventions across organisations, facilities and systems with respected, identifiable professional leaders at every level (both top-down and within and across peer-groups). The co-ordination of multiple mechanisms of commitment was considered essential to facilitating cultural and system change, because, as summed up by this manager, from the UK, “if you want to implement something new, you need to get lots of stakeholders on board.” [54:p.727] This also illustrates the important point that leaders can only lead effectively if they have followers who are convinced by their vision and the direction they are taking their organisation. Within and between studies, many participants expressed unmet needs for involvement in the development and implementation of interventions. For some professionals, opposition to change appeared to emerge from feelings of exclusion, alienation, limited sense of ownership, or lack of understanding of the underlying rationale for the change. [42,50,52–54,57,61] These factors were also observed in childbearing women, some of whom found it unacceptable that health professionals were making efforts to keep their labour physiological without understanding why. [52–52,61] The degree of opposition encountered was related to the extent to which an intervention was going against the local cultural norms. In such contexts, a lack of effective, sustainable leadership, little overt organisational buy-in, no mandatory requirement to change or no long-term accountability for caesarean section rates were associated with a lack of convinced followership, which was a significant barrier to change. As a midwife in Iran said “One of the problems we have is that by presenting a program, we cannot expect the program to be implemented in the best way.” [57: p1376] In another Iranian study,  and in Lebanon  and Chile , the need for a National Task Force with obstetric and midwifery representation was noted. Hospitals that achieved success in reducing rates identified nursing and medical leaders who endorsed and championed the project, and who made change an institution wide policy priority. [40,50,51,56]
Effective leadership, within and between professional groups, was also an important mediator of doctors and midwives’ openness to change in their everyday work. [42,46,47,49,50–58,60,61] This SoFs (15), is related to SoFs 7 (normative cultures of multi-disciplinary working between professionals) and others (including SoFs 3 and 4). It is distinct in its focus on attitudes towards the reassigning of workloads (shifting professional roles), new work (as a consequence of the intervention) and the importance of pre-existing workload pressures in implementation considerations. Across settings the importance of additional resource allocation was voiced. For example, in the UK, Japan, and Iran, midwives perceived midwifery care models as unmanageable unless more midwives were employed. [46,50,57] In Iran, it was also suggested that increasing the workloads of midwives had had the adverse effect of increasing caesarean section rates, as midwives came under pressure to free-up hospital beds.  Where interventions redefined the doctor’s role (family doctors and obstetricians) by shifting lead-professional responsibility to midwives, doctors discontent was evident. In the UK (Wales), doctors expressed concerns that they no longer had an overview of the overall maternity unit workload. Their new role, “placed in a much more technical position”, meaning they were confined to “coming in like the fire brigade.” [53:p.233;54:p732] Other doctors opposition to midwife led care was interpreted by study authors as fear of a shift in medical authority, loss of financial benefits, for both individuals and facilities, and the convenience of scheduled caesarean section, which made workloads more manageable (with less time on the wards, or on-call).
Addressing fears about safely reducing caesarean section rates through education and training (SoFs 16 and 17).
In 14 studies, stakeholder fears concerning the safely of reducing caesarean section rates were reported. [27,36,39,40,42,46,47,49,50,52–55,57,61,62] In the UK (in Scotland and Wales), fears about compromised clinical safety for women were described by doctors, and by some midwives, following a shift to midwifery-led models of care. [50,52–54] In contrast, in Canadian, UK and USA settings with the lowest caesarean section rates, midwives and obstetricians were more confident that support for women to give birth normally was where midwifery’s strength lay, with obstetric colleagues being well-trained to deal with any complications. [36,50,52–54,61] Practices and skill levels identified as facilitators of low caesarean section rates included “well-trained, technically facile obstetricians who feel comfortable allowing a long 2nd stage, who are competent at delivering breeches vaginally… and who encourage VBAC’s.” [40: p,44] Despite this, while some decision-makers cited several advantages to vaginal birth, many health professionals focused on the risks. Defensive practice was talked about as a barrier to reducing unnecessary caesarean section in seven studies. [27,42,46,47,49,55,61] A lack of confidence in the safety of normal birth on the part of some women was also noted [27,52–54,61], with a Midwife in Iran suggesting one reason for this was that “…society has spent more time on teaching the process of suing rather than introducing the labor to the general public.” [47p:5].
The importance of education and training that prioritises normal birth and continuous quality improvement was reported in eight studies from high- and middle income settings. [40,42,46,47,55,56,57,61] The needs discussed included better prenatal education for women, and training of health professionals in clinical skills, clinical audit and the actual programme content of specific interventions or programmes targeted to reduce unnecessary caesarean section. The need for such training to be available and accessible to all stakeholders is encapsulated in this quote from a nurse in the US: “I would provide the residents with more education on normal … I would want every single nurse on this unit to go through a childbirth education series, not the 1-day class, but a series. I would like to make the series available to every single patient here, at an affordable cost. Every single patient!” [61;p342]
Dealing with complex adaptive systems by understanding, and tailoring to local context (SoFs 18 and 19).
The importance of understanding and effectively responding to local context, culture and pre-existing initiatives was evident in 16 studies as important mediators of negotiating support or resistance to change. [27,40,42,47–58,60–62] At country level distinctions were made between Chile and Lebanon for example. In Lebanon the convenience of caesarean section was suggested to be the foremost consideration with the need to address patience and skills in vaginal delivery in the “new generation” of obstetricians. Within countries there was also evidence of how the same interventions had different effects depending both upon the culture into which they were introduced and how they were accomplished therein. [50,52–54,56,62] Existing practice patterns, including maternal request for caesarean section, staff attitudes, relationships between professional groups and synergy with other initiatives (financial strategies and incentives, other guidelines and concurrent policies, evidence-based practice, local audit priorities) were all discussed. One UK study noted concurrent strategies intended to increase the normal birth rate (i.e. targeting home birth) as potential confounders, nevertheless caesarean section and instrumental delivery rates continued to rise, with the culture of individual units a significant factor.  There was recognition of the need for local tailoring of interventions, and for acknowledgment of how local culture must be actively and continuously negotiated as part of a wider system.
The subtleties of change-in-the-making were highlighted in 14 studies that reported how adaptive, multi-faceted interventions that accommodated local adaptation could optimally contribute to successful change programmes. [28,39,40,42,46,47,50–54,56,58–61] Examples of local adaptation included moving elective caesarean sections to a newly opened operating suite, which reduced scheduling conflicts that occurred when sharing space , obstetricians learning from midwives in ways they did not learn during their training about how to counsel women in early labour , and recognising “obstetricians did not attend the initial meetings related to the initiative”; but when “a separate meeting was arranged to fit with their time commitments”, that “was well attended.” [56: p337] Stakeholders described interventions that were continuously and creatively negotiated on-the-ground in ways that were not easily captured or anticipated. The mechanisms included inspiring confidence, and patience with variation in the length of time required to bring about change in different organisational cultural contexts. Some of the factors that contributed to development and effectiveness of interventions were opportunistic. For instance, they may have capitalised on other developments in other areas of the health system, so they were built alongside a general change in culture, rather than adherence to a particular checklist, or rigid protocol. Successful programmes also tended to have built-in mechanisms for multi-disciplinary collaboration and communication, and a commitment to continuous quality improvement so that adaptations could be made as evidence of local tinkering came to light. Without mechanisms to identify and address such issues, there was some evidence of no effect on caesarean section rates, or they continued to rise, as women previously identified as "normal" were re-classified as potentially "at risk" [52–54] or indications were found to fulfil insurance criteria .
In the final interpretive synthesis stage of the analysis (Fig 2) findings were combined to represent our interpretation, through a line of argument.
Line of argument synthesis.
Maternity care is a complex adaptive system. Interventions to reduce caesarean section are unlikely to be successful unless account is taken of power, at all levels of the local health system and society, and until cultural norms and relationships are factored into the intervention process. Mechanisms of effect to achieve change include attention to effective leadership and followership; management of resistance to shifting power relations and to fear of responsibility for risk; and fostering of belief in the importance of reducing the caesarean section rate, with corresponding education of women and the training of health professionals. There is evidence to suggest this can be achieved by continuous dynamic assessment of, and tailoring to, local cultural norms and beliefs, as an essential and intrinsic part of the evaluation and implementation process of any new intervention or approach. Specific facilitators include multi-factorial programmes that build belief in, and valuing of, the need to reduce unnecessary caesarean section with all maternity stakeholders involved; authentic buy-in from effective leadership at all levels; three-way communication between women, midwives and doctors that includes listening as well as telling; and turning perceived losses (such as financial penalties, loss of professional roles and power, and perceived vulnerability to litigation) into gains (including pride in caesarean section rate, positive working relationships, better birth environments and improved quality of care for women and families).
Global health communities have begun to mobilise to address unnecessary caesarean section. [1–7,11,12,15–17] This systematic qualitative evidence synthesis illustrates how this societal willingness to change may not be effective or sustainable if it does not pay attention to the underlying mechanisms that incentivise or block successful social, organizational and system change. We found a combination of health system and cultural factors at play. This review makes explicit that approaches to optimize the use of caesarean section are more likely to succeed if they address stakeholders concerns about power, workloads and responsibilities; if they incorporate effective leadership and followership, and multidisciplinary teamwork, effective training (including women’s educational needs), collaboration and engagement; if they create a culture and environment that is consistent and supports policies, to ensure that system deficiencies do not create perverse incentives to increase caesarean section; if they consider and build upon stakeholders’ beliefs, fears and concerns on safety and quality of care; and if they have built-in adaptive mechanisms so that evolving is possible when unexpected local issues come to light.
Several quantitative systematic reviews, including a Cochrane Review, have previously evaluated the effectiveness and safety of interventions for reducing caesarean sections. [11,15–17,63–64] However, the interventions tested have resulted in limited success to date. The barriers and facilitators highlighted by this QES are a step forward to understanding why interventions may have limited success, how health system and cultural factors converge, and what the mechanisms of effect to achieve change are. It shows the interconnectedness between all stakeholders involved and how interventions to reduce unnecessary caesarean section ought to address the concerns and needs of each and every one. There is a reciprocal relationship between the design and delivery of health systems and organizations, the beliefs and values of service providers, and of service users, and the normative assumptions of local communities and societies. Each component of this interactive weave is shaped by the deficiencies, limitations and opportunities of local structures and cultures, and each has the potential to influence barriers and facilitators to change. Our findings provide a new point of departure for interventions in the future, that starts with understanding the mechanisms that are most likely to generate effective interventions, and that insists on local tailoring of the means of implementing these mechanisms, rather than with a one size fits all intervention.
Limitations and strengths of the review
To the best of our knowledge this is the first global qualitative synthesis that brings together the evidence-base of what stakeholders say are the barriers and facilitators to the implementation of non-clinical interventions to reduce unnecessary caesarean section targeted at organizations, facilities and systems. Existing studies are sparse and limited, methodologically. We were unable to undertake the sub-analyses we planned, as there were too few studies in each sub-group to do this meaningfully. The systematic methodology and GRADE-CERQual assessment we used is a strength of the review, as is the inclusion of studies from 17 countries across high-, middle- and low-income settings, including three non-English language papers. [27–29]
Implications for future research
Our findings suggest that some form of a priori formative research into a means of determining and accounting for local context and cultures may be of benefit in the design of multifaceted interventions in this area in the future, to ensure that likely mechanisms of effect are harnessed in the study design. Controlled studies of interventions, using adaptive designs, and including nested qualitative components that capture the nature and sustainability of local adaptation within randomised clusters of sites could add to the developing evidence base surrounding interventions to reduce unnecessary caesarean section. The use of the Robson’s 10 group classification is becoming increasingly internationally accepted as a means to monitor and compare caesarean section rates [7,65]. Routine monitoring of changes in practice may provide a foundation for best practice achievements that can be shared outside of traditional intervention randomised controlled trial designs.  The introduction of “living guidelines” provides an opportune platform to share best practice that can be emulated elsewhere. This may be more attuned to how the present review suggests change is achieved in practice.
The global concern on the unprecedented increase of caesarean section has translated into societal willingness to change this trend by implementing interventions to optimize the use of caesarean section. This systematic review presents the evidence-based for critical structural, health system and organizational factors that will require careful local consideration in the design and implementation of such interventions. We propose that these factors are investigated in-depth in local initial formative research to ensure that likely mechanisms of effect are harnessed in the design of any intervention considered at country level.
S2 Table. CERQual summary of evidence profile.
We would like to thank Newton Opiyo for his comments throughout the review process. We would also like to thank Qian Long and Meghan Bohren for their continuing support and discussion about the development of qualitative evidence synthesis and the GRADE-CERQual method for assessing confidence in findings.
- 1. Miller S, Abalos E, Chamillard M, Ciapponi A, Colaci D, Comandé D et al. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. Lancet. 2016; 388: 2176–92 pmid:27642019
- 2. Eshaug AG, Rosenthal MB, Lavis JN, Brownlee S, Schmidt H, Nagpal S et al. Levers for addressing medical underuse and overuse: achieving high-value health care. Lancet. 2017; 390: 191–202 pmid:28077228
- 3. Boatin AA, Schltoheuber A, Betran AP, Moller AB, Barros AJD, Boerma T et al. Within country inequalities in caesarean section rates: observational study of 72 low and middle income countries. BMJ 2018: 360: k55. pmid:29367432
- 4. Lumbiganon P, Laopaiboon M, Gulmezoglu AM, Souza JP, Taneepanichskul S, Ruyan P et al. Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007–08. Lancet. 2010; 375: 490–9. pmid:20071021
- 5. Souza JP, Gulmezoglu A, Lumbiganon P, Laopaiboon M, Carroli G, Fawole B et al. Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the 2004–2008 WHO Global Survey on Maternal and Perinatal Health. BMC medicine. 2010; 8: 71. pmid:21067593
- 6. Betran 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;11(2): e0148343. pmid:26849801
- 7. World Health Organization. WHO Statement on Caesarean Section Rates. WHO/RHR/15.02; 2015.
- 8. United Nations General Assembly. Transforming our world: the 2030 Agenda for Sustainable Development. 2015. Available from: http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E
- 9. Kleinert Sabine, Horton Richard. From universal healthcare to right care for health. The Lancet. 390:10090. https://doi.org/10.1016/S0140-6736(16)32588-0
- 10. United Nations. 2015 The global strategy for Women’s, children’s and adolescents’ health (2016–2030) available from: http://globalstrategy.everywomaneverychild.org/
- 11. Innie Chen, Newton Opiyo, Emma Tavender, Sameh Mortaz-Hejri, Tamara Rader, Jennifer Petkovic et al. Non-clinical interventions for reducing unnecessary caesarean section. Cochrane Review Update (Forthcoming)
- 12. Gibbons LL, Belizán JM, Lauer JA, Betrán AP, Merialdi M, Althabe F. The global numbers and costs of additionally needed and unnecessary caesarean sections performed per year: overuse as a barrier to universal coverage. Working Paper—World Health Report 2010. Available from: http://www.who.int/healthsystems/topics/financing/healthreport/30C-sectioncosts.pdf
- 13. Noblit GW, Hare RD. Meta-ethnography: Synthesizing Qualitative Studies. 1st ed. Thousand Oaks, California: Sage Publications; 1988.
- 14. Carol Kingdon, Soo Downe, Ana Betran. The use of interventions to reduce unnecessary caesarean sections targeted at women, communities and the public: a qualitative evidence synthesis. PROSPERO 2017 CRD42017059453
- 15. Khunpradit S, Tavender E, Lumbiganon P, Laopaiboon M, Wasiak J, Gruen RL. Non-clinical interventions for reducing unnecessary caesarean section. Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD005528.
- 16. Chaillet N, Dumont A. Evidence-based strategies for reducing cesarean section rates: a meta-analysis. Birth. 2007;34: 53–64. pmid:17324180
- 17. Hartmann KE, Andrews JC, Jerome RN, Lewis RM, Likis FE, McKoy JN et al. Strategies to Reduce Cesarean Birth in Low-Risk Women [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US). AHRQ Comparative Effectiveness Review 2012; Report No.: 12(13)-EHC128-EF.
- 18. Noyes J, Hannes K, Booth A, Harris J, Harden A, Popay J et al. on behalf of the Cochrane Qualitative and Implementation Methods Group. Chapter 20: Qualitative research and Cochrane reviews. In: Higgins JPT, Green S (editors), Cochrane Handbook for Systematic Reviews of Interventions Version 5.3.0 (updated October 2015). The Cochrane Collaboration, 2015. Available from http://qim.cochrane.org/supplemental-handbook-guidance
- 19. Booth A. Searching for qualitative research for inclusion in systematic reviews: a structured methodological review. Systematic Reviews. 2016; 5: 74. pmid:27145932
- 20. Wilczynski NLMS Hayes RB. Search strategies for identifying qualitative studies in CINAHL. Qual. Health Res. 2007;17: 705–710 pmid:17478652
- 21. Wong SSWN Hayes RB. Developing optimal search strategies for detecting clinically relevant studies in MEDINE. Stud Health Technol Inform. 2004;107: 311–316 pmid:15360825
- 22. Walters LA, Wilczynski NLMS, Hayes . Developing Optimal Search Strategies for Retrieving Clinically Relevant Qualitative Studies in EMBASE. Qual Health Res. 2006; 16: 162–8 pmid:16317183
- 23. McKibbon KAWN Hayes RB. Developing optimal search strategies for retrieving qualitative studies in PsycINFO. Eval Health Prof. 2006; 29: 440–454 pmid:17102065
- 24. World Health Organisation. Appropriate technology for birth. Lancet. 1985
- 25. Clara Bermúdez-Tamayo Mira Johri, Francisco Jose Perez-Ramos Gracia Maroto-Navarro, Africa Caño-Aguilar Leticia Garcia-Mochon et al. Evaluation of quality improvement for cesarean sections programmes through mixed methods. Implemenation Science 2014 (9):182
- 26. Kaboré C, Ridde V, Kouanda S, Queuille L, Somé PA, Agier I et al. DECIDE: a cluster randomized controlled trial to reduce non-medically indicated caesareans in Burkina Faso. BMC Pregnancy and Childbirth. 2016;16: 322 pmid:27769190
- 27. Liu L, Tao FB, Huang K. Qualitative study on affecting factors of continuing increasing in caesarean section rate in rural area. Modern Preventive Medicine. 2010; 37: 3865–9. (Chinese)
- 28. Mbaye EM, Dumont A, Ridde V, Briand V. ‘Doing more to earn more’: caesarean sections based on three cases of exemption from payment in Senegal. Sante publique. 2011;23: 207–219 (French) pmid:21896215
- 29. Zhu X, Lu H, Hou R, Pang RY. Influencing factors of natural delivery: a qualitative analysis. Journal of Nursing Administration. 2013; 13: 3–4. (Chinese)
- 30. Lotfi R, Tehrani FR, Dovom MR, Torkestani F, Abedini M, Sajedinejad S. Development of strategies to reduce cesarean delivery rates in Iran 2012–2014: a mixed methods study. Int J Prev Med. 2014; 5:1552–1556 pmid:25709791
- 31. Walton C, Yiannousiz K, Gatsby H. Promoting midwifery-led care within an obstetric unit. British Journal of Midwifery. 2005;13: 750–755
- 32. Kennedy HP, Grant J, Sandall J. Elective caesarean delivery: A mixed-method qualitative investigation. Midwifery. 2013; 29:e138–e144 pmid:23434026
- 33. Kennedy HP, Grant J, Walton C, Shaw-Battista J, Sandall J. Normalizing birth in England: A qualitative study. Journal of Midwifery and Women’s Health. 2010;55: 262–269 pmid:20434087
- 34. Walsh D, Downe S. Appraising the quality of qualitative research. Midwifery. 2006;22: 108–19. pmid:16243416
- 35. Downe S, Simpson L, Trafford K. Expert intrapartum maternity care: a meta-synthesis. Journal of Advanced Nursing. 2007; 57:127–140. pmid:17214749
- 36. Sakala C. Midwifery care and out-of-hospital birth settings: How do they reduce unnecessary caesarean section births? Soc. Sci. Med. 1993; 37:1233–1250 pmid:8272902
- 37. Lewin S, Glenton C, Munthe-Kaas H, Carlsen B, Colvin CJ, Gulmezoglu M et al. Using qualitative evidence in decision making for health and social interventions: an approach to assess confidence in findings from qualitative evidence syntheses (GRADE-CERQual). PLoS Medicine. 2015; 12 (10): e1001895. pmid:26506244
- 38. Lewin S, Bohren MA, Rashidian A, Munthe-Kaas H, Glenton C, Colvin CJ et al. Applying the GRADE-CERQual approach: making an overall CERQual assessment of confidence and creating a Summary of Qualitative Findings table. Implementation Science. 2018; 13: 2 pmid:29384079
- 39. Campero L, Garcia C, Diaz C, Ortiz O, Reynoso S, Langer A. “Alone, I wouldn’t have known what to do”: A qualitative study on social support during labour and delivery in Mexico.” Soc. Sci. Med.1998; 47: 395–403 pmid:9681909
- 40. Ontario Women’s Health Council (OWHC) Attaining and maintaining best practices in the use of caesarean sections. Report. 2000
- 41. Shelp A. Women Helping Women: The Somali Doula Initiative. IJCE. 2004; 19: 4–7
- 42. Kabakian-Khasholian T, Kaddour A, DeJong J, Shayboub R, Nassar A. The policy environment encouraging C-section in Lebanon. Health Policy. 2007;83: 37–49 pmid:17178426
- 43. Witter S, Diadhiou M. Key informant views of free delivery and caesarean policy in Senegal. African Journal Reproductive Health. 2008;12:93–112
- 44. Witter S, Drame FB, Cross S. Maternal fee exemption in Senegal: is the policy a success? African Journal of Midwifery and Women’s Health. 2009; 3: 5–10
- 45. Schmidt JO, Ensor T, Hossain A, Khan S. Vouchers as demand side financing instruments for health care: a review of the Bangladesh maternal voucher scheme. Health Policy. 2010; 96: 98–107 pmid:20138385
- 46. Behuruzi R, Hatem M, Fraser W, Goulet L, Ii M, Misago C. Facilitators and barriers in the humanization of birth in Japan. BMC Pregnancy and Childbirth. 2010; 10: 25 pmid:20507588
- 47. Yazdizadeh B, Nedjat S, Mohammad K, Rashidian A, Changizi N, Majdzadeh R. Cesarean section rate in Iran, multidimensional approaches for behavioral change of providers: a qualitative study. BMC Health Services Research. 2011; 11: 159 pmid:21729279
- 48. Huang K, Tao F, Bogg L, Tang S. Impact of alternative reimbursement strategies in the new cooperative medical scheme on caesarean delivery rates: a mixed-method study in rural China. BMC Health Services Research. 2012;12: 217 pmid:22828033
- 49. Binfa L, Pantoja L, Ortiz J, Gurovich M, Cavada G. Assessment of the implementation of the model of integrated and humanised midwifery health services in Santiago. Midwifery. 2013: 29: 1151–1157 pmid:23932035
- 50. Cheyne H, Abhyankar P, McCourt C. Empowering change: Realist evaluation of a Scottish Government programme to support normal birth. Midwifery. 2013; 29: 1110–1121 pmid:23968777
- 51. Dunn S, Sprague AE, Fell DB, Dy J, Harrold JA, Lamontagne B et al. The Use of a Quality Indicator to Reduce Elective Repeat Caesarean Section for Low-Risk Women Before 39 Weeks’ Gestation: The Eastern Ontario Experience. J Obstet Gynaecol Can. 2013; 35: 306–316 pmid:23660037
- 52. Hunter B. Implementing a National Policy Initiative to Support Normal Birth: Lessons from the All Wales Clinical Pathway for Normal Labour. J Midwifery Womens Health. 2010; 55: 226–233. pmid:20434082
- 53. Hunter B, Segrott J. Using a Clinical Pathway to Support Normal Birth: Impact on Practitioner Roles and Working Practices. BIRTH. 2010;37: 227–235 pmid:20887539
- 54. Hunter B, Segrott J. Renegotiating inter-professional boundaries in maternity care: implementing a clinical pathway for normal labour. Sociology of Health & Illness. 2014; 36: 719–737.
- 55. Colomar M, Cafferata ML, Aleman A, Castellano G, Elorrio EG, Althabe F et al. Mode of Childbirth in Low-Risk Pregnancies: Nicaraguan Physicians’ Viewpoints. Matern Child Health J. 2014; 18: 2382–2392 pmid:24740720
- 56. Marshall JL, Spilby H, McCormick F. Evaluating the ‘Focus on Normal Birth and Reducing Caesarean section Rates Rapid Improvement Programme’: A mixed method study in England. Midwifery. 2015; 31: 332–340 pmid:25467600
- 57. Janani F, Kohan S, Taleghani F, Ghafarzadeh M. Challenges to implementing physiologic birth program (PBP): A qualitative study of midwives’ opinions in Iran. Acta Medica Mediterranea. 2015; 31: 1373
- 58. Witter S. Cost and impact of policies to remove and reduce fees for obstetric care in Benin, Burkina Faso, Mali and Morocco. International Journal for Equity in Health. 2016;15:123 pmid:27483993
- 59. Rishworth A, Bisung E, Luginaah I. It's Like a Disease: Women's perceptions of caesarean sections in Ghana's Upper West Region. Women and Birth. 2016; 29: e119–e125 pmid:27265201
- 60. Lange IL, Kanhonou L, Goufodiji S, Ronsmans C, Filippi V. The costs of ‘free’: Experiences of facility-based childbirth after Benin’s caesarean section exemption policy. Social Science & Medicine. 2016; 168: e62
- 61. Kennedy HP, Doig E, Tillman S, Straus A, Williams B, Pettker C et al. Perspectives on Promoting Hospital Primary Vaginal Birth: A Qualitative Study. BIRTH. 2016; 43: 336–345 pmid:27500371
- 62. Binfa L, Pantoja L, Ortiz J, Gurovich M, Cavada G, Foster J. Assessment of the implementation of the model of integrated and humanised midwifery health services in Chile. Midwifery. 2016; 35: 53–61 pmid:27060401
- 63. Lundgren I, Smith V, Nilsson C, Vehvilainen-Julkunen K, Nicoletti J, Devane D et al. Clinician-centred interventions to increase vaginal birth after caesarean section (VBAC): a systematic review. BMC Pregnancy Childbirth. 2015; 15:16 pmid:25652550
- 64. Catling-Paull C, Johnston R, Ryan C, Foureur MJ, Homer CS. Non-clinical interventions that increase the uptake and success of vaginal birth after caesarean section: a systematic review. J Adv Nurs. 2011; 67:1662–76 pmid:21535091
- 65. Betrán AP, Vindevoghel N, Souza JP, Gülmezoglu AM, Torloni MR. A Systematic Review of the Robson Classification for Caesarean Section: What Works, Doesn't Work and How to Improve It. PLoS ONE. 2014; 9: e97769. pmid:24892928