Periodic Reporting for period 3 - QUALI-DEC (Appropriate use of Caesarean section through QUALIty DECision-making by women and providers)
Reporting period: 2023-01-01 to 2024-06-30
Despite long-standing international concerns and debates, the proportion of caesarean births continues to rise. This trend is not limited to high-income countries, but is largely concentrated in low- and middle-income countries. Overuse of caesarean section (C-section) has adverse consequences on maternal and child health. It also deviates essential resources worldwide and hinders universal access to healthcare services.
Reducing caesarean sections will have a significant impact on quality of care for women and new-borns by reducing short-term and long-term complications. It will also reduce unnecessary healthcare expenditure.
The QUALI-DEC project aims to improve decision-making for the most appropriate mode of birth (vaginal or caesarean section) by healthcare providers and by women themselves in low- and middle income countries. It provides pregnant women, their relatives and providers with pragmatic tools to guide their choice. These include a decision aid booklet to support pregnant women in their choice of delivery mode, guidelines for women to be accompanied by a person of their choice during labour and delivery, and non-clinical tools for providers to evaluate and improve their practice. Our research focuses on the conditions under which these tools are implemented, whether they are accepted by the main stakeholders and whether they produce the expected effects.
Reducing caesarean sections will have a significant impact on quality of care for women and new-borns by reducing short-term and long-term complications. It will also reduce unnecessary healthcare expenditure.
The QUALI-DEC project aims to improve decision-making for the most appropriate mode of birth (vaginal or caesarean section) by healthcare providers and by women themselves in low- and middle income countries. It provides pregnant women, their relatives and providers with pragmatic tools to guide their choice. These include a decision aid booklet to support pregnant women in their choice of delivery mode, guidelines for women to be accompanied by a person of their choice during labour and delivery, and non-clinical tools for providers to evaluate and improve their practice. Our research focuses on the conditions under which these tools are implemented, whether they are accepted by the main stakeholders and whether they produce the expected effects.
We started our activities in January 2020. After eighteen months, we have partially achieved our objectives due to the COVID-19 pandemic. This situation limited our travel from Europe to the countries participating in the study and within the countries themselves. For this reason, some field activities could not be carried out, which caused delays in project progress.
We developed the research protocol and obtained the necessary ethical agreements to conduct this type of research in the four participating countries: Argentina, Vietnam, Thailand and Burkina Faso. We were able to complete preliminary research to understand the context and adapt our tools from the perspective of women and the health system. To compensate for the inability to travel and train healthcare providers on site, we have developed an online 5-days training course that is ready for use. In each of the 32 participating hospitals, we identified several providers who were responsible for implementing the tools to improve caesarean section decision-making. To evaluate the effects of these tools on maternal and perinatal health we set up a health information system in the participating hospitals to collect monthly statistics over the duration of the project. We also planned to measure more specific health indicators by conducting surveys before and after the intervention period among a sample of women who gave birth in the participating hospitals. The first survey (before intervention) was conducted in Burkina Faso and is ongoing in the other three countries. Once this survey is completed, the identified healthcare providers will be trained to implement the intervention tools in each hospital. The project is led by nine partner institutions. Each partner plays a specific role while contributing to the activities of the others. We communicate the products of our research in a variety of ways, including through social networks.
We developed the research protocol and obtained the necessary ethical agreements to conduct this type of research in the four participating countries: Argentina, Vietnam, Thailand and Burkina Faso. We were able to complete preliminary research to understand the context and adapt our tools from the perspective of women and the health system. To compensate for the inability to travel and train healthcare providers on site, we have developed an online 5-days training course that is ready for use. In each of the 32 participating hospitals, we identified several providers who were responsible for implementing the tools to improve caesarean section decision-making. To evaluate the effects of these tools on maternal and perinatal health we set up a health information system in the participating hospitals to collect monthly statistics over the duration of the project. We also planned to measure more specific health indicators by conducting surveys before and after the intervention period among a sample of women who gave birth in the participating hospitals. The first survey (before intervention) was conducted in Burkina Faso and is ongoing in the other three countries. Once this survey is completed, the identified healthcare providers will be trained to implement the intervention tools in each hospital. The project is led by nine partner institutions. Each partner plays a specific role while contributing to the activities of the others. We communicate the products of our research in a variety of ways, including through social networks.
The organisational structure we have put in place for the QUALI-DEC project will facilitate communication between partners and reduce the impact of the COVID-19 pandemic on the progress of the project. Particularly, the electronic portfolio will be used by our partners to organise the 5-days training of healthcare providers. The portfolio will also contribute to develop a MOOC for health care professionals from hospitals participating or not in the QUALI-DEC project.
The findings of the baseline formative research and cross-sectional survey will be used to build research capacity for analysis and writing of scientific peer-review publications at country level. As planned in the original protocol, these results were already used to adapt the QUALI-DEC intervention.
We expect that the implementation of the QUALI-DEC intervention will be beneficial for:
• empowering women and improving women’s participation in the decision-making process regarding mode of birth (with the information provided through the DAT);
• supporting women at labour and delivery (by fostering companionship in all hospitals and the information provided through the DAT);
• implementing best practices in clinical care (with the help of the opinion leaders, the audit cycles for caesarean section indications in low-risk women and the use of clinical protocols);
• promoting better knowledge and attitudes of health professionals and women for an improved decision-making process and quality of care;
• optimization of caesarean section use;
• improvement of maternal and perinatal outcomes.
Specifically, the findings of QUALI-DEC project will help to change the national guidelines in Vietnam whom update is rather slow. It also helps Vietnamese policy managers to develop quality of care indicators that hospitals could document afterwards. In Thailand, the decision-analysis tool was included in the Thai national antenatal care booklet. For this reason, we expect that the impact will extend beyond the participating hospitals in this country. Reduction of unnecessary C-section (QUALI-DEC project) should be scaled up to other hospitals in participating countries.
The findings of the baseline formative research and cross-sectional survey will be used to build research capacity for analysis and writing of scientific peer-review publications at country level. As planned in the original protocol, these results were already used to adapt the QUALI-DEC intervention.
We expect that the implementation of the QUALI-DEC intervention will be beneficial for:
• empowering women and improving women’s participation in the decision-making process regarding mode of birth (with the information provided through the DAT);
• supporting women at labour and delivery (by fostering companionship in all hospitals and the information provided through the DAT);
• implementing best practices in clinical care (with the help of the opinion leaders, the audit cycles for caesarean section indications in low-risk women and the use of clinical protocols);
• promoting better knowledge and attitudes of health professionals and women for an improved decision-making process and quality of care;
• optimization of caesarean section use;
• improvement of maternal and perinatal outcomes.
Specifically, the findings of QUALI-DEC project will help to change the national guidelines in Vietnam whom update is rather slow. It also helps Vietnamese policy managers to develop quality of care indicators that hospitals could document afterwards. In Thailand, the decision-analysis tool was included in the Thai national antenatal care booklet. For this reason, we expect that the impact will extend beyond the participating hospitals in this country. Reduction of unnecessary C-section (QUALI-DEC project) should be scaled up to other hospitals in participating countries.