By Will Boggs MD

(Reuters Health) – Unnecessary cesarean-section deliveries (C-sections) might decline if a variety of interventions targeting patients, healthcare professionals and hospitals were implemented, suggests an updated review of existing research.

“For women, targeted prenatal educational support programs may help reduce unnecessary caesarean section, and this supports the notion that women benefit from having adequate information to make an informed choice,” lead author Dr. Innie Chen from the University of Ottawa in Canada told Reuters Health.

“Ongoing communication with the healthcare provider regarding the options available for vaginal birth is an important component,” she added.

While C-section delivery can reduce complications associated with childbirth and can be lifesaving for both the mother and the baby in certain circumstances, there is no evidence that it benefits women or babies when the procedure is not required.

Moreover, like any surgery, C-section can be associated with significant risks to the health of the woman and baby, as well as to future pregnancies.

Most national expert societies recommend vaginal delivery in the absence of maternal or fetal reasons for delivering by cesarean. Yet C-section rates are increasing globally and are well above the 10 percent to 15 percent rate the World Health Organization has estimated to be sufficient to minimize maternal and newborn deaths, the authors write in the Cochrane Database of Systematic Reviews.

The study team reviewed 29 medical studies of interventions, such as training or counseling programs, that either targeted pregnant couples or their physicians in efforts to reduce unnecessary C-section rates. Chen and her colleagues analyzed both the quality of each study’s evidence and whether it showed the intervention works.

Among the interventions targeting pregnant women or couples, childbirth training workshops seem to reduce C-section rates significantly and increase spontaneous vaginal birth rates. Nurse-led relaxation training programs and psychosocial couple-based prevention programs also seem to reduce C-section rates. The quality of the evidence for training was poor, however, and neither study looked at whether these interventions affected maternal or newborn complications or deaths, Chen’s team notes.

There was high-quality evidence for interventions aimed at doctors, such as clinical practice guidelines along with mandatory second opinions, especially when combined with audits and feedback, the researchers found. Physician education by local opinion leaders also seems to be effective in reducing unnecessary C-sections, although none of the doctor-targeted interventions made sizeable differences in C-section rates and there was little difference in deaths or complications.

As for targeting healthcare organizations or hospitals, studies found that combining midwifery with in-hospital labor and delivery coverage by the obstetrician seems to reduce C-section rates, compared with a private practice model of care. However, the evidence quality was low and did not look at mortality or complications.

Surprisingly, interventions that don’t appear to be effective outnumber those that do.

Prenatal education, education in breathing and relaxation techniques, pelvic floor muscle training exercises with (versus without) telephone follow-up, group therapy and education of public health nurses on childbirth classes, among other interventions, have little or no impact on C-section rates, the review found.

“We are very uncertain as to the effect of other interventions identified on caesarean section rates as the certainty of the evidence is very low,” the researchers conclude.

“While caesarean section can be lifesaving for both mother and baby, caesarean section rates vary widely worldwide and are rising globally,” Chen said in an email. “Many caesarean sections may be unnecessary, and the reasons are complex, including both clinical and non-clinical considerations.”

“Women, healthcare providers, healthcare systems and societies need to work together to decrease the number of unnecessary caesarean sections within their institutions, regions, countries, and globally,” she added.

SOURCE: Cochrane Database of Systematic Reviews, online September 28, 2018.