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To assess social inequalities in the use of antenatal care (ANC), facility based delivery (FBD), and modern contraception (MC) in two contrasting groups of countries in sub-Saharan Africa divided based on their progress towards maternal mortality reduction. Six countries were included in this study. Three countries (Ethiopia, Madagascar, and Uganda) had <350 MMR in 2010 with >4.5% average annual reduction rate while another three (Cameroon, Zambia, and Zimbabwe) had >550 MMR in 2010 with only <1.5% average annual reduction rate. All of these countries had at least three rounds of Demographic and Health Surveys (DHS) before 2012. We measured rate ratios and differences, as well as relative and absolute concentration indices in order to examine within-country geographical and wealth-based inequalities in the utilization of ANC, FBD, and MC. In the countries which have made sufficient progress (i.e. Ethiopia, Madagascar, and Uganda), ANC use increased by 8.7, 9.3 and 5.7 percent, respectively, while the utilization of FBD increased by 4.7, 0.7 and 20.2 percent, respectively, over the last decade. By contrast, utilization of these services either plateaued or decreased in countries which did not make progress towards reducing maternal mortality, with the exception of Cameroon. Utilization of MC increased in all six countries but remained very low, with a high of 40.5% in Zimbabwe and low of 16.1% in Cameroon as of 2011. In general, relative measures of inequalities were found to have declined overtime in countries making progress towards reducing maternal mortality. In countries with insufficient progress towards maternal mortality reduction, these indicators remained stagnant or increased. Absolute measures for geographical and wealth-based inequalities remained high invariably in all six countries. The increasing trend in the utilization of maternal care services was found to concur with a steady decline in maternal mortality. Relative inequality declined overtime in countries which made progress towards reducing maternal mortality.

This multicenter, cluster-randomized trial showed that an intervention involving audits of indications for cesarean delivery, feedback, and implementation of best practices resulted in a significant but small reduction in the cesarean delivery rate as compared with usual care. Rates of cesarean delivery are high in developed countries. 1 – 3 In Canada, these rates increased from 21.2% to 28.0% between 2000 and 2008 and remained stable until 2011. 4 – 6 High rates of cesarean delivery are of substantial concern owing to the potential harm to the mother and her baby associated with a medically unnecessary cesarean delivery and to the related costs of health care. 7 – 15 Providing evidence-based guidance to health professionals regarding the appropriate selection of women who could benefit from cesarean delivery is now a priority. Systematic reviews of strategies designed to reduce cesarean delivery rates and to improve . . .

ObjectivesAcross Canada, in the last decade, incidence rates of sexually transmitted and blood-borne infections (STBBI) have peaked (syphilis) or plateaued (hepatitis C virus (HCV) and HIV). Key populations (gay, bisexual and other men who have sex with men, trans and gender-diverse people, and people who use injection drugs) are at greater risk for these STBBIs, so correctly predicting risk before screening potentially infected individuals is crucial. We developed and validated a diagnostic clinical risk prediction model (CRPM) estimating HIV, HCV and syphilis risk for two key populations in two Canadian provinces.MethodsWe used 20 variables and STBBI test results from a cross-sectional study evaluating multiplexed testing (detection of coinfections) in New Brunswick and Quebec (n=400) to develop our CRPM. We randomly split the data into development (n=300) and validation (n=100) datasets using clinic-stratified sampling. We used Bayesian predictive projection with development data to select ranked STBBI predictors. We obtained the ORs of the highest performing submodel measured as area under the receiver operating curve (AUC), sensitivity and specificity with 89% credible intervals (89% CrI) using validation data. Analyses were performed in R (≥V.4.2.3).ResultsOut of 400 participants, 73 were infected with HIV (n=16), HCV (n=60), and/or syphilis (n=5). An internally validated submodel with two predictors (past drug injection, type of past sexually transmitted infection) displayed the highest AUC (0.79; 89% CrI 0.66 to 0.79), sensitivity (0.85; 89% CrI 0.79 to 0.91) and specificity (0.30; 89% CrI 0.15 to 0.50). The predictor contributing most to STBBI risk was past drug injection (OR=7.62; 89% CrI 4.41 to 13.07).ConclusionsThis Bayesian-based CRPM is the first to identify high-risk individuals for HIV, HCV and syphilis with an overall good performance that minimises case missing. After additional validation, it could serve as a promising novel tool for prescreening key populations and improve Canadian STBBI multiplexed screening strategies.

Public health interventions should be designed with scale in mind, and researchers and implementers must plan for scale-up at an early stage. Yet, there is limited awareness among researchers of the critical value of considering scalability and relatively limited empirical evidence on assessing scalability, despite emerging methodological guidance. We aimed to integrate scalability considerations in the design of a study to evaluate a multi-component intervention to reduce unnecessary caesarean sections in low- and middle-income countries. First, we reviewed and synthesized existing scale up frameworks to identify relevant dimensions and available scalability assessment tools. Based on these, we defined our scalability assessment process and adapted existing tools for our study. Here, we document our experience and the methodological challenges we encountered in integrating a scalability assessment in our study protocol. These include: achieving consensus on the purpose of a scalability assessment; and identifying the optimal timing of such an assessment, moving away from the concept of a one-off assessment at the start of a project. We also encountered tensions between the need to establish the proof of principle, and the need to design an innovation that would be fit-for-scale. Particularly for complex interventions, scaling up may warrant rigorous research to determine an efficient and effective scaling-up strategy. We call for researchers to better incorporate scalability considerations in pragmatic trials through greater integration of impact and process evaluation, more stringent definition and measurement of scale-up objectives and outcome evaluation plans that allow for comparison of effects at different stages of scale-up.

Caesarean section (CS) can prevent maternal and neonatal mortality and morbidity. However, it involves risks and high costs that can be a burden, especially in low and middle income countries. The aim of this study is to assess its magnitude and correlates among women of reproductive age in the urban and rural areas of Vietnam. We analyzed microdata from the national Multiple Indicator Cluster Survey (MICS) conducted in 2014 by using a representative sample of households at the national level in both urban and rural areas. A total of 1,350 women who delivered in institutional settings in the two years preceding the survey were included. Frequency and percentage distributions of the variables were performed. Bivariate and multivariate logistic regression analyses were undertaken to identify the factors associated with CS. Odds ratios with a 95% confidence interval were used to ascertain the direction and strength of the associations. The overall CS rate among the women who delivered in healthcare facilities in Vietnam has rapidly increased and reached a high level (29.2%). After controlling for significant characteristics, living in urban areas doubles the likelihood of undergoing a CS (OR = 1.98; 95% CI 1.48 to 2.67). Maternal age at delivery over 35 years is a major positive correlate of CS. Beyond this common phenomenon, different distinct lines of socioeconomic and demographic cleavage operate in urban compared with rural areas. The differences regarding the correlates of CS according to the place of residence suggest that specific measures should be taken in each setting to allow women to access childbirth services that are appropriate to their needs.

ObjectiveTo explore women’s expectations and experiences of care and support from pregnancy to childbirth in Burkina Faso, with a focus on the role and impact of companions and providers.DesignAn exploratory qualitative study based on in-depth interviews with purposively sampled participants and employing reflexive thematic analysis.SettingTwo public hospitals in urban Burkina Faso having implemented the ‘QUALIty DECision-making by women and providers for appropriate use of caesarean section’ intervention.Participants24 purposively selected postpartum women with variation in terms of parity, mode of birth, labour companionship experiences, education level and occupation were interviewed before discharge from the hospital.ResultsThe two themes generated from the analysis elucidate how women rely on providers and companions to navigate uncertainty and vulnerability experienced during pregnancy and childbirth. Women viewed providers as essential for managing the biomedical risks of childbirth and voiced their need for care at critical moments. They expected companions to enhance the non-clinical aspects of their experiences by providing spiritual support and alleviating feelings of loneliness. However, participants also expressed ambivalence about companions witnessing intimate aspects of their birth experience and valued the ability to choose a companion as means to preserve personal integrity.ConclusionsBoth providers and labour companions play an essential role in enhancing women’s experiences of pregnancy and childbirth in Burkina Faso. Additional research and programmatic efforts are needed to support women’s equitable participation in patient–provider interactions and operationalise the notion of choice of a labour companion in a contextually appropriate manner.

BackgroundObjective: This study aimed to use the Robson Ten Group Classification System (TGCS) to assess caesarean section (CS) rates and other outcomes in eight referral hospitals in Burkina Faso before the implementation of non-clinical interventions to reduce unnecessary CSs.DesignThis is a cross-sectional study.SettingWe conducted a 9-month prospective observational study on women who gave birth at eight referral hospitals in Burkina Faso between 1 April 2020 and 31 December 2020.ParticipantsWe analysed 24 643 women who gave birth at the eight participating hospitals during the study period.Outcomes measuresWe reported the relative size, CS rate and absolute contribution of each Robson group. These indicators were calculated for both referred and non-referred women. Oxytocin administration and stillbirth rates were calculated for women without previous CS and with a single fetus at cephalic presentation at term (groups 1–4).ResultsOverall, 24 643 women gave birth at the eight participating hospitals during the 9- month study period. The overall CS rate was 30.6%. Women in spontaneous labour with a single fetus in the cephalic presentation at term without previous CS (groups 1 and 3) had high CS rates (26.5% and 15%, respectively), low oxytocin use (7.9% and 6.5%, respectively), and high stillbirth rates (3.4% and 3.9%, respectively). These subgroups of women were major contributors to the overall CS rate.ConclusionOur results indicate that, in referral hospitals in Burkina Faso, the CS practice for referred women in groups 1 and 3 of the TGCS should receive special attention. These results also reveal areas for clinical improvement to reduce primary CS, especially in nulliparous women. The use of the TGCS is important in low-income countries where low CS rates at the population level may conceal suboptimal labour management in healthcare facilities.Trial registeration number ISRCTN67214403.

Maternal request for caesarean section has often been cited to justify the increasing caesarean section rates worldwide. However, we lack evidence on the impact of women's preference for caesarean section on this dramatic tendency. Given the need to develop appropriate strategies to reduce unnecessary caesarean section, the objective of this study was to assess the association between women's preference for caesarean section and its actual use, and to estimate the proportion of caesarean section associated with women's preference for caesarean section in Argentina, Burkina Faso, Thailand and Viet Nam. A cross-sectional hospital-based survey among postpartum women was conducted in 32 hospitals (8 per country) between 2020 and 2022. We selected women with no potential medical indication for caesarean section among a random sample of women who delivered in participating facilities during the data collection period. We chose a propensity score matching approach, to compare the probability of giving birth by caesarean section between women who, late in pregnancy, preferred caesarean section and those who preferred vaginal birth. A total of 1,827 low-risk women were included, of whom 10.4% preferred a caesarean section and the average caesarean section rate was 24.5%. The results show that, on average, preference for caesarean section increased the probability of having a caesarean section by 32% (CI 95% [0.23-0.41]; p < 0.001). The relative risk was estimated at 2.69 (CI 95%: 2.43; 2.95) and the fraction of caesarean section associated with women's preference was estimated at 15% (CI 95%: 12.9% - 16.9%). Although women's preference plays a role in the use of caesarean section in the participating hospitals, it likely accounts for only a small proportion of the caesarean section performed, highlighting the need for multidimensional, context-specific strategies to reduce unnecessary caesarean sections (providing women with evidence-based information, improving clinicians' adherence to guidelines and shared decision-making, addressing systemic factors…).

Background Thailand’s cesarean section rates continue to rise despite national mandates for evidence-based practice tools, such as the Robson classification. As the clinical effectiveness of these mandates remains limited, this study explored healthcare providers’ perceptions of evidence-based practice implementation and the barriers and facilitators influencing the use of clinical practice guidelines to address unnecessary cesarean sections. Method A descriptive qualitative study was conducted across eight hospitals participating in the QUALI-DEC project in Thailand. In-depth interviews were conducted with 42 healthcare providers, including administrators, obstetricians, and nurses. Data were analyzed using thematic analysis based on Braun and Clarke’s approach. The study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guideline. Results The analysis identified three key themes: (1) From evidence to action, highlighting the necessity of localizing guidelines, engaging stakeholders, and evaluating effectiveness to ensure usability; (2) Barriers to evidence-based practice utilization, revealing how individual experience and hierarchy often override evidence, alongside a lack of structured feedback mechanisms and operational constraints; and (3) Facilitators for successful implementation, emphasizing the need to raise awareness regarding unnecessary cesarean section, promote positive attitudes towards evaluation, and leverage guideline adherence as a mechanism for legal protection. Conclusion The findings suggest that collaborative leadership and systematic feedback mechanisms may support evidence-based practice adoption. They also highlight contextual factors, including the perceived clinical and legal protection roles of guidelines, that may inform strategies to address unnecessary cesarean sections in Thailand.

Caesarean section rates are increasing worldwide, and since the 2000s, several researchers have investigated women's demand for caesarean sections. The aim of this article was to review and summarise published studies investigating caesarean section demand and to describe the methodologies, outcomes, country characteristics and country income levels in these studies. This is a systematic review of studies published between 2000 and 2017 in French and English that quantitatively measured women's demand for caesarean sections. We carried out a systematic search using the Medline database in PubMed. The search strategy identified 390 studies, 41 of which met the final inclusion criteria, representing a total sample of 3 774 458 women. We identified two different study designs, i.e., cross-sectional studies and prospective cohort studies, that are commonly used to measure social demand for caesarean sections. Two different types of outcomes were reported, i.e., the preferences of pregnant or non-pregnant women regarding the method of childbirth in the future and caesarean delivery following maternal request. No study measured demand for caesarean section during the childbirth process. All included studies were conducted in middle- (n = 24) and high-income countries (n = 17), and no study performed in a low-income country was found. Measuring caesarean section demand is challenging, and the structural violence leading to demand for caesarean section during childbirth while in the labour ward remains invisible. In addition, the caesarean section demand in low-income countries remains unclear due to the lack of studies conducted in these countries. We recommend conducting prospective cohort studies to describe the social construction of caesarean section demand. We also recommend conducting studies in low-income countries because demand for caesarean sections in these countries is rarely investigated.