Interventions in Reducing Caesarean Section in the World: A Systematic Review

Caesarean section without medical indication imposes many problems to families, personnel and medical equipment causing some side effects to pregnant woman and foetus, compared to natural childbirth. The present study aimed to evaluate the interventions in reducing caesarean section in the world. This study was a systematic review using Embase, PubMed, Scopus, Web of Science, Science Direct, Magiran and SID databases and grey literature. All studies conducted during 2000–2018 were reviewed and finally the studies with inclusion and exclusion criteria were selected. A total of 19 studies were selected among 5,559 studies. The interventions conducted for reducing caesarean section included training the specialists and women by using Six Sigma method, changing the guidelines, reviewing the definition of natural childbirth various stages, encouraging the natural childbirth and expanding painless childbirth. All interventions were divided into educational strategy and managerial strategy. The interventions can be implemented to change the behaviour of physicians and attitude of pregnant women in order to reduce caesarean section. In this regard, the authorities are recommended to make more efforts.


Interventions in Reducing Caesarean Section in the World: A Systematic Review
Introduction Childbirth is one of the most sensitive and important services of the health system in all societies and caesarean section is considered as one of the main concerns in this regard (1). Caesarean section refers to the removal of the placenta, embryo and membranes by cutting the abdominal wall and uterus (2). Although caesarean section has played a significant role in reducing the mortality and morbidity of high-risk natural childbirth in the last century, its high level is a challenging issue during the recent decades (3).
Caesarean section, without medical indication, creates a lot of troubles on families, medical personnel and medical equipment which can lead to side effects for pregnant women and foetus compared to natural childbirth including the problems related to anaesthesia, post-operative infection, high haemorrhage and thromboembolism (4)(5)(6). In addition, caesarean i) caesarean or caesarean section or repeat caesarean section or pregnancy or pregnant woman or parturition or birth or labour; and ii) intervention or policy or plan or programme or, strategy or strategic planning; and iii) decrease or change or impact or health impact assessment.

Eligibility Criteria
The inclusion criteria for selecting the studies related to the field of research included: i) the studies published during 2000-2018 ii) the studies in English or Persian and iii) the studies referring to at least one aspect of policy interventions to reduce caesarean section. The exclusion criteria included the letter to the editor, commentaries and the articles presented at the conferences.

Quality Assessment
After extracting the articles from the abovementioned databases, they were evaluated using the descriptive-analytical, Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist and the articles without any good quality of reporting were excluded.

Results
A total of 5,559 articles were reviewed, among which 2,778 articles were repetitive. A total of 2,781 articles were screened of which 2,680 articles were eliminated in the review of the title and abstract. Then, the full text of 101 articles was studied among which 82 articles were excluded (62 articles due to inadequate results and 20 articles due to poor quality). Finally, 19 articles were included. The abovementioned items are listed in Figure 1.

Data Extraction
After reviewing the quality of articles, 19 articles were eventually reviewed by three individuals. The information obtained from the articles were included in Word software and in the table containing the author's name, year of publication, sample size, analysis method, type of intervention, method of investigation, the most important results and conclusion. section can have some side effects for infant such as respiratory problems, hospitalisation at the NICU, the possibility of infection, asthma in childhood and reduced breastfeeding (7). Some studies indicated that the reduction of caesarean section affects the maternal and neonatal mortality (8)(9)(10).
Further, caesarean section leads to more costs than natural childbirth (11,12). Douangvichit et al., in their study, at two public hospitals in Latos indicated that the average cost for caesarean section and natural childbirth is 270 and 59 dollars, respectively (13). Based on the World Health Organization (WHO) statistics in different countries, the expected caesarean section should be 10%-15% and it is announced that there is no reason to increase the caesarean section (14). Based on the latest reports from 150 countries in the world, 18.6% of childbirths in the world are performed by caesarean section which is from 6.6% in developed countries and 27.2% in less developed countries (15).
Considering its effects on maternal health and reducing the cost of treatment and the economy of the family and country, most governments adopted some measures to reduce this problem. Such policies and interventions include the changes in the steps of natural childbirth leading to some caesarean section decisions and free natural childbirth (16). Since no study has been conducted on the interventions and policies implemented in different countries to reduce caesarean section, this study aimed to review the policies adopted in this area and evaluate their effectiveness.

Study Design
This systematic review study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (17). The present systematic review study aimed to examine the interventions to reduce caesarean section in the world during 2000-2018 through searching in Embase, PubMed, Scopus, Web of Science, Science Direct, Magiran, SID and grey literature.

Search Strategy
The key words and search strategy were as follows: places. Most studies were conducted after the year 2010 (76%). Asia (67%) allocated the most studies. In terms of research methodology, most of the studies were interventional (67%) and 21% were retrospective studies related to the evaluation programmes, which were already conducted while 12% of the studies were combined. The context of other studies is shown in Table 1.

Summary of Reviewed Articles
A total of 19 articles conducted in different parts of the world during the year 2000-2018 were evaluated after screening in terms of quality and relevance. The processes of reviewing the studies are presented in Figure 1.
Regarding to the target population of the studies, 11 studies were conducted in hospital, 6 studies in health centres and 2 studies in other  The strategies obtained from the results of the studies were divided into managerial and educational strategies.

Educational Strategy
This strategy is a collection of methods and tools for raising the awareness of pregnant women, their families and specialists. Based on the current studies, this strategy has the following sub-categories:

805,000
Paying some money to maternity specialist to encourage childbirth.
In the state of Madhaya, the fee paid for caesarean rates was higher than natural childbirth and the fee was ascendant while in the state of Gujarat, a fixed fee was paid to specialists based on the childbirth

Discussion
The results of this study indicated that education is effective in reducing caesarean section. The results of this study are consistent with studies of Spinelli et al. (18) and Ferguson et al. (19) but inconsistent with the studies of Artieta-Pinedo et al. (20) and, Bostani and Rafat (21).
It seems that the differences in the studied population such as the level of education, attitude of people and the readiness of people to attend educational classes are not affected by the difference between the results obtained from these studies. Other factors affecting the outcomes of education includes the skills and experiences of the trainer, the extent he addressed all the aspects of the subject and whether he was able to transfer it to the learners. In addition, the number of learners and their interest in learning, the time and number of hours spent in the classroom are influential in this regard.
The findings of this study indicated that training the husbands is effective in reducing caesarean section. Noghaee and Hadizadeh indicated that implementing the educational programme and raising the awareness of men can be effective in social protection of women (22).
Considering that men are one of the important pillars of reproductive health services, their role as the closest person to their spouse was confirmed in supporting the women and running family planning programmes. Thus, it is suggested that men should be trained and justified to transfer the learned knowledge to their spouses, which results in increasing women's awareness and reducing caesarean section.
Sharghi et al. indicated a significant relationship between the opinion of the spouse and the desire to choose caesarean section (23). In another study, Faraji Darkhaneh and Farjad Bastani indicated that 64% of women considered the role of the spouse in choosing the method of childbirth (24).
The results of this study indicated that using a midwife is effective in reducing caesarean section. As a result, the presence of a midwife after the childbirth, facilitates the pregnant women readiness for infants and postpartum affairs. Furthermore, the results of Kozhimannil et al.'s study indicated that the presence of a midwife is effective in reducing caesarean section (25).
Considering the role of midwife in the care of pregnant women before, during and after childbirth, as well as preventing the complications and risks of pregnancy by this group of people, it is recommended to pay more attention to this issue and provide special conditions and facilities for using pregnant women including the easy and inexpensive access.
The results of this study indicated that the evaluation and indication of caesarean section as well as using the feedback to specialists had a slight effect on the rate of caesarean section. The results of Khunpradit et al.'s review study (26) are in line with the results of this study. The results of Tavarez et al.'s study indicated that the feedback of performance to pediatric emergency physicians over a three-month period is ineffective in the management of patients with diarrhea and vomiting (27). In another study, Tu et al. confirmed that the announcement of hospital indicators is ineffective in improving the indices (28). The results of these studies were inconsistent with those in the present study.
Based on the results of a meta-analysis study, feedback and evaluation were effective at a rate of 13% in reducing the caesarean section (29). In addition, the results of some studies are not in line with those in the present study (30)(31)(32)(33).
It seems that the underlying characteristics of the environment where feedback is performed including the amount of personnel's attention and belief in feedback is not ineffective in the obtained results. Sargeant et al. indicated that the reaction and perception of physicians to multi-stage feedbacks can affect their performance (34). However, the characteristics of service providers, the way of providing feedback and the extent of real feedback to personnel may not be ineffective in their feedback.
Physician-patient relationship culture in Iran indicates that medical team can play an important role in controlling or stimulating caesarean statistics. It is suggested that physicians should always be given the necessary feedback in this regard. Obviously, this control has a moral value physically and economically. The findings of this study stated the level of tariffs on caesarean section reduction. The results of the study by Fabri and Murta confirmed this finding (35).
Interventions in the developed countries (change in guidelines) were more systematic in this study and involved a wide range of women, leading to the better process of natural childbirth and caesarean section reduction. However, the interventions in developing countries including Iran had a personal dimension including only a few people who are learners. The lack of transparency in the research method in a limited number of studies was one of the limitations encountered by the researchers in this study. It is suggested that future studies should include the interventions, which are more systematic and functional.

Conclusion
Finally, the researcher believed that modifying the referral system for childbirth is considered as the most important method for reducing the caesarean section. All the patients should first be examined by midwife and referred to a specialist in case of necessity and the need for the indications of caesarean section. Further, training the pregnant women and their husbands, performing natural childbirth as free, studying and making decision for caesarean section by experienced physicians in the hospital, encouraging natural childbirth with the spread of painless childbirth are considered as effective.