Evaluating the ‘Focus on Normal Birth and Reducing Caesarean section Rates Rapid Improvement Programme’: A mixed method study in England☆
Introduction
Caesarean section rates have risen rapidly over the last three decades causing concern globally. Considerable variation is apparent both between countries and across areas and providers within countries (Bragg et al., 2010, Declercq et al., 2011). There is no consensus on what caesarean section rate is acceptable but in 1985 a World Health Organisation study group suggested no additional benefits were associated with rates higher than 10–15% (World Health Organization, 1985) and evidence from more recent studies continues to support this (e.g. Althabe et al., 2006, Gibbons et al., 2010). However, in 2007 several countries reported overall caesarean section rates above 30% (e.g. Italy 39%, Portugal 35%, United States 32% and Switzerland 32%) and only one industrialised country, the Netherlands reported a rate within the recommended range (14%) (Declercq et al., 2011, Hollowell, 2011). In England since 1990 there has been a virtual doubling of the national caesarean section rate to 24.6% in 2007/2008 (Health and Social Care Information Centre, 2009) and this has been stable since then (Health and Social Care Information Centre, 2010, Health and Social Care Information Centre, 2011, Health and Social Care Information Centre, 2012, Health and Social Care Information Centre, 2013).
Caesarean section plays an important role in ensuring the safety of mother and infant but these large increases in caesarean section rates have not been accompanied by measurable improvements in either maternal or neonatal mortality or morbidity. There is a growing body of evidence to suggest that caesarean section can result in increased risk of maternal mortality (Deneux-Tharaux et al., 2006) and maternal and infant morbidity (e.g. Villar et al., 2007, MacDorman et al., 2008, Blanchette, 2011). Studies have demonstrated that caesarean birth can increase the risk of neonatal mortality (Gray et al., 2007, MacDorman et al., 2008), admission to neonatal unit (Villar et al., 2007) respiratory distress syndrome and difficulty with bonding and breastfeeding (Churchill et al., 2006). Women may experience increased risk of infection (Liu et al., 2007, Villar et al., 2007), haemorrhage and thrombosis (Deneux-Tharaux et al., 2006) and complications in subsequent pregnancies, such as, placental problems and uterine rupture (Landon et al., 2004, Villar et al., 2006). Therefore it follows that halting this rapid increase in caesarean section rates would reduce morbidity for women and their babies.
It has been postulated that higher prevalence of factors such as first pregnancy, older maternal age, previous caesarean section, breech presentation and medical complications such as diabetes, hypertension and obesity may explain variation in caesarean section rates. However, considerable variation remains even after controlling for such factors (Bragg et al., 2010, Hanley et al., 2010) leading to the conclusion that the most likely reason for variation in rates is difference in thresholds for intervention and variations in preferred models of care at institutional and practitioner levels (Klein et al., 2011, Knight and Sullivan, 2010).
Research has been conducted in a number of countries and systems of care to assess the effectiveness of initiatives aiming to influence professional behaviour to lower caesarean section rates. These include: obstetric clinical interventions, such as external cephalic version for breech presentation and promoting vaginal birth after caesarean section (Lagrew and Morgan, 1996, Walker et al., 2002); provision of continuous support in labour, either non-professional (Hodnett et al., 2011) or professional (Janssen et al., 2007), midwifery led care in birth centres (Gottvall et al., 2011, Overgaard et al., 2011) and out-of-hospital settings (Sakala, 1993). Quality related initiatives have also been shown to be effective, such as: promoting the use of evidence-based clinical guidelines (Iglesias et al., 1991), mandatory second opinion (Althabe et al., 2004, Mawson, 2004) and audit with feedback (Main, 1999, Robson et al., 1996). Chaillet and Dumont (2007) conducted a systematic review and concluded that clinical practice can be improved and caesarean section rates can safely be reduced using multifaceted strategies based on audit and feedback and that identification of barriers to change is a key aspect of success. A systematic review by Catling-Paull et al. (2011) assessed the effectiveness of a range of non-clinical interventions with potential to increase uptake and success of vaginal birth after caesarean section and found that guidelines are influential, especially when adapted locally, and that feedback to obstetricians, use of opinion leaders and individualised information given to women are also effective. Local ownership of the desire to reduce caesarean section rates was identified as a key factor.
In the 1990s a Working Group in Ontario examined practices at four hospitals with low caesarean section rates to discover how these rates were maintained (Caesarean Section Working Group et al., 2000). Important factors identified included: cultural aspects such as pride in low rates, a culture of birth as a normal physiological process, the way teams worked together and strong team leadership and commitment to evidence-based practice and other quality improvement activities mentioned above. A key factor highlighted was the ability to manage change. The programme evaluated in this paper was influenced by the work in Ontario (Baldwin et al., 2010, Brodrick et al., 2011). The NHS Institute for Innovation and Improvement issued a tender for an independent evaluation.
This programme was facilitated by a team comprising one obstetrician, two senior midwives and an improvement associate (Institute Team) who worked with maternity services teams in England to use a ‘Toolkit’ to self-assess the processes and behaviours in their service and to develop a shared vision to promote normal birth and reduce caesarean section rates (NHS Institute for Innovation and Improvement, 2007). This programme that drew on theories of innovation and aimed to achieve rapid service improvement (Fraser, 2002) was part of the Spread and Adopt Rapid Improvement Programme that was implemented in July 2008 within NHS England, a health-care system which is free at the point of use for all residents in England and is centrally funded through taxation. Further detail about the development of the initiative and the Toolkit has been reported previously (Baldwin et al., 2007, Baldwin et al., 2010). The aims of the ‘Focus on Normal Birth and Reducing Caesarean Section Rates’ programme were to promote normal birth and reduce caesarean section rates, consider how a culture in a maternity unit can impact on caesarean section rates, and encourage multidisciplinary working and provide training in service improvement tools.
The programme was offered to 20 NHS trusts selected from 68 applications and comprised: the Toolkit and facilitation for multidisciplinary teams. Local network events were also available to all maternity units. The Toolkit contained self-improvement pathways designed to be used in a workshop environment, one to encourage teams to consider the organisational characteristics of their Trust and three clinical pathways: keeping first pregnancy and labour normal; vaginal birth after caesarean section (VBAC) and elective caesarean section. It also contained a range of tools and measures to support service improvements identified by Trust teams (NHS Institute for Innovation and Improvement, 2007). The tools were designed to be non-prescriptive but to stimulate discussion within multidisciplinary workshops with the aim of developing a shared vision prior to action planning.
This paper evaluates the ‘Focus on Normal Birth and Reducing Caesarean Section Rates’ programme by exploring changes in caesarean section rates, use of service improvements tools and how cultures and multidisciplinary working may have impacted on these within participating maternity units.
Section snippets
Methods
A mixed methods approach was used to evaluate and understand the impacts of this complex, multifaceted initiative. This included collection and analysis of mode of birth data provided by 20 hospital Trusts who took part in the programme, web-based questionnaires administered to key individuals in all 20 Trusts and in-depth semi-structured telephone interviews conducted with key individuals in a sample of six Trusts. Data were used together to understand different aspects of the initiative, the
Findings
Mode of birth data was obtained from all 20 Trusts; however, data from one Trust were excluded from the analysis because data provided were not of sufficient quality and were therefore unreliable. Mean total caesarean section rate declined marginally by 0.5% (26.4% compared to 25.9%) from the baseline period (1 July–31 December 2008) to the period 1 January 2009–31 January 2010. The biggest reduction was in the first six months (1 January 2009–30 June 2009) when the mean rate fell to 25.5%. In
Environment and Trust culture
The unique environment and culture of each Trust influenced the activities chosen to promote normality and reduce caesarean section rates. Fifty-three questionnaire respondents indicated the extent to which the initiative helped them to understand their organisation and its culture in a range of ways. Responses can be seen in Graph 1. Notably, all respondents indicated that it had been very helpful or of some help to identify practices or behaviours they would like to change and most felt it
Discussion
The ‘Focus on Normal Birth and Reducing Caesarean Section Rates’ programme was well-received and most respondents identified benefits for their organisation and for women׳s care. The non-dictatorial, facilitative nature of the programme was appreciated for ease of use in a variety of different local contexts. All components of the programme were considered helpful: the Toolkit was considered to be clear, easy to understand and provided focus and practical application; the Institute Team was
Conclusions
It appears unlikely that any one particular quality assurance approach will achieve the required reductions in caesarean section rates across the range of westernised maternity systems and settings. For organisations concerned about their caesarean section rate, an analysis of the local situation should be carried out to identify local barriers and characteristics that need to be addressed. These may include robust performance data and aspects of organisational culture, such as a philosophy of
Sources of funding
The study was funded by the National Health Service (NHS) Institute for Innovation and Improvement. Funders had no part in the conduct of the study.
Conflict of interest
Authors declare they have no conflicts of interest.
Acknowledgements
We thank all of the maternity care professionals and service user representatives who completed questionnaires and took part in interviews. We also thank Joyce Craig for joint project management and analysis of birth statistics. Sara Christensen׳s transcription of audiotapes and Jenny Brown׳s administrative support throughout the project were much appreciated, as was the generosity of the Rapid Improvement Programme team in sharing information and experiences, and facilitation of this
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The work was carried out when all three authors were employed at the University of York.