7. Effects of interventions targeted at healthcare professionals.
| Study | Quality assessment | Outcome | Intervention | Control | Effect | Certainty (GRADE) | |||||||
| Design | Risk of bias | Inconsistency | Indirectness | Imprecision | Other considerations | Relative (95% CIa) or P value | |||||||
| Althabe 2004 | RT | Not serious | Single study | Not serious | Not serious | None | All CS | Mean baseline rate (34,735 women): 26.3 Mean follow‐up rate (35,675): 24.7 Mean rate change: ‐1.6 |
Mean baseline rate (39,175 women): 24.6 Mean follow‐up rate (39,638): 24.9 Mean rate change: 0.3 |
Mean difference in rate change: ‐1.9 (‐3.8 to ‐0.1) |
㊉㊉㊉㊉ HIGH |
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| Elective CS | Mean baseline rate (34,735 women): 8.9 Mean follow‐up rate (35,675): 9.1 Mean rate change: 0.1 |
Mean baseline rate (39,175 women): 9.1 Mean follow‐up rate (39,638): 9.0 Mean rate change: ‐0.1 |
Mean difference in rate change: 0.2 (‐1.4 to 1.8) | ||||||||||
| Intrapartum CS | Mean baseline rate (34,735 women): 17.4 Mean follow‐up rate (35,675): 15.6 Mean rate change: ‐1.8 |
Mean baseline rate (39,175 women): 15.4 Mean follow‐up rate (39,638): 15.9 Mean rate change: 0.4 |
Mean difference in rate change: ‐2.2 (‐4.3 to ‐0.1) | ||||||||||
| Maternal mortality | Mean baseline rate per 10,000 livebirths (34,735 women): 3.2 Mean follow‐up rate per 10,000 livebirths (35,675 women): 4.3 |
Mean baseline rate per 10,000 livebirths (39,175 women): 5.9 Mean follow‐up rate per 10,000 livebirths (39,638 women): 7.5 |
Mean difference in rate change: 0.66 (‐0.4 to 5.3) (re‐analysed) |
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| Neonatal mortality | Mean baseline rate (34,735 women): 1.1 Mean follow‐up rate per 10,000 livebirths (35 675 women): 0.9 |
Mean baseline rate (39,175 women): 1.1 Mean follow‐up rate (39,638 women): 1.0 |
Mean difference in rate change (95% CI): ‐0.1 (‐0.4 to 0.3) |
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| Neonatal morbidity | NR | ‐ | ‐ | ‐ | |||||||||
| Chaillet 2015 | Cluster‐RT | Not serious | Single study | Not serious | Not serious | None | Overall CS | Baseline: 5484/24,388 (22.5%) Post‐intervention: 5128/23,484 (21.8%) |
Baseline: 6671/28,698 (23.2%) Post‐intervention: 6767/28,781 (23.5%) |
OR 0.90 (0.80 to 0.99)b RD ‐1.8% (‐3.8 to ‐0.2)b |
㊉㊉㊉㊉ HIGH |
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| Elective repeat caesarean section | Baseline: 1995/24,388 (8.2%) Post‐intervention: 1931/23,484 (8.2%) |
Baseline: 2404/28,698 (8.4%) Post‐intervention: 2598/28,781 (9.0%) |
RD – 0.6% | ||||||||||
| Low risk group: CS | Baseline: 971/11478 (8.5%) Post‐intervention: 763/10067 (7.6%) |
Baseline: 1256/14717 (8.5%) Post‐intervention: 1172/13019 (9.0%) |
RD ‐1.7% (‐3.0 to ‐0.3) | ||||||||||
| Hemminki 2008 | Cluster‐RT | Seriousc | Single study | Not serious | Seriousd | None | CS | 166/845 (19%) | 116/723 (16%) | OR 1.29 (0.99 to 1.67) |
㊉㊉㊀㊀ LOWc,d |
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| Liang 2004 | ITS | Seriouse | Single study | Not serious | Not serious | None | CS | Change in level of total caesarean deliveries at 12 monthsf: ‐2.4% (‐11.4% to 6.7%) Change in slopef: 1.34% (‐2.5% to 5.2%) |
㊉㊀㊀㊀ VERY LOWe |
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| Lomas 1991 | Cluster‐RT | Not serious | Single study | Not serious | Not serious | None | Audit and feedback | Opinion leader education | Control |
㊉㊉㊉㊉ HIGH |
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| Elective CS | 69.7% (62.4 to 77.0%) | 53.7% (46.5 to 61.0%) | 66.8% (61.7 to 72.0%) | ||||||||||
| Unscheduled CS | 18.6% (13.9 to 23.2% | 21.4% (16.8 to 26.1%) | 18.7% (15.4 to 22.1%) | ||||||||||
| Trial of labour rates (%) | 21.4% (13.9 to 29.0%) | 38.2% (30.6 to 45.7%) | 28.3% (23.0 to 33.7%) | ||||||||||
| Vaginal births (%) | 11.8% (5.8 to 17.7%) | 25.3% (19.3 to 31.2%) | 14.5% (10.3 to 18.7%) | ||||||||||
| Low Apgar score < 7 at 5 mins (%) | 5.9 (4.2 to 7.6) | 0.9 (0.0 to 2.6) | 1.2 (0.0 to 2.4) | ||||||||||
| Duration of hospital stay (%) | < 6 days: 27.9 6 days: 29.9 > 6 days: 42.2 |
< 6 days: 46.6 6 days: 31.4 > 6 days: 22.0 |
< 6 days: 32.2 6 days: 31.1 > 6 days: 36.7 |
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| Mohammadi 2012 | CBA (reanalysed as ITS) |
Seriouse | Single study | Not serious | Not serious | None | CS | Change in level of caesarean deliveries during the intervention: ‐14.6% (‐24.4% to ‐4.8%), P = 0.02 Change in slope ‐0.07% (‐1.5% to 1.3%), NS |
㊉㊀㊀㊀ VERY LOWe |
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| Poma 1998 | ITS | Seriouse | Single study | Not serious | Not serious | None | CS | Change in level of total caesarean deliveries (primary and repeat caesarean sections) at 24 months: ‐6.6% (‐10.1 to ‐3.2); change in slope: ‐0.11% (‐0.25 to 0.02) (data reanalysed) |
㊉㊀㊀㊀ VERY LOWe |
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| Scarella 2011 | ITS | Seriouse | Single study | Not serious | Not serious | None | CS | Change in level of caesarean deliveries during intervention: ‐11% (‐23.2 to 1.2%), NS Change in slope: ‐1.1% (‐6.4 to 4.2%), NS Change in level of caesarean deliveries in the immediate post‐intervention period compared with the intervention period: 8.6% (2.1 to 15.2%), P = 0.022 Change in slope: ‐0.3% (‐1.6 to 0.9%), NS |
㊉㊀㊀㊀ VERY LOWe |
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| About the certainty of the evidence (GRADE)* High: this research provides a very good indication of the likely effect; the likelihood that the effect will be substantially different† is low. Moderate: this research provides a good indication of the likely effect; the likelihood that the effect will be substantially different† is moderate. Low: this research provides some indication of the likely effect; however, the likelihood that it will be substantially different† is high. Very low: this research does not provide a reliable indication of the likely effect; the likelihood that the effect will be substantially different† is very high. *This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate' †Substantially different = a large enough difference that it might affect a decision | |||||||||||||
| CBA: controlled before‐after study; CS: caesarean section; ITS: interrupted time series; NR: not reported; NS: not significant; OR: odds ratio; RD: risk difference; RR: risk ratio; RT: randomised trial. aNumbers in parentheses are 95% confidence limits. bDowngraded one level for serious imprecision (confidence interval includes null effects) cAdjusted in between‐group comparison of the change from the preintervention period to the post‐intervention period (adjusted for hospital and patient characteristics). dDowngraded one level for serious risk of bias (pilot study with no sample size calculation; unit of analysis error). eDowngraded one level for possible confounding (unclear whether the intervention occurred independently of other changes over time). fTwo standardised effect sizes are obtained from ITS analysis: change in level (also called 'step change') and change in trend (also called 'change in slope') before and after the intervention. Change in level = difference between the observed level at the first intervention time point and that predicted by the pre‐intervention time trend; change in trend = difference between post‐ and pre‐intervention slopes. A negative change in level and slope indicates a reduction in caesarean section rate. | |||||||||||||