Table 1. Strategies of the two-stage intervention for reducing CS rates in Guangzhou, China, 2010–2016.

Intervention Elements	Stage 1 (October 1, 2010–September 30, 2014)		Stage 2 (October 1, 2014–December 31, 2016)
	Plans and Strategies	Outputs	Plans and Strategies	Outputs
Health education	(1) Professional training	(1) 125 full-time health education professionals trained, covering all 12 districts	(1) Professional training	(1) 233 full-time health education professionals trained, covering all 12 districts
	● 1 full d/session, 4 sessions/person		● Duration, frequency, and target skills: same as Stage 1
	● Target skills: communication, presentation, community-level health education methodology		● Training at least 1 professional from each maternity facility
	(2) Community lecturing	(2) 100 lectures delivered, covering all 12 districts	(2) Community lecturing	(2) 100 lectures delivered, covering all 12 districts
	● Target subjects: pregnant women and their families		● Target subjects, duration, coverage, and main topics: same as Stage 1
	● 90 min/lecture		● Additional topics: labor analgesia, maternal mental health
	● Main topics: pregnancy planning, advantages of vaginal delivery, maternal nutrition and exercise, postpartum care for vaginal and cesarean delivery
	(3) Publicity platform building	(3) Leaflets and presenting posters disseminated in all communities and maternity facilities, videos played on approximately 40% of the buses across the city	(3) Publicity platform building	(3) Leaflets, posters, and videos: same as Stage 1; publicity videos played on local TV channels and outdoor LED screens across the city, educational articles posted on local newspapers and social media
	● Cooperating with professional and designers		● Production, approaches, and main topics: same as Stage 1
	● Including leaflets, posters, videos		● Additionally including multimedia approaches
	● Main topics: vaginal birth, routine prenatal care, maternal lifestyles during pregnancy, postpartum care
			(4) “Toolbox” production	(4) A “toolbox” produced, containing 800+ collated and reorganized items of materials, with full access open to all health education professionals
			● For creating new health education materials
			● Including a collection of relevant articles, leaflets, posters, videos
			● Including raw materials (e.g., slide templates, pictures, footage, etc.)
			● Covering main topics in (2) and (3)
Skills training	(1) Expert on-site instructions	(1) Experts assigned to 82 primary and secondary healthcare institutions, each expert working on site for 100 d	(1) Core skills training	(1) 100 obstetricians, 100 midwives, 100 pediatricians, and 100 pediatric nurses trained
	● Target subjects: obstetricians, anesthesiologists, and midwives from primary and secondary healthcare institutions		● Target subjects: obstetricians, midwives, pediatricians, and pediatric nurses from primary and secondary healthcare institutions
	● Target skills: up-to-date clinical knowledge and skills		● Target skills: the same core skillset for obstetrics and gynecology, pediatrics, maternal and child health at Stage 1
	● Approaches: teaching, thematic training, discussion of challenging cases, and surgical demonstration		● Off-the-job training for 2 mo in designated training centers with exit exams
	(2) Core skills training	(2) 200 obstetricians, 100 neonatologists, and 100 midwives trained	(2) Advanced skills training	(2) Training coverage of 100% in all maternity facilities
	● Target subjects: backbones of obstetricians, neonatologists, and midwives from primary healthcare institutions		● Target subjects and skills: same as Stage 1
	● Target skills: core knowledge and skills in perinatal practice (e.g., analgesic vaginal delivery, labor process monitoring using partogram, etc., with the emphasis of reducing unnecessary clinical interventions)
	● Off-the-job training for 3–6 mo in designated tertiary hospitals with exit exams
	(3) Advanced skills training	(3) Training coverage of 100% in all primary and secondary healthcare institutions
	● Target subjects: obstetric, pediatric, midwifery, and anesthesiologic professionals from primary and secondary healthcare institutions
	● Target skills: pediatric advanced life support
Equipment and technical support for primary and secondary maternity facilities	Not applicable	Not applicable	(1) Basic equipment support	(1) 68 primary and secondary maternity facilities supported, covering all 12 districts
			● Target departments: obstetric and pediatric outpatient, emergency, inpatient, ICU, and medical laboratory departments
			(2) Specific technical support	(2) Experts assigned to 10 selected maternity facilities, each expert working on site for 3 mo
			● Expert in-site instructions on specific techniques
			● Target institutions: selected secondary maternity facilities based on demands and existing resources
			● Target techniques: vital sign monitoring, forceps delivery, and neonatal resuscitation
Capacity building for the maternal near-miss care system	(1) Capacity expansion for municipal-level maternal near-miss care centers	(1) 6 new municipal-level maternal near-miss care centers established for specific diseases	(1) Capacity building for district-level maternal near-miss care centers	(1) 8 new district-level maternal near-miss care centers established; a long-term municipal-district twinned support system set up
	● From “one for all” to “specialized maternity intensive care”		● Increasing the number of centers based on the demand of district
			● Developing municipal-district twined support to enhance technical cooperation

Information in this table was obtained from the proposals and annual reports of the Action Plan for Safe Motherhood and Infancy.

Abbreviations: CS, cesarean section; ICU, intensive care unit; LED, light emitting diode