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Table 2 Study characteristics

From: A systematic review on the effectiveness of implementation strategies to postpone elective caesarean sections to ≥ 39 + (0–6) weeks of gestation

Study Region, setting, data source, study design, funding Intervention Control Outcomes
Allen 2020 South Carolina, USA
All birthing hospitals
National Vital Statistics data from the National Center for Health Statistics from 2009 to 2015
(Controlled) Before-after study*
Funding: NR
Category: Regional policy (quality improvement)
South Carolina Birth Outcomes Initiative (SCBOI) was at first (2011) voluntary for all South Carolina birthing hospitals, which implemented strategies such as patient and provider education. The state’s Medicaid director declared that if rates were not suitably reduced with the voluntary programme, he would institute a nonpayment policy for EED.
2013: “Hard-stop” Policy for a state (South Carolina). If an EED was not medically justified (defined as diabetes, hypertension, eclampsia, breech, and other pregnancy abnormalities, medical conditions present at the time of delivery like premature rupture of membranes, prolonged labour, foetal distress; according to Joint Commission’s conditions possibly justifying delivery < 39 weeks), the hospital would attempt to “hard stop” the procedure from being scheduled. Medicaid and Blue Cross Blue Shield (covering 85% of births in South Carolina) both followed the policy.
Rationale for implementation strategy:
South Carolina having the 4th highest EED rate in the country
Implementation of intervention:
Voluntary programme September 2011, “hard-stop” January 2013
Period after intervention:
September 2011 to December 2012 voluntary programme, “hard-stop” January 2013–September 2015
No policy implemented
Period before intervention:
2009–September 2011
Primary:
EED rate at term < 39 WG
Supplementary analysis: ECS rate at term < 39 WG
Dunn 2013 Eastern Ontario, Canada
10 hospitals of a local health integration network (1 level 3, 3 level 2, 6 level 1)
Database BORN Ontario (Birth Record Database 2009–2010 and 2010–2011)
Before-after study
Funding: NR
Category: Regional quality reform (continuous quality improvement)
Incentive-based quality improvement project setting the rate of ERCS at term in low-risk women performed < 39 WG to 30% as a quality indicator
- Letter describing the project
- Site specific rates
- Custom query report instructions for data retrieval
- Chart audit tool to review cases
- Knowledge-to-action plan
- BIS birth record definitions
- Knowledge-to-action evidence summary
- 6 months follow-up call
Rationale for implementation strategy:
Chaillet et al. and recommendations from the Registered Nurses’ Association of Ontario Toolkit [36, 48]
Implementation of intervention:
31 March 2010
Period after intervention:
01 April 2010–31 March 2011
No quality reform implemented
Period before intervention:
01 April 2009–31 March 2010
Primary:
ERCS rate at term < 39 WG
Adjustment:
No adjustment
Gurol-Urganci 2014 England
63 NHS trust
Database (routinely collected HES database captures patient demographics and clinical information for all admissions to English NHS trusts)
Interrupted time series
Funding: NR
Category: Publication of a guideline
2004 NICE Guideline: caesarean section. Recommendation: planned CS should not routinely be carried out before 39 weeks [11]
Rationale for implementation strategy:
NA
Implementation of intervention:
April 2004
Period after intervention:
April 2004–28 February 2009
No guideline published
Period before intervention:
01 April 2000–01 April 2004
Primary:
ECS rate at term ≥ 39 WG
Adjustment:
No adjustment
Hutcheon 2015 Vancouver, Canada
British Columbia Women’s Hospital
Tertiary care teaching hospital
Hospital database, which contains linked clinical, administrative, and operating room databases. These include the BC Perinatal Database Registry, the Canadian Institute for Health Information’s Discharge Abstract Database, and the hospital surgery scheduling records (ORSOS)
Interrupted time series
Funding:
- One author holds New Investigator awards from the Canadian Institutes of Health Research and the Michael Smith Foundation for Health Research.
- Two authors hold Chercheur- Boursier awards from the Fonds de Recherche en Santé Quebec.
Category: Local hospital policy (quality improvement)
Limitation for low-risk planned CS < 39 WG at the level of the operating room booking clerk. Operating room booking clerk required confirmation of WG of at least 39 + 0 based on the last menstrual period, revised with early ultrasound using the algorithm from the Society of Obstetricians and Gynecologists of Canada, prior to booking the surgery.
Rationale for implementation strategy:
NR
Implementation of intervention:
01 April 2008
Period after intervention:
01 April 2008–31 March 2012
No policy implemented (the timing of a planned CS was at the discretion of the attending physician)
Period before intervention:
01 April 2005–31 March 2008
Primary:
CS rate at term < 39 WG
Adjustment:
maternal age, prepregnancy body mass index, and number of previous CS
Macallister 2019 Western Australia
Database
MNS, NETS WA database and neonatal unit admission records. The MNS receives notifications on all midwifery attended births in WA. The NETS WA database contains information on all aspects of the retrieval process
Before-after study
Funding: NR
Category: Publication of a guideline
2006 RANZCOG guideline: Timing of elective caesarean section at term
Recommendation: It is recommended that elective caesarean section in women without additional risks should be carried out at approximately 39 WG [13]
Rationale for strategy:
NA
Implementation of intervention:
November 2006
Period after intervention:
01 January 2008–31 December 2014
No guideline published
Period before intervention:
01 January 2003–31 December 2006
Primary:
CS rate at term < 39 WG
Adjustment:
No adjustment
Nicholl 2010 New-South-Wales, Australia
Tertiary referral hospital
Local database
Before-after study
Funding: NR
Category: Local hospital education (multifaceted intervention)
Developed by: Obstetric consultant, delivery suite midwifery manager, clinical research midwife, delivery suite staff, quality improvement advisor, maternity data analyst
Intervention: Pre-emptive education of midwifery/ obstetric staff, evidence folders in key clinical areas, background data/objectives discussed at clinical meetings focusing antenatal clinic/delivery suite. Process change on dating/booking system:
- Indications for CS mandatory at booking, as WG
- Delivery suite staff refer on to Clinical Director CS booking without clinical indication for delivery < 39 WG. Criteria: maternal or foetal condition that would benefit from early delivery (local clinical database)
Rationale for implementation strategy:
NR
Implementation of intervention:
March 2007 to August 2007
Period after intervention:
NR
Booking system: direct referral from clinicians in outpatients department, wards/private consulting rooms to delivery suite staff, only basic details required to complete the booking. No screening of indication for the procedure in place.
Period before intervention:
2005–2006
Primary:
CS rate at term < 39 WG
NICU admission
Adjustment:
No adjustment
Nicoll 2004 Glasgow, Scotland
Royal Maternity Hospital, Glasgow
Registry and operating theatre books. (Labour ward register of births)
Before-after study
Funding: NR
Category: Local hospital quality reform (audit and feedback)
Recommendation to delay ECS ≥ 39 WG without obstetric indication for early-term delivery. An audit was performed before and after the intervention. The results of the first audit cycle were presented to obstetric and paediatric staff. Afterwards recommendation was given. WG was measured with last menstrual period and ultrasound in week 20.
Rationale for implementation strategy:
NR
Implementation of intervention:
1 January 1998
Period after intervention:
June 1999–June 2000
No quality reform implemented
Period before intervention:
Cycle I: October 1996–October 1997
Primary:
CS rate at term < 39 WG
Secondary:
NICU admission
Adjustment:
No adjustment
Snowden 2016 Oregon, USA
49 hospitals providing maternity care
Database (vital statistics data provided by the Oregon Center for Health Statistics)
Before-after study
Funding: Supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under Policy R40 Award (number R40 MC268090201).
One author is supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (grant number R00 HD079658-03).
Category: Regional policy (quality improvement)
“Hard-stop” policy for a state (Oregon). The policy limited early-term deliveries by requiring review and approval for any delivery without documented indication (gestational hypertension, preeclampsia, eclampsia, foetal growth restriction) < 39 WG
Rationale for implementation strategy:
NR
Implementation of intervention:
2011
Period after intervention:
2012–2013 [2011 excluded, because of unexposed time periods of intervention]
No policy implemented
Period before intervention:
2008–2010
Primary:
CS rate at term < 39WG
Secondary:
NICU admission
Adjustment:
multivariable logistic regression for maternal race/ethnicity, parity, insurance status, prenatal care, maternal age and education, certified nurse-midwife attendant
Tanger 2010 Amsterdam, the Netherlands
VU University Medical Center
Database and registry; National Pediatrician Registration Database, the 2nd line (LVR2) and operating registrations (OPERA) selected on the Primary Sector Code CS. Then, both data sets were combined to one complete database
Before-after study
Funding: None
Category: Local hospital policy (quality improvement)
ECS will be planned ≥ 39 WG in the absence of comorbidities (preeclampsia, maternal infection, (suspicion of) foetal distress, severe birth defects of the foetus, maternal gestational diabetes, or diabetes mellitus). According to the protocol, every ECS indication was resolved in the weekly meeting of paediatricians and obstetrics. WG was measured with ultrasound in the first trimester.
Rationale for implementation strategy:
NICE Guideline CG13 and ACOG Committee Opinion No. 394 [11, 49]
Implementation of intervention:
NR
Period after intervention:
January 2003–December 2007
No policy implemented
Period before intervention:
1994–1998
Primary:
CS rate at term ≥ 39 WG
Adjustment:
No adjustment
Yamasato 2014 Honululu, Hawaii
Kapi’olani Medical Center for Women and Children
Database (outcomes obtained from data fields in maternal and neonatal charts)
Before-after study
Funding: Hawaii Pacific Health Research Institute
Category: Local hospital policy (quality improvement)
Any delivery induction required the patient to be ≥ 39 WG and by ACOG dating criteria or have a medical condition (according ACOG and the Joint Commission National Quality Measures for Perinatal Care) justifying induction. In the absence of a medical indication for induction, a minimum Bishop score of 6 is required. Inductions not meeting criteria were not to be scheduled without approval by the Department Chair. WG was measured according to the ACOG practice bulletin No. 107 [50]
Rationale for implementation strategy:
ACOG practice bulletin no. 107 [50]
Implementation of intervention.
2011
Period after intervention:
2010–31 March 2012
No policy implemented
Period before intervention:
01 June 2010–2011
Primary:
Induction rates at term ≤ 39 WG
Adjustment:
Multivariable logistic regression on maternal characteristics
  1. Category: Type of intervention (regional quality reform, hospital internal quality reform, regional policy, local hospital policy, local hospital education, publication of a guideline)
  2. *Authors controlled with number from other states without any strategy to reduce early elective induction. However, in the subgroup of early elective CS, no control was reported
  3. ACOG The American Congress of Obstetricians and Gynecologists, BIS BORN Information System, BORN Better Outcomes Registry & Network, CS caesarean section, ECS elective caesarean section, EED early elective delivery, ERCS elective repeat caesarean section, HES hospital episode statistics, MNS midwives notification system, NA not applicable, NETS WA Newborn Emergency Transport Service Western Australia, NHS National Health Services, NICE The National Institute for Health and Care Excellence, NICU neonatal intensive care unit, NR not reported, RANZCOG Royal Australian and New Zealand College of Obstetricians and Gynecologists, WA Western Australia, WG week of gestation