The worldwide rise in caesarean section (CS) rate is a major healthcare issue, with rates reported as high as 32% in the United States (US) and 37% in Brazil [1, 2]. In the Netherlands, the overall CS rate has increased from 8.1% to 13.6% over the recent decade. Although this rise is relatively low compared to other countries, a striking detail is that the most impressive rise, in absolute numbers, was among healthy women with a singleton in vertex position between 37 and 42 weeks gestation . However, an increasing CS rate does not imply an improved outcome for mother and infant . CS are associated with an increased risk of maternal mortality as well as serious morbidity, such as admission to the intensive care unit (Odds Ratios (ORs) between 30.8 and 63.4), hysterectomy (ORs between 3.2 and 13.5), and puerperal infection (OR 3.0) [5–7].
Besides the short-term risks, CS have an impact on the mother’s future reproductive health, for example uterine rupture, placenta praevia, or placenta accreta [8, 9].
There is no evidence suggesting a better neonatal outcome from the increased CS rate in terms of mortality, intracranial haemorrhage, or impaired neurological development in the general population [10, 11]. In fact, an elective CS performed before 39 completed weeks is associated with respiratory distress and admission to the neonatal intensive care unit [11, 12].
The question arises what causes the worldwide increase in CS rate considering the fact that in most situations there are no apparent benefits of a CS for mother and child; the costs are higher compared to vaginal birth ; and the incidence of both maternal and neonatal complications are increased. There are concerns about the increasing rate of planned CS as well as a declining rate of vaginal birth after a previous CS (VBAC) in the US and Australia [13, 14].
To optimize CS practice, the Royal College of Obstetricians and Gynaecologists (RCOG) developed an evidence-based guideline (NICE: National Institute of Clinical Evidence) with clear recommendations for obstetric care. Similar recommendations, which have a direct effect on the decision to perform a CS, are also mentioned in the different guidelines of the Dutch Society of Obstetrics and Gynaecology (NVOG), Society of Obstetricians and Gynaecologists of Canada (SOGC), American College of Obstetrics and Gynaecology (ACOG), and National Guideline Clearinghouse from the US department of health and human services (NGC).
Despite the introduction of evidence-based guidelines, the CS rate continues to increase. We hypothesize that poor adherence to the guidelines plays a key role in the rising CS rate. In order to optimize adherence to the CS guidelines, the stepwise model by Grol can be used to select the proper strategies [15, 16]. The first step in this model is to analyze the current care (measured by valid quality indicators) compared to the optimal care as described in evidence-based guidelines, and to determine which barriers and facilitators might influence the implementation of optimal care. Subsequently, a tailor-made implementation strategy can be developed with activities applied to the determined barriers. In the last step, the strategy is executed and evaluated in terms of effectiveness, feasibility, and costs.
In view of the rising CS rate, this study aims are:
To develop a set of quality indicators on the decision to perform a CS based on key recommendations of both Dutch and international guidelines.
To gain insight into actual adherence of Dutch gynaecologists to guideline recommendations on the performance of CS.
To explore barriers and facilitators that have a direct effect on application of guideline recommendations regarding CS.
To develop, execute and evaluate a strategy in order to improve care and possibly decrease the CS incidence for a similar neonatal outcome, based on the information gathered in steps two and three.