IRD (French Institute for Research on sustainable Development), CEPED (IRD-Université Paris Descartes), Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, Paris, France.
Research Institute of Health Sciences, Ouagadougou, Burkina Faso.
BMC Med. 2019 May 2;17(1):87. doi: 10.1186/s12916-019-1320-y.
In Burkina Faso, facility-based caesarean delivery rates have markedly increased since the national subsidy policy for deliveries and emergency obstetric care was implemented in 2006. Effective and safe strategies are needed to prevent unnecessary caesarean deliveries.
We conducted a cluster-randomized controlled trial of a multifaceted intervention at 22 referral hospitals in Burkina Faso. The evidence-based intervention was designed to promote the use of clinical algorithms for caesarean decision-making using in-site training, audits and feedback of caesarean indications and SMS reminders. The primary outcome was the change in the percentage of unnecessary caesarean deliveries. Unnecessary caesareans were defined on the basis of the literature review and expert consensus. Data were collected daily using a standardized questionnaire, in the same way at both the intervention and control hospitals. Caesareans were classified as necessary or unnecessary in the same way, in both arms of the trial using a standardized computer algorithm.
A total of 2138 and 2036 women who delivered by caesarean section were analysed in the pre and post-intervention periods, respectively. A significant reduction in the percentage of unnecessary caesarean deliveries was evident from the pre- to post-intervention period in the intervention group compared with the control group (18.96 to 6.56% and 18.27 to 23.30% in the intervention and control groups, respectively; odds ratio [OR] for incremental change over time, adjusted for hospital and patient characteristics, 0.22; 95% confidence interval [CI], 0.14 to 0.34; P < 0.001; adjusted risk difference, - 17.02%; 95% CI, - 19.20 to - 13.20%). The intervention did not significantly affect the rate of maternal death (0.75 to 0.19% and 0.92 to 0.40% in the intervention and control groups, respectively; adjusted OR 0.32; 95% CI 0.04 to 2.23; P = 0.253) or intrapartum-related neonatal death (4.95 to 6.32% and 5.80 to 4.29% in the intervention and control groups, respectively, adjusted OR 1.73; 95% CI 0.82 to 3.66; P = 0.149). The overall perinatal mortality data were not available.
Promotion and training on clinical algorithms for decision-making, audit and feedback and SMS reminders reduced unnecessary caesarean deliveries, compared with usual care in a low-resource setting.
The DECIDE trial is registered on the Current Controlled Trials website: ISRCTN48510263 .
在布基纳法索，自 2006 年实施国家分娩和紧急产科护理补贴政策以来，医疗机构剖宫产率显著提高。需要采取有效和安全的策略来预防不必要的剖宫产。
我们在布基纳法索的 22 家转诊医院进行了一项多方面干预的整群随机对照试验。该循证干预措施旨在通过现场培训、剖宫产指征的审核和反馈以及短信提醒来促进使用临床算法进行剖宫产决策。主要结局是不必要剖宫产的百分比变化。根据文献复习和专家共识，将不必要的剖宫产定义为。数据每天使用标准化问卷收集，在干预和对照医院以相同的方式收集。在试验的两个臂中，使用标准化的计算机算法，以相同的方式将剖宫产分为必要或不必要。
在干预前和干预后期间，分别分析了 2138 名和 2036 名接受剖宫产的妇女。与对照组相比，干预组在干预前至干预后的时间内，不必要剖宫产的百分比显著降低（干预组和对照组分别为 18.96%至 6.56%和 18.27%至 23.30%；调整医院和患者特征后的时间增量比值比，0.22；95%置信区间，0.14 至 0.34；P<0.001；调整风险差异，-17.02%；95%置信区间，-19.20 至-13.20%）。该干预措施并未显著影响产妇死亡率（干预组和对照组分别为 0.75%至 0.19%和 0.92%至 0.40%；调整后的比值比 0.32；95%置信区间 0.04 至 2.23；P=0.253）或产时相关新生儿死亡（干预组和对照组分别为 4.95%至 6.32%和 5.80%至 4.29%；调整后的比值比 1.73；95%置信区间 0.82 至 3.66；P=0.149）。整体围产期死亡率数据不可用。
与低资源环境中的常规护理相比，促进和培训决策的临床算法、审核和反馈以及短信提醒可减少不必要的剖宫产。
DECIDE 试验在当前对照试验网站上注册：ISRCTN48510263。
