Strategies For Reducing Cesarean Section Rates:a Meta-analysis

Objective: The objectives of this meta-analysis were to assess the effectiveness ofinterventions for reducing the cesarean section rates and to assess the impact of thisreduction on maternal and perinatal mortality and morbidity.Methods: The relative Chinese and English databases were consulted systematicallyto search prospective and retrospective studies, which involved rigorous evaluation ofa strategy for reducing cesarean section rates. Specific information was abstracted,and then heterogeneity, meta-analysis and meta-regression were computed usingSTATA version12.0.Results: Among the14included studies, a significant reduction of cesarean sectionrate was found by random meta-analysis (pooled RR=0.93[0.91-0.95]). No evidenceof publication bias was identified. To a large extent four covariables explained thevariation. They were strategy used, number of centers, total number of women andtype of providers. The study included six kinds of strategies. Audit and feedback(pooled RR=0.951[0.932,0.971]), quality improvement (pooledRR=0.791[0.744,0.84]), multifaceted strategies（pooled RR=0.831[0.77-0.88]），psychoprophylaxis（pooled RR=0.681[0.49-0.95]），educational strategy（pooled RR=0.850[0.42-1.71]），doula（pooled RR=0.590[0.39-0.90]）. Among included studies,no significant differences were found for perinatal and neonatal mortality andperinatal and maternal morbidity with respect to the mode of delivery. Two studiesshowed a significant reduction of NICU admission rate. One study showed rate of lowApgar score at one-minutes (<7) decrease statistically.Conclusion:(1)Active management of labor, which was consisted of organizational componentand medical component, was efficient in reducing cesarean section rate and the totalduration of labor. In addition, it have no impact on maternal and perinatal mortality and morbidity.(2) The medical audit and feedback cycle build up a supervise system for cesareansection. The feedback was provided in special conference. The guidelines wereimplemented rigorously and modification of management took place. Consequently,the rate of vaginal delivery increased, and the cesarean section rate drop down.(3)A key part of AMOR-IPAT method of care was the estimation of an upper limit ofthe optimal time of delivery for each patient. Patients who approach their riskthreshold without developing spontaneous labor could be offered a preventiveintervention in the form of labor induction. The method encouraged labor to occur atearlier gestational ages when the cephalopelvic disproportion and uteroplacentalinsufficiency did not take place. Hence the lower cesarean delivery rate that wasassociated with AMOR-IPAT exposure was paralleled by a lower rate of fetal distress.(4) Educational strategy was mainly about giving women explanation of the labormechanism and the method of push down. Therefore, the puerpera would be in betterpsychological state be for labor.(5) Cesarean delivery rate was decreased by doula because the method used verbalencouragement, touch and so on to support women.(6) psychoprophylaxis decreased cesarean rate by pattern breath and relaxation. Thenumber of women-asking cesarean descended.(7)If several strategies were implemented together, every strategy would be moreefficient.