Re-Striking the Indications in the Improvement of Avoidable Caesarian Section: A Cluster Randomized Control Trial

Cesarean section (CS) rates are on the rise globally, creating serious public health concern with their increased risk of morbidity and mortality for low-risk pregnancies. The aim of this study is to identify whether re-striking the indications of CS can reduce the rate of unnecessary procedures at a system level, whilst preserving maternal and fetal outcomes.

This cluster randomized controlled trial recruited 277 Bangladeshi antenatal patients between 2020 and 2021, evaluating them in two groups: 138 individuals in the intervention group and 139 in the control group. A CS was recommended for any deviation from normal labor progression, with clinical experts providing second opinions and ongoing patient care in the intervention group. The incidence risk ratio (IRR) was calculated utilizing bias-corrected multivariable Poisson regression models and adjusting for cluster variation and plausible confounders.

We utilized cluster-adjusted samples with identical baseline characteristics among study groups. Re-striking the indication reduces the likelihood of CS (IRR = 0.87, 95% CI = 0.82-0.93; p < 0.001). The difference in the likelihood of maternal birth canal injury (p = 0.16) and the requirement of maternal resuscitation (p = 0.31) remained similar across the study arms. Although the APGAR score and perinatal mortality were identical across the two clusters, the likelihood of neonatal admission decreased (IRR = 0.59, 95% CI = 0.37-0.93; p = 0.02) in re-striking arms. After re-striking, the CS indication rate in the intervention group dropped from 60.1% to 44.2%, resulting in a 15.9% net reduction in CS events.

Re-striking the primary indications for cesarean sections is crucial for reducing avoidable deliveries; that is why it should be integrated into hospital policy to benefit patients and the healthcare system.