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Reporting the QUALI-DEC intervention to optimize cesarean section use in low- and middle-income countries: A

Alexandre Dumont¹, Celina Gialdini², Ramon Escuriet^3,4

¹Université Paris Cité and Université Sorbonne Paris Nord, IRD, Inserm, Ceped, Paris, France.

International Journal of Gynaecology and Obstetrics: the Official Organ of the International Federation of Gynaecology and Obstetrics

|January 22, 2026

Abstract

Objective:

To describe the Appropriate Use of Cesarean Section Through Quality Decision-Making (QUALI-DEC) intervention-a multifaceted strategy to optimize the use of cesarean section in low- and middle-income countries-using the Template for Intervention Description and Replication (TIDieR) checklist to enable replication and scale-up.

Methods:

The QUALI-DEC intervention was implemented between July 2022 and April 2024 in 32 hospitals among Argentina, Burkina Faso, Thailand, and Viet Nam. Following the 12-item TIDieR checklist, we report in detail the four components of the intervention: (i) opinion leaders to promote evidence-based practices, (ii) audit and feedback using the Robson Ten Group Classification System, (iii) a Decision Analysis Tool to support informed decision-making by women, and (iv) companionship during labor and childbirth. Implementation processes, training, resources, and contextual adaptations were systematically documented.

Results:

Opinion leaders were pivotal in training staff, leading audits, and sustaining implementation. Healthcare workers from participating facilities were trained in using clinical algorithms, the Ten Group Classification System, audit report forms, the Decision Analysis Tool, and the World Health Organization model of companionship. The intervention was coupled with online technology to facilitate training, data collection, and feedback loops. Overall, the QUALI-DEC intervention was feasible across diverse contexts, with variations reflecting local culture, infrastructure, and policy.

Conclusion:

Appropriate cesarean section use is shaped by women, providers, and organizational factors, making behavioral change complex. The QUALI-DEC intervention provided a pragmatic, team-based strategy to empower women and engage healthcare providers in evidence-based and patient-centered decision-making. Using the TIDieR checklist ensured a detailed description, supporting replication, implementation, and monitoring in other maternity units in low- and middle-income countries.

Trial Registration:

ISRCTN67214403.

Keywords:

audit and feedback cesarean section companionship complex intervention decision aid maternity units opinion leaders

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