A scoping review of educational practices in caesarean section training

Caesarean Section (CS) is the most frequently performed abdominal surgery. Procedure-related mortality following CS is up to 100 times higher in Low- and Middle-Income Countries (LMICs) compared to High-Income Countries (HICs) when comparing outcomes between countries classified by the World Bank's income classification. In LMICs, CS are often conducted by junior doctors with limited supervision, highlighting the need for effective training strategies. This scoping review aimed to systematically identify, describe and map existing educational strategies for training novice surgeons in CS, to identify approaches that may be applicable in LMICs settings.

This scoping review was conducted according to the guidelines from the Joanna Briggs Institute. Studies describing educational interventions, training strategies or assessment approaches for CS were included, all study designs and data sources were considered. Published literature between 2001 and June 2025 was searched using terms and synonyms related to caesarean section, assessment, training and education. Databases PubMed/Medline, Epistemonikos, EMBASE, ScienceDirect, Web of Science/Scopus, and ERIC/EBSCHOST were searched. Data were extracted using a predefined charting database and synthesis was conducted using a hybrid deductive-inductive approach. Studies were classified according to the World Bank's 2022-2023 country income levels according to the country in which the study was conducted. Studies were categorised by teaching modality, assessment and learning outcomes, the learning curve and resource requirements. The Kirkpatrick model was applied to evaluate training outcomes.

A total of 45 data sources were included, 31 (69%) were conducted in HICs, and 14 (31%) in LMICs. Simulation-based training was the most common teaching strategy (53%) and was often combined with video or classroom-based training. When outcomes were assessed, most (75%) reported improvements in knowledge, skills or confidence (Kirkpatrick levels 1-2); few assessed behavioural or clinical outcomes (Kirkpatrick levels 3-4). Improvements in clinical outcomes were mainly observed in large-scale emergency obstetric training programs. Learning curve analyses indicated that operative time and blood loss appear to plateau after 15-30 cases.

Published research on educational strategies for CS is limited, particularly in LMIC settings, and few have been assessed for impact beyond participant-level outcomes. Promising approaches include blended learning, team-based training, and simulations. There is an urgent need for affordable, reproducible training strategies for LMICs, accompanied by an evaluation framework that assesses the impact on clinical outcomes.