Strategies to address global cesarean section rates: A review of the evidence

Background: The steadily increasing global rates of cesarean section has become one of the most debated topics in maternity, care. This paper reviews and reports on the success of strategies that have been developed in response to this continuing challenge. Methods:A literature search identified studies conducted between 1985 and 2001 from the Cochrane Database of Systematic Reviews, Medline, Sociofile, Current Contents, Psyclit, Cinahl, and EconLit databases. An additional search of electronic databases for Level I evidence (systematic reviews.), Level 2 (randomized controlled trials), Level 3 (quasi-experimental studies), or Level 4 (observational studies) was performed. Selection criteria used to identify studies for review included types of study, participant, intervention, outcome measure, and study. Results: Interventions that have been used in an attempt to reduce cesarean section rates were identified; they are categorized as psychosocial, clinical, and structural strategies. Two clinical interventions, (external cephalic version, vaginal birth after a previous cesarean) and one psychosocial intervention (one-to-one trained support during labor) demonstrated Level I evidence for reducing cesarean section rates. Conclusions: Although the evidence for one-to-one care and external cephalic version came from both developed and developing settings, the systematic review,for vaginal birth after a cesarean was restricted to studies conducted in the United States. The effective implementation of the preceding strategies to reduce cesarean rates may, depend on the social and cultural milieu and on associated beliefs and practices.