Interventions targeted at health professionals to reduce unnecessary caesarean sections : a qualitative evidence synthesis

Objective: To establish the views and experiences of healthcare professionals in relation to interventions targeted at them to reduce unnecessary caesareans. Design: Qualitative evidence synthesis. Setting: Studies undertaken in high-income, middle-income and low-income settings. Data sources: Seven databases (CINAHL, MEDLINE, PsychINFO, Embase, Global Index Medicus, POPLINE and African Journals Online). Studies published between 1985 and June 2017, with no language or geographical restrictions. We hand-searched reference lists and key citations using Google Scholar. Study selection: Qualitative or mixed-method studies reporting health professionals' views. Data extraction and synthesis: Two authors independently assessed study quality prior to extraction of primary data and authors' interpretations. The data were compared and contrasted, then grouped into summary of findings (SoFs) statements, themes and a line of argument synthesis. All SoFs were Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) assessed. Results: 17 papers were included, involving 483 health professionals from 17 countries (nine high-income, six middle-income and two low-income). Fourteen SoFs were identified, resulting in three core themes: philosophy of birth (four SoFs); (2) social and cultural context (five SoFs); and (3) negotiation within system (five SoFs). The resulting line of argument suggests three key mechanisms of effect for change or resistance to change: prior beliefs about birth; willingness or not to engage with change, especially where this entailed potential loss of income or status (including medicolegal barriers); and capacity or not to influence local community and healthcare service norms and values relating to caesarean provision. Conclusion: For maternity care health professionals, there is a synergistic relationship between their underpinning philosophy of birth, the social and cultural context they are working within and the extent to which they were prepared to negotiate within health system resources to reduce caesarean rates. These findings identify potential mechanisms of effect that could improve the design and efficacy of change programmes to reduce unnecessary caesareans.