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Interventions targeted at health professionals to reduce unnecessary caesarean sections: a qualitative evidence synthesis
  1. Carol Kingdon1,
  2. Soo Downe1,
  3. Ana Pilar Betran2
  1. 1 School of Community Health and Midwifery, Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
  2. 2 Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
  1. Correspondence to Dr Carol Kingdon; ckingdon{at}


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.

PROSPERO registration number CRD42017059455.

  • caesarean section
  • over treatment
  • qualitative evidence synthesis
  • health professionals

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  • Contributors APB and CK designed the review with input from SD. CK and SD conducted the searches, identification and screening with agreement by consensus of all authors on final inclusions. CK extracted data, with CK and SD agreeing initial, emergent and final themes. All authors contributed to writing the paper. All authors read and approved the final manuscript.

  • Funding This work was supported by the United States Agency for International Development (USAID) and the UNDP-UNFPA-Unicef-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, a cosponsored program executed by the WHO.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement This is a qualitative evidence synthesis. Original research data are contained in the included studies. Data interpretation is contained in the manuscript. Further information can be obtained from the corresponding author.

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