Maternity service organisational interventions that aim to reduce caesarean section: a systematic review and meta-analyses

Chapman, Anna, Nagle, Cate, Bick, Debra, Lindberg, Rebecca, Kent, Bridie, Calache, Justin, and Hutchinson, Alison M. (2019) Maternity service organisational interventions that aim to reduce caesarean section: a systematic review and meta-analyses. BMC Pregnancy and Childbirth, 19. 206.

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Caesarean sections (CSs) are associated with increased maternal and perinatal morbidity, yet rates continue to increase within most countries. Effective interventions are required to reduce the number of non-medically indicated CSs and improve outcomes for women and infants. This paper reports findings of a systematic review of literature related to maternity service organisational interventions that have a primary intention of improving CS rates.


A three-phase search strategy was implemented to identify studies utilising organisational interventions to improve CS rates in maternity services. The database search (including Cochrane CENTRAL, CINAHL, MEDLINE, Maternity and Infant Care, EMBASE and SCOPUS) was restricted to peer-reviewed journal articles published from 1 January 1980 to 31 December 2017. Reference lists of relevant reviews and included studies were also searched. Primary outcomes were overall, planned, and unplanned CS rates. Secondary outcomes included a suite of birth outcomes. A series of meta-analyses were performed in RevMan, separated by type of organisational intervention and outcome of interest. Summary risk ratios with 95% confidence intervals were presented as the effect measure. Effect sizes were pooled using a random-effects model.


Fifteen articles were included in the systematic review, nine of which were included in at least one meta-analysis. Results indicated that, compared with women allocated to usual care, women allocated to midwife-led models of care implemented across pregnancy, labour and birth, and the postnatal period were, on average, less likely to experience CS (overall) (average RR 0.83, 95% CI 0.73 to 0.96), planned CS (average RR 0.75, 95% CI 0.61 to 0.93), and episiotomy (average RR 0.84, 95% CI 0.74 to 0.95). Narratively, audit and feedback, and a hospital policy of mandatory second opinion for CS, were identified as interventions that have potential to reduce CS rates.


Maternity service leaders should consider the adoption of midwife-led models of care across the maternity episode within their organisations, particularly for women classified as low-risk. Additional studies are required that utilise either audit and feedback, or a hospital policy of mandatory second opinion for CS, to facilitate the quantification of intervention effects within future reviews.

Item ID: 58884
Item Type: Article (Research - C1)
ISSN: 1471-2393
Keywords: Caesarean section; Systematic review; Meta-analysis; Organisational interventions; Childbirth; Maternity service; Midwife-led care
Copyright Information: © The Author(s). 2019. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.
Date Deposited: 09 Jul 2019 21:55
FoR Codes: 42 HEALTH SCIENCES > 4204 Midwifery > 420499 Midwifery not elsewhere classified @ 75%
32 BIOMEDICAL AND CLINICAL SCIENCES > 3215 Reproductive medicine > 321502 Obstetrics and gynaecology @ 25%
SEO Codes: 92 HEALTH > 9205 Specific Population Health (excl. Indigenous Health) > 920507 Womens Health @ 100%
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