ENhancinG vAGinal dElivery in Greece through educational and behavioral interventions among maternity care providers regarding labor management: the ENGAGE stepped-wedge randomized prospective trial protocol
Authors: Vrachnis Nikolaos , Antonakopoulos Nikolaos , von Dadelszen Peter , Vidler Marianne , Maroudias Georgios , Bone Jeffrey , Sandhu Ash , Loukas Nikolaos , Magee Laura , Roussos Nikolaos , Kassaris Stefania , Fotiou Alexandros , Zygouris Dimitrios , Adonakis Georgios , Akrivis Christodoulos , Antsaklis Aris , Athanasiadis Apostolos , Bontis Nikolaos , Daniilidis Angelos , Daponte Alexandros , Daskalakis Georgios , Deligeoroglou Efthimios , Dinas Konstantinos , Drakakis Peter , Gerede Angeliki , Grimbizis Grigorios , Iacovidou Nicoletta , Kambas Nikolaos , Katasos Theodoros , Katsetos Christos , Katsikis Ilias , Makrigiannakis Antonios , Matalliotakis Michail , Messini Christina , Mikos Themis , Nikolettos Nikolaos , Pados Georgios , Paschopoulos Minas , Patsouras Konstantinos , Siahanidou Soultana , Sioulas Vasileios , Skentou Chara , Stavros Sofoklis , Temmerman Marleen , Tsikouras Panagiotis , Tsitsis Vasilios , Vlahos Nikolaos , Rodolakis Alexandros , Papageorghiou Aris , Loutradis Dimitrios 
Published: August 2024

Abstract
Background
There is an emerging need to systematically investigate the causes for the increased cesarean section rates in Greece and undertake interventions so as to substantially reduce its rates. To this end, the ability of the participating Greek obstetricians to follow evidence-based guidelines and respond to other educational and behavioral interventions while managing labor will be explored, along with barriers and enablers. Herein discussed is the protocol of a stepped-wedge designed intervention trial in Greek maternity units with the aforementioned goals in mind, named ENGAGE (ENhancinG vAGinal dElivery in Greece).

Methods
Twenty-two selected maternity units in Greece will participate in a multicenter stepped-wedge randomized prospective trial involving 20,000 to 25,000 births, with two of them entering the intervention period of the study each month (stepped randomization). The maternity care units entering the study will apply the suggested interventions for a period of 8–18 months depending on the time they enter the intervention stage of the study. There will also be an initial phase of the study lasting from 8 to 18 months including observation and recording of the routine practice (cesarean section, vaginal birth, and maternal and perinatal morbidity and mortality) in the participating units. The second phase, the intervention period, will include such interventions as the application of the HSOG (the Hellenic Society of Obstetrics and Gynecology) Guidelines on labor management, training on the correct interpretation of cardiotocography, and dealing with emergencies in vaginal deliveries, while the steering committee members will be available to discuss and implement organizational and behavioral changes, answer questions, clarify relevant issues, and provide practical instructions to the participating healthcare professionals during regular visits or video conferences. Furthermore, during the study, the results will be available for the participating units in order for them to monitor their own performance while also receiving feedback regarding their rates. Τhe final 2-month phase of the study will be devoted to completing follow-up questionnaires with data concerning maternal and neonatal morbidities that occurred after the completion of the intervention period. The total duration of the study is estimated at 28 months. The primary outcome assessed will be the cesarean section rate change and the secondary outcomes will be maternal and neonatal morbidity and mortality.

Discussion
The study is expected to yield new information on the effects, advantages, possibilities, and challenges of consistent clinical engagement and implementation of behavioral, educational, and organizational interventions described in detail in the protocol on cesarean section practice in Greece. The results may lead to new insights into means of improving the quality of maternal and neonatal care, particularly since this represents a shared effort to reduce the high cesarean section rates in Greece and, moreover, points the way to their reduction in other countries.

Trial registration
NCT 04504500 (ClinicalTrials.gov). The trial was prospectively registered.
Ethics Reference No: 320/23.6.2020, Bioethics and Conduct Committee, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece