How does hospital organisation influence the use of caesarean sections in low- and middle-income countries? A cross-sectional survey in Argentina, Burkina Faso, Thailand and Vietnam for the QUALI-DEC project
Authors: Etcheverry Camille , Betrán Ana Pilar , de Loenzien Myriam , Robson Michael , Kaboré Charles , Lumbiganon Pisake , Carroli Guillermo , Mac Quoc Nhu Hung , Gialdini Celina , Dumont Alexandre ,   the QUALI-DEC research group, Ravit Marion , Ramos Mendoza Isabella , Opiyo Newton , Bohren Meghan , Kabore Charles , Yaya Bocoum Fadima , Tiendrébéogo Simon , Zerbo Roger , Boriboonhirunsarn Dittakarn , Jampathong Nampet , Kongwattanakul Kiattisak , Ratinthorn Ameporn , Musigavong Olarik , Campodonico Liana , Carroli Berenise , Garcia Camacho Gabriela , Giordano Daniel , Gamerro Hugo , Mac Quoc Nhu Hung , Truong Thao , Thien Ngo Tran Minh , Toan Bui Duc , Khanh Trang Huynh Nguyen , Tuyet Hoang Thi Diem , Hanson Claudia , Molsted-Alvesson Helle , Annerstedt Kristi Sidney , Romero Mariana , Escuriet Ramon , Canet Olga , Zamboni Karen , Lombard Laurence 
Published: January 2024

Abstract
Background
Improving the understanding of non-clinical factors that lead to the increasing caesarean section (CS) rates in many low- and middle-income countries is currently necessary to meet the challenge of implementing effective interventions in hospitals to reverse the trend. The objective of this study was to study the influence of organizational factors on the CS use in Argentina, Vietnam, Thailand and Burkina Faso.

Methods
A cross-sectional hospital-based postpartum survey was conducted in 32 hospitals (8 per country). We selected women with no potential medical need for CS among a random sample of women who delivered at each of the participating facilities during the data collection period. We used multilevel multivariable logistic regression to analyse the association between CS use and organizational factors, adjusted on women’s characteristics.

Results
A total of 2,092 low-risk women who had given birth in the participating hospitals were included. The overall CS rate was 24.1%, including 4.9% of pre-labour CS and 19.3% of intra-partum CS. Pre-labour CS was significantly associated with a 24-hour anaesthetist dedicated to the delivery ward (ORa = 3.70 [1.41; 9.72]) and with the possibility to have an individual room during labour and delivery (ORa = 0.28 [0.09; 0.87]). Intra-partum CS was significantly associated with a higher bed occupancy level (ORa = 1.45 [1.09; 1.93]): intrapartum CS rate would increase of 6.3% points if the average number of births per delivery bed per day increased by 10%.

Conclusion
Our results suggest that organisational norms and convenience associated with inadequate use of favourable resources, as well as the lack of privacy favouring women’s preference for CS, and the excessive workload of healthcare providers drive the CS overuse in these hospitals. It is also crucial to enhance human and physical resources in delivery rooms and the organisation of intrapartum care to improve the birth experience and the working environment for those providing care.

Trial registration
The QUALI-DEC trial is registered on the Current Controlled Trials website (https://www.isrctn.com/) under the number ISRCTN67214403.