Background Caesarean section rates are increasing globally. The factors contributing to this increase are complex, and identifying interventions to address them is challenging. Non-clinical interventions are applied independently of a clinical encounter between a health provider and a patient. Such interventions may target women, health professionals or organisations. They address the determinants of caesarean births and could have a role in reducing unnecessary caesarean sections. This review was first published in 2011. This review update will inform a new WHO guideline, and the scope of the update was informed by WHO's Guideline Development Group for this guideline. Objectives To evaluate the e ectiveness and safety of non-clinical interventions intended to reduce unnecessary caesarean section. Search methods We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers in March 2018. We also searched websites of relevant organisations and reference lists of related reviews. Selection criteria Randomised trials, non-randomised trials, controlled before-a er studies, interrupted time series studies and repeated measures studies were eligible for inclusion. The primary outcome measures were: caesarean section, spontaneous vaginal birth and instrumental birth. Non-clinical interventions for reducing unnecessary caesarean section (Review)

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Background: Audit and feedback (A&F) is among the most widely used implementation strategies, providing healthcare professionals with summaries of their practice performance to prompt behaviour change and optimize care. Wide variability in effectiveness of A&F has spurred efforts to explore why some A&F interventions are more effective than others. Unpacking the variability of the content of A&F interventions in terms of their component behaviours change techniques (BCTs) may help advance our understanding of how A&F works best. This study aimed to systematically specify BCTs in A&F interventions targeting healthcare professional practice change. Methods: We conducted a directed content analysis of intervention descriptions in 287 randomized trials included in an ongoing Cochrane systematic review update of A&F interventions (searched up to June 2020). Three trained researchers identified and categorized BCTs in all trial arms (treatment & control/comparator) using the 93-item BCT Taxonomy version 1. The original BCT definitions and examples in the taxonomy were adapted to include A&F-specific decision rules and examples. Two additional BCTs (‘Education (unspecified)’ and ‘Feedback (unspecified)’) were added, such that 95 BCTs were considered for coding. Results: In total, 48/95 BCTs (50%) were identified across 360 treatment arms at least once (mean=5.2, SD=2.8, range=1-29 per treatment arm). The most common BCTs were ‘Feedback on behaviour’ (present 89% of the time; e.g., feedback on drug prescribing), ‘Instruction on how to perform the behaviour’ (71%; e.g., issuing a clinical guideline), ‘Social comparison’ (52%; e.g., feedback on performance of peers), ‘Credible source’ (41%; e.g., endorsements from respected professional body), and ‘Education (unspecified)’ (31%; e.g., giving a lecture to staff). The 287 control/comparator arms contained on average 3.0 BCTs (SD=2.4, range=1-15), of which the most common were identical to those identified in treatment arms. Conclusions: A&F interventions to improve healthcare professional practice include a moderate range of BCTs, focusing predominantly on providing behavioural feedback, sharing guidelines, peer comparison data, education, and leveraging credible sources. We encourage the use of our A&F-specific list of BCTs to improve knowledge of what is being delivered in A&F interventions. Our study provides a basis for exploring which BCTs are associated with intervention effectiveness. Trial registrations: N/A