A systematic review on the effectiveness of implementation strategies to postpone elective caesarean sections to ≥ 39 + (0–6) weeks of gestation

Abstract

Background Caesarean sections often have no urgent indication and are electively planned. Research showed that elective caesarean section should not be performed until 39 + (0–6) weeks of gestation to ensure best neonatal and maternal health if there are no contraindications. This was recommended by various guidelines published in the last two decades. With this systematic review, we are looking for implementation strategies trying to implement these recommendations to reduce elective caesarean section before 39 + (0–6) weeks of gestation. Methods We performed a systematic literature search in MEDLINE, EMBASE, CENTRAL, and CINAHL on 3rd of March 2021. We included studies that assessed implementation strategies aiming to postpone elective caesarean section to ≥ 39 + (0–6) weeks of gestation. There were no restrictions regarding the type of implementation strategy or reasons for elective caesarean section. Our primary outcome was the rate of elective caesarean sections before 39 + (0–6) weeks of gestation. We used the ROBINS-I Tool for the assessment of risk of bias. We did a narrative analysis of the results. Results We included 10 studies, of which were 2 interrupted time series and 8 before-after studies, covering 205,954 elective caesarean births. All studies included various types of implementation strategies. All implementation strategies showed success in decreasing the rate of elective caesarean sections performed < 39 + (0–6) weeks of gestation. Risk difference differed from − 7 (95% CI − 8; − 7) to − 45 (95% CI − 51; − 31). Three studies reported the rate of neonatal intensive care unit admission and showed little reduction. Conclusion This systematic review shows that all presented implementation strategies to reduce elective caesarean section before 39 + (0–6) weeks of gestation are effective. Reduction rates differ widely and it remains unclear which strategy is most successful. Strategies used locally in one hospital seem a little more effective. Included studies are either before-after studies (8) or interrupted time series (2) and the overall quality of the evidence is rather low. However, most of the studies identified specific barriers in the implementation process. For planning an implementation strategy to reduce elective caesarean section before 39 + (0–6) weeks of gestation, it is necessary to consider specific barriers and facilitators and take all obstetric personal into account. Systematic review registration PROSPERO CRD42017078231

Role of gestational age and maternal biological factors in early term neonatal morbidity

“…Although no association was found between cesarean section and newborn morbidity, the percentage of cesarean sections in both ETNBs (47.7%) and FTNBs (42.7%) was higher than the WHO recommendation of 10%-15% 26 , a situation that has been occurring in high, medium, and low income countries 27 . As cesarean section impairs the prognosis of ETNBs 28,29 , some countries have implemented strategies to reduce deliveries before 39 weeks 30 with good results; for example, not performing any indicated deliveries (both induction of labor and cesarean) before 39 weeks in uncomplicated pregnancies. In 2021, the ACOG and the U.S. Maternal Fetal Medicine Society updated the medical and obstetric indications for defining the time of delivery, considering that, in some cases, deferring birth until 39 weeks may increase the risk for both mother or fetus.…”

Comparison of Neonatal outcome of elective cesarean section done at 37–38 weeks of gestation and at 39-40 weeks of gestation

“…Several publications have confirmed this link, whether in terms of total newborn respiratory morbidity or specific neonatal respiratory morbidity [8,9]. The effectiveness of corticosteroid therapy in lowering the frequency of respiratory distress in premature infants born before 34 weeks and even 37 weeks was proven some time ago [10,11]. Obstetricians and pediatricians have assumed fetal maturity at 37 weeks for the past four decades.…”