xC-Safe: Optimising maternal and perinatal outcomes through safe and appropriate caesarean sections in low- and middle-income countries (LMIC)

问题是什么？剖腹产被认为是孕妇及其婴儿的救命手术。然而，在低收入和中等收入国家，剖腹产母亲的死亡率是高收入国家剖腹产母亲的100倍。在这些情况下，剖腹产也会导致终身健康问题，影响妇女的生活质量和安全生育更多子女的能力。他们的婴儿在剖腹产过程中或剖腹产后不久死亡的风险也很高。在低收入和中等收入国家，剖腹产后结果不佳的三个主要原因是：1.不适当的剖腹产（例如，进行“太多，太快”或“太少，太晚”）2。不安全的做法，在执行程序3。分娩护理不合标准（例如，阴道分娩未达到高潮，导致晚期分娩时复杂的剖腹产）。造成上述问题的原因有很多，例如缺乏进行安全剖腹产的知识和技能（以及实现安全阴道分娩-正常分娩和使用器械分娩）。此外，对剖腹产和使用真空或产钳的态度，助产士的边缘化，功能失调的团队合作，指责和医疗法律问题的文化，家庭成员和社区在决策中的影响，妇女和医疗保健提供者之间以及临床医生之间的沟通技巧差，以及无法确定为什么要进行剖腹产，这些都使问题恶化。对于上述复杂的问题，没有单一的解决办法。我们需要提高剖腹产的安全性，并确保只在需要时进行。为此，我们将通过与妇女及其支持网络、医疗保健提供者、政策制定者和其他相关利益攸关方合作，共同制定可接受、公平、可持续的循证干预措施，并在各种环境中以成本效益高的方式加以调整或扩大。我们的目标是什么？我们提出了一项为期5年的计划，旨在改善低收入和中等收入国家剖腹产手术后的母婴结局。该方案（C-Safe）计划（二）确保剖腹产是出于正确的理由（C-Why），（二）提高剖腹产的安全性（C-Op），（三）促进阴道分娩时的安全和尊重护理，包括使用器械安全分娩（C-Non）。将在印度和坦桑尼亚各四家医院（30 000例分娩）实施C-Safe干预措施，包括实施综合培训方案、增强地方舆论领袖（C-Safe冠军）和母亲的权能、开展团队工作以及通过审计和反馈进行学习。我们该怎么办？C-Safe计划包括四个工作包，将（i）确定并汇集有关干预措施效果和结果的证据，（ii）根据其对当地主要专业人员，当地孕产妇护理用户和社区成员的重要性对干预措施和结果进行排名，（iii）与区域医疗保健提供者，妇女和决策者一起制定干预措施，以确定哪些措施是有益的，可接受的，相关性、可获得性和可行性;（iv）测试C-Safe战略是否改变了实践，增加了医疗保健提供者对干预措施的接受，以及接受干预的妇女人数。我们还将评估成本，以及医疗保健提供者、妇女、她们的家庭和社区成员对参与其中的看法。以及让妇女和她们的社区参与研究的各个方面，都是核心特征。团队成员是谁？该团队包括医生、助产士、研究设计专家、患者和公众参与团体、培训人员和政策制定者。他们得到了世界卫生组织、联合国儿童基金会、Jhpiego、专业协会、ELLY慈善机构成员的支持。

WHAT IS THE PROBLEM?Caesarean section is considered a life-saving procedure for pregnant women and their babies. Yet, in low- and middle-income countries, mothers who give birth by caesarean section are 100 times more likely to die than those having the procedure in high-income countries. In these settings, caesarean sections also contribute to life-long health problems that affect the women's quality of life and their ability to safely have more children. Their babies are also at high risk of dying during or soon after caesarean section.The three main reasons for poor outcomes after caesarean section in low- and middle-income countries are: 1. Inappropriate caesarean sections (e.g. performed 'too many, too soon' or 'too little, too late') 2. Unsafe practices in performing the procedure 3. Substandard care in labour (e.g. not culminating in vaginal birth which leads to complicated caesarean sections in advanced labour). Many issues contribute to the above problems such as lack of knowledge and skills to undertake safe caesarean section (and to achieve safe vaginal births - both normal and by using instruments). In addition, attitudes towards caesarean section and use of vacuum or forceps, marginalisation of midwives, dysfunctional teamwork, a culture of blame and medico-legal concerns, influence of family members and communities in decision-making, poor communication skills between women and healthcare providers and amongst clinicians, and inability to determine why caesarean sections are performed worsen the problem.WHAT IS NEEDED?There is no single solution to the above complex problems. We need to both improve the safety of caesarean sections and ensure they are only done when needed. To do this, we will co-develop evidence-based interventions that are acceptable, equitable, sustainable and which can be adapted or scaled-up cost-effectively across settings, by collaborating with women and their support networks, healthcare providers, policymakers and other relevant stakeholders. WHAT IS OUR AIM?We propose a 5-year Programme that aims to improve mother and baby outcomes following caesarean sections in low- and middle-income countries. The Programme (C-Safe) plans to (ii) ensure caesarean sections are done for the right reasons (C-Why), (ii) improve their safety (C-Op), and (iii) promote safe and respectful care in labour resulting in vaginal births, including safe delivery with instruments (C-Non). The C-Safe intervention will be implemented using a comprehensive training Programme, empowerment of local opinion leaders (C-Safe Champions) and mothers, team-based working, and learning through audit and feedback, in four hospitals each in India and Tanzania (30,000 births). WHAT WILL WE DO?The C-Safe Programme involves four work packages that will (i) identify and bring together evidence on the effects of interventions and outcomes, (ii) rank the interventions and outcomes according to their importance to key local professionals, local maternity care users, and community members, (iii) develop the interventions with regional healthcare providers, women and policymakers on what is considered to be beneficial, acceptable, relevant, accessible and feasible and (iv) test whether the C-Safe strategy changes practices and increases uptake of the intervention by healthcare providers, as well as the number of women receiving it. We will also assess costs and views of healthcare providers, women, their family and community members on being part of it. Building academic and training capacity and capability, and involving women and their communities in all aspects of the study, are core features.WHO ARE THE TEAM MEMBERS?The team includes doctors, , midwives, experts in study design, patient and public involvement groups, trainers, policymakers. They are supported by members of the World Health Organization, UNICEF, Jhpiego, Professional associations, ELLY Charity.