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

问题出在哪里？剖腹产被认为是孕妇及其婴儿的救命手段。然而，在低收入和中等收入国家，剖腹产的母亲死亡的可能性是高收入国家剖腹产母亲的100倍。在这些情况下，剖腹产还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孩子的能力。他们的婴儿在剖腹产时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，剖腹产结局不佳的三个主要原因是：1.不适当的剖腹产(例如，剖腹产进行得太多、太快或太少、太晚)2.进行剖腹产的不安全做法3.分娩护理不达标(例如，阴道分娩没有达到高潮，导致在高级分娩中进行复杂的剖腹产)。许多问题导致了上述问题，例如缺乏进行安全剖腹产(以及实现安全阴道分娩--包括正常分娩和使用器械)的知识和技能。此外，对剖腹产和使用吸尘器或钳子的态度、助产士被边缘化、团队合作失调、责备和医疗法律关切的文化、家庭成员和社区在决策中的影响、女性与医疗保健提供者之间和临床医生之间糟糕的沟通技能，以及无法确定为什么要进行剖腹产，这些都加剧了问题。需要什么？上述复杂问题没有单一的解决方案。我们既需要提高剖腹产的安全性，又要确保只有在需要的时候才进行剖腹产。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，共同开发可接受的、公平的、可持续的循证干预措施，并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，在不同环境中以成本效益的方式调整或扩大干预措施。我们的目标是什么？我们提出了一个为期5年的计划，旨在改善低收入和中等收入国家剖腹产后的母婴结局。该方案(C-SAFE)计划(2)确保剖腹产是出于正确的理由(C-为什么)，(2)提高剖腹产的安全性(C-Op)，以及(3)促进安全和尊重的分娩护理，导致阴道分娩，包括使用器械安全分娩(C-NON)。C-SAFE干预措施将通过综合培训方案、增强当地舆论领袖(C-SAFE倡导者)和母亲的能力、基于团队的工作以及在审计和反馈中学习的方式在印度和坦桑尼亚各四家医院(30000名新生儿)实施。我们将怎么做？C-SAFE计划包括四个工作包，它们将(I)确定并汇集关于干预措施和结果的证据，(Ii)根据干预措施和结果对当地主要专业人员、当地妇幼保健用户和社区成员的重要性对干预措施和结果进行排名，(Iii)与地区医疗保健提供者、妇女和政策制定者一起制定被认为有益、可接受、相关、可获得和可行的干预措施，以及(Iv)测试C-Safe战略是否改变了做法，增加了医疗保健提供者对干预措施的接受程度，以及接受干预的妇女人数。我们还将评估医疗保健提供者、妇女、她们的家人和社区成员参与其中的成本和意见。建设学术和培训能力和能力，并让妇女及其社区参与研究的所有方面是核心特征。团队成员是谁？团队包括医生、助产士、研究设计专家、患者和公共参与小组、培训员和政策制定者。它们得到了世界卫生组织、联合国儿童基金会、Jhpiego、专业协会、Elly Charity的成员的支持。

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.