***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND Latin America has a high rate of caesarean sections . We tested the hypothesis that a hospital policy of m and atory second opinion , based on the best existing scientific evidence , reduces the hospital caesarean section rate by 25 % , without increasing maternal and perinatal morbidity and mortality . METHODS 36 hospitals in Argentina ( 18 ) , Brazil ( eight ) , Cuba ( four ) , Guatemala ( two ) , and Mexico ( four ) , were r and omly assigned to intervention or control in a matched pair design . All physicians in the intervention hospitals deciding a non-emergency  caesarean section  had to follow a policy of m and atory second opinion . The primary outcome was the overall caesarean section rate in the hospitals after a 6-month implementation period . We also assessed women 's satisfaction with labour and delivery care and physicians'acceptance of the second opinion policy . FINDINGS A total of 34 hospitals attending 149?276 deliveries were r and omised and completed the protocol . The m and atory second opinion policy was associated with a small but significant reduction in rates of caesarean section ( relative rate reduction 7.3 % ; 95 % CI 0.2 - 14.5 ) , mostly in intrapartum sections ( 12.6 % ; 0.6 - 24.7 ) . Other maternal and neonatal outcomes and women 's perceptions and satisfaction with the process of care were similarly distributed between the groups . INTERPRETATION In hospitals applying this policy of second opinion , 22 intrapartum caesarean sections could be prevented per 1000 deliveries , without affecting maternal or perinatal morbidity , and without affecting mothers ' satisfaction with the care process OBJECTIVE Our purpose was to determine whether completion of the medical audit cycle in labor ward practice could safely reduce cesarean section rates . STUDY DESIGN A retrospective medical audit of all deliveries from 1984 to 1988 was performed . The groups of women contributing most to the overall cesarean section rate were identified . Strategies for labor management directed at the primary indication for cesarean section ( dystocia ) were developed and introduced . The effect was monitored prospect ively from 1989 through 1992 . Data were analyzed with the chi 2 test . RESULTS A total of 21,125 deliveries were studied . After management change the overall cesarean section rate was decreased ( 9.5 % vs 12 % , p < 0.0001 ) . In our population spontaneously laboring nulliparous women with a singleton , cephalic , term pregnancy contributed a significant number of cesarean sections 1982 to 1988 ( 19.7 % of all cesarean sections ) . Applying principles of early diagnosis and treatment of dystocia in these women result ed in a decrease in the cesarean section rate ( 2.4 % vs 7.5 % , p < 0.0001 ) . This was primarily responsible for the overall decrease in the cesarean section rate . CONCLUSION Effective medical audit of labor management can reduce cesarean section rates BACKGROUND A woman 's childbirth experience has an influence on her future preferred mode of delivery . This study aim ed to identify determinants for women who changed from preferring a planned vaginal birth to an elective cesarean section after their first childbirth . METHODS This prospect i ve longitudinal observational study involved two units that provide obstetric care in Hong Kong . A  mail survey was sent to 259 women 6 months after their first childbirth . These women had participated in a longitudinal cohort study that examined their preference for elective cesarean section in the antenatal period of their first pregnancies . Univariate and multivariate analyses were performed to identify determinants for women who changed from preferring vaginal birth to elective cesarean section . RESULTS Twenty-four percent ( 23.8 % , 95 % CI 18.4 - 29.3 ) of women changed from preferring vaginal birth to elective cesarean section after their first childbirth . Determinants found to be positively associated with this change included actual delivery by elective cesarean section ( OR 106.3 , 95 % CI 14.7 - 767.4 ) intrauterine growth restriction ( OR 19.5 , 95 % CI 1.1 - 353.6 ) , actual delivery by emergency cesarean section ( OR 8.4 , 95 % CI 3.4 - 20.6 ) , higher family income ( OR 3.2 , 95 % CI 1.1 - 8.8 ) , use of epidural analgesia ( OR 2.6 , 95 % CI 1.0 - 6.8 ) , and higher trait anxiety score ( OR 1.1 , 95 % CI 1.0 - 1.3 ) . The most important reason for women who changed from preferring vaginal birth to elective cesarean section was fear of vaginal birth ( 24.4 % ) . CONCLUSIONS A significant proportion of women changed their preferred mode of delivery after their first childbirth . Apart from reducing the number of cesarean sections in nulliparous women , prompt provision of education to women who had complications and investigations into fear factors during vaginal birth might help in reducing women 's wish to change to elective cesarean section BACKGROUND In 1994 a five-year prospect i ve observational study ( including 38,541 singleton live-born deliveries ) based on maternal and neonatal hospital administrative discharge data for DRGs 370 - 375 was launched at Cedars Sinai Medical Center ( CSMC ) in Los Angeles . In 1993 a cesarean section ( C-section ) reduction task force was first convened and several interventions were conducted and monitored during a two-year period . In 1995 CSMC joined the Institute for Healthcare Improvement 's ( IHI 's ) national collaborative on lowering C-section rates . RESULTS The first intervention involved physician education ( gr and rounds ) and occurred during the preintervention baseline period . Providing physician-specific data had been implemented before participation in the IHI collaborative . Two other interventions were implemented before the collaborative versus 13 interventions after . The C-section rate decreased from 26.0 % in the baseline period in 1993 to 20.5 % in 1997 , a 21.2 % reduction . During the postintervention period , the C-section rate increased to 23.5 % . There was no statistically or clinical ly significant increase in clavicular fractures , brachial plexus injuries , or cerebral hemorrhage in the four study years , compared to the baseline period . DISCUSSION It is possible to safely reduce C-section delivery rates . Activities are now under way to involve additional private physician leaders in the continuous quality improvement effort . Although the small increase in the C-section rate during the postintervention period may represent statistical variation , and in itself may not be clinical ly significant , it supports the thesis that ongoing , continuous organizational support is required to achieve and maintain gains This study explored the effects of the diagnosis-related group (DRG)-based prospect i ve payment system ( PPS ) operated by voluntarily participating organizations on the  cesarean section ( CS ) rates , and analyzed whether the participating health care organizations had similar CS rates despite the varied participation periods . The study sample included delivery cl aims data from the Korean national health insurance program for the year 2003 . Risk factors were identified and used in the adjustment model to distinguish the main reason for CS . Their risk-adjusted CS rates were compared by the reimbursement methods , and the organizations ' internal and external environments were controlled . The final risk-adjustment model for the CS rates meets the criteria for an effective model . There were no significant differences of CS rates between providers in the DRG and fee-for-service system after controlling for organizational variables . The CS rates did not vary significantly depending on the providers ' DRG participation periods . The results provide evidence that the DRG payment system operated by volunteering health care organizations had no impact on the CS rates , which can lower the quality of care . Although the providers joined the DRG system in different years , there were no differences in the CS rates among the DRG providers . These results support the future expansion of the DRG-based PPS plan to all health care services in Korea Objective . To study whether use of psychoprophylaxis during labor affects course of labor and experience of childbirth in nulliparous women . Design . Cohort study . Setting . Women were recruited from 15 antenatal clinics in Sweden between October 2005 and January 2007 . Sample . A total of 857 nulliparous women with a planned vaginal delivery . Methods . Using data from a r and omized controlled trial of antenatal education where the allocated groups were merged , we compared course of labor and experience of childbirth between women who used psychoprophylaxis during labor and those who did not . Data were collected by question naires in mid‐pregnancy and three months after birth , and from the Swedish Medical Birth Register . Logistic regression was used to assess associations . Main outcome measures . Mode of delivery , augmentation of labor , length of labor , Apgar score , pain relief and experience of childbirth as measured by the Wijma Delivery Experience Question naire . Results . Use of psychoprophylaxis during labor was associated with a lower risk of emergency cesarean section ( adjusted odds ratio ( OR ) 0.57 ; 95 % confidence interval ( CI ) 0.37–0.88 ) , but an increased risk of augmentation of labor ( adjusted OR 1.68 ; 95 % CI 1.23–2.28 ) . No statistical differences were found in length of labor ( adjusted OR 1.32 ; 95 % CI 0.95–1.83 ) , Apgar score < 7 at five minutes ( adjusted OR 0.82 ; 95 % CI 0.33–2.01 ) , epidural analgesia ( adjusted OR 1.13 ; 95 % CI 0.84–1.53 ) or fearful childbirth experience ( adjusted OR 1.04 ; 95 % CI 0.62–1.74 ) . Conclusion . Psychoprophylaxis may reduce the rate of emergency cesarean section but may not affect the experience of childbirth Background Caesarean section ( CS ) has become an increasingly common method of delivery worldwide , rising in the UK from 9 % of deliveries in 1980 to over 21 % 2001 . This increase , and the question of whether CS should be available to women on request , has been the subject of considerable debate , and national reports and guidelines have specifically highlighted the importance of patient choice in the decision making process . For women who have already experienced CS , the UK National Institute of Clinical Excellence recommends that the decision should consider maternal preferences and priorities in addition to general discussion of the overall risks and benefits of CS . Decision aids for many different medical treatment and screening decisions have been developed and evaluated , but there is relatively little evidence for the use of decision aids for choice of mode of delivery among women with a previous CS . The aim of the study is to evaluate two interventions to assist decision making about mode of delivery among pregnant women with one previous CS . Methods / design Women with one previous CS are recruited to the trial during their booking visit at approximately 12–20 weeks ' gestation in participating maternity units in Bristol , Weston and Dundee . Using central r and omisation , women are allocated to one of three arms : information programme and website ; decision analysis ; usual care . Both interventions are computer-based , and are design ed to provide women with detailed information about the potential outcomes for both mother and baby of planned vaginal delivery , planned CS and emergency CS . The decision analysis intervention additionally provides a recommended ' preferred option ' based on maximised expected utility . There are two primary outcomes ( decisional conflict and actual mode of delivery ) , and five secondary outcomes ( anxiety , knowledge , perceptions of shared decision making ; satisfaction with decision making process , proportion of women attempting vaginal delivery ) . Primary follow up for the question naire measures is at 36–37 weeks ' gestation , and a total of 660 women will be recruited to the study . The primary intention-to-treat analyses will comprise three pair-wise comparisons between decision analysis , information and usual care groups , for each of the two primary outcomes . A qualitative study will investigate women 's experiences of the decision making in more depth , and an economic evaluation from the perspective of the NHS will be conducted . Discussion Provision of information to women facing this decision appears variable . The DiAMOND study aims to inform best practice in this area by evaluating the effectiveness of two interventions design ed to aid decision making Objective To compare the numbers of vaginal deliveries and delivery satisfaction among women with fear of childbirth r and omised to either psychoeducation or conventional surveillance during pregnancy Please cite this paper as : Bernitz S , Roll and R , Blix E , Jacobsen M , Sjøborg K , Øian P. Is the operative delivery rate in low‐risk women dependent on the level of birth care ? A r and omised controlled trial . BJOG 2011;118:1357–1364 Background Evaluating complex interventions in health services faces various difficulties , such as making practice changes and costs . Ways to increase research capacity and decrease costs include making research an integral part of health services and using routine data to judge outcomes . The purpose of this article is to report the feasibility of a pilot trial relying solely on routinely collected register data and being based on ordinary health services . Methods The example intervention was education to public health nurses ( PHN ) ( childbirth classes ) to reduce caesarean section rates via pre-delivery considerations of pregnant women . 20 maternity health centers ( MHC ) were paired and of each 10 pairs , one MHC was r and omly allocated to an intervention group and the other to a control ; 8 pairs with successful intervention were used in the analyses ( 1601 mothers ) . The women visiting to the study maternity centers were identified from the Customer Register of Helsinki City . A list of the study women was made using the mother 's personal identification number , visit date , the maternity center code , 
    Output:
    
There was insufficient evidence that audit and feedback , training of public health nurses , insurance reform , external peer review and legislative changes are effective .
Implementation of guidelines with m and atory second opinion can lead to a small reduction in caesarean section rates , predominately in intrapartum sections .
Peer review , including pre-caesarean consultation , m and atory secondary opinion and postcaesarean surveillance can lead to a reduction in repeat caesarean section rates .
Guidelines disseminated with endorsement and support from local opinion leaders may increase the proportion of women with previous caesarean sections being offered a trial of labour in certain setting s. Nurse-led relaxation classes and birth preparation classes may reduce caesarean section rates in low-risk pregnancies