title: Mandatory second opinion to reduce rates of unnecessary caesarean sections in Latin America: a cluster randomised controlled trial.
abstract: BACKGROUND
  Latin America has a high rate of caesarean sections. We tested the hypothesis that a hospital policy of mandatory 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 randomly 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 mandatory 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.
  
  
  RESULTS
  A total of 34 hospitals attending 149?276 deliveries were randomised and completed the protocol. The mandatory 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Latin American Center for Perinatology, Pan American Health Organization, WHO, Montevideo, Uruguay. althabef@clap.ops-oms.org
authors.forename: Fernando
authors.initials: F
authors.lastname: Althabe
authors.forename: José M
authors.initials: JM
authors.lastname: Belizán
authors.forename: José
authors.initials: J
authors.lastname: Villar
authors.forename: Sophie
authors.initials: S
authors.lastname: Alexander
authors.forename: Eduardo
authors.initials: E
authors.lastname: Bergel
authors.forename: Silvina
authors.initials: S
authors.lastname: Ramos
authors.forename: Mariana
authors.initials: M
authors.lastname: Romero
authors.forename: Allan
authors.initials: A
authors.lastname: Donner
authors.forename: Gunilla
authors.initials: G
authors.lastname: Lindmark
authors.forename: Ana
authors.initials: A
authors.lastname: Langer
authors.forename: Ubaldo
authors.initials: U
authors.lastname: Farnot
authors.forename: José G
authors.initials: JG
authors.lastname: Cecatti
authors.forename: Guillermo
authors.initials: G
authors.lastname: Carroli
authors.forename: Edgar
authors.initials: E
authors.lastname: Kestler
mesh_terms: D000328:Adult; D002585:Cesarean Section / Q000706:statistics & numerical data*; D019317:Evidence-Based Medicine; D005260:Female; D006300:Health Services Misuse; D006761:Hospitals / Q000706:statistics & numerical data; D006801:Humans; D007231:Infant, Newborn; D007843:Latin America; D016134:Organizational Policy; D017060:Patient Satisfaction; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D012017:Referral and Consultation