title: Evaluating the 'Focus on Normal Birth and Reducing Caesarean section Rates Rapid Improvement Programme': A mixed method study in England.
abstract: BACKGROUND
  caesarean section plays an important role in ensuring safety of mother and infant but rising rates are not accompanied by measurable improvements in maternal or neonatal mortality or morbidity. The 'Focus on Normal Birth and Reducing Caesarean section Rates Rapid Improvement Programme' was a facilitative initiative developed to promote opportunities for normal birth and reduce caesarean section rates in England.
  
  
  OBJECTIVE
  to evaluate the 'Focus on Normal Birth and Reducing Caesarean section Rates' programme, by assessment of: impact on caesarean section rates, use of service improvements tools and participants׳ perceptions of factors that sustain or hinder work within participating maternity units.
  
  
  METHODS
  a mixed methods approach included analysis of mode of birth data, web-based questionnaires and in-depth semi-structured telephone interviews.
  
  
  METHODS
  twenty Hospital Trusts in England (selected from 68 who applied) took part in the 'Focus on Normal Birth and Reducing Caesarean section Rates Rapid Improvement Programme' initiative. In each hospital Trust, the head of midwifery, an obstetrician, the relevant lead for organisational development, a supervisor of midwives, or a clinical midwife and a service user representative were invited to participate in the independent evaluation.
  
  
  METHODS
  collection and analysis of mode of birth data from 20 participating hospital Trusts, web-based questionnaires administered to key individuals in all 20 Trusts and in-depth semi-structured telephone interviews conducted with key individuals in a sample of six Trusts.
  
  
  RESULTS
  there was a marginal decline of 0.5% (25.9% from 26.4%) in mean total caesarean section rate in the period 1 January 2009 to 31 January 2010 compared to the baseline period (1 July-31 December 2008). Reduced total caesarean section rates were achieved in eight trusts, all with higher rates at the beginning of the initiative. Features associated with lower caesarean section rates included a shared philosophy prioritising normal birth, clear communication across disciplines and strong leadership at a range of levels, including executive support and clinical leaders within each discipline.
  
  
  CONCLUSIONS
  it is important that the philosophy and organisational context of care are examined to identify potential barriers and facilitative factors.
authors.affiliation: Department of Health Sciences, The University of York, Seebohm Rowntree Building, Heslington, York YO10 5DD, UK. Electronic address: joyce.marshall@hud.ac.uk.
authors.forename: Joyce L
authors.initials: JL
authors.lastname: Marshall
authors.affiliation: Department of Health Sciences, The University of York, Seebohm Rowntree Building, Heslington, York YO10 5DD, UK.
authors.forename: Helen
authors.initials: H
authors.lastname: Spiby
authors.affiliation: Department of Health Sciences, The University of York, Seebohm Rowntree Building, Heslington, York YO10 5DD, UK.
authors.forename: Felicia
authors.initials: F
authors.lastname: McCormick
mesh_terms: D000328:Adult; D002585:Cesarean Section / Q000706:statistics & numerical data*; D004739:England; D005260:Female; D006293:Health Promotion / Q000379:methods; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D008880:Midwifery / Q000379:methods / Q000639:trends; D009321:Natural Childbirth / Q000706:statistics & numerical data*; D011247:Pregnancy
keywords: Caesarean rates; Mixed methods; Normal birth; Service improvement programme