title: Evaluation of quality improvement for cesarean sections caesarean section programmes through mixed methods.
abstract: BACKGROUND
  The rate of avoidable caesarean sections (CS) could be reduced through multifaceted strategies focusing on the involvement of health professionals and compliance with clinical practice guidelines (CPGs). Quality improvements for CS (QICS) programmes (QICS) based on this approach, have been implemented in Canada and Spain.
  
  
  OBJECTIVE
  Their objectives are as follows: 1) Toto identify clusters in each setting with similar results in terms of cost-consequences, 2) Toto investigate whether demographic, clinical or context characteristics can distinguish these clusters, and 3) Toto explore the implementation of QICS in the 2 regions, in order to identify factors that have been facilitators in changing practices and reducing the use of obstetric intervention, as well as the challenges faced by hospitals in implementing the recommendations.
  
  
  METHODS
  Descriptive study with a quantitative and qualitative approach. 1) Cluster analysis at patient level with data from 16 hospitals in Quebec (Canada) (n = 105,348) and 15 hospitals in Andalusia (Spain) (n = 64,760). The outcome measures are CS and costs. For the cost, we will consider the intervention, delivery and complications in mother and baby, from the hospital perspective. Cluster analysis will be used to identify participants with similar patterns of CS and costs based, and t tests will be used to evaluate if the clusters differed in terms of characteristics: Hospital level (academic status of hospital, level of care, supply and demand factors), patient level (mother age, parity, gestational age, previous CS, previous pathology, presentation of the baby, baby birth weight). 2) Analysis of in-depth interviews with obstetricians and midwives in hospitals where the QICS were implemented, to explore the differences in delivery-related practices, and the importance of the different constructs for positive or negative adherence to CPGs. Dimensions: political/management level, hospital level, health professionals, mothers and their birth partner.
  
  
  CONCLUSIONS
  This work sets out a new approach for programme evaluation, using different techniques to make it possible to take into account the specific context where the programmes were implemented.
authors.affiliation: Centre de recherche du CHUS, 12e Avenue Nord, Sherbrooke QC J1H 5 N4, Canada. clara.bermudez.tamayo@gmail.com.
authors.forename: Clara
authors.initials: C
authors.lastname: Bermúdez-Tamayo
authors.forename: Mira
authors.initials: M
authors.lastname: Johri
authors.forename: Francisco Jose
authors.initials: FJ
authors.lastname: Perez-Ramos
authors.forename: Gracia
authors.initials: G
authors.lastname: Maroto-Navarro
authors.forename: Africa
authors.initials: A
authors.lastname: Caño-Aguilar
authors.forename: Leticia
authors.initials: L
authors.lastname: Garcia-Mochon
authors.forename: Longinos
authors.initials: L
authors.lastname: Aceituno
authors.forename: François
authors.initials: F
authors.lastname: Audibert
authors.forename: Nils
authors.initials: N
authors.lastname: Chaillet
mesh_terms: D000293:Adolescent; D000328:Adult; D000704:Analysis of Variance; D002585:Cesarean Section / Q000191:economics / Q000592:standards*; D016000:Cluster Analysis; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D008423:Maternal Age; D007744:Obstetric Labor Complications / Q000601:surgery; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D015397:Program Evaluation; D058996:Quality Improvement; D011792:Quebec; D013030:Spain; D019564:Unnecessary Procedures / Q000191:economics; D055815:Young Adult