title: Determinants and materno-fetal outcomes related to cesarean section delivery in private and public hospitals in low- and middle-income countries: a systematic review and meta-analysis protocol.
abstract: Despite the well-established morbidity, mortality, long-term effects, and unnecessary extra-cost burden associated with cesarean section delivery (CSD) worldwide, its rate has grown exponentially. This has become a great topical challenge for the international healthcare community and individual countries. Estimated at three times the acceptable rate as defined by the World Health Organization in 1985, the continued upward trend has been fuelled by higher income countries. Some low- and middle-income countries (LMICs) have now taken the lead, and the factors contributing to this situation are poorly understood. The expansion of the private healthcare sector may be playing a significant role. Distinguishing between the public and private hospitals' role is critical in this investigation as it has not yet been approached. This review aims to systematically synthesize knowledge on the determinants of the CSD rate rise in private and public hospitals in LMICs and to investigate materno-fetal and materno-infant outcomes of CSD in perinatal period, between private and public hospitals.
  
  
  
  We will include studies published in English, French, Spanish, and Portuguese since 2000, using any experimental design, including randomized controlled trials (RCTs), non-RCTs, quasi-experimental, before and after studies, and interrupted time series. Outcomes of interest are the determinants of CSD and materno-fetal and materno-infant outcomes. We will only include studies carried out in private and public hospitals in LMICs. The literature searches will be conducted in the following databases: MEDLINE, Embase, CINAHL, Cochrane database, LILACS, and HINARI. We will also include unpublished studies in the gray literature (theses and technical reports). Using the two-person approach, two independent review authors will screen eligible articles, extract data, and assess risk of bias. Disagreements will be resolved through discussion with a third author. Results will be presented as structured summaries of the included studies. If possible, a meta-analysis will be conducted and, subsequently, an analysis for heterogeneity will be implemented.
  
  
  
  The proposed systematic review of the CSD rate rise will provide up-to-date evidence in regard to differences in proportions, determinants, and materno-fetal and materno-infant outcomes in perinatal period, between private and public hospitals in LMICs. We believe that this knowledge synthesis will help to shed light on the evidence and support evidence-informed decision-making with a view to addressing the issue in LMICs.
  
  
  
  PROSPERO CRD42016036871.
authors.affiliation: École Nationale de Santé Publique, Ouagadougou, Burkina Faso. kone23ide@gmail.com.|Université Laval, 2325 rue de l'Université , Québec (Québec), G1V 0A6, Canada. kone23ide@gmail.com.
authors.forename: Idrissa
authors.initials: I
authors.lastname: Beogo
authors.affiliation: International Health Program, National Yang Ming University, 155 Sec 2, Linong St. 112, Taipei, Taiwan.
authors.forename: Bomar
authors.initials: B
authors.lastname: Mendez Rojas
authors.affiliation: Faculty of Nursing, Université Laval, Ferdinand-Vandry Building, 1050 Avenue de la Médecine, Québec City (Québec), G1V 0A6, Canada.
authors.forename: Marie-Pierre
authors.initials: MP
authors.lastname: Gagnon
mesh_terms: D002585:Cesarean Section / Q000009:adverse effects / Q000401:mortality / Q000706:statistics & numerical data* / Q000639:trends; D003906:Developing Countries; D005260:Female; D016304:Hospitals, Private; D006779:Hospitals, Public; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008428:Maternal Mortality; D015201:Meta-Analysis as Topic; D054238:Perinatal Mortality; D011183:Postoperative Complications / Q000209:etiology; D012107:Research Design; D000078202:Systematic Reviews as Topic
keywords: Cesarean section; Low- and middle-income countries; Materno-fetal outcome; Systematic review