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Table 1 Sequence of initiatives introduced for reducing caesarean section (CS) rate

From: Reducing caesarean section rate in an urban hospital serving women attending privately in India – a quality improvement initiative

Year Initiatives
2002 • Created unit of full-time salaried consultant obstetricians
• Began monthly audit of CS cases and review of medical literature
• Started antenatal classes
2003–08 • Continued audit but frequency declined after 2005
• Sent consultants to observe care in other maternity and midwifery units
• Invited obstetric expert for providing guidance on care practices
2011 • Joined improvement collaborative
2012 • Began monthly presentation of data within the unit on CS and other perinatal measures with focus on low-risk first birth mothers (Robson’s groups 1 and 2) and with consultant name unblinded
• Recruited more experienced junior obstetricians for labour ward care
• Reached consensus on management of abnormal fetal heart rate (FHR) as per standard guidelines and started regular FHR tracing review meetings
2013 • Drafted clinical guidelines for management of labour (admission, induction, augmentation, oxytocin administration, and others)
• Revised labour documentation to enable comprehensive data capture
• Trained and recruited additional nurses to enable of 1:1 support for all first-birth mothers in active labour
2014 • Drafted clinical guidelines for antenatal care
• Strengthened antenatal preparation with additional childbirth counsellors and involvement of birth partners
• Increased empowerment of junior obstetricians in the labour ward through use of structured communication with consultant obstetricians
2015 • Began group practice with select consultants enabling shared decision-making for challenging cases
• Changed clinical leadership with “positive deviant” obstetrician becoming the lead
2016–2018 • Focused on promoting trial of labour after caesarean (TOLAC)
• Consolidated group practice by involving all consultants