Abstract

BACKGROUND:
The rising caesarean section (C-section) rates in India—42.4% in Andhra Pradesh, as per National Family Health Survey(NFHS)-5—exceed WHO recommendations, posing a challenge to maternal and perinatal health systems. The C-Safe pilot was designed as a system-level intervention to reduce unnecessary C-sections, improve clinical decision-making, and promote evidence-based intrapartum care in low- and middle-income countries (LMICs).

OBJECTIVES:
To design, implement, and evaluate a comprehensive intervention targeting health system practices related to C-sections in a public hospital in Andhra Pradesh,India

METHODS:
The pilot study was conducted at the District Hospital (DH) Tenali using a mixed-methods implementation research approach. The intervention trained 33 healthcare providers—including obstetricians, paediatricians, midwives, and nurses—on the C-Safe model: (1) C-Op (safe operative care protocols); (2) C-Y (classification and audit tools); and (3) C-Non (promotion of vaginal and assisted vaginal births). A structured mentoring framework (both physical and virtual) guided implementation. Real-time data were collected using the WHO Robson and C-Y classification, tracked via REDCap, and reviewed weekly for adaptive learning purposes.

RESULTS:
The intervention resulted in a 2% decrease in overall C-section rates and a significant decline in primiparous C-sections (from 60% in 2023 to 36% in 2024-Health Management Information System). Placenta previa-related C-sections dropped from 26% to 10%, while audit data showed improved alignment with clinical indications. AVB uptake and surgical safety checklist use increased and mentoring enhanced team coordination and confidence.

CONCLUSIONS:
The C-Safe pilot demonstrates that strengthening systems—focused on midwifery-led models, task sharing, audits, and mentoring—can improve outcomes and lower unnecessary C-sections. It provides a scalable, evidence-based framework for LMICs.

KEY MESSAGE:
The C-Safe pilot in Andhra Pradesh shows that system-level interventions—combining classification tools, audits, midwifery-led care, and structured mentoring—can reduce unnecessary caesarean sections and strengthen intrapartum care. This evidence-based model offers a scalable, context-adaptable framework for improving maternal outcomes across health systems in low- and middle-income countries. Labour and birth - caesarean section