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SIMPLE study

Sectio implementie studie


Current Dutch practice on caesarean sections: Identification of barriers and facilitators for optimal care


Go to the SIMPLE website

Caesarean (CS) delivery rates continue to increase worldwide. In the last 20 years the CS rate in the Netherlands increased from 5 to 15%. CS have no clear benefit for overall neonatal outcome and are associated with higher maternal complications and high costs. Dutch guidelines offer different clear recommendations on factors that have a direct effect on the decision to perform a CS. This study aims to provide insight into current adherence of Dutch gynaecologists to these guideline recommendations. Moreover, facilitators and barriers for guideline non-adherence are studied and a tailored implementation strategy will be developed and tested in a feasibility study.


Study design
The current Dutch care will be studied in 20 hospitals (N=80 gynaecologists). After the development of quality indicators 1000 files on the performed CS are analyzed regarding the adherence to the guideline recommendations. To get insight into Dutch practices compared to international data, basic obstetrical data will be extracted from the delivery database. A barrier analysis will be carried out based on the results of the current care study. Two groups of hospitals will be identified in the upper and lower extremes of the 'adherence distribution': 5 hospitals with the lowest and 5 hospitals with the highest adherence scores. Factors that determine the decision to perform a CS or not (barriers and facilitators) will be analyzed in both groups using semi-structured interviews among 15-20 health care professionals and 15-20 patients. A questionnaire will be used to study the 'prevalence' of these factors among all obstetric gynaecologists in the Netherlands and among 200 experienced patients. Based on the outcomes of the current care study and the barrier analysis, an implementation strategy will be developed and tested.

Study population
Current care study:

All women (1000) who underwent a CS in one of the 20 participating hospitals during the study period of 3-4 months.


Barrier analysis

Qualitative: 15-20 health care professionals and 15-20 experienced patients from the hospitals in the upper and lower extremes of the 'adherence distribution'.

Quantitative: all obstetric gynaecologists in the Netherlands and among 200 experienced patients.


The intervention will be developed as part of the study.


Outcome measures
Current care study:

The main outcome is the adherence to the quality indicators regarding the process, structure and outcome (maternal and fetal) of care and the number of preventable CS.

Furthermore, Dutch practice as compared to international data.


Barrier analysis

Factors that determine the decision to perform a CS or not (barriers and facilitators).


Power/data analysis
In the current care study, in 20 hospitals a sample size of 80 professionals and 1000 patients need to be included assuming a deviation from the recommendations of 25%, a precision of 5% and an ICC of 0,2.

Time schedule
Assessment of quality indicators: 5 months

Data gathering and interviews: 12 months

Development implementation strategy: 6 months

Feasibility study: 12 months

Analysis feasibility study: 3 months

Dr. H.C.J. Scheepers, Maastricht UMC

Dr. R.P.M.G. Hermens, IQ Healthcare Nijmegen



Prof. Dr. J. G. Nijhuis, Maastricht UMC

Drs. S. Melman, Maastricht UMC

Dr. A. Kwee, UMC Utrecht

Health Technology Assessment
Dr. C. Dirksen, HTA Maastricht UMC

ZonMW - www.ZonMW.nl



Drs. Sonja Melman, arts-onderzoeker,

Maastricht Universitair Medisch Centrum, P. Debyelaan 28, 6229 HX Maastricht

Tel: 043 3874768

E-Mail: simple@studies-obsgyn.nl