Table 2 How to use this protocol. This table provides an overview of how to use this protocol

How can you use this guide?

There are complex and multiple factors contributing to rising caesarean section rates, and these factors may vary widely between countries. Prior to implementing any interventions to reduce caesarean section rates, research should be conducted to understand women’s and providers’ views on why rates are increasing in a particular setting. To inform this process, WHO proposes this template for formative research that can be adapted and implemented in different contexts. Conducting this formative research will help you to identify the local reasons for increasing caesarean section rates and how to design and develop locally feasible and acceptable interventions to reduce rates.

Who can use this guide?

The primary audience for this guideline and research protocol template are health professionals responsible for developing regional, national, and local health protocols and policies, as well as midwives, obstetricians, nurses, medical practitioners, healthcare managers and policymakers in all settings and countries [1]. Any countries, research teams or program developers who are interested and committed to reduce the use of unnecessary caesarean section in their context are welcome to use this protocol to conduct their own research.

What is included in this guide?

This formative research project consists of three main research activities: (1) document review; (2) readiness assessment; and (3) primary qualitative research with women, healthcare providers, and healthcare administrators. The document review and readiness assessment will help the research teams to identify important barriers and enablers about policies, protocols, practices and organization of care to describe and assess the service context ahead of implementation. The qualitative research is organized according to interventions that may reduce unnecessary caesarean section, and will help to develop key implementation considerations for each intervention. Twelve potential interventions have been identified through the guideline development process (see Additional file 1). It is envisioned that the research team and key stakeholders will select one or more interventions for potential implementation in their context, based on a prioritisation exercise. Each intervention is described in detail in a “module” that outlines the following:

 1. Background and overview of the intervention

 2. Supporting evidence

 3. Theory of change

 4. Guiding principles

 5. Interview/focus group discussion guide for each participant group

The WHO guideline recommends that multifaceted (rather than single-component) interventions are used to reduce unnecessary caesarean section. If two or more interventions are prioritised, then it is envisioned that data collection efforts can be combined for the participant groups. For example, if both interventions include a component for in-depth interviews with healthcare providers, then it would be reasonable to combine the discussion guide questions into one interview to improve efficiency.

Where do I begin?

Given the current state of research evidence about caesarean section rates and drivers, we hypothesize that there are two scenarios in which research teams would use this protocol (Fig. 2). Once the research team has identified which scenario they fit into, and prioritised which interventions to implement, then local ethics approval should be sought.