Accepted for/Published in: JMIR mHealth and uHealth
Date Submitted: May 7, 2020
Date Accepted: Sep 22, 2020
The Effect on Cesarean Section Rates of an SMS Based Educational Intervention for Pregnant Women in China: A quasi-randomized controlled trial
ABSTRACT
Background:
Consensus exists that appropriate regional caesarean rates should not exceed 15% of births, but China’s may exceed 50% in some areas, prompting numerous calls for their curtailment. Now, China’s 2016 two-child policy has heightened the implications of national caesarian section trends.
Objective:
This study leverages pervasive cellular phone access amongst Chinese citizens to test the effect of a low-cost and scalable prenatal advice program on caesarian section rates.
Methods:
Participants were pregnant women presenting for antenatal care at a clinic in Xi’an, China. Assignment was quasi-randomized and utilized factorial assignment based on the expecting mother’s birthday. Participants were assigned into one of four groups, each receiving a different set of messages, including 1) a comparison group that received only a few “basic” messages, 2) a group receiving messages primarily regarding care-seeking, 3) a group receiving messages primarily regarding good home prenatal practices, and 4) a group receiving all text messages from all groups. Messages were delivered throughout pregnancy and were tailored to the woman’s gestational week. The main outcome was the rates of cesarean delivery reported in the intervention arms. Data analysts were blinded to treatment assignment.
Results:
In total, 2,115 women completed the trial and corresponded follow-up surveys. In the unadjusted analysis, the group receiving all texts was associated with an odds ratio of 0.77 (P=.06), though neither set separately yielded significant impact. Adjusting for potentially confounding covariates shows that the group with all texts sent together is associated with an odds ratio of 0.67 (P=.01). Notably, a previous caesarian section evoked an odds ratio of 11.78 (P<.001), highlighting that having a caesarian section now predicts future caesarean in subsequent pregnancy.
Conclusions:
Sending pregnant women in rural China short informational messages with integrated advice regarding both care-seeking and good home prenatal practices may have reduced women’s likelihood of undergoing a caesarean. Reducing clear medical indications for caesarian section seems to be the strongest potential pathway of the effect. Caesarian section based on only maternal request did not seem to occur regularly in our study population. Preventing unnecessary caesareans now may have a long-term impact on future caesarean section rates. Clinical Trial: Clinicaltrials.gov, NCT02037087, Clinicaltrials.gov, Jan. 14, 2014
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