الفهرس 
Introduction and Aim of the WorkOnly 14 pages are availabe for public view
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Abstract
Caesarean section (CS) is a life-saving surgery that should be used only when indicated. The cesarean section (CS) rate has increased over recent decades. In Egypt 2014, the CS rate was 52% (five times the CS rate in 2000 EDHS). The increasing rates of morbidity and mortality of the woman and her baby during CS creates the need to limit the escalation of the CS practice. At the same time, this rising trend definitely has major implications on the limited health care resources in a developing country. The RCOG Guidelines provides evidence-based recommendations on best practice.
Findings of the present study revealed that the rate of Caesarean section in Dar Ismail Maternity Hospital of Alexandria governorate, Egypt was 61% (August 2016- December 2017) and that previous CS was the most important indication for most of the repeat CS. The great majority (97.5 %) of patients with previous one cesarean section had repeat CS in spite of the presence of audits and monitoring for Caesarean section rate, maternal and neonatal morbidity and mortality, this percentage showed some change after the intervention program where 0.5% of patients having one CS ended into successful VBAC. It is worth mentioning that the decision to perform VBAC or repeat cesarean section was taken according to obstetrician’s point of view and hospital circumstances
(presence of the anesthesiologist, empty operation room, and adequate time of the day
……) regardless of the specific guidelines or patient consent, and in the absence of strong medical justification for CS.
Most of the obstetricians in the hospital were not aware about the presence of guidelines for CS not to mention RCOG guidelines of repeat cesarean section -even those working for more than 5 years in the facility. Thus, patient counselling was not based on robust evidence-based guidelines.
The partograph - a part of the pregnant woman‟s file- that should be regularly filled during the follow up of the delivery, was filled after finishing the delivery, hence, the recording of data was inaccurate and biased.
Despite being fundamental to changing practice, knowledge remains the starting point in the behavior change process. Therefore, it was not a surprise that the marked improvement in obstetrician’s knowledge after the intervention program was not accompanied by a demonstrable improvement in practice. This conclusion points to the need to put more effort in motivating and enabling physicians to follow the RCOG guidelines.
Decision making in relation to repeat caesarean is a complex process involving several parties. Enforcing health polices , motivating physicians, organizing in-service training and monitoring of CS deliveries are urgently needed to avoid unnecessary CS. Future studies should work on motivating and enabling adherence to RCOG guidelines along with enhancing knowledge about the risk of unnecessary CS aiming to achieve a substantial increase in normal delivery rates in health facilities.
6.2. Conclusion
This study supports the notion that although knowledge is an important predisposing factor for behavioral change, it is not sufficient to cause change. Different barriers hinder the adherence of obstetricians to guidelines; need to be tackled more profoundly.
We highlight the intrapersonal factors but in practice, still we need to work more steadily on the enabling factors to raise the self-efficacy and confidence through the training of obstetricians to gain more skills and more confidence about their ability to overcome any medico-legal problem, also through raising the financial incentives of the vaginal birth.
Attitude and belief to change the socially accepted concept of the safety of cesarean section need for more work on the interpersonal factors.
6.3. Recommendations:
In light of the previous results, the following recommendations are to be considered: A-Physician-related recommendations:
• Developing educational programs to enhance physicians‟ awareness and knowledge about RCOG guidelines and to orient their attitudes and beliefs towards the importance of advocating for vaginal delivery among eligible women including those with a previous CS.
• Addressing obstetricians‟ perceived barriers regarding VBAC including fear of complications, medico-legal problems, and non-rewarding financial yield.
• Providing in-service training of obstetricians on patient counselling and proper usage of partograph.
B- Health facility-related (health policy)recommendations:
• Formulation and application of standardized updated evidence-based clinical practice national guidelines based on the RCOG guidelines.
• Implementation and activation of policies in hospitals encouraging antenatal and intra-partum management of VBAC deliveries.
• Mandatory solicitation of second opinion before performing caesarean section.
• Activation of Caesarean section audits and timely feedback to health-care professionals.
C- Pregnant female-related (women)recommendations:
• Increase awareness of pregnant females about the unnecessary risks of unnecessary CS.
• Correct myths, views, fears and beliefs of women about vaginal birth and VBAC through health educators, rural women leaders and print media as posters and pamphlets.
• Encourage childbirth training workshops, relaxation-training and psycho-educational programs for women suffering from fear of pain or social pressure in MCH centers and maternity hospitals.
• Educate women and families on meaningful effective communication with providers underscoring the significance of informed decision-making regarding the mode of delivery.