ArticleImplementation science communications2025
Planning for scale: analysis of adaptations and contextual factors influencing scale-up of the QUALI-DEC intervention to optimize caesarean section use.
Article in Implementation science communications, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundResearchers are encouraged to plan for scale through purposeful and guided assessment of scalability of an intervention. This study analysed factors potentially influencing scale-up and synthesised early adaptations of the QUALI-DEC intervention aiming to improve the appropriate use of caesarean section. The intervention consists of opinion leader engagement, audit and feedback for caesarean section, a tool to help women make an informed decision on the mode of birth, and labour companionship.
methodsWe conducted a framework analysis, which was guided by the scalability assessment framework by Zamboni et al., a 34-item checklist with a three-point scale. We used data from the formative research including a document review, hospital readiness assessment and qualitative interviews conducted between March 2019 and May 2020 in 32 facilities across Argentina, Burkina Faso, Thailand, and Viet Nam. Data were deductively coded based on the four dimensions of the scalability framework. Our findings were validated with implementing partners across countries.
resultsWe identified the perceived relevance of the intervention by women and providers and the presence of relevant key clinical guidelines as factors that may ease scalability of QUALI-DEC. Labour companionship and the decision-analysis tool were perceived as harder to scale-up and requiring additional changes to existing healthcare structures. Most of the study facilities reported high workload and time constraints as implementation barriers. Thailand was the only country with a national policy to reduce unnecessary caesarean sections. Legal disputes were common and followed a structured process in Thailand and Argentina, which may support preference of caesarean section due to fear of litigation. Early adaptations included development, revision and translation of educational material, monetary compensation of opinion leaders and reaching consensus on clinical guidelines to be used across hospitals, most of which are deemed conducive to scale up.
conclusionsPlanning for scale-up is a key feature of the QUALI-DEC intervention. Scale-up may not be guaranteed at this point of the intervention since effectiveness and cost-effectiveness are not demonstrated yet. However, the investment in studying scale-up opportunities is a core contribution to implementation research. This exercise informed implementation and scale-up strategies of the QUALI-DEC intervention.
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