Current Dutch Practice on Caesarean Sections: Identification of Barriers and Facilitators for Optimal Care (SIMPLE)

Maastricht University Medical Centre (MUMC) logo

Maastricht University Medical Centre (MUMC)




Caesarean Section


Other: Implementation aids

Study type


Funder types



17100.3006 (Other Grant/Funding Number)

Details and patient eligibility


Caesarean (CS) delivery rates in the Netherlands increased from 5 to 15% the last 20 years. CSs have no clear benefit for overall neonatal outcome and are associated with higher maternal complications and high costs. Dutch guidelines offer clear recommendations on factors that have a direct effect on the decision to perform a CS. Hypothesis: there is incomplete adherence to the recommendations from the guidelines on CS among Dutch gynaecologists. This study consists of four phases: 1. Development of quality indicators: A set of quality indicators regarding the process, structure and outcome of care will be developed according to the RAND-modified Delphi method. A representative, national expert panel consisting of 12 to 15 obstetricians and midwives will participate. 2. Current care study: The current Dutch care will be studied in 20 hospitals (N=80 gynaecologists). 1000 files on performed CSs are analyzed regarding the adherence to the developed quality indicators. To get insight into Dutch practices compared to international data, basic obstetrical data will be extracted from the delivery database. 3. Barrier analysis: 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 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 patients. 4. Controlled before- and-after (CBA) study: Based on the outcomes of the current care study and the barrier analysis, a tailor made implementation strategy will be developed in order to increase adherence to the CS quality indicators. Target groups will be selected with focus on women with both a high incidence of the indicator and low indicator adherence. The strategy will be executed and evaluated in a CBA-study in 12 hospitals (6 intervention, 6 control) in terms of effectiveness, experiences and costs. The sample size will be dependent on the target group and adherence to the quality indicators regarding this target group. These data will be available after performing the current care and the barrier study.


1,000 estimated patients




No Healthy Volunteers

Inclusion criteria

  • A previous caesarean section in a 3-4 month time period.

Exclusion criteria

  • Major congenital malformality
  • Fetal death prior to onset of delivery
  • Duration of pregnancy less than 24 weeks of gestation

Trial design

1,000 participants in 2 patient groups

Caesarean section
Other: Implementation aids
Vaginal birth (control)
Other: Implementation aids

Trial contacts and locations



Data sourced from

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