Developing criteria for Cesarean Section using the RAND appropriateness method

A consensus development study using a modified version of the RAND Appropriateness Method (RAM). We generated scenarios from valid clinical guidelines and expert opinions. A panel of experts participated in consensus development: first round via mail (12 members), second round face-to-face (9 members). We followed the RAM recommendations for the development of the scenario lists, rating scales, and statistical analyses.294 scenarios relevant to cesarean section were identified. 191 scenarios were considered appropriate, of which 125 scenarios were agreed upon. The panel found cesarean inappropriate for 21% of scenarios, and 'equivocal' for 14% of scenarios.RAM is useful for identifying stakeholder views in settings with limited resources. The participants' views on appropriateness of certain indications differed with available evidence. A large number of scenarios without agreement may partly explain why it has been difficult to curb the growth in cesarean section rate.Healthcare systems face significant challenges in response to changes in population needs and increasing costs. Studies show that a large proportion of healthcare offered may be inappropriate or unnecessary, ranging from 15 to 40 per cent in different countries and healthcare settings [1,2].Different methods and tools have been developed to measure the appropriateness of care and develop valid criteria and recommendations for healthcare providers [3-5]. Most evidence originates from high income countries and it may not be possible for low and middle income countries to generate the expertise and resources required for the development of valid clinical guidelines [6]. Human interpretation plays an important role in the development of guidelines, and cultural and health system characteristics influence the way the evidence is interpreted and put into recommendation [4,7].One of the most commonly performed surgical interventions is cesarean section. According to the WHO, a maximum of 15 per cent of deliv