• Joyce L Marshall, Helen Spiby, and Felicia McCormick.
• Department of Health Sciences, The University of York, Seebohm Rowntree Building, Heslington, York YO10 5DD, UK. Electronic address: joyce.marshall@hud.ac.uk.
• Midwifery. 2015 Feb 1; 31 (2): 332-40.

Backgroundcaesarean section plays an important role in ensuring safety of mother and infant but rising rates are not accompanied by measurable improvements in maternal or neonatal mortality or morbidity. The 'Focus on Normal Birth and Reducing Caesarean section Rates Rapid Improvement Programme' was a facilitative initiative developed to promote opportunities for normal birth and reduce caesarean section rates in England.Objectiveto evaluate the 'Focus on Normal Birth and Reducing Caesarean section Rates' programme, by assessment of: impact on caesarean section rates, use of service improvements tools and participants׳ perceptions of factors that sustain or hinder work within participating maternity units.Designa mixed methods approach included analysis of mode of birth data, web-based questionnaires and in-depth semi-structured telephone interviews.Participantstwenty Hospital Trusts in England (selected from 68 who applied) took part in the 'Focus on Normal Birth and Reducing Caesarean section Rates Rapid Improvement Programme' initiative. In each hospital Trust, the head of midwifery, an obstetrician, the relevant lead for organisational development, a supervisor of midwives, or a clinical midwife and a service user representative were invited to participate in the independent evaluation.Methodscollection and analysis of mode of birth data from 20 participating hospital Trusts, web-based questionnaires administered to key individuals in all 20 Trusts and in-depth semi-structured telephone interviews conducted with key individuals in a sample of six Trusts.Findingsthere was a marginal decline of 0.5% (25.9% from 26.4%) in mean total caesarean section rate in the period 1 January 2009 to 31 January 2010 compared to the baseline period (1 July-31 December 2008). Reduced total caesarean section rates were achieved in eight trusts, all with higher rates at the beginning of the initiative. Features associated with lower caesarean section rates included a shared philosophy prioritising normal birth, clear communication across disciplines and strong leadership at a range of levels, including executive support and clinical leaders within each discipline.Conclusionsit is important that the philosophy and organisational context of care are examined to identify potential barriers and facilitative factors.Copyright © 2014 Elsevier Ltd. All rights reserved.

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