{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,8]],"date-time":"2026-01-08T06:59:07Z","timestamp":1767855547205,"version":"3.49.0"},"reference-count":29,"publisher":"BMJ","issue":"6","license":[{"start":{"date-parts":[[2025,2,20]],"date-time":"2025-02-20T00:00:00Z","timestamp":1740009600000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000865","name":"Bill and Melinda Gates Foundation","doi-asserted-by":"publisher","award":["INV-No OPP1173484"],"award-info":[{"award-number":["INV-No OPP1173484"]}],"id":[{"id":"10.13039\/100000865","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Qual Saf"],"accepted":{"date-parts":[[2024,12,17]]},"published-print":{"date-parts":[[2025,6]]},"abstract":"<jats:sec>\n                  <jats:title>Background<\/jats:title>\n                  <jats:p>Countries with resource-poor health systems have struggled to improve access to and the quality of caesarean section (C-section; CS) for women seeking care in public health facilities. Access to C-section in Bihar State remains very low, while access has increased in many other contexts.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>We used quality improvement (QI) combined with targeted resource management to test and implement changes that were designed to increase C-section delivery. We compared C-section delivery percentages after the interventions across eight intervened (QI) hospitals and between QI hospitals and the remaining 22 non-intervened (non-QI) hospitals with baseline CS &lt;10%. We linked patterns of improvement and sustainability to theoretical drivers of improvement and timing of interventions.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>In QI hospitals, C-section percentage increased from 2.9% at baseline to 5.9% in the intervention phase and 4.6% in the post intervention phase. In non-QI hospitals, we observed a small change (2.6\u20133.3%) during the same time period of the interventions in the QI hospitals. Addition of skilled personnel resulted in increased C-section percentage in QI hospitals (3.6\u20135.9%) but not non-QI hospitals (3.4\u20133.2%).<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>C-section availability increased for a population of women giving birth following initiation of QI BTS collaborative in a low-income country public sector setting that has historically struggled to provide this service. Addition of obstetric and operating room resources alone, without interventions to support system changes, may not result in additional increase in C-section delivery. The adaptive implementation model may contribute to efforts to provide more access to C-sections in other very resource-limited settings.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1136\/bmjqs-2024-017454","type":"journal-article","created":{"date-parts":[[2025,2,20]],"date-time":"2025-02-20T13:20:36Z","timestamp":1740057636000},"page":"404-412","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":2,"title":["Quality improvement collaborative to increase access to caesarean sections: lessons from Bihar, India"],"prefix":"10.1136","volume":"34","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3045-1649","authenticated-orcid":false,"given":"Abha","family":"Mehndiratta","sequence":"first","affiliation":[{"name":"Institute for Healthcare Improvement, New Delhi, India"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Prabir Ranjan","family":"Moharana","sequence":"additional","affiliation":[{"name":"Care India, New Delhi, Delhi, India"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tanmay","family":"Mahapatra","sequence":"additional","affiliation":[{"name":"Care India, New Delhi, Delhi, India"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sridhar","family":"Srikantiah","sequence":"additional","affiliation":[{"name":"Care India, New Delhi, Delhi, India"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sunil","family":"Babu","sequence":"additional","affiliation":[{"name":"Care India, New Delhi, Delhi, India"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sarita","family":"Simba","sequence":"additional","affiliation":[{"name":"State Health Society, Bihar, India"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sanjiv","family":"Daulatrao","sequence":"additional","affiliation":[{"name":"Care India, New Delhi, Delhi, India"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Vikas","family":"Pandey","sequence":"additional","affiliation":[{"name":"Care India, New Delhi, Delhi, India"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rahul","family":"Shastri","sequence":"additional","affiliation":[{"name":"Care India, New Delhi, Delhi, India"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Srinivas","family":"Kodiyath","sequence":"additional","affiliation":[{"name":"Care India, New Delhi, Delhi, India"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sulagna","family":"Mukherjee","sequence":"additional","affiliation":[{"name":"Care India, New Delhi, Delhi, India"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Pramod","family":"Sah","sequence":"additional","affiliation":[{"name":"Care India, New Delhi, Delhi, India"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0963-0899","authenticated-orcid":false,"given":"Pierre","family":"Barker","sequence":"additional","affiliation":[{"name":"Global Health, Institute for Healthcare Improvement, Cambridge, Massachusetts, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2025,2,20]]},"reference":[{"key":"2025090411035887000_34.6.404.1","doi-asserted-by":"publisher","DOI":"10.1016\/j.rhm.2015.07.007"},{"key":"2025090411035887000_34.6.404.2","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2017-006926"},{"key":"2025090411035887000_34.6.404.3","doi-asserted-by":"crossref","DOI":"10.1002\/hsr2.1274","article-title":"Global increased cesarean section rates and public health implications: A call to action","volume":"6","author":"Angolile","year":"2023","journal-title":"Health Sci Rep"},{"key":"2025090411035887000_34.6.404.4","doi-asserted-by":"publisher","DOI":"10.1016\/j.siny.2021.101199"},{"key":"2025090411035887000_34.6.404.5","doi-asserted-by":"publisher","DOI":"10.1111\/1471-0528.16744"},{"key":"2025090411035887000_34.6.404.6","doi-asserted-by":"crossref","DOI":"10.1186\/s12889-021-11750-4","article-title":"Geographical variability and factors associated with caesarean section delivery in India: a comparative assessment of Bihar and Tamil Nadu","volume":"21","author":"Roy","year":"2021","journal-title":"BMC Public Health"},{"key":"2025090411035887000_34.6.404.7","unstructured":"Wolrd Health Organization . Caesarean section rates continue to rise, amid growing inequalities in access. 2023. Available: https:\/\/www.who.int\/news\/item\/16-06-2021-caesarean-section-rates-continue-to-rise-amid-growing-inequalities-in-access"},{"key":"2025090411035887000_34.6.404.8","doi-asserted-by":"publisher","DOI":"10.1016\/S2214-109X(19)30036-1"},{"key":"2025090411035887000_34.6.404.9","unstructured":"data.gov.in . Open government data (ogd) platform india. 2022. 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