"Us with them": Co-designing a caesarean section consent and debriefing intervention in West Cameroon

Technical Summary: "Us with them": Co-designing a caesarean section consent and debriefing intervention in West Cameroon

Problem Statement
In the West Region of Cameroon, informed consent (IC) and post-operative debriefing for caesarean sections (C-sections) are frequently suboptimal or absent. This deficiency contributes to a lack of women-centred care, mistrust in health facilities, and potential violations of patient rights. While C-section rates in the region are high (6.2%–10.0%), the delivery of the procedure is often characterized by disrespectful practices, poor communication, and a lack of cultural sensitivity. Existing literature indicates low prevalence of proper IC and debriefing in sub-Saharan Africa, with scarce guidelines to address these gaps. The problem is compounded by structural issues, including financial barriers, understaffing, and a lack of medico-legal protection for providers, which often leads to defensive practices rather than patient-centred communication.

Methodology
The study employed a participatory co-design approach between February and May 2025 to develop a context-specific, hospital-based intervention. The process involved three distinct stakeholder groups:

1. Intended beneficiaries: 59 post-C-section women and community representatives.
2. Frontline providers: 78 C-section providers (including midwives, nurses, general practitioners, and one obstetrician-gynaecologist).
3. Hospital leadership: 29 directors of public and private hospitals.

The co-design process followed a four-phase cascade (planning, conducting, evaluating, reporting) and utilized a three-step workshop model:

• Phase 1: Five all-day workshops with women and community representatives to identify needs and preferences.
• Phase 2: Five all-day workshops with frontline providers to formulate solutions and address operational constraints.
• Phase 3: An 11th workshop with hospital directors to scrutinize feasibility, establish consensus, and validate the final intervention components.

Data collection methods included standardized self-administered forms, semi-structured questionnaires (pre- and post-workshop), real-time synthesis on visual aids, field notes, and photographic documentation. The intervention design was guided by the WHO Framework on Integrated People-Centred Health Services and the WHO Health Systems Building Blocks. The final intervention was described using the TIDieR (Template for Intervention Description and Replication) checklist. Feasibility was assessed using a structured matrix based on the TELOS framework (Technological, Economic, Legal, Organizational, Scheduling), and the co-design process itself was evaluated using the PROSECO framework.

Key Contributions and Intervention Components
The co-design process yielded a multi-component intervention comprising four core elements:

1. In-service Training: A one-day, on-site seminar for frontline providers covering disrespect and abuse in maternity care, medico-legal requirements, respectful maternity care, women's rights, and psycho-emotional support.
2. Standard Operating Procedure (SOP) with Harmonized Tools: A unified SOP detailing the steps for IC and debriefing in both elective and emergency settings. This includes a harmonized consent form and a unified debriefing discharge checklist. A key feature is the designation of a "co-consenter" (a third party chosen by the woman) to witness the process without overriding the woman's autonomous decision.
3. Internal Audit: The designation of a "hospital champion" in each facility to motivate providers, monitor completion rates of consent and debriefing forms, conduct phone checks with discharged women, and submit monthly SWOT (Strengths, Weaknesses, Opportunities, Threats) reports to hospital directors.
4. External Supervision, Monitoring, and Evaluation: A scheme led by the Regional Delegation for Public Health involving monthly on-site supportive supervision, review of audit reports, and engagement with community leaders to ensure accountability.

Results

• Stakeholder Engagement: Participation was high (attendance >95%), with no attrition. Over 80% of participants rated the co-design process as "good" or "very good."
• Divergent Priorities: While all groups supported women's autonomous decision-making, specific emphases varied:
  • Women/Community: Prioritized emotional support, written discharge advice, and zero tolerance for suboptimal practices.
  • Providers: Emphasized robust documentation for medico-legal protection and the need for capacity building.
  • Directors: Focused on capacity building, cultural friendliness, and the need for formal endorsement by regional authorities.
• Feasibility: Hospital directors rated the intervention's feasibility as high or very high across most domains, with the exception of financial, infrastructural, and technical constraints. The estimated implementation timeline was three months.
• Contextual Adaptations: The intervention successfully navigated local patriarchal norms by creating a flexible model where the woman chooses her support person, balancing cultural expectations with the principle of autonomous consent.

Significance and Claims
The paper claims that this co-design process successfully produced a context-specific, multi-component intervention that is well-accepted and deemed feasible by diverse stakeholders. The study positions itself as a methodological contribution, demonstrating how participatory approaches can be used to operationalize women-centred care and strengthen accountability in low-resource settings.

The authors assert that the intervention:

• Shifts the governance model by designating the woman as the primary decision-maker and "proprietor" of her clinical information.
• Provides a "dual-sided shield" that holds providers accountable while offering them legal protection against unsubstantiated litigation.
• Offers a replicable methodology for contextualizing informed consent and debriefing principles in non-Western, collectivistic African communities.

The paper modestly notes that the intervention has not yet been formally tested for clinical effectiveness and that the co-design process did not include traditional rulers or religious authorities, which are identified as limitations. The authors conclude that the intervention warrants implementation and further research to evaluate its impact on consent and debriefing practices.