CS rates upto 80-90% are reported in certain areas. What are the contributing factors in developed and developing world? Should we regulate the practice? There is a changing trend nowadays with rising incidences of lower segment cesarian sections. What is the effect of this on women's health? Should we do so something to reduce the rising rate?
The complications and the cost burden in the health care system is huge.
To my mind the alarming rise in CS section is due to the wrong attitude of doctors to give live baby under any circumstances. This is as a result to avoid litigation, manhandling (in case of some inadvertent catastrophe and disrepute. Funnily no EBM is applied when doing CS. Some indications very common now a days have no scientific basis like
1. IVF pregnancy
2. Oligoamnios
3. Twins
4. Preeclamsia
5. Abrutpio platentae with IUD
just to mention a few.
Remedy? That is a difficult question to answer.
There should be compulsory audit of all CS section by competent authority. But is this possible?
Some doctors are advising their patients to have elective Cesarean births. They are telling them it's easier, they don't have to go through labor, & their pain can be controlled or eliminated. They are apparently not sharing information about the increased risks. Some patients really believe that they can be cut open and not feel pain later. They are not prepared for the increased difficulty in moving around & caring for the baby. They don't anticipate increased difficulty breastfeeding. And, they are the only patients in the hospital who are expected to care for another patient after major abdominal surgery!
Also of concern are the implications for subsequent pregnancies that have increased risks of maternal morbidity. Some colleagues used local data to try to identify what strategies would have the biggest impact on reducing the caesarean rate. See http://www.ncbi.nlm.nih.gov/pubmed/23520978.
Among women with a first birth, singleton, vertex-presenting fetus at term, increasing the vaginal birth rate following induction of labour by 20% potentially has greatest impact, with a 12.1% relative decrease in the overall caesarean rate. Surprisingly, this was estimated to have a bigger population-level impact than reducing pre-labour caesareans.
In the USA a variety of risk factors - increasing rates of obesity, delaying pregnancy until later age, and excessive weight gain during pregnancy to name a few - probably contribute to increasing C/S rates. In addition, the 39 week rule has probably not helped in that in limits the use of labor induction to respond to the presence of these and similar risk factors. Pre-existing obesity, advanced maternal age and excessive weight gain during pregnancy are all risk factors that are not on the "list" of accepted "indications" for induction prior to 39w 0d, but they are certainly risk factors that might be used to estimate a optimal time for delivery with reference to minimizing cesarean risk. I have published several articles wherein the optimal time of delivery - using combinations of such "intermediate-level risk factors - seems to be prior to 39 weeks 0 days of gestation for a substantial number of patients. However, in the USA, I am no longer able to act on those estimations due to the 39-week rule. I would add that the adoption of the 39-week rule over the past 10 years was associated (in recently published studies) with both an increase in the USA'a rate of term stillbirth and NICU admission - so it is not clear that the adoption of the 39 week rule has improved neonatal outcomes (and has probably caused significant harm).
Mind you there are some areas where the rate of the operation is still low and we need to increase it
My whole professional life (since 1975) (70% in sub-Saharan Africa) I have tried to keep the CS rate low, with often a sense of failure if I decided to propose a CS nevertheless. It was not very difficult for me I was always employed, not in private practice. Therefore whether it became a CS, a spontaneous vaginal delivery or an instrumental delivery made no difference in my finances. In private practice obstetricians are dependent on their reputation with has often not very much to do with the quality of the treatment. A CS can be done in 20 minutes and earns you more than a vaginal delivery that can take hours of intense concentration and even then there are no guarantees. Patients who deliver vaginally tend to appreciate the doctor less ("I did it myself") than after a (unneeded) CS - a high tech miracle often fatal only 100 years ago. Also in private practice but also often in non-private practice you have the tendency to protect yourself: if at 11 pm a patient is labouring and you estimate a 20% chance that she will deliver vaginally and the next morning you have a clinic or theatre programme and the anaesthetist is much friendlier at 11 pm than 3 am.......There many mechanisms that increase the CS rate. By law doctors should be paid as much for a CS as for a spontaneous vaginal or instrumental delivery. An 8 hour shifts will reduce the CS rates probably.
In well-resourced circumstances with low parities high CS rates are a waste but not that bad, the pendulum will probably swing back.
I am more worried about CS rates in areas where there is no guarantee of professionally attended delivery next time, very especially if access to reliable contraception and safe abortion is also not guaranteed. There are presently 60 million refugees, the number of failed states seems to increase. Rape is an instrument of war. Doctors working in (future) unstable areas should be very reluctant to create a uterine scar. There are areas where a symphysiotomy is not seldom indicated see: Women dancing and jumping after a previous symphysiotomy, Bulawayo, Zimbabwe. https://www.youtube.com/watch?v=ht2SPZE-ST8
The shaky camerawork is mine.
What worries me also is that women who have a CS are often not given the option of a tuba ligation, preferably (but often not possible in the very areas where alternative reliable contraception is not-obtainable) already discussed at the antenatal clinic. "You have now 1-8 children, suppose you need a CS would you 9and your partner) like then a TL also" . To have this discussion seems to me a human/ reproductive right.
How many women in South Sudan, Democratic Republic of Congo, Syria, Libya, Southeast Turkey, Afghanistan die(d) of a ruptured scar 2-20 years after a doctor (perhaps from a relieve organisation) felt satisfied after a well-performed CS for perhaps a non-reassuring foetal heart pattern? These countries had CS rates in 2012 of 3.2%, 7.2%, 19.2%, 26.8%, 48.0%, 4.0% respectively (Molina et al. 2015).
My concern is the unmet need for CS especially in the SSA where were are still doing very complicated emergency CS for indications including Obstructed Labour with catastrophic uterine rupture and fistula and life threatening sepsis. We need an increase in the timely CS rates in our health facilities. We wish to see every woman who needs a CS accessing it timely and safely. Access to safe anaesthesia and antibiotics are our major concern....
We are talking about women who for all sorts of reasons (money, transport, distrust, bad experiences with health professionals, first permission from husband needed) come late to hospital. No guarantee that the next time she will come in time. She often will not make it because the scar has ruptured before arrival. A WHO report about CSs in sub-Saharan Africa states: “Emergency cesareans, when performed, are often too late to reduce perinatal deaths” (Shah 2009). How many craniotomies do you do to prevent a scar if there is no hope for the foetus anyway?
Shah A, Fawole B, M'imunya JM, Amokrane F, Nafiou I, Wolomby JJ, et al. 2009.Cesarean delivery outcomes from the WHO global survey on maternal and perinatal health in Africa. Int J Gynaecol Obstet 107:191–197. doi: 10.1016/j.ijgo.2009.08.013. Accessed 12 May 2016 from: http://www.who.int/reproductivehealth/topics/best_practices/GS_in_Africa.pdf
Letters
Symphysiotomies are important option in developing world
BMJ 2001; 323 doi: http://dx.doi.org/10.1136/bmj.323.7316.809a (Published 06 October 2001)
Cite this as: BMJ 2001;323:809
D A A Verkuyl, head, obstetrics and gynaecology ([email protected])
Author affiliations
EDITOR—Payne mentions possible legal action by women who had a “barbaric” symphysiotomy in Ireland.1 Many symphysiotomies were done in Roman Catholic countries, because contraception was illegal, even for medical indications, and women might have many caesarean sections with all the inherent risks.
In poor areas of the world thousands of women die or are maimed for life because they cannot obtain a symphysiotomy. The money, staff, and political stability to give all women in need access to a caesarean section are often not available. A symphysiotomy needs far less training and can be done in clinics without doctors. Most indigenous gynaecologists stopped teaching symphysiotomies about 20 years ago, thinking that development would make them obsolete. Instead, health services for the poor have sometimes deteriorated.
A typical example is that of a woman of 17 going into labour in Mozambique. No delivery has occurred after 16 hours. Three scenarios are possible.
Scenario 1—She is transported to the local clinic, where nothing can be done. The midwife is not trained or authorised to do a symphysiotomy. Hours later a macerated baby is delivered. If the woman survives she will probably be abandoned: she leaks urine continuously, and her vagina is so scarred that it is 1.5 cm deep.
Scenario 2—Somehow, transport to the nearest hospital (in Zimbabwe) is found. On arrival she has a fever and severely infected liquor, but there is fetal heart action. The doctor organises a caesarean section. The baby dies three hours later of trauma and infection. The woman has a severe
postoperative infection, which affects the uterine incision. If she has not become infertile she will try again to deliver at home (the dead baby, wound infection, pain, and cost have not won her over to "Western" health care). The scar will rupture, and she will die. The doctor will never find out.
Scenario 3—The doctor does a symphysiotomy 10 minutes after admission (no need for a nurse anaesthetist, electricity). This early intervention and because the head needs no forceful disimpaction, saves the baby—or perhaps it still dies. The next time, though, she has a larger pelvis and no scar in the uterus, and she may deliver successfully.
I have never heard of anybody dying of a symphysiotomy, whereas outside private city hospitals caesarean sections have a mortality of 1% in Africa. And often a woman with a inadequate pelvis will need once a symphysiotomy and 4 CS that means 4x 1% chance to die.
Reading in the BMJ about barbaric symphysiotomies will increase political resistance to this operation. Training in symphysiotomy might work though, especially if the technique was improved; the operation might then become politically correct.
References
1.↵Payne G.Ireland orders inquiry into “barbaric” obstetric practices.BMJ2001;322: 1200. (19 May.)FREE Full Text
"And often a woman with a inadequate pelvis will need once a symphysiotomy and 4 CS that means 4x 1% chance to die." What I mean but did not formulate well Is that say a girl of 17 with a small pelvis will often need one symphysiotomy after which she will deliver normally say 3 times. If she had a CS she will often have 3 more CS that means 4x 1% mortality risk. Symphysiotomies have virtually no mortality risk, see: Björklund K. 2002. Minimally invasive surgery for obstructed labour: A review of symphysiotomy during the twentieth century (including 5000 cases). BJOG 109:236–248.
The increased rates are alarming.One contributing factor for the repeated CS is a previous CS and decreased VBAC rates which are mainly due to defensive medicine.An interesting study from Middle East where I am working:G Puliyath. Vaginal Birth After Caesarean Section (VBAC): A Descriptive Study From Middle East. The Internet Journal of Gynecology and Obstetrics. 2008 Volume 11 Number 2.
I answered this question with our newly published paper in BJOG. When money involved in the decision, it is complicated.
I agree with you Kirsten Small that that best labor management can reduce the rate of operative delivery
I totally agree with Liu , you have to look in with countries the S/C is raising. This is not a global problem. This is the problem of some countries.
Yes Linas Rovas in some countries there in a need to raise the cesarean delivery rate e.g. Africa
CS rates are now globally around 19% of lifebirths(1). Those countries with low rates, mostly, have not low-rates by choice I am sad to say, but because of lack of resources, I think. Of course I do not know what percentage you see as a problem. If you mean 40% you are right if you mean 20% you are not. In poor African countries private doctors in the cities have 30% CS rates, suggesting that if everybody gets rich there the CS rates will be 30% overall.
(1) Molina G, Weiser TG, Lipsitz SR, Esquivel MM, Uribe-Leitz T, Azad T, et al. Relationship Between Cesarean Delivery Rate and Maternal and Neonatal Mortality. JAMA 2015;314:2263–70. doi:10.1001/jama.2015.15553. eTable 1.
The article from China documents lowering the CS rate from 51% by reducing the elective cesareans. It is easy to lower a 51% CS rate to 36%. I dont think that is what the person asking the question is interested in.
The idea promoted here on the above posts that African birth outcomes would profit from higher cesarean rates is incorrect. Birth outcomes improve by educating women, birth control, clean water, micro and macro nutrient availability, less disease, eliminating teenage pregnancy and eliminating AIDS and the bad social conditions that cause AIDS. Once a woman is healthy and has adequate and appropriate nutrition, and is not having babies every year, even without birth assistance, things go fine. Not only dont you need a cesarean. You barely need birth assistance.
The problem with CS is it kills women. The maternal mortality rate from CS is 20 per 100.000 or 1 in 5000. The worst maternal mortality rate in Africa (and Afganistan) is 1 in 100. But doubling the CS rate in those places will just kill more women, who are not good candidates for major abdominal surgery, leaving more orphans.
How to reduce the CS rate? Easy. We need a public relations campaign organized by the families of the women who died from unnecessary elective cesareans, There are 100 to 300 of them in the US alone every year. It would go along the lines of the campaign to make people wear seat belts:
instead of BUCKLE UP FOR SAFETY, billboards could be posted with
WANT TO SURVIVE BIRTH? HAVE a PLANNED ATTENDED HOMEBIRTH.
50% to 70% of cesareans are performed because of DYSTOCIA. Dystocia has no definition.
Anyone interested in lowering CS rates, would probably find attached article and picture compelling evidence that Dystocia is never a justification for CS.
Rather Partisan, ? conflict of interest. literature eclectic
Threatening to fall off your bike also does not have a generally accepted definition although it can be quite dangerous and most non-drunks recognise it when it happens. I worked 25 years in Africa and can tell you that labour does not need to take 4 days and you do not need to be malnourished to get a vesico-vaginal fistula. That CS rates are higher than 15% is not necessary in my view but I do not work in a high suing frequency society. Others (doctors and mothers) would say if I have to increase the CS rate from 15 to 40% to reduce the perinatal mortality with 1/1000: fine. Then there are no objective reasons to disagree.
It is a relative one in some settings it is still under conducted while in some setting it is over practiced
There are some MDs who are convinced cesarean is a better way to deliver. They tend to have higher rates of C/S. Also, induction of labor is still very popular, which obviously leads to more cesareans. Other common labor practices, such as epidurals, also increase the risk. Sometimes it's just better to let nature take its course.
"Sometimes it's just better to let nature take its course."
But nobody wants to take any risks !! This is alarming. What is your take on incresed litigations based on the poor fetal outcomes, especially hypoxia.
Fear of a poor outcome is certainly real, & cesareans are definitely justified if indications are there. But, convenience of the MD & patient are too often a factor. By "nature", I meant spontaneous labor without a lot of unnecessary intervention. Just because it's 5 p.m. is not a good indication for a C/S.
The assumption that induction increases rates of C/S is based on belief and not high-quality medical objective evidence. Recent research suggests the opposite (ACOG "debate" last spring suggested better outcomes could be obtained for both mother and baby if all pregnancies were to be induced if they reached 39 weeks). The choice with risk-based induction is between IOL now vs. expectant management until later (the choice is not between IOL and spontaneous labor).....and waiting until later means larger baby and older placenta and greater likelihood of needing an indicated IOL. Those three things DO increase the risk for C/S. Waiting until later also means higher chances of term stillbirth. I am aware of several practice sites where a relatively high IOL rate (35->50%) was associated with very low (i.e., single digit) cesarean delivery rates. Go figure. Practice sites in Connecticut, New Jersey, Pennsylvania, Florida and Italy. But very few are interested in interfering with the "nature" of pregnancy via the regular use of IOL in order to obtain better outcomes for moms and babes.
Seen this?
Educational including the references:
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31819-6/fulltext?elsca1=etoc
- Badges
- Science topic