22 feb. WHY THE CESAREAN SECTION RATE HAS INCREASED? – EDITORIAL
Aris Antsaklis
University of Athens, Greece
Cesarean Section is the most common major surgical procedure in many developed countries. The epidemic of Cesarean deliveries first started in the late 90’s in the USA and subsequently extended to Europe and in other continents. The incidence rate of Cesarean sections worldwide has doubled in the past 10 years.
Simultaneously, Cesarean section complications have decreased. Nowadays the risks and complications of Cesarean delivery for healthy women are very low due to increased safety of anesthetic techniques and due to prophylactic treatment of infection and thromboembolism which make Cesarean section delivery a reasonable elective option for childbirth. Nevertheless, medical problems which are associated with previous Cesarean sections are abnormal placentation and wet lung disease.
In the USA primary and repetitive Cesarean deliveries reached their highest level which is more than 30% and is still rising, representing a 40% increase rate since 1996.The tremendous variation of Cesarean rates in the USA illustrates the influence of different non clinical parameters. The lowest rats are in New Mexico (22.8%) and Utah (22.9%) while the highest rates are in Louisiana (39.6%) and New Jersey (39.4%). Another very important statistic is that in 11 states the Cesarean section rate is more than 35%. Similar regional variations have been noted in Australia, Canada and Latin America. In New Haven Yale hospitals over 32,000 deliveries from 2003 to 2009, the Cesarean section rate increased from 26% to 36.5% respectively and the 50% increase was due to primary Cesarean section.
Cesarean section births in developed countries accounts for 21.3% of births in the UK (2001), 23% in New Ireland (2001), 23.3% in Australia (2003) and over 50% of births in private hospitals in Chile, Argentina and Brazil. Cesarean section accounts for 20.25% of births in the UK, 40% of cesarean sections are planned and the remaining 60% are unplanned procedures while70% of unplanned Cesarean sectionis a result of dystocia (prolonged labor), suspected fetal compromise, fetal mal-presentation and previous Cesarean birth.
In China, from 1998 – 2008 the Cesarean section rate increased from 3.4% (1998) to 39.3 (2008). Cesarean section delivery was more common in well-educated and wealthy women and in among those with health insurance. The rate has alarmingly increased in all socioeconomic groups including the poor, the uneducated and the rural population. In urban areas in 2008, the rate of Cesarean sections was over 40%.
The introduction of the “one child policy” in 1979, may have contributed indirectly to the rise of the incidence rate. Hospital records in China indicate that a high proportion of Cesarean sections are performed due to:
1. Nonspecific clinical indications
2. Social reasons and
3. on Maternal request
In general, there has been public health concern for over 30 years about the increasing Cesarean section rate. Although, a global phenomenon, the timing and rate of increase hasdifferences between countries and marked differences in rates persist. In 1985, WHO issued a consensus statement suggesting there were no additional health benefits associated with the increase of Cesarean section rate above10-15%. This consensus was based on an examination of estimates of national Cesarean rates and maternal and perinatal mortality rates from various countries. But there is no consistency and this ideal rate and artificial declaration of an ideal rate should be discouraged. Goals for achieving an optimal Cesarean section rate should be based on maximizing the best possible maternal and neonatal outcomes, taking into account available medical and health resources and maternal preferences. Thus, the optimal Cesarean rates will vary over time and across different populations according to individual and social circumstances. The Cesarean delivery rate varies widely by country, health care facilities, social status and delivering physician. Cesarean delivery rate has increased for womenin all age groups, all racial and ethnic groups and for infants of all gestational ages.
In order to reduce the Cesarean section rate we need methods to improve the rates of vaginal delivery and methods to decrease the rates of Cesarean delivery. To do so requires a clear understanding of the fundamental reasons for high primary Cesarean section rates.
Primary Cesarean deliveries are the most important target for reduction. Since, primary Cesarean section leads to an increased risk of repeat Cesarean section. Primary Cesarean delivery rate has increased because some indications have an increased use.
The explanations for the increased rate of primary Cesarean deliveries include:
1. Changes in maternal characteristics with:
· Increased maternal age >of age 35
· Reduced parity
· High pre-pregnancy weight >70 kgms
· Increased weight gain during pregnancy> 20 gr
2. Changes in obstetric practice with:
· Increased use of FHR monitoring
· Increased rates of labor induction, epidural anesthesia
· Increase Cesarean section for breech presentation
· Reduction of use of mid-pelvic forceps (from 7.5 to 2%)
3. Social factors:
· Malpractice litigation for delayed performance of Cesarean section
· Negligence claims after an unnecessary Cesarean section
· Socioeconomic factors (it us well known that low incidence rates of Cesarean section rates
correlates with low social status )
The primary Cesarean section rate has increased partly because of Cesareand delivery on maternal request which accounts for 4%-18% of all Cesarean deliveries. Cesarean section on maternal request is defined as “a Cesarean delivery for a singletonon maternal request at term in the absence of any medical obstetric indications”. This generates both clinical and ethical controversies and concerns.Women request Cesarean section because of:
· Extreme tocophobia
· Previous Cesarean section
· Previous negative birth experience
· Planning a smaller family size
· Convenience
· Pelvic preservation and
· Reduction of neonatal mortality
When we asked a mother who had had a Cesarean, why it was performed and who had initiated it, just 1 woman among nearly 1600 survey participants reported that she had planned first Cesarean with no medical reason at her own request.
There are different issues to be considered regarding Cesarean Sections on maternal request:
1. Is performing patient choice Cesarean section consistent with good professional medical practice?
· Physicians should make every effort to ensure that the rights of all patients are respected.
2.How should doctors respond to patients who request Cesarean section?
· Doctors should recommend against it and work together with patients. The NIH statement in 2006 supports the idea that if a woman requests information on a Cesarean section in the absence of medical indication, her healthcare provider should engage in non-directive counselling.
3. Should Cesarean section on maternal request be routinely offered to all pregnant women?
· There is no evidence that is medically reasonable and doctors are obligated to present all medically alternatives. But there is no obligation to initiate such a discussion with the patient.
The Cochrane review on Cesarean section for non-medical reasons in 2009 concluded that “No studies met the inclusion criteria to prove the benefit of wide use of Cesarean section on maternal request”. FIGO guidelines in 2004 state that: “because hard evidence of benefit does not exist, performing Cesarean section for non-medical reasons is ethically not justified”.
The absence of reliable evidence supporting the clinical benefit or clinical harm of the procedure should not be interpreted as an assumption of clinical benefit for non-medically indicated Cesarean section. For those women who desire Cesarean section without any indications, her health care provider should consider specific risk factors such as:
· Age
· Body mass index
· Gestational age
· Reproductive plans
· Previous experience with labor
Previous Cesarean section is a risk factor for abnormal placentation and the risk rises with the number of previous Cesarean section deliveries. Additionally, advanced maternal age and multiparity are risk factors for abnormal placentation. Placenta previacarries significant maternal mortality and morbidity including massive hemorrhage.
Vaginal birth after Cesarean section (VBAC) has been actively promoted since 1996 as a method to reduce the rising Cesarean delivery rate. VBAC rate continues to decline from 28.3% in 1996 to 12.7 %in 2002. The reasons for this decrease concerns the safety of mother and infant since there is a strong association between previousCesarean section and the risk of uterine rupture in subsequent pregnancy and the factors which increase uterine rupture are maternal age, labor induction and increased birth weight.
Since, there are no randomized controlled trials assessing the benefits and harms of planned elective Cesarean section and planned induction of labor for women with a prior Cesarean section, any results and conclusions must be interpreted with caution.
The interventions to reduce primary Cesarean section include:
· Avoid Cesarean section in primigravida using every practical measure
· Continuous education on obstetric interventions and guidelines for breech and operative vaginal birth
· Education of women to change their perception on birth
· Limit tocophobia
· Adopt policies that promote safe vaginal delivery
At present, we have to continue our practice based on the sources of the best evidence available.
