C-sections: getting the balance right

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THE FIRST successful Caesarean section (CS) recorded in Ireland was performed in 1738 by Mary Donally, a midwife, on a farmer’s wife who had been in labour for 12 days. She resutured the uterus and skin, and dressed the wound with the white of an egg. Within four weeks ... the woman had recovered and was able to walk a mile. The survival of the mother after Caesarean section, however, was unusual. In 1884, a review of 134 operations reported a maternal mortality of 56 per cent ...

… between 1932 and 1946, … only 2,273 (1.4 per cent) Caesareans were performed and 61 (3 per cent) of these were associated with maternal death.

By the end of the 20th century Caesarean births had become much safer for the mother. In 1985, the World Health Organisation concluded: “There is no justification for any region to have CS rates higher than 10-15 per cent”. Yet, in the generation since remarkable differences in global, regional, national and hospital CS rates have evolved. In underdeveloped countries, particularly African, CS rates remain around 2-3 per cent, in part because there is often no obstetrician available to do the operation.

Maternal mortality rates in these countries remain stubbornly high due to the lack of resources. In a report from 119 countries between 1991 and 2003, only 3.4 per cent of high-income countries had a CS rate of less than 10 per cent compared with 76.3 per cent of low-income countries. The maternal mortality rate per 100,000 live births was 630 deaths in the low-income countries compared with 54 in the high- income countries.

The risk of maternal death per million births has been estimated at 17-20 for a vaginal delivery, 59 for an elective CS and 182 for an emergency CS. Mortality risks of CS are low, but they are dependant on the healthcare setting and are higher in resource-poor countries.

Rising CS rates increase foetal risks. Elective Caesarean births increase the risk of transient tachypnoea of the newborn and respiratory disease syndrome ...

In developed countries, however, Caesarean birth has become so safe that rates have soared as women and their obstetricians strive to avoid the perceived risks and traumas of vaginal birth ...

Similar increases have been reported in other developed countries and there is no evidence that CS rates have reached a plateau.

In many developing countries, Caesarean section rates are too low, resulting in preventable adverse outcomes for mothers and their babies. In developed countries, there are growing concerns that CS rates are too high, particularly in circumstances where there is little medical justification for the operation.

A Caesarean delivery in the current pregnancy also has long-term implications … it increases the need for either emergency or elective Caesareans for future babies. It increases the future risk of catastrophic obstetric complications such as uterine rupture or peripartum hysterectomy ...

Another concern about the rising CS rates is the impact on healthcare budgets with resources becoming more limited in the face of the economic recession … costs for Caesarean delivery were twice those for spontaneous vaginal delivery … for each 1 per cent reduction in the CS rate in England, the health services would save £8.8 million annually. Avoiding a first Caesarean delivery will also reduce economic costs in the longer term by decreasing repeat Caesareans.

The main reasons for the rise in CS rates in developed countries are the safety of the procedure and the perceived risks of labour. It has been fuelled by the carpe diem mentality of modern life where women and their doctors focus on the short-term outcomes of the current pregnancy without considering the long-term consequences for a woman’s health. This short-termism is more likely in circumstances where a woman is planning to have a small family.

Policymakers … have suggested target CS rates, for example … a CS rate of 20 per cent. However, such targets, including the WHO target, may be unrealistic. The optimum CS depends on local healthcare resources and service quality, and not on national or international recommendations. There is also a danger that, in attempting to meet hospital targets a Caesarean is not done in individual cases when it should have been done. This may have serious adverse consequences clinically and subsequent high financial costs medically and legally.

Optimising CS rates … needs to start with improvements in data collection and analysis to identify why Caesarean sections are done, and whether the results in some hospitals are outside an acceptable norm …

Any financial analysis also needs to consider the medico-legal costs of poor quality care. The CS rates cannot be considered in isolation, not just from the quality of clinical practices but also from the resources and organisation that underpin service delivery …

Melissa Maimann, Essential Birth Consulting 0400 418 448