Rising
caesarean section rate in developed countries is
not the best option for childbirth
..........................................................................................................................
Md. Nazrul Islam Mondal, Ph.D
Department of Population Science and Human Resource
Development
University of Rajshahi
Rajshahi-6205
Bangladesh
Phone: +88-0721-751217
Mobile: +88-01716389187
Email: nazrul_ru@yahoo.com
..........................................................................................................................
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ABSTRACT
Obstetric
interventions, especially caesarean sections
(CS) have increased in recent years in all
developed countries. The steady rise in
CS rate is an emerging issue of concern
in mother-child health care and a matter
of international attention. Unnecessary
CS have resulted in increased infection,
hemorrhage, organ damage, drug complications,
prematurity, increased neonatal illness,
and longer hospitalization. Nevertheless,
CS rates tend to vary widely with clinical
and socio-demographic factors of patients
as well as the attitudes of health providers.
Consequently, national CS rates do not reflect
what is happening locally, supporting the
trend toward monitoring rates at the level
of individual hospital or physician. Thus,
the main purpose of this study is to explain
the complications and responsiveness about
CS as well as to encourage women in their
childbearing ages (15-49) years to make
their decision for experiencing vaginal
delivery.
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Key
words: Pregnancy, Caesarean section rates,
Vaginal delivery, Obstetricians, Health hazards,
HIV transmission.
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Human childbirth is one of
the most important natural processes of human
life. It has also however always been a very painful
process and complications endangering the mother
and baby are always a possibility. CS is a surgical
process where birth is through an incision in
the wall of the uterus, rather than through the
vagina, which has a lot of controversy surrounding
it in today's society. It is almost certainly
one of the oldest operations in surgery, with
its origin lost in antiquity and ancient methodology.
Originally performed only in the interests of
the mother, it is now used quite freely in the
interest of the fetus too. The justification for
CS includes both medical and non-medical reasons.
It may be planned in advance (elective section)
or be performed at short notice, particularly
if there are complications or difficulty in labor
(emergency section). An elective CS is performed
one to two weeks before the baby's due date. This
ensures the baby is mature before delivery. Now
the number of elective CS has risen more slowly
than the number of emergency CS. Approval rate
of CS without medical indication varies considerably
in different countries. According to a survey
conducted by United States (US), 46.2% of gynecologists
would choose CS for themselves or their partner
after a low-risk pregnancy [15]; in contrast 98%
of Norwegian obstetricians prefer vaginal delivery
[5]. It thus became an obstetric dogma that all
obstetricians should struggle to achieve vaginal
delivery, and prevent unnecessary CS. Again, several
factors such as decreasing maternal morbidity
and mortality after CS, patient autonomy, possible
damage to the pelvic floor due to vaginal delivery
and forensic aspects might influence an obstetrician
to perform CS without medical indication. CS rates
over recent decades have widely been condemned
as being too high. Certainly their doubling over
the last 20 years followed, rather than mediated,
sharp declines in maternal and peri-natal mortality.
Their huge variation in the developed world (6-38%)
cannot be explained on obstetric grounds, and
numerous analyses have shown that there are chief
determinants of two to three fold differences
within countries.
The incidence of CS is seen
to increase in primigravidas as compared to multigravidas.
Obviously, the safest birth is spontaneous vaginal
birth, but doctors need a system to support women
to get through CS. The indications for CS are
usually maternal, fetal or physical-related factors
or a mixture of the three. In some situations
a CS may be the only safe option for mother and
baby, which all involve there being a complication
during pregnancy or labor, for example when: i)
the placenta lies so low in the uterus that it
covers the exit to the birth canal, ii) the obstetrician
finds out that the baby's health is threatened
due to lack of oxygen, iii) the baby is in an
abnormal position, iv) the baby is very large
in size, v) the mother is carrying twins, triples
or other multiples, vi) there is vaginal bleeding
and a natural delivery is not about to happen,
vii) the umbilical cord falls forwards and the
baby cannot be delivered easily, viii) the mother
will be unable to deliver the baby herself. In
other situations a CS may be considered the safest
option even though a vaginal birth is a possibility:
i) if the baby is lying with its head upwards,
ii) if the mother is affected by high blood pressure
or other illness, iii) if the unborn baby is too
small or too weak to survive a natural birth,
iv) if the mother has had a CS birth before. In
very rare cases, the mother is so anxious about
the delivery that a CS is considered. Several
early studies showed that an elective CS significantly
reduced mother-to-child transmission of HIV compared
to vaginal birth.
These are fundamentals of the
vast increase in the number of CS that are performed
and the fact that most of the procedures are done
without any medical reasons. These numbers are
still on the rise and there is a major push to
decrease the number of CS and to return to natural
childbirth. This is a very topical issue in modern
western societies and the question of why officials
feel this move away from CS and towards natural
childbirth needs to be made, and whether this
is valid, is explained as a part of this investigative
study.
The CS rates have risen through
a combination of medical, cultural and organizational
factors. There have been a number of reports of
international and national differences in CS rates
from both developed and developing countries and
multi-factorial causes determine the increasing
trend of CS rates. There is concern about the
dramatic increase and ongoing overuse of CS. The
rate for first-time mothers may approach one in
three [9]. Every year since 1970 no less than
5.2% of American women have given birth via major
abdominal surgery and today more than one in four
or 27.6% of women have a CS for the birth of their
baby, and New York State's rate of CS is 28.4%
[35] and the figures are still rising. The average
CS rate for NY City hospitals is 26.4%. The hospitals
with the highest CS are performed yearly in Latin
America revealing CS rates ranging from 16.8%
up to 40% [6]. In the 1950s, 3% of births in England
were by CS and by the early 1980s this had risen
to 10% and in the 1990s rates started to climb
rapidly, from 12% in 1990 to 21% in 2001, in 2000,
the CS rates in Wales was 24%, Northern Ireland
23.9% and Scotland 21% [12]. In 2003, the CS rates
are 22% in England, 24.3% in Scotland, 24.5% in
Wales and 25.8% in Northern Ireland in 2002. In
1970, 20% of births in Brazil were CS and this
has now risen to 40%. New Brunswick has one of
the highest CS rates in Canada: 27% in 2001-2002,
compared to a national average of 23% of in-hospitals
[8]. According to the annual report of the Sotomayor
Maternity hospital in Guayaquil, Ecuador, 58%
of the total births were CS [18]. Korea shows
the world's highest rate of CS. In 1999, the rate
was 43.5% and it was 40.5% and 38.6% in 2001 and
the first half of 2003, respectively. In this
connection, the World Health Organization (WHO)
recommended that there is no justification for
any region to have a higher CS rates than 10-15%
[37].
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HAZARDS OF CS TO THE MOTHER |
No evidence supports the idea
that elective CS is as safe as vaginal birth for
mother or baby and the complications for the mothers
are common. Maternal mortality attributed to CS
is very difficult to calculate, because the incidence
of maternal death sometimes is due to underlying
disease rather than the surgical procedure. In
fact, the increase in CS births risks the health
and well-being of childbearing women and their
babies. Complications, particularly infections,
are more common in woman having CS than woman
having vaginal delivery. Reported rates of post-cesarean
surgical site infection varies greatly from 0.3%
in Turkey [38], 11.6% in Brazil [31], to 18.37
in Saudi Arabia [13]. The main risks are for the
mother, such as heavy bleeding at the time of
surgery and after delivery, infection in the wound
or the development of a blood clot in the leg
veins. Further, there are risks to CS, especially
the small but important risk of abnormally positioned
or adherent placentation with recurrent abdominal
delivery [2]. Even this, however, needs to be
offset against the avoidance of pelvic surgery
in later life. Then there is the increased relative
risk of respiratory distress with pre-labor CS
at 38 weeks [24], although this is usually treatable
with a good outcome, unlike unexplained intrauterine
death at or after the same gestational age [10].
Women run 5 to 7 times the risk of death with
CS compared with vaginal birth [33]. Complications
during and after the surgery include surgical
injury to the bladder, uterus and blood vessels
(2%), hemorrhage (1 to 6% women require a blood
transfusion), anesthesia accidents, blood clots
in the legs (6 to 20 per 1000), pulmonary embolism
(1 to 2 per 1000), paralyzed bowel (10 to 20%
mild cases, 1% severe) [29], and infection (up
to 50 times more common) [1]. 10% of women report
difficulties with normal activities two months
after the birth, and 25% report pain at the incision
site as a major problem and one in fourteen still
report incisional pain six months or more after
delivery [11]. Twice as many women require rehospitalization
as women having normal vaginal birth [20]. Especially
with unplanned CS, women are more likely to experience
negative emotions, including lower self-esteem,
a sense of failure, loss of control, and disappointment.
They may develop postpartum depression or post-traumatic
stress syndrome [32]. Some mothers express dominant
feelings of fear and anxiety about their CS as
long as five years later, and women having CS
are less likely to decide to become pregnant again.
As is true of all abdominal surgery, internal
scar tissue can cause pelvic pain, pain during
sexual intercourse, and bowel problems. Reproductive
consequences compared with vaginal birth include
increased infertility [17], miscarriage [16],
placenta previa, placental abruption [21], and
premature birth [9]. Even in women planning repeat
CS, uterine rupture occurs at a rate of 1 in 500
versus 1 in 10,000 in women with no uterine scar
[30].
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HAZARDS OF REPEAT CS TO THE MOTHER |
Elective repeat
CS is riskier for the mother and not any safer
for the baby [25] and for previous CS, 7 out
of 10 women or more who are allowed to labor
without undue restrictions will give birth vaginally,
thus ending their exposure to the dangers of
CS. Patients with two CS were not given trial
of labour at all and were subjected to CS when
they were term. Elective CS carries twice the
risk of maternal death compared with vaginal
birth [14]. Old scar tissue increases the likelihood
of surgical injury. One more woman in every
100 with a history of more than one CS will
have an ectopic pregnancy [16]. Hemorrhage associated
with ectopic pregnancy is one of the leading
causes of maternal death in the US. Compared
with women with no uterine scar, women have
more than 4 times the risk of placenta previa
with one prior CS, 7 times the risk with two
to three prior CS, and 45 times the risk with
four or more prior CS [2]. Placenta previa more
than doubles the chance of the baby dying and
increases the rate of preterm birth more than
6-fold [9]. Compared with women with prior births
and no previous CS, women with one prior CS
or more have as much as 3 times the risk of
placental abruption [16]. With placental abruption,
6 in every 100 babies will die, and 3 in 10
will be born too early [23]. The odds of placenta
accreta jump from 1 in 1,000 with one prior
CS to 1 in 100 with more than one prior CS [3].
Nearly all women with this complication will
require a hysterectomy, nearly half will have
a massive hemorrhage, and as many as 1 in 11
babies and 1 in 14 mothers will die [26]. The
incidence of placenta accreta has increased
10 fold in the last 50 years and now occurs
in 1 in 2,500 births [1]. Women having elective
repeat CS are more likely to experience hemorrhage
requiring transfusion, blood clots, and infection
[30]. Postpartum recovery after repeat CS is
even more difficult when there is another child
or children to care for. So, it cannot necessarily
be concluded that CS is more dangerous than
vaginal birth because pre-existing conditions
may have influences on the decision to carry
out CS and the outcome.
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HAZARDS OF CS TO THE BABY |
Especially with
planned CS, some babies will inadvertently be
delivered prematurely. Babies born even slightly
before they are ready may experience breathing
and breastfeeding problems. At least 1-2% babies
will be cut during the surgery [36]. Studies
comparing elective CS or CS for reasons unrelated
to the baby with vaginal birth find that babies
are 50% more likely to have low Apgar scores,
5 times more likely to require assistance with
breathing, and 5 times more likely to be admitted
to intermediate or intensive care [4]. Babies
born after elective CS are more than four times
as likely to develop persistent pulmonary hypertension
compared with babies born vaginally [22]. Persistent
pulmonary hypertension is life threatening.
Mothers are more likely to have difficulties
forming an attachment with the infant [21].
This may be because women are less likely to
hold and breastfeed their infants after birth
and have rooming in and because of the difficulties
of caring for an infant while recovering from
major surgery. Babies are less likely to be
breastfed. The adverse health consequences of
formula feeding are numerous and can be severe.
Some health
care experts believe that half of those are
unnecessary in the way that they are performed
for non-medical reasons like the patient or
doctor's personal schedule or simply due to
women's preferences, though not acceptable.
A recent birth certificate-based study on deliveries
in Louisiana demonstrated that the changes in
the state's CS rate from 1993-2000 were not
related to changes in potential risk factors
as reported on birth certificates and concluded
there was a high rate of unnecessary CS [19].
The CS rates have fluctuated somewhat over the
years as health care professionals have come
to varying conclusions about the relative advantages
of CS and vaginal deliveries. There are several
factors, which have contributed to the rise
in CS rates, and these factors have been the
subject of intense debate. While doctors state
that decisions to perform CS are based on concerns
of patient's safety some women feel that their
choice is contained by doctors' interest in
more lucrative and less time-consuming births.
A fear of malpractice suits has also likely
influenced the rates of surgical invention.
In some cases, doctors are pressured by hospital
officials to perform CS in order to avoid liability.
Better socioeconomic conditions were associated
with higher CS rates. Some pregnant women demanded
a CS as were afraid of pain. It is very important
that a woman makes her own informed decision
in association with her healthcare team, concerning
mode of delivery. Consequently, CS increases
many of the risks to mothers and babies. Beijing
has seen the rapid increase in CS in the past
two decades and more, with the highest rate
reaching 60% in some hospitals. The CS rates
stood at an average 19.5% annually in Beijing
during the 1980-1984 periods. The rate had kept
rising in the following years and hitting 47.92%
by the end of 2004. A recent national survey
in the United Kingdom (UK) indicated that 92%
of women wanted to be delivered by the route
that was safest for the baby: the same survey
showed that 54% of obstetricians thought that
was by CS [34]. There are further reasons why
the CS rate is destined to rise further. Firstly,
women in the developed world are reproducing
later in life, and rising age correlates linearly
with CS rates [28]. Next, babies are getting
bigger, as are their mothers [7]. Indeed, anthropologically
man is the only mammal in which the fetal head
almost entirely occupies the maternal pelvis,
and has and is evolving away from a reliance
on vaginal birth [32]. Finally, the litigation
costs resulting from vaginal delivery continue
to rise exponentially. One wonders how much
longer society, and particular health care providers,
will continue to be able to afford vaginal delivery.
Patient choice is assuming greater importance
in maternity care and in this light efforts
to reduce the CS rate further seems doomed.
Medical opinion is changing with a further rise
in rates not only to be expected, but may also
be desirable. The assumption that CS rates are
too high is no longer tenable, and reducing
rates may be counter to maternal and fetal interests.
CS rates in the twenty first century will be
driven up by consumer demand [27], and will
almost certainly exceed 50%. As the CS rate
has increased year on year so the gynecological
complications of vaginal birth have been highlighted
in the medical and lay press. This has led to
many women believing that vaginal birth is an
outdated, unnecessarily prolonged, painful and
humiliating experience. Birth is a natural process
and so when there are no complications there
should be no need for it to be made into a medical
procedure. Aforementioned are valid arguments
supporting the decline in the number of CS performed
which is an important issue today.
There is a general
consensus amongst clinicians that a high CS
rate is undesirable. One way to respond to this
would be to set targets for a reduced CS rate.
For this women must give unbiased information
on the benefits and risks of vaginal birth versus
CS. Hospitals should evaluate variations in
CS rates among practitioners at their institution.
The obstetric community should educate clinicians,
hospital management, and patients that CS based
on non-clinical factors is not associated with
improved maternal or neonatal outcomes. Institutions
should use comparative outside data on CS rates
to evaluate their own CS rates. Hospitals or
practitioner groups with high CS rates can consider
establishing separate 24 hour, in house obstetric
coverage by physicians who are solely responsible
for the management of the intrapartum patient.
To be effective, actions to reduce CS would
need to involve public health authorities, medical
associations, medical schools, doctors, midwives,
nurses, the media, and the general population.
There is an alternative approach - careful differentiation
during pregnancy of high risk and low risk groups
of pregnant women with different management
of labor. The low risk group may be attended
during labor by primary care attendants without
electronic monitoring but with strict criteria
for referral. A close cooperation between midwives,
general practitioners, and obstetricians, with
mutual respect for each others' special abilities,
is a prerequisite for such a system to work.
This study examines
reasons for the increase in the CS rate and
the complications for health policy, The most
common way that women in the developed countries
give birth was by CS. So, the overall CS rate
has increased significantly by increasing the
number of women who have a first, or primary
CS. Many changes have occurred in obstetric
practice in the past decades. The rising CS
rate has been associated with a fall in operative
vaginal deliveries, as well as a fall in spontaneous
births. The change in the obstetric population
to delay in child bearing and smaller families,
will have contributed to the change but the
huge countrywide differences in CS rate noted
in the USA and the UK is disquieting and is
suggestive that not all operative deliveries
are necessary. So far, this study may help to
encourage women to make their decision for experiencing
vaginal delivery, as an overwhelming majority
of the experts in the field would choose it
for themselves or for their partners. Researchers
must take this issue seriously so as to oppose
the unnecessary medical risks and economic burdens
involved with unwanted CS births.
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