Cesarean Delivery Rates and Pregnancy Outcomes
October 1, 2006 3 minutes read
Cesarean Delivery Rates and Pregnancy Outcomes
Abstract & Commentary
By John C. Hobbins, MD, Professor and Chief of Obstetrics, University of Colorado Health Sciences Center, Denver, is Associate Editor for OB/GYN Clinical Alert.
Dr. Hobbins reports no financial relationship to this field of study.
Synopsis: High rates of caesarean delivery do not necessarily indicate better perinatal care and can be associated with harm.
Source: Villar J, et al. Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. Lancet. 2006;367:1819-1829. Erratum in: Lancet. 2006;368:580.
The increased rate of cesarean section in the United States has been the subject of many editorials over the last 3 years and the very recent spurt in elective cesareans has triggered commentary varying from "this is unconscionable" to "why not?" In a report in the Lancet the authors attempted, in a very creative way, to see if increasing the CSR had a beneficial or detrimental effect on perinatal morbidity, perinatal mortality and or maternal morbidity. They used perinatal data from the WHO involving 11 countries in Latin America for a 6-month period in 2005. Because of the tendency toward confounding variables when assessing associations between Cesareans and outcomes, the authors used a variety of statistical methods to weed out bias.
They randomly selected 8 countries from the 35 where perinatal data were available, and then randomly selected 120 facilities that had at least 1000 deliveries per year. These chosen institutions included private hospitals, "public" hospitals, and those funded by social security. Each of these, in turn, was classified according to the complexity of problems seen at these hospitals.
After selecting the populations to study, the authors then used various end points to evaluate outcome. For example, to evaluate maternal morbidity they assumed that the need for blood transfusion and hysterectomy meant severe post partum hemorrhage. Other abnormal variables were admission to the intensive care unit, a maternal hospital stay of greater than seven days, or the need for antibiotics (as an indicator of maternal infection). The perinatal complication variables included intrapartum fetal death, preterm birth at less than 37 weeks, and greater than seven day stay in the NBSCU.
The results were fascinating. The lowest CSR came from the public hospitals in Argentina (26%), but, with the exception of Ecuador where the CSR was 40%, the other public hospitals had rates below 30 percent. The highest CSR came from private hospitals in Mexico, yielding a 78% total Cesarean rate and more than 80% of those were contributed by elective Cesarean sections.
Besides the strikingly high rates of Cesarean sections in these Latin American countries, there did not appear to be any improvement in outcome. In fact, the opposite was occurring. While Cesarean section rates were rising in these countries, there were increases in the rates of every indicator mentioned above pertaining to maternal and perinatal morbidity and mortality. All of these correlations were statistically significant.
Commentary
Until recently, the decision to have the Cesarean section was generally in the hands of the provider. However, for valid reasons involving patient autonomy, the patient has had a much greater role in the decision making regarding the route of delivery. Since few providers in the United States read the Lancet, I am offering this review as a public service. I think the authors have summed up their conclusion quite well. "Our results show how a medical intervention or treatment that is effective when applied to sick individuals in emergency situations can do more harm than good when applied to healthy populations."
The increased rate of cesarean section in the United States has been the subject of many editorials over the last 3 years and the very recent spurt in elective cesareans has triggered commentary varying from "this is unconscionable" to "why not?"You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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