C-Sections Double Since 2000: Rich Too Many, Poor Too Few

Becky McCall

October 15, 2018

Cesarean section (C-section) births almost doubled between 2000 and 2015 globally, with those in many middle- and high-income settings having the procedure too often, while women in low-income countries often don't have access to this method of birth even when it's needed.

The "alarming" findings were presented and discussed in a series of articles published in the October 13 issue of The Lancet and launched at the International Federation of Gynecology and Obstetrics (FIGO) World Congress in Brazil.

At the same time, the World Health Organization (WHO) has issued new guidelines specifically designed to reduce unnecessary C-sections.

According to the Lancet series, it is estimated that 10% to 15% of births need to be by C-section because of medical complications, suggesting that average use should lie somewhere between these levels. But the new report shows a fifth of births worldwide were by C-section in 2015, up from 12% in 2000.

Overall, the analysis of WHO and United Nations Children's Fund (UNICEF) databases shows that C-sections have increased by 3.7% each year between 2000 and 2015.

"The data drawn from 169 countries include 98.4% of the world's births; we estimate that 29.7 million (21.1%) births occurred through C-section in 2015, which was almost double the number of births by this method in 2000 (16.0 million [12.1%] births)," write the authors. Senior author on two of the three articles and second author on the third is Marleen Temmerman, MD, PhD, Aga Khan University, Kenya, and Ghent University, Belgium.

Remarking on the imbalance between under- and over-use, Temmerman says: "The large increases in C-section use — mostly in richer settings for nonmedical purposes — are concerning because of the associated risks for women and children. C-sections can create complications and side effects for mothers and babies, and we call on healthcare professionals, hospitals, funders, women, and families to only intervene in this way when it is medically required."

And regarding underuse in lower income regions, she added, "In cases where complications do occur, C-sections save lives, and we must increase accessibility in poorer regions, making C-sections universally available, but we should not overuse them."

The series authors also note that, for healthcare professionals, improved education, guidelines, and communication, and second-opinion policies may be helpful to address influences such as women's requests, convenience, financial incentives, and fear of litigation.

In particular, in some regions C-sections are seen as protective and physicians are less likely to be sued if complications occur than during vaginal delivery. And the authors warn that in many settings young physicians are becoming experts in C-section while losing confidence in their abilities to assist in vaginal birth.

And in an accompanying editorial by Ingela Wiklund, PhD, from the Karolinska Institute, Stockholm, Sweden, and colleagues, there is criticism about the omission of midwives from the picture, with emphasis that midwife-led care can help allay the fears of women, such as issues regarding the labor pain associated with vaginal birth.

In Sub-Saharan Africa, Too Few; in North America, Too Many

Of note, the new data show wide disparities between regions of the world. South Asia saw the fastest rise in C-sections, at 6.1% per year, shifting from underuse in 2000 to overuse in 2015, with C-section rates increasing from 7.2% of births to 18.1%, respectively.

Sub-Saharan Africa continues to show a low rate of C-sections, increasing from 3% to 4.1% of births in West and Central Africa, and from 4.6% to 6.2% in Eastern and Southern Africa. The low use of C-section here implies that women and babies are at much higher risk of dying because they cannot access lifesaving surgery during childbirth, write the authors.

In contrast, in North America, Western Europe, Latin America, and the Caribbean rates increased between 2000 and 2015 from 24.3% to 32% in North America, from 19.6% to 26.9% in Western Europe, and from 32.3% to 44.3% in Latin America and the Caribbean. 

Brazil and China, typically emergent economies, showed a rise in C-sections with distinctive trends of high rates mainly in women with low-risk pregnancies and those who were having a second or later C-section.

"Almost universal use of C-section has been reported for the births of wealthier women in private health facilities in Brazil," write the series authors.

Also in Brazil, particularly high levels of C-sections were seen in women who were highly educated compared with less well-educated women (54.4% of births versus 19.4%).  

Indeed, another accompanying commentary by Gilberto Magalhães Occhi, Minister of Health of Brazil, and colleagues sets out the country's strategies to optimize C-section use.

In low- and middle-income countries generally, the wealthiest women were six-times more likely to have a C-section than women of lower incomes. C-sections in these countries were also 1.6-times more likely to be performed in a private than public hospital.

And in countries with the highest levels of births overall, there were large differences in C-section use between regions. For example, differences between rates of C-section in provinces in China ranged from 4% to 62%, and inter-state differences in India ranged from 7% to 49%.

In fact, many countries where C-section use is over 40% are in the low-to-middle-income bracket; for example, Dominican Republic, with a rate of 58.1% (2014); Brazil at 55.5% (2015); Egypt at 55.5% (2014), and Turkey at 53.1% (2015), to name a few.  

FIGO Position Paper on Stopping Epidemic of C-Sections

As part of the series, FIGO has published a position paper entitled, "How to stop the Caesarean section epidemic."

"Worldwide there is an alarming increase in C-section rates. The medical profession on its own cannot reverse this trend," note Gerard Visser, MD, from the University Medical Centre, Utrecht, the Netherlands, and chair of FIGO's Committee on Safe Motherhood and Newborn Health, and colleagues.

"Drivers for the increasing C-section rates can vary between countries and include a loss of medical skills to confidently and competently attend a (potentially difficult) vaginal delivery, as well as medico-legal issues," they say.

Six recommendations to reduce unnecessary C-sections are proposed in the position paper, including:

  • Informing women of the benefits and risks of C-sections;

  • Matching costs for C-section and vaginal birth (using a mean fee);

  • Ensuring hospitals publish their annual C-section rates; and

  • With respect to very low income countries, particularly in rural areas, ensuring there is adequate access to skilled care, appropriate fetal surveillance, and assisted births or operative delivery.

And with respect to reimbursement for procedures, Visser and colleagues point out that "the only aspect that has consistently resulted in a significant reduction in C-section rates has been an altered reimbursement model for doctors and hospitals that favor vaginal delivery."

WHO on Nonclinical Intervention to Lower C-Section Rates

Meanwhile, in new guidance on nonclinical interventions specifically designed to reduce unnecessary C-sections, the first of its kind, WHO has made a number of recommendations.

These include educational interventions for women and families to support meaningful dialogue with providers and informed decision-making on mode of delivery, use of clinical guidelines, audits of C-sections, and timely feedback to health professionals about C-section practices.

With respect to inequalities in access to C-sections, as reflected by the data published in series, WHO notes in a press release that "while many women in need of C-sections still do not have access to C-section, particularly in low resource settings, many others undergo the procedure unnecessarily, for reasons which cannot be medically justified."

WHO also draws attention to the financial implications involved, noting that "C-sections are also costly, and high rates of unnecessary C-sections can therefore pull resources away from other essential health services, particularly in overloaded and weak health systems."

But WHO also recognize that the problem is complex and answers will be multifaceted, which effective solutions will need to recognize. "Interventions that have multiple components are likely to be more successful and are therefore more desirable," they note.

Involve Midwives More

Nevertheless, echoing the complex nature of the problem in their commentary, Wiklund and colleagues write: "This Lancet series does not give due attention to the impact of investing in midwives and midwife-led continuity of care."

"Conjecture that blames mothers for the high C-section rate, either because of their poor health (eg, obesity or hypertension) or because they are demanding medically unnecessary C-section due to fear or disinterest in labor, ignores the wider systems issues that drive the growing reliance on C-section," they observe.

Commitment to women-centered care "is a key strategy to achieve equitable and optimal use of C-section. This model includes evidence on continuous labor support and approaches that prioritize positive human relationships such as addressing women's fear of labor pain."

Temmerman, Visser, and Wiklund have reported no relevant financial relationships.

Lancet. October 12, 2018 issue. WHO guidance

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