Revisiting the 30 years old doctrine of Cesarean Delivery Rate.
The World Health Organization (WHO)
recommended in 1985 that cesarean delivery rates should not exceed 10 to 15 per
100 live births to optimize maternal and neonatal outcomes.
A study by Molina G. et al published in December edition of JAMA concludes
that higher Higher Cesarean Delivery Rates May Be OK.
This cross sectional, ecological study
was carried out to estimate the contemporary relationship between national
levels of cesarean delivery and maternal and neonatal mortality.
Data was collected from all 194 WHO
member states from year 2005 to 2012, including cesarean section rates,
health expenditure per capita, fertility rate, and life expectancy.
For the 118 countries for which 2012
data were not available, the 2012 cesarean delivery rate was imputed from other
years.
The main outcome studied was the
relationship between population-level cesarean delivery rate and maternal
mortality ratios (maternal death from pregnancy related causes during pregnancy
or up to 42 days postpartum per 100,000 live births) or neonatal mortality
rates (neonatal mortality before age 28 days per 1000 live births).
Among the 172 countries with
observed data, variability in the international cesarean delivery rate
between countries ranged from (12.6 per
100 live birth to 24.0 per 100 live
births; South Sudan had the lowest cesarean
delivery rate (0.6%), while Brazil had the highest (55.6%).
 | ||
| Mean National Estimates for Countries According to Cesarean Delivery Rates, With Total Volume of Cesarean Deliveries for Each Category---JAMA December 1, 2015, Vol 314, No. 21 |
In 2013, almost one third of
the babies in US were delivered by LSCS, while Canada
and Australia
have a CS rate of 27.3 and 32.3 respectively.
CS rates are rising globally
and it is driven by number of factors like almost complete elimination
of vaginal breech delivery, as well as a significant decrease in operative
vaginal deliveries and vaginal birth after cesarean. Many women also
specifically request cesarean delivery.
Increased level of fetal surveillance has led to increase in
intrapartum CS due to presumed fetal distress, but it has not improved the
overall rate of perinatal mortality and cerebral palsy.
The estimated global number
of cesarean deliveries for 2012 was 22.9 million, yielding a global cesarean
delivery rate estimate of 19.4 per 100 live births, which was higher than
recommended 10% to 15% by WHO.
The authors say that due to
ecological nature of the study it can only document association and no cause
and effect result can be inferred.
The study is important as it
challenges a 30 year old message that a cesarean rate of less than 15% should
be an optimal target of all health care institutions.
Hence, National cesarean
delivery rates of up to approximately 19 per 100 live births were associated
with lower maternal or neonatal mortality among WHO member states. Previously
recommended national target rates for cesarean deliveries may be too low.
It also suggests that
efforts to reduce cesarean section rates may not improve patient outcomes.
In an accompanying editorial, Mary E. D'Alton, MD, and Mark P. Hehir, MD, from Columbia University College of Physicians and Surgeons in New York City write that "The optimal level of cesarean delivery cannot be as simple as a one-fits-all figure to be applied to all institutions and health care systems, and the obstetrical community must accept the fact that 'the appropriate' cesarean delivery rate remains unknown. However, it is not whether the cesarean delivery rate is high or low that really matters, but rather whether appropriate performance of cesarean delivery is part of a system that delivers optimal maternal and neonatal care after consideration of all relevant patient and health system information."
In an accompanying editorial, Mary E. D'Alton, MD, and Mark P. Hehir, MD, from Columbia University College of Physicians and Surgeons in New York City write that "The optimal level of cesarean delivery cannot be as simple as a one-fits-all figure to be applied to all institutions and health care systems, and the obstetrical community must accept the fact that 'the appropriate' cesarean delivery rate remains unknown. However, it is not whether the cesarean delivery rate is high or low that really matters, but rather whether appropriate performance of cesarean delivery is part of a system that delivers optimal maternal and neonatal care after consideration of all relevant patient and health system information."
References:
- United Nations sustainable development knowledge platform. Open Working Group proposal for sustainable development goals. https://sustainabledevelopment.un.org/sdgsproposal. Accessed December, 2015
- World Health Organization. Appropriate technology
for birth. Lancet. 1985;2(8452):436-437.
PubMed
- World Bank. World development indicators. http://data.worldbank.org/indicator. Accessed December, 2015
- http://www.medscape.com/viewarticle/855283
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