All generalization are
false including the recent statement by India’s Union women and Child Development
Minister about bringing down the
C-section rate to 10%. The minister recently asked the health minister
to issue a mandate to all the hospitals displaying the C-section rates. She
took this action in response to a Change.org petition against hospitals and
doctors profiteering by pushing women towards surgical deliveries instead of
natural vaginal birth.
The petition has received
1.3 lakh signatures so far, a number that is not much looking at the total
population of the country.
"We have entered
into an area, very sorry to say, in the last 20 years, where doctors care more
about money than about patients' health. We would like the hospitals to display
data on how many cesarean section deliveries they have done," said the
Minister.
"The normal
Cesarean delivery rate in a country would not be more than 10 percent, because
it is usually done as a last resort. In this country, it is extremely high
because it brings the doctor more money," she further added.
Well, you cannot
generalize and mandate a uniform C-section rate for all the hospitals in all
the states across country. It all depends upon the healthcare infrastructure,
geographical location, access to prenatal care and surgical expertise and the
needs of individual woman.
Pointing a finger at the
obstetrician and asking her to stop doing C-section is like treating a symptom
instead of going into the root of problem. A hospital can have a C-section rate
as high as 70% if it a tertiary care high risk hospital.
A review of trends around
the world shows that currently about 18.6% of births take place by Cesarean
section. The rates vary from as low as 2% to as high as 50%. In U.S.A, about 1.3
million babies are delivered by Cesarean every year, which roughly equals to
every 1 in every 3 children born in US(33%).
The WHO
recommends that the ‘ideal’ rate of C-section for optimum maternal and
fetal outcome should be around 10-15%.This was
based on the observation that
some countries with the lowest perinatal mortality rates had cesarean delivery
rates that were less than 10 per 100 live births. The study also has
insufficient data and relied upon average C-section rate from multiple previous
year.
However, new study
recently examined the relationship between C-section rates and maternal and
neonatal mortality in 194 countries around the globe concluded that C-section
rate up to 19 percent is associated with lower maternal and neonatal outcome.
C-section delivery rates above 19 percent showed no further improvement in
maternal and neonatal mortality rates.[1] Researchers
used mathematical modeling to impute C-section rates for countries where data
was missing and to account for other contributing factors such as health
expenditure.
Latin America and the
Caribbean region has the highest CS rates (40.5%) while some countries in Africa
have the lowest (7%). Brazil occupies the top slot with a rate that exceeds 50%
(55.6%).
The study found out that
in countries with very low C-section rate, people did not have access to basic
healthcare and surgical facilities resulting in high maternal and neonatal
morbidity and mortality. In fact, a study by WHO concluded that in countries
with C-section rate < 10%, there is an additional need for 0.8 – 3.2 million
CS every year to improve maternal and neonatal mortality and morbidity. [2]
Dr. Thomas Weiser, an
assistant professor of surgery at Stanford School of Medicine says
“As countries increase the number of C-sections they provide, mortality
goes down— but only to a point, when the C-section rate tops 19 percent,
benefits for maternal and infant health plateau.
Increasing C-section rates
in recent years are due to modern technology of continuous FHS monitoring in
labor room which is a two-way sword, practicing defensive medicine, rise in
on-demand C-sections beside other maternal and perinatal factors that come into play.
According to ACOG "
Safe reduction of the rate of primary cesarean deliveries, is the only way
to lower
the repeat cesarean section rate
and total cesarean rate."
To conclude, it is impossible
to form a policy regarding relationship between delivery methods and birth
outcomes. Each case must be decided taking into consideration social, medical,
obstetrical and healthcare factors.
Our goal as an
obstetrician should be to see that every woman who needs a C-section should get
one and every woman who does not need a C-section should not get one.
