Global cesarean section rates almost double since the turn of the century

Globally, the cesarean section rate has almost doubled since 2000, with wide geographical variations based on economic prosperity. The rate is unprecedently high, reaching almost 60% in some parts of Latin America and as low as 5% in southern Africa. The intervention is often overused unnecessarily in some parts of the world and denied to mothers in the area where it is needed the most. The linear increases in rates make it highly unlikely that it will be reversed soon.

The considerable variation in C-section rates indicates that the increase is not backed by scientific evidence, as evident by a whopping 6·2 million unnecessary caesareans performed each year, half of which are done in Brazil and China.

Lancet launched a three-part series on optimizing the cesarean section rates at the World Congress of Gynecology and Obstetrics (FIGO) on Oct 18. Simultaneously, the World Health Organization (WHO) also published guidelines on October 11 to reduce the incidence of unnecessary cesarean sections. 

The WHO guidance is unique because it includes the first ever non-clinical interventions to decrease the rising cesarean rates. The guidance consists of 3 sets of separate recommendations targeted at women, healthcare professionals, and health organization and systems.

Those addressed at women, stress the importance of health education to allay fear of childbirth and misconceptions. The WHO guidance states, comprehensive health education, including tailored information and support about childbirth fear, pain relief, and the advantages and disadvantages of cesarean sections, should be provided to all women.

Providers guidance is crucial in a sense it includes a mandatory second opinion for cesarean section indication, audit and timely feedback in good resource settings to bring down the cesarean rates. Another significant recommendation is the equal remuneration for the vaginal birth and cesarean deliveries.

The guidance also acknowledges other barriers towards practicing evidence-based medicines such as cultural beliefs, litigations, increased surgical skills of younger providers with decreasing confidence in conducting difficult vaginal births.

As the part of the Lancet series, the editorial by Wiklund and colleagues highlights the importance of investing in midwives and midwives-led care in bringing down the global cesarean section rate. Trained midwives can provide continuous and watchful support during labor, creating an atmosphere of trust that may calm the patients resulting in more natural births.

The series further analyzed the significant trends of cesarean section in Brazil and China. Both are emerging economies with the highest cesarean section rates seen in wealthier, educated women in private clinics as compared to less well-educated women (54.4% of births versus 19.4%). Wealthier women are 6 times more likely to have surgical delivery as compared to women from a low socioeconomic background.

FIGO also issued a position paper on how to curb the recent cesarean section epidemic. 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 note, “Worldwide there is an alarming increase in C-section rates. The medical profession on its own cannot reverse this trend.

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 tricky) vaginal delivery, as well as medico-legal issues."

In the position paper, FIGO calls upon governmental bodies, UN partners, professional organizations, women's groups, and other stakeholders to join hands to bring down the global cesarean section rates.

The six recommendations by FIGO includes:

• Educating the women about benefits and harm of operative delivery
• Matching the rates of surgical and vaginal deliveries, especially in private practice
• Making mandatory for hospitals to publish their Cesarean section rates
• Ensuring that all hospitals adopt a uniform classification system for CS
• Reinvesting the money saved from lower cesarean section to improve the infrastructure
• Increasing access to skilled care, fetal monitoring and assisted births in low-income, rural areas

The authors further note that the only aspect that has consistently resulted in a significant reduction in CS rates has been an altered reimbursement model for doctors and hospitals that favor vaginal delivery. This has been shown in Portugal following wide dissemination of information on the increased risks of CS, as well as in governmental hospitals in Iran and in a large hospital setting in Shanghai.

WHO recommendations non-clinical interventions to reduce unnecessary caesarean sections

Lancet series: Optimising caesarean section use

Global epidemiology of use of and disparities in caesarean sections

Short-term and long-term effects of caesarean section on the health of women and children

Interventions to reduce unnecessary caesarean sections in healthy women and babies

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FIGO position paper: how to stop the caesarean section epidemic

Appropriate use of caesarean section globally requires a different approach

Strategic measures to reduce the caesarean section rate in Brazil

Editorial

Stemming the global caesarean section epidemic

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Ana Pilar Betrán: seeking the optimum use of caesarean section

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Nearly 10% of young women worldwide prefer Cesarean section to vaginal birth as delivery option

One in ten young women prefers cesarean section to vaginal birth as her choice of delivery in a seemingly healthy pregnancy, because of fear of uncontrollable labor pains and physical damage says the result of large study published in Journal of Reproductive Health.

All attempts to bring down cesarean section rates in middle income and developed countries have mostly focused on educating the physicians and midwives, changing hospital policies and environment and less on patient education and knowledge about benefits of vaginal births.

It is estimated that 6.2 million unnecessary cesarean sections (CS) are performed worldwide each year and most countries that participated in this study exceeds the optimal limit between 10-19%.

Recently, psychological indication of Cesarean Section has emerged as an important contributing in increasing the global cesarean rate. A survey of 6000 European found that 16.7% of primiparas and 31.7% of multiparas had a CS without medical indications because of severe fear of childbirth.

The current study recruited student from Universities and Schools across 8 OECD countries (Australia, Canada, Chile, England, Germany, Iceland, New Zealand, United States.

Childless young men and women who plan to have one child in near future were sent online questionnaire, of which 6571 completed the survey.

During the final analysis, overall 10.8% of women wanted to have a CS in a healthy future pregnancy, with the highest rate of 16.0% in Australia.

The most common reason cited was fear of labor pains and maintain vaginal integrity, the other being CS is well planned and good for mother’s health.

Regression analysis showed that students who studied health science had significant less fear and lower odds of preferring CS.

Epidural analgesia might theoretically appear a lucrative solution, but it increased the rates of instrumental delivery and created a lasting negative impression in long term.

All women expressed a significant interest in knowing more about anatomy and process of childbirth.

The authors concluded, “Education sessions delivered online, through social media, and face-to-face using drama and stories told by peers (young women who have recently had babies) or celebrities could be designed to maximize young women’s capacity to understand the physiology of labor and birth, and the range of methods available to support them in coping with labor pain and to minimize invasive procedures, therefore reducing fear of pain, bodily damage, and loss of control. The most efficacious designs and content for such education for young women and girls remains to be tested in future studies.”

Abstract, Full Text.

Microbirthing: The " Vaginal Seeding" is growing fad, but thin evidence concerns physicians!

Every 4^th baby in UK is born by Caesarean Section. Parents of the Caesar babies are requesting a procedure called as ‘microbirthing’ or ‘vaginal seeding’.

Vaginal seeding involves taking a swab from mother’s vagina and swabbing it over babies face, eyes, mouth and skin immediately after caesarean birth.

This article is based on recent editorial in BMJ (BMJ 2016; 352:i227) by Cunnington A.J. et al “Vaginal seeding” of infants born by caesarean section. How should health professionals engage with this increasingly popular but unproved practice?

Our body is colonized with millions of microbes, collectively called as microbiota. They outnumber our cells by 10:1. The microbiota varies according to parts of our body and also person to person. As described by microbiology professor Graham Rook at University College London, we are designed to live in nature’s biodiverse ecosystem encountering our old microbial friends as part of our early immune education.

During the process of vaginal birth, specific species of good bacteria are transferred to the baby during and immediately after birth via the birth canal, immediate skin-to-skin contact and breastfeeding. This is the seeding of the baby's microbiome. The process heralds the training of baby’s immune system to recognize between ‘good’ and ‘bad’ bacteria and protect the neonate from diseases now and also in future.  Large epidemiological studies and reviews have concluded that babies delivered by C-section have moderately high risk of obesity, asthma, and autoimmune diseases, these  diseases being associated with alteration in microbiota.

For babies entering this world via a C-section, this microbial transfer from the mother to baby is interfered with or bypassed completely. According to the latest research if the baby is not seeded with mother’s bacteria, it can have significant health consequences. Dr Rodney R Dietert, Professor of Immunotoxicology at Cornell University says “Over the past 20-30 years, we've seen dramatic increases in childhood asthma, type 1 diabetes, coeliac disease, childhood obesity. We've also seen increases in Caesarean delivery. Does Caesarean cause these conditions? No. What Caesarean does is not allow the baby to be seeded with the microbes. The immune system doesn't mature, and the metabolism changes. It's the immune dysfunction and the changes in metabolism that we now know contribute to those diseases and conditions.”

So, many researchers advocate that even if vaginal birth is not possible, immediate skin to skin contact and breast feeding should be initiated.

A new documentary “MICROBIRTH” warns how our children are born could have serious repercussions for their lifelong health. “Microbirth” is a new sixty minute documentary looking at birth in a whole new way: through the lens of a microscope. Investigating the latest scientific research, the film reveals how we give birth could impact the lifelong health of our children. http://microbirth.com

In spite of all the hypotheses, we lack scientific proof at present. The newborn may be at risk of developing infection, being exposed to vaginal commensals that the mother maybe harboring without any symptoms. These include group B streptococcus (the most common cause of neonatal sepsis), herpes simplex virus, Chlamydia trachomatis, and Neisseria gonorrhoeae (the last two, causes of ophthalmia neonatorum). These pathogens may also be transferred on a vaginal swab, potentially voiding the protection offered by elective caesarean section.

Clinically we are aware of only one clinical trial going on, called as Potential Restoration of the Infant Microbiome (PRIME) trial. That study is expected to be completed in February, 2019.It is looking at the neonatal microbiota according to mode of birth, the women being screened beforehand for potential pathogens.

Dr. Cunnington, who is the lead author of the article, affirms the lack of sufficient evidence to put vaginal seeding into routine practice. Studies need to be sufficiently large, randomized and need follow up of many years before a recommendation can be made.  

In a statement Dr Cunnington says: "Demand for this process has increased among women attending hospitals in the UK - but this has outstripped professional awareness and guidance. At the moment we're a long way from having the evidence base to recommend this practice. There is simply no evidence to suggest it has benefits - and it may carry potential risks." He also believes in fully informing the risks and harm of this simple procedure to the patients who are demanding it.

He also emphasizes that there are other ways of   influencing baby’s microbiota at birth and “Encouraging breast feeding and avoiding unnecessary antibiotics may be much more important than worrying about transferring vaginal fluid on a swab.”

References:

http://www.criver.com/about-us/eureka/blog/april-2014/early-immune-education

http://articles.mercola.com/sites/articles/archive/2014/12/27/seeding-baby-microbiome.aspx

http://www.actionbioscience.org/genomics/the_human_microbiome.html

http://www.nytimes.com/2013/08/29/science/human-microbiome-may-be-seeded-before-birth.html?_r=0

http://www.huffingtonpost.co.uk/toni-harman/microbirth-babys-mircobiome_b_4947959.html

https://clinicaltrials.gov/show/NCT02407184?link_type=CLINTRIALGOV&access_num=NCT02407184