,This week much of the focus has been on the global rise in the number of caesarean births following The Lancet publication of a 3-part series ‘Optimising caesarean section use’. The series, available here, details the occurrence of caesarean births from data collected from 169 countries, reviews the short and long term effects of CS on the health of women and children and outlines interventions to reduce unnecessary CS in health women and babies.
Global epidemiology of use of and disparities in caesarean sections
The first part of the series titled ‘Global epidemiology of use of and disparities in caesarean sections’ reviews the trends in CS use globally estimating 29.7 millions births occurred through CS in 2015.
Figures suggest rates have almost doubled since 2000 from 12.1% to 21.1% of births however there was significant variation in rates across regions. Caesarean birth rates ranged from 58.15% of births in Dominican Republic to 0.6% in South Sudan. Those low-income countries have inadequate access to CS posing higher risk of mortality to those women. In comparison use of CS for higher income families was well above the rate expected based on obstetric indications.
The paper recommends:
‘Optimisation of CS use is needed, underpinned by a better understanding of demand and supply factors that drive the overuse of CS and by greater efforts to ensure universal access to CS for all women.’
Short-term and long-term effects of caesarean section on the health of women and children
The second part of the series titled ‘Short-term and long-term effects of caesarean section on the health of women and children’ highlights that the prevalence of maternal morbidity and mortality is higher after CS than vaginal birth.
It is suggested that the estimated risk of death from an emergency intrapartum CS is up to 4 time higher than vaginal birth with severe acute maternal morbidity (including haemorrhage, uterine rupture, anaesthetic complication and cardiac arrest) also higher. The paper highlights that almost everyone who has a CS increases risk of certain morbidities in future pregnancies.
Interventions to reduce unnecessary caesarean sections in healthy women and babies
The final part of the series titled ‘Interventions to reduce unnecessary caesarean sections in healthy women and babies’ investigates factors for CS use and the type and effects of interventions to reduce CS.
Clinical interventions including external cephalic version for breech delivery at term, vaginal breech delivery in appropriately selected women, and vaginal birth after CS could reduce CS rates. Additional approaches including labour companionship and midwife led care have been associated with safer outcomes and positive maternal experiences.
One of the key messages is:
‘…approaches that prioritise positive human relationships, promote respectful and collaborative multidisciplinary teamwork, and address clinicians’ beliefs and attitudes and women’s fear of labour pain and of poor quality of care, might be effective in reducing CS use or increasing physiological labour and birth.’
Schematic representation of factors related to women, society, health providers, and health-care organisations that affect the frequency of caesarean section use at the local level; these factors surround the obstetric and clinical factors that also affect the frequency of births by caesarean section, which are represented in the middle by the Robson 10-group classification