AMERICAS - Caesarean section is one of the most common surgeries in the world, with rates continuing to rise, particularly in high- and middle-income countries.
Although it can save lives, caesarean section is often performed without medical need, putting women and their babies at-risk of short- and long-term health problems. A new statement from the World Health Organization (WHO) underscores the importance of focusing on the needs of the patient, on a case by case basis, and discourages the practice of aiming for "target rates".
Caesarean section may be necessary when vaginal delivery might pose a risk to the mother or baby – for example due to prolonged labour, foetal distress, or because the baby is presenting in an abnormal position. However, caesarean sections can cause significant complications, disability or death, particularly in settings that lack the facilities to conduct safe surgeries or treat potential complications.
Since 1985, the international healthcare community has considered the "ideal rate" for caesarean sections to be between 10% and 15%. New studies reveal that when caesarean section rates rise towards 10% across a population, the number of maternal and new-born deaths decreases. But when the rate goes above 10%, there is no evidence that mortality rates improve.
It is estimated that globally, the rate of caesarean section is higher than the ideal. In the Americas, the average is 38.9%, according to the most recent data from 25 countries. However, this figure could be higher given that in many cases it does not include caesarean sections done by private sector health services.
"It´s very worrisome that almost four out of every 10 births in the region are by C-section," said Suzanne Serruya, director of the Latin American Center for Perinatology, Women, and Reproductive Health (CLAP) of the Pan American Health Organization (PAHO), regional office for the Americas of WHO. "Doctors, midwives, obstetric nurses, those responsible for health policies, mothers and fathers, and society as a whole should work together to reduce this number and use caesarean sections only when it´s needed for medical reasons."
Across a population, the effects of caesarean section rates on maternal and newborn outcomes such as stillbirths or morbidities like birth asphyxia are still unknown. More research on the impact of caesarean section on women's psychological and social well-being is still needed.
"Having too many caesarean sections is exposing more women to new health problems, like abnormal placentation, which in the case of a second caesarian section can occur in 40% of cases, and in the case of a third caesarian, can occur all the way up to 60% of cases. This represents a risk for maternal death by hemorrhage," warned Bremen de Mucio, regional advisor on Sexual and Reproductive Health in PAHO/WHO´s CLAP.
Due to their increased cost, high rates of unnecessary caesarean sections can pull resources away from other services in overloaded and weak health systems.
The lack of a standardized internationally-accepted classification system to monitor and compare caesarean section rates in a consistent and action-oriented manner is one of the factors that has hindered a better understanding of this trend. WHO proposes adopting the Robson classification as an internationally applicable caesarean section classification system.
The Robson system classifies all women admitted for delivery into one of 10 groups based on characteristics that are easily identifiable, such as number of previous pregnancies, whether the baby comes head first, gestational age, previous uterine scars, number of babies and how labour started. Using this system would facilitate comparison and analysis of caesarean rates within and between different facilities and across countries and regions.
"Information gathered in a standardized, uniform and reproducible way is critical for health care facilities as they seek to optimize the use of caesarean section and assess and improve the quality of care," explains Dr Marleen Temmerman, Director of WHO's Department of Reproductive Health and Research. "We urge the healthcare community and decision-makers to reflect on these conclusions and put them into practice at the earliest opportunity.