Elsevier

The Lancet

Volume 367, Issue 9525, 3–9 June 2006, Pages 1819-1829
The Lancet

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Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America

https://doi.org/10.1016/S0140-6736(06)68704-7Get rights and content

Summary

Background

Caesarean delivery rates continue to increase worldwide. Our aim was to assess the association between caesarean delivery and pregnancy outcome at the institutional level, adjusting for the pregnant population and institutional characteristics.

Methods

For the 2005 WHO global survey on maternal and perinatal health, we assessed a multistage stratified sample, comprising 24 geographic regions in eight countries in Latin America. We obtained individual data for all women admitted for delivery over 3 months to 120 institutions randomly selected from of 410 identified institutions. We also obtained institutional-level data.

Findings

We obtained data for 97 095 of 106 546 deliveries (91% coverage). The median rate of caesarean delivery was 33% (quartile range 24–43), with the highest rates of caesarean delivery noted in private hospitals (51%, 43–57). Institution-specific rates of caesarean delivery were affected by primiparity, previous caesarean delivery, and institutional complexity. Rate of caesarean delivery was positively associated with postpartum antibiotic treatment and severe maternal morbidity and mortality, even after adjustment for risk factors. Increase in the rate of caesarean delivery was associated with an increase in fetal mortality rates and higher numbers of babies admitted to intensive care for 7 days or longer even after adjustment for preterm delivery. Rates of preterm delivery and neonatal mortality both rose at rates of caesarean delivery of between 10% and 20%.

Interpretation

High rates of caesarean delivery do not necessarily indicate better perinatal care and can be associated with harm.

Introduction

Rates of caesarean delivery have risen from about 5% in developed countries in the early 1970s1, 2, 3, 4, 5 to more than 50% in some regions of the world in the late 1990s.6 Many factors have contributed to this rise, including improved surgical and anaesthetic techniques, reduced risk of post-operative complications, demographic and nutritional factors,7, 8 providers' and patients' perception of the safety of the procedure,9 obstetricians' defensive practice,10 changes in health systems,11 and patient demand.12, 13 Caesarean delivery is thought to protect against urinary incontinence, prolapse, and sexual dissatisfaction, increasing its appeal.14, 15 Finally, the rise in numbers of women opting for a caesarean might also be affected by obstetricians' defence of women's rights to choose their method of delivery.16

Medical strategies, such as mandatory second opinion before doing a caesarean section, have not reduced the numbers of caesarean deliveries,17 and a randomised trial to compare perinatal outcomes and satisfaction of caesarean delivery on demand for all women versus caesarean delivery only when clinically indicated is being contemplated.18 Before such practice can be assessed and an appropriate trial designed, however, the optimum proportion of caesarean deliveries for any particular institution, based on the risk profile of that institution's pregnant population, needs to be identified.13, 19, 20

Our aim was to assess the association between rates of caesarean delivery and maternal and perinatal outcomes at the institutional level.

Section snippets

Population

We designed the 2005 WHO global survey on maternal and perinatal health to explore the relation between rates of caesarean delivery and perinatal outcomes in the medical institutions of eight randomly selected countries in the region of the Americas, using a multistage stratified sampling procedure. We obtained data between Sept 1, 2004, and March 30, 2005.

After country selection, we identified a representative sample of geographic areas within each country and, within these geographic areas, a

Results

Figure 1 shows the trial profile. The number of institutions per geographic region ranged from six in Paraguay to 21 in Mexico; deliveries per country ranged from nearly 3500 in Paraguay to 21 000 in Mexico, and five other countries contributed more than 10 000 deliveries each to the sample. Most of the health institutions were urban; 50 were tertiary-level, 51 were district hospitals, 11 were primary-care units with surgical facilities, and eight classified as other type of institution. 40

Discussion

Our findings indicate that increase in rates of caesarean delivery is associated with increased use of antibiotics postpartum, greater severe maternal morbidity and mortality, and higher fetal and neonatal morbidity, even after adjustment for demographic characteristics, risk factors, general medical and pregnancy associated complications, type and complexity of institution, and proportion of referrals. The high rates of caesarean delivery and its more frequent indications were similar across

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