Fast track — ArticlesCaesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America
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
References (30)
- et al.
Maternal height and newborn size relative to risk of intrapartum caesarean delivery and prenatal distress
B J Obstet Gynecol
(2001) - et al.
Obstetricians' personal choice and mode of delivery
Lancet
(1996) What is the right number of caesarean sections?
Lancet
(1997)- et al.
Obstetricians say yes to maternal request for elective caesarean section: a survey of current opinion
Eur J Obstet Gynecol Reprod Biol
(2001) - et al.
Mandatory second opinion to reduce rates of unnecessary caesarean sections in Latin America: a cluster randomised controlled trial
Lancet
(2004) - et al.
Physician cesarean delivery rates and risk-adjusted perinatal outcomes
Obstet Gynecol
(2003) An evaluation of cesarean section in the United States
(1979)Cesarean childbirth
(1981)- et al.
Is a rising caesarean section rate inevitable?
B J Obstet Gynecol
(1998) - et al.
Annual summary of vital statistics—2002
Pediatrics
(2003)
Caesarean section: clinical guidelines
Rates and implications of caesarean sections in Latin America: ecological study
BMJ
Effects of maternal characteristics on cesarean delivery rates among US Department of Defense healthcare beneficiaries, 1996–2002
Birth
Relation between private health insurance and high rates of caesarean section in Chile: qualitative and quantitative study
BMJ
Medicaid coverage and medical interventions during pregnancy
Int J Health Care Finance Econ
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