Cesarean section: medical benefits and costs

Cesarianas: percepção de risco e sua indicação pelo obstetra em uma maternidade pública no Município do Rio de Janeiro

A taxa de cesariana entre as maternidades públicas municipais da cidade do Rio de Janeiro no ano de 2000 foi de 30,1%. Com taxas tão elevadas, nossas hipóteses são que as indicações de cesarianas nestas unidades não estão restritas apenas às indicações clínicas. Este artigo tem como objetivo analisar as representações de médicos sobre os riscos inerentes da cesariana que influenciam a sua indicação. Neste estudo qualitativo, realizado com observação participante de plantões e entrevistas com obstetras, pudemos identificar que as indicações feitas pelos obstetras da unidade pública estudada sofrem influência de diversos fatores não obstétricos: a insegurança quanto às manobras obstétricas, a fragmentação do atendimento e o medo da responsabilização jurídica, entre outros. O artigo sugere que a banalização desta intervenção no serviço privado traz para o serviço público um desvio da prática obstétrica que compromete não apenas a qualidade da assistência pública, como pode colocar em risco a vida de mulheres e bebês.

Institutional Factors in Cesarean Delivery Rates: Policy and Research Implications

OBJECTIVE

To examine the association of health care institutional characteristics with cesarean delivery.

METHODS

Cross-sectional data from Taiwan's National Health Insurance database was used, covering all 270774 women admitted for singleton deliveries, in 2000. Bivariate and multiple logistic regression analyses were used.

RESULTS

The overall cesarean rate was 32.3% of all deliveries. Obstetrics and gynecology clinics (with fewer than 10 beds) had a very high likelihood of cesarean delivery compared with all categories of hospitals (odds ratios 17-25), after adjusting for clinical complications and patient, physician, and institutional characteristics. The likelihood of cesarean delivery was similar across hospitals, regardless of level and ownership category. High cesarean propensity at clinics arose from higher cesarean rates in all complication categories, including "No complications." The overall hospital cesarean rate, 31.2%, is also higher than that in other developed countries with universal health care coverage.

CONCLUSION

Taiwan has very high cesarean rates, with a particularly high propensity for this procedure at clinics. The cesarean delivery profile in the various clinical complication categories suggests a significantly lower clinical threshold triggering cesarean delivery decisions in Taiwan, especially at obstetrics and gynecology clinics. Countries currently having or contemplating large expansions in health insurance coverage should document obstetric practice profiles before initiating coverage expansions. There is also a need for well designed research on the medical and life-satisfaction impacts of cesarean compared with vaginal delivery to enable an informed policy stand on this issue.

Associations between perinatal interventions and hospital stillbirth rates and neonatal mortality

BACKGROUND

Previous studies suggest that high risk and low birthweight babies have better outcomes if born in hospitals with level III neonatal intensive care units. Relations between obstetric care, particularly intrapartum interventions and perinatal outcomes, are less well understood, however.

OBJECTIVE

To investigate effects of obstetric, paediatric, and demographic factors on rates of hospital stillbirths and neonatal mortality.

METHODS

Cross sectional data on all 65 maternity units in all Thames Regions, 1994-1996, covering 540 834 live births and stillbirths. Hospital level analyses investigated associations between staffing rates (consultant/junior paediatricians, consultant/junior obstetricians, midwives), facilities (consultant obstetrician/anaesthetist sessions, delivery beds, special care baby unit, neonatal intensive care unit cots, etc), interventions (vaginal births, caesarean sections, forceps, epidurals, inductions, general anaesthetic), parental data (parity, maternal age, social class, deprivation, multiple births), and birthweight standardised stillbirth rates and neonatal mortality.

RESULTS

Unifactorial analyses showed consistent negative associations between measures of obstetric intervention and stillbirth rates. Some measures of staffing, facilities, and parental data also showed significant associations. Scores for interventional, organisational, and parental variables were derived for multifactorial analysis to overcome the statistical problems caused by high intercorrelations between variables. A higher intervention score and higher number of consultant obstetricians per 1000 births were both independently and significantly associated with lower stillbirth rates. Organisational and parental factors were not significant after adjustment. Only Townsend deprivation score was significantly associated with neonatal mortality (positive correlation).

CONCLUSIONS

Birthweight adjusted stillbirth rates were significantly lower in units that took a more interventionalist approach and in those with higher levels of consultant obstetric staffing. There were no apparent associations between neonatal death rates and the hospital factors measured here.

Indications for cesarean deliveries in Norway

OBJECTIVE

The purpose of this study was to investigate the indications for cesarean deliveries in Norway, related to type of operation, parity, and gestational age.

STUDY DESIGN

This was a prospective survey that used information provided by clinicians at 24 maternity units. Two thousand seven hundred seventy-eight cesarean deliveries were included, which represents 69.7% of all cesarean deliveries in Norway during the study period.

RESULTS

The cesarean delivery rate varied by maternal and gestational age, parity, and hospital of delivery. Seven indications accounted for 77.7% of the operations: fetal stress (21.9%), failure to progress (20.7%), previous cesarean delivery (8.9%), breech presentation >or=34 weeks of gestation (8.4%), maternal request (7.6%), preeclampsia (6.2%) and failed induction (4.0%). Of the total deliveries, 64.3% were emergency operations.

CONCLUSION

Accurate information about indications for cesarean deliveries in Norway has been obtained. Two thirds of all deliveries were emergency operations; the most important indications were fetal stress and failure to progress. In the elective cesarean delivery group, the two most important indications were previous cesarean delivery and maternal request.

Attitudes of Singapore women toward cesarean and vaginal deliveries

OBJECTIVES

To assess the attitude, knowledge, and expectations of Asian pregnant women toward cesarean and vaginal deliveries.

METHODS

Written questionnaires were given to pregnant women attending the National University Hospital antenatal clinics, and 160 responses were tabulated and analyzed using SPSS software.

RESULTS

The participation rate was 65% and 50% of the respondents were Chinese, 20% Indian, 21% Malay, 2% White, and 9.2% Other. The median age was 31 years, and approximately 43% were primiparas. Only 3.7% of them would prefer an elective cesarean delivery, and although 50% had friends or relatives who requested one, only 3% felt that this influenced their preference. The most common reasons for choosing a cesarean delivery were avoiding labor pains and lowering the risk of fetal distress. When asked which modality they would recommend to their friends, only 2% expressed that they would recommend cesarean delivery; however, 71% stated that women should have the right to request a cesarean delivery. Awareness of complications arising from vaginal and cesarean deliveries was generally low and related to the frequency of these complications. There was no significant correlation between demographic characteristics and maternal preference for mode of delivery.

CONCLUSIONS

Asian women largely prefer a vaginal delivery, and their attitude toward cesarean delivery on demand is comparable with that of Western women. Cultural or ethnic differences are unlikely to affect maternal preference for cesarean delivery in Singapore women.

Beyond the simple economics of cesarean section birthing: women's resistance to social inequality

This research explored the reasons for women's preferences for cesarean section births in Pelotas, Brazil. It is argued that women strategize and appropriate both medical knowledge and the technology of cesarean sections as a creative form of responding to larger public debates (and the practices that produced them) on the need for and causes of (de)medicalization. Questioning the reasons why some women engage more actively in this process than others elucidates the ways local forms of power engage gender, economic and medical ideologies. The current debate on why some women prefer c-section deliveries, or indeed if they really do at all, has diverted attention from the utility of the technology itself. This paper argues that for some women, the effort to medicalize the birth process represents a practical solution to problems found within the medical system itself. I end by exploring the socio-biological conditions that have produced a need for the technology.

A critical appraisal of cesarean section rates at teaching hospitals in India

OBJECTIVES

To obtain an estimate of cesarean section rates and examine the indications and consequences at teaching hospitals in India.

METHODS

Information was obtained on total number of normal and cesarean deliveries during 1993-1994 and 1998-1999 from 30 medical colleges/teaching hospitals. In addition, prospective data were recorded for a period of 2 months on 7017 consecutive cesarean sections on indications for cesarean delivery, associated complications and mortality.

RESULTS

The overall rate of cesarean section increased from 21.8% in 1993-1994 to 25.4% in 1998-1999. Among the 7,017 cesarean section cases, 42.4% were primigravidas, 31% had come from rural areas, 20.8% were referred including 8% with history of interference, 66% were booked cases, period of gestation was less than 37 weeks in 21.7% and in 18% the surgery was elective. Major indications for cesarean section included dystocia (37.5%), fetal distress with or without meconium aspiration (33.4%), repeat section (29.0%), malpresentation (14.5%) and PIH (12.5%). Maternal and perinatal mortality was 299/100,000 and 493/1,000 deliveries, respectively, and is high in spite of the increase in the cesarean section rates.

CONCLUSIONS

There is need for standardized collection of information on all aspects of childbirth to ascertain the incidence and indications of cesarean section nationally so that comparison and improvements of care can take place.

Predictors of obstetric intervention rates: case-mix, staffing levels and organisational factors of hospital of birth

We performed a cross-sectional study of all Thames maternity units, 1994-96, including 540,834 live and stillbirths. In contrast to recent media speculation, no association of caesarean section rates with midwifery staffing levels was found after adjustment for confounders. The only association with staffing was with levels of junior obstetric staffing, which could be a reflection of less experienced management of labour. Caesarean section rates were also associated positively with the levels of delivery beds, which could be a reflection of the closer monitoring of labour that may result from increased bed availability. Both caesarean section and instrumental vaginal delivery rates were associated with epidural rates, which was expected from the literature. Variations in epidural rates were mainly associated with variations in demographic case-mix, due possibly to patient demand. Demographic case-mix was also associated with instrumental vaginal deliveries but not the caesarean section rate.

Strategies to address global cesarean section rates: a review of the evidence

BACKGROUND

The steadily increasing global rates of cesarean section has become one of the most debated topics in maternity care. This paper reviews and reports on the success of strategies that have been developed in response to this continuing challenge.

METHODS

A literature search identified studies conducted between 1985 and 2001 from the Cochrane Database of Systematic Reviews, Medline, Sociofile, Current Contents, Psyclit, Cinahl, and EconLit databases. An additional search of electronic databases for Level 1 evidence (systematic reviews), Level 2 (randomized controlled trials), Level 3 (quasi-experimental studies), or Level 4 (observational studies) was performed. Selection criteria used to identify studies for review included types of study participant, intervention, outcome measure, and study.

RESULTS

Interventions that have been used in an attempt to reduce cesarean section rates were identified; they are categorized as psychosocial, clinical, and structural strategies. Two clinical interventions, (external cephalic version, vaginal birth after a previous cesarean) and one psychosocial intervention (one-to-one trained support during labor) demonstrated Level 1 evidence for reducing cesarean section rates.

CONCLUSIONS

Although the evidence for one-to-one care and external cephalic version came from both developed and developing settings, the systematic review for vaginal birth after a cesarean was restricted to studies conducted in the United States. The effective implementation of the preceding strategies to reduce cesarean rates may depend on the social and cultural milieu and on associated beliefs and practices.

The case against elective cesarean section

Prominent American and British obstetricians have been advocating for performing more Cesareans. They argue that Cesarean section is as safe or nearly as safe as vaginal birth, eliminates pelvic floor damage and the consequent symptoms caused by vaginal birth, is safer for the infant, and is desired by many women; however, abundant evidence in the medical literature refutes the validity of those claims.

Rates of cesarean births in Hong Kong: 1987-1999

BACKGROUND

High cesarean birth rates are an issue of international public health concern. The purpose of this paper was to examine the annual incidence and secular trend of cesarean births in Hong Kong and to correlate these rates with socioeconomic, demographic, and health indicators for the population since 1987.

METHODS

This was a descriptive and ecologic study. Annual population rates of cesarean sections were estimated for 1987 from a population-based survey, and for 1993 through 1999 from government data sources. The number of excess cesarean sections was calculated for each year using the 15 percent upper limit as proposed by the World Health Organization.

RESULTS

From 1987 to 1999 the overall annual cesarean section rate rose steadily from 16.6 to 27.4 per 100 hospital deliveries, resulting in a 65 percent increase over 12 years. The mean difference in rates of surgical delivery between public (mean(public) = 16.0%) and private (mean(private) = 43.4%) institutions was 27.4 percent (95% confidence interval (CI) = 24.1, 30.7; p < 0.001).

CONCLUSIONS

This is the first systematic report of secular variations of cesarean delivery rates in Asia. The high rates and increasing trend represent an unnecessary excess risk for mothers and their infants. Various strategies combating high cesarean rates have been proposed and have succeeded elsewhere. Concerted action from health care professionals, public health authorities, the general population, and the media is urgently required to implement solutions to reduce the rate of cesarean delivery.

Factors associated with vaginal birth after cesarean in a maternity hospital of Rio de Janeiro

OBJECTIVES

Identifying characteristics associated with vaginal birth after cesarean.

STUDY DESIGN

Case-control study based on medical records.

STUDY POPULATION

women with previous cesarean, who had delivered in a public Rio de Janeiro maternity hospital between 1992 and 1996.

SAMPLE

141 cases (vaginal births after cesarean) and 304 controls (a new cesarean after other(s)). Multivariate analysis with logistic regression was carried out.

RESULTS

The following characteristics were associated with greater probability of vaginal birth (IC=95%): only one previous cesarean (OR=19.05; IC=6.88-52.76); cervical dilatation at admission above 3 cm (OR=8.86; IC=4.93-15.94); gestational age below 37 weeks (OR=3.01; IC=1.40-6.46); history of at least one previous vaginal birth (OR=2.12; IC=1.18-3.82); level of education below high school (OR=1.94; IC=1.02-3.69). Chronic hypertension reduced the chances of vaginal birth (OR=0.44; IC=0.22-0.88).

CONCLUSIONS

Among the factors that can be modified to reduce the number of repeated cesareans are: trial of labor promotion, reducing admission of women at early stages of labor and adequate hypertension management during pregnancy.

CONDENSATION

Among the factors that can be modified to reduce the number of repeated cesareans are: the trial of labor promotion for women who present previous cesarean, reducing admission of women at early stages of labor and adequate hypertension management during pregnancy.

Decision-case mix model for analyzing variation in cesarean rates

This article contributes a decision-case mix model for analyzing variation in c-section rates. Like recent contributions to the literature, the model systematically takes into account the effect of case mix. Going beyond past research, the model highlights differences in physician decision making in response to obstetric factors. Distinguishing the effects of physician decision making and case mix is important in understanding why c-section rates vary and in developing programs to effect change in physician behavior. The model was applied to a sample of deliveries at a hospital where physicians exhibited considerable variation in their c-section rates. Comparing groups with a low versus high rate, the authors' general conclusion is that the difference in physician decision tendencies (to perform a c-section), in response to specific obstetric factors, is at least as important as case mix in explaining variation in c-section rates. The exact effects of decision making versus case mix depend on how the model application defines the obstetric condition of interest and on the weighting of deliveries by their estimated "risk of Cesarean." The general conclusion is supported by an additional analysis that uses the model's elements to predict individual physicians' annual c-section rates.

Physician gender and cesarean sections

BACKGROUND

Among consumers insurers, and providers there is pervasive concern regarding the high incidence of cesarean section delivery. To date, attempts to reduce these rates have focused on the clinical behavior of providers resulting in only minimal changes. Therefore, non-medical variables must be investigated as potential explanatory factors for the decision to perform cesarean delivery.

METHODS

Data were collected on clinical and non-clinical factors for obstetrician-gynecologists delivering at Yale-New Haven Medical Center to measure the impact of these factors on the performance of cesarean sections. Specifically, variation in patient demographic, ante- and intra-partum risk variables, practice setting, and doctor-specific characteristics were examined. Using contingency table and logistic regression analyses the contribution of selected factors was evaluated.

RESULTS

Multivariate modeling revealed that male physicians were significantly more likely than their female colleagues to perform cesarean section. This relationship was particularly strong in the university practice setting.

CONCLUSIONS

Efforts to reduce the incidence of cesarean section need to focus on the continuing education of health care providers and the delineation of non-clinical factors as essential elements in the election of specific clinical therapies.

Are Brazilian women really choosing to deliver by cesarean?

Brazil has among the highest cesarean section rates in the world, with 36% of women in the country delivering surgically. Women, especially those who deliver in private hospitals with cesarean rates in the 80-90% range, are often portrayed as actively choosing to deliver surgically. Doctors typically promote this view, also common in the popular understanding of the phenomenon, that it is women's demand for a cesarean that is behind the high rates. Academic analyses tend to present a more balanced view with doctors' motives for wanting to perform cesareans included alongside descriptions of women's motives for the procedures. What is typically missing from such analyses is a discussion of the power differences between women and doctors. Doctors clearly have more decision-making power in the hospital birthing situation, and their medical expertise and authority is often marshaled to convince a woman to "choose" a cesarean. Using data collected from a postpartum survey, participant observation in hospital obstetrics wards, and in-depth interviews. I offer evidence which refutes many of the hypotheses associated with why women might prefer to deliver by cesarean. I also show that the majority of women surveyed in two cities in Brazil, particularly first-time mothers, do not seek to deliver by cesarean. Through an analysis of conversations between doctors and women during labor and delivery, and through women's narratives of their delivery experiences, I also show some of the mechanisms that doctors use in order to induce so-called demand for surgical delivery and argue that they are very active participants in the ongoing construction of the culture of cesarean section in Brazil.

Caesarean section delivery in Kerala, India: evidence from a National Family Health Survey

Ensuring safe pregnancy and motherhood occupies a pivotal role and has been considered as one of the key issues in the framework of reproductive and child health programmes. Evidence from research studies indicate that there is a growing tendency for caesarean section deliveries especially during complications confronted at the time of pregnancy and delivery. The present study focuses on the demographic, antenatal care, spatial and socio-economic variables associated with caesarean section delivery in Kerala, India. The data from the National Family Health Survey has been utilised for this purpose. The results from logistic regression models indicate that maternal age, birth order, current age, births in health institutions and spatial differences were significantly associated with caesarean section deliveries in Kerala. The older cohorts of mothers were found at higher risk to have caesarean section when compared to their younger counterparts. When controlled for demographic variables, the odds for caesarean section was about 1.7 times more likely to occur in private health institutions. The inclusion of spatial and socio-economic variables has neither influenced the demographic and antenatal care variables nor showed any significant association with caesarean section delivery in the state. The present study calls for that a detailed investigation on behavioural aspects of both the physician and the patient with regard to type of delivery in the state. Information related to pregnancy and health related aspects needs to be monitored more accurately, both in the public and private hospitals, to understand the determinants associated with caesarean section.

Women's perceptions of caesarean section: reflections from a Turkish teaching hospital

Caesarean section as a contentious topic has attracted attention world-wide and different dimensions of the issue has been investigated. The primary reason behind these initiatives have been the upsurge of caesarean sections both in the developed and developing world and the realisation that the operation may not always contribute positively to the mother's and baby's health. By contrast, several studies have demonstrated both the short and long term negative effects. Research has also revealed that factors other than medical necessity play an important role in the decision to perform a caesarean section. Turkey, although reliable data does not exist, can be classified among the countries experiencing the caesarean epidemic, at least among highly educated and wealthy mothers. This research, exploring the perceptions of mothers in a teaching hospital with a high caesarean rate, is a rare example of its kind in Turkey. The main finding is the dissatisfaction of the mothers undergoing caesareans during their stay in the hospital.

Cardiotocography only versus cardiotocography plus PR-interval analysis in intrapartum surveillance: a randomised, multicentre trial. FECG Study Group

BACKGROUND

There is a need to improve the sensitivity and specificity of fetal monitoring during labour. We compared the gold standard, cardiotocography, with cardiotocography plus time-interval analysis of the fetal electrocardiogram in fetal surveillance. The aim was to find out whether time-interval analysis decreased the need for operative intervention due to fetal distress.

METHODS

We did a randomised, prospective trial in five hospitals in the UK, Hong Kong, the Netherlands, and Singapore. 1038 women undergoing high-risk labours were randomly assigned fetal monitoring by cardiotocography alone, or cardiotocography plus fetal electrocardiography (ECG). Outcomes measured were rates of operative intervention, and neonatal outcome. Analysis was by intention to treat.

FINDINGS

515 women were assigned management by cardiotocography, and 523 cardiotocography plus fetal ECG. There was a trend towards fewer operative interventions for presumed fetal distress in the time-interval analysis plus cardiotocography group (63 [13%] vs 78 [16%]), but this was not significant (relative risk 0.80 [95% CI 0.59-1.08], p=0.17). There was no significant difference between groups in the proportion of babies who had an umbilical arterial pH of 7.15 or less (51 [11%] vs 49 [11%]; 1.01 [0.7-1.47]), or in the frequency of unsuspected acidaemia (42 [9%] vs 35 [8%]; 1.17 [0.76-1.79]).

INTERPRETATION

The addition of time-interval analysis of the fetal electrocardiogram during labour did not show a significant benefit in decreasing operative intervention. There was no significant difference in neonatal outcome.

Factors associated with preterm births in southeast Brazil: a comparison of two birth cohorts born 15 years apart

An increase in preterm deliveries in Ribeirão Preto stimulated an analysis of possible explanatory factors. Two cohorts of singleton livebirths were studied, the first based on 6746 births in 1978-9 and the second based on 2846 births in 1994. A logistic regression was carried out to assess the association of preterm birth with several sociodemographic, behavioural and clinical variables, including year of survey. Delivery in private settings compared with a public setting, maternal age of < or = 17 compared with any other age group, and mothers who had had previous abortions and previous stillbirths were associated with greater rates of preterm birth. Although there was an increase in preterm birth rates regardless of mode of delivery, the increase was greater in the caesarean section group than in the vaginal delivery group. Over the study period, deliveries in private hospitals and caesarean section operations increased markedly (from 4% to 36% and from 30% to 51% respectively). Caesarean section may be the main contributor to the increase of preterm birth rate in this study. It is essential to ensure that health-care staff, especially those in private facilities, are properly educated and audited.

Rates and implications of caesarean sections in Latin America: ecological study

OBJECTIVES

To estimate the incidences of caesarean sections in Latin American countries and correlate these with socioeconomic, demographic, and healthcare variables.

DESIGN

Descriptive and ecological study.

SETTING

19 Latin American countries.

MAIN OUTCOME MEASURES

National estimates of caesarean section rates in each country.

RESULTS

Seven countries had caesarean section rates below 15%. The remaining 12 countries had rates above 15% (range 16.8% to 40.0%). These 12 countries account for 81% of the deliveries in the region. A positive and significant correlation was observed between the gross national product per capita and rate of caesarean section (r(s)=0.746), and higher rates were observed in private hospitals than in public ones. Taking 15% as a medically justified accepted rate, over 850 000 unnecessary caesarean sections are performed each year in the region.

CONCLUSIONS

The reported figures represent an unnecessary increased risk for young women and their babies. From the economic perspective, this is a burden to health systems that work with limited budgets.

The relationship between Caesarean section and neonatal mortality in very-low-birthweight infants born in Washington State, USA

We examined the associations between Caesarean section and neonatal mortality in singleton liveborn very-low-birthweight (VLBW) infants (500-1499 g) born during 1984-95 in Washington State, USA, using data from the Washington State birth certificate files. The infants included in this study had no life-threatening congenital malformations and had not been delivered by a repeat Caesarean without a trial of labour (n = 5182). For infants weighing 500-749, 750-999, 1000-1249 and 1250-1499 g, the neonatal mortality rates were 57.8%, 18.6%, 9.7% and 4.7%, respectively, and the Caesarean section rates were 28.4%, 47.8%, 48.0% and 44.6%. The adjusted odds ratios (ORs) for neonatal death associated with Caesarean section were 0.55 [95% confidence interval 0.38, 0.78] for the 500-749 g infants (n = 1059), and 1.15 [0.91, 1.45] for the larger (750-1499 g) infants, after adjustment for birth year, type of hospital, birthweight, presence or absence of labour, breech/malpresentation, and other obstetric indications for Caesarean section (prolapsed cord, placenta praevia, eclampsia, pre-eclampsia and chronic hypertension). However, when the larger (750-1499 g) vertex-presenting (n = 3248) and breech/malpresenting (n = 809) infants were considered separately, the adjusted ORs were 1.42 [1.05, 1.91] and 0.37 [0.23, 0.58] respectively. In contrast, among infants weighing 500-749 g, the ORs were not modified by presentation. The results were similar when we restricted analyses to infants without the above obstetric indications for Caesarean section. Because such an observational study is liable to unmeasurable biases and incomplete reporting of obstetric complications, these OR estimates may be subject to residual confounding. In their present state, these recent population-based data support the view that Caesarean sections do not enhance the neonatal survival of larger (> 750 g) VLBW babies when obstetric complications are absent. The possibility of a protective effect of Caesarean section on the survival of breech/malpresenting infants and infants weighing 500-749 g deserves further studies.

Declining cesarean delivery rates in California: an effect of managed care?

OBJECTIVES

We hypothesized that movement from traditional indemnity insurance to managed care in California between 1983 and 1994 would lead to reductions in the rate of cesarean delivery.

STUDY DESIGN

We decomposed the frequency of cesarean delivery with each primary diagnosis into the product of the diagnosis rate among all women and the cesarean delivery rate among women with the given diagnosis (conditional cesarean delivery rate). We used logistic regression to estimate the diagnosis and conditional cesarean delivery rates.

RESULTS

Adjusted and observed cesarean delivery rates are indistinguishable. Both the diagnosis rates and the conditional cesarean delivery rates contributed to the increase in the cesarean delivery rate between 1983 and 1987. The subsequent decline is attributable to the decline in the repeated cesarean delivery rate.

CONCLUSIONS

The increase in managed care in California played no apparent role in the decline in the cesarean delivery rate. With the exception of Kaiser health maintenance organizations, managed care providers and indemnity insurers managed deliveries similarly.

Maternal mortality after cesarean section in The Netherlands

BACKGROUND

To assess cesarean section-related maternal mortality in The Netherlands during 1983-1992.

METHODS

A nationwide confidential enquiry into the causes of maternal death.

RESULTS

The risk of dying after vaginal birth was 0.04 per 1000 vaginal births (65/1.763.999) compared to 0.53 per 1000 cesarean births (57/108.587). The direct risk of dying from cesarean section was 0.13 per 1000 operations (14/108.587). In some women cesarean section did not initiate, but contributed to, the train of events leading to death. Adding this associated risk to the direct risk gives a fatality rate of 0.28 per 1000 cesarean births (30/108.587).

CONCLUSIONS

Although cesarean section is a relatively safe procedure nowadays, birth by cesarean section in The Netherlands is seven times more hazardous than vaginal birth. Keeping the cesarean birth rate as low as possible is therefore in the interest of women of reproductive age.

Mother-to-infant HIV transmission: timing, risk factors and prevention

Identifying when--during pregnancy, delivery or the postnatal period--transmission of human immunodeficiency virus (HIV) from mother to infant usually takes place is critical to the development of methods to prevent maternal-infant transmission. Evidence is reviewed in this paper as to whether transmission occurs prepartum (early or late in gestation), intrapartum, or postpartum with breast feeding. Evidence in support of the notion of prepartum transmission has come from isolation of HIV from aborted fetal organs, comparison of maternal-child viral genotypes and study of neonatal cell-mediated immune responses. Evidence against prepartum transmission is that fewer than half of the children later known to be HIV-infected can be identified by virological tests carried out close to birth. A reduced rate of transmission in infants delivered by Caesarean section, and a reduced risk of transmission to second-born twins delivered vaginally, offers support to the view that intrapartum factors influence the risk of HIV transmission. Transmission through breast feeding can occur if a mother is infected postpartum and seems to pose some additional risk if she is already infected at parturition. The risk of infection increases with the stage of maternal HIV disease, but specific immunological, clinical and viral characteristics need to be investigated further. A clinical trial of zidovudine, used during late pregnancy and delivery and given to the infant at birth, has reported a significant reduction in transmission. Primary prevention of HIV infection in women remains a principal priority.

Explaining excessive rates of cesareans and other childbirth interventions: contributions from contemporary theories of gender and psychosocial development

The current rate of cesarean sections in the U.S. is too high. Numerous mothers and babies are being placed at unnecessary risk of medical, behavioral and psychological complications. The problem has proven resistant to solution on a large scale, despite serious efforts on the part of a variety of individuals and groups. This paper considers reports on the interactions between obstetricians and mothers in labor in light of findings and theory in the areas of gender and psychosocial development. Examination of processes and standards of care in light of these findings and theory leads to the conclusion that the present model of obstetric services is consistent with a masculine style, and offers far less than optimal care for women. In fact, the gender-inappropriate elements of the model itself probably contribute to the excessive rates of interventions in labor. Social, political and historical factors are seen to support the obstetric model as is, leading to some pessimism about the possibility that the model could be modified sufficiently without major social change. The obstetric model is compared briefly with the more gender appropriate model of care provided by midwives.

Midwifery care and out-of-hospital birth settings: how do they reduce unnecessary cesarean section births?

In studies using matched or adjusted cohorts, U.S. women beginning labor with midwives and/or in out-of-hospital settings have attained cesarean section rates that are considerably lower than similar women using prevailing forms of care--physicians in hospitals. This cesarean reduction involved no compromise in mortality and morbidity outcome measures. Moreover, groups of women at elevated risk for adverse perinatal outcomes have attained excellent outcomes and cesarean rates well below the general population rate with these care arrangements. How do midwives and out-of-hospital birth settings so effectively help women to avoid unnecessary cesareans? This paper explores this question by presenting data from interviews with midwives who work in home settings. The midwives' understanding of and approaches to major medical indications for cesarean birth contrast strikingly with prevailing medical knowledge and practice. From the midwives' perspective, many women receive cesareans due to pseudo-problems, to problems that might easily be prevented, or to problems that might be addressed through less drastic measures. Policy reports addressing the problem of unnecessary cesarean births in the U.S. have failed to highlight the substantial reduction in such births that may be expected to accompany greatly expanded use of midwives and out-of-hospital birth settings. The present study--together with cohort studies documenting such a reduction, studies showing other benefits of such forms of care, and the increasing reluctance of physicians to provide obstetrical services--suggests that childbearing families would realize many benefits from greatly expanded use of midwives and out-of-hospital birth settings.

Medically unnecessary cesarean section births: introduction to a symposium

Between 1965 and 1986, the United States cesarean section rate increased from 4.5 to 24.1%. Increasingly, childbearing women and their advocates, along with many others, have recognized that a large proportion of cesareans confers a broad array of risks without providing any medical benefit. A growing literature examines the diverse causes of medically unnecessary cesareans and the diverse effects of surgical birth on women, infants, and families. Various programs and policies have been proposed or implemented to reduce cesarean rates. In recent decades, many other nations have also experienced a sharply escalating cesarean section rate. It is reasonable to conclude that a largely uncontrolled international pandemic of medically unnecessary cesarean births is occurring. The level of political, analytic, and programmatic activity that has occurred in the U.S. regarding medically unnecessary surgical births does not seem to be paralleled in other nations with sharply escalating rates. This symposium was organized with the objective of presenting the U.S. experience with various dimensions of the problem of medically unnecessary cesareans to an international audience. Although preliminary and inadequate, it is hoped that this experience will encourage policy leaders and investigators throughout the world to recognize and address the problem of run-away cesarean section births. The first section of this introduction summarizes the U.S. experience with medically unnecessary cesareans from the perspective of trends, causes, consequences, and solutions. The second section covers the same topics, presenting selected material from various other nations throughout the world. In the course of these overviews, I introduce the symposium's seven contributions, most of which focus on circumstances in the U.S.