Caesarean section--past and present

Communication Intervention Using Digital Technology to Facilitate Informed Choices at Childbirth in the Context of the COVID-19 Pandemic: Protocol for a Randomized Controlled Trial

BACKGROUND

In Brazil and other low- and middle-income countries, excess interventions in childbirth are associated with an increase in preterm and early-term births, contributing to stagnant morbidity and mortality of mothers and neonates. The fact that women often report a negative experience with vaginal childbirth, with physical pain and feelings of unsafety, neglect, or abuse, may explain the high acceptability of elective cesarean sections. The recognition of information needs and of the right to informed choice during childbirth can help change this reality. The internet has been the main source of health information, but its quality is highly variable.

OBJECTIVE

This study aimed to develop and evaluate an information and communication strategy through a smartphone app with respect to childbirth, to facilitate informed choices for access to safer and evidence-based care in the context of the COVID-19 pandemic.

METHODS

A randomized controlled trial, with 2 arms (intervention and control) and a closed, blind, parallel design, will be conducted with a smartphone app designed for behavior and opinion research in Brazil, with women of reproductive age previously registered on the app. After completing an entry questionnaire to verify the eligibility criteria and obtaining ethical consent, approximately 20,000 participants will be randomly allocated to the intervention and control groups at a 1:1 ratio. Participants allocated to the intervention group will be invited to engage in a digital information and communication strategy, which is designed to expand evidence-based knowledge on the advantages and disadvantages of options for labor and childbirth and the safety of the care processes. The information is based on the guidelines of the Ministry of Health and the World Health Organization for a positive childbirth experience and has been updated to include the new challenges and disruptions in maternity care within the context of the COVID-19 pandemic. The control group will receive information regarding disposable and reusable diapers as a placebo intervention. The groups will be compared in their responses in generating the birth plan and the entry and exit questionnaires, regarding responses less or more aligned with the guidelines for a positive childbirth experience. A qualitative component to map information needs is included.

RESULTS

The digital trial started recruiting participants in late October 2020, and data collection has been projected to be complete by December 2020.

CONCLUSIONS

This study will evaluate an innovative intervention that has the potential to promote better communication between women and providers, such that they can make better choices using an approach suitable for use during the COVID-19 pandemic.

TRIAL REGISTRATION

The Brazilian Clinical Trials Registry U1111-1255-8683; http://www.ensaiosclinicos.gov.br/rg/RBR-3g5f9f/.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/25016.

Cesarean section and childhood infections: Causality for concern?

In this Perspective, Gordon Smith discusses the findings of Miller et al, and the balance of risks and benefits associated with different modes of delivery.

A cross sectional analytic study of modes of delivery and caesarean section rates in a private health insured South African population

Background

Monitoring Caesarean Section (CS) rates is essential to ensure optimal use of the procedure. Information on CS rates in the South African private sector is limited and information from this study will assist in planning for the proposed NHI in South Africa.

Objectives

The objectives of this paper are to assess mode of delivery patterns and to determine CS rates amongst South African private health insurance scheme members; and to assess the extent to which CS rates are influenced by age and health status of the mother.

Methods

The 2015 claims for members of 10 health insurance schemes were analysed to assess delivery type patterns. Mode of delivery patterns were assessed by 6 delivery types: emergency, elective and “other” for caesarean deliveries; and non-assisted, assisted and “other” for vaginal deliveries; as well as by age and health condition of the mother.

Results

Of a total of 6,542 births analysed, 4,815 were CS giving a CS rate of 73·6% (95% CI 72·5%;74·7%). Emergency CS were the most common mode of delivery (39·7%), followed by elective CS (39·5%). CS rates increased with increasing maternal age and were higher for women with a medical condition.

Conclusions

CS rates for the South African private sector are considerably higher than the safe rates recommended by the WHO. The high CS rates is a cause for concern for the health system under the proposed NHI. To support initiatives encouraging evidence based practice, further research is required to understand the drivers for the high CS rates.

What Are Optimal Cesarean Section Rates in the U.S. and How Do We Get There? A Review of Evidence-Based Recommendations and Interventions

Cesarean sections (CSs) are the most commonly performed surgical procedures in the world today. Global epidemiological studies from the last decade suggest that the optimal CS rates in developed countries exist somewhere between 15% and 19%. Despite these findings, CS rates in the United States have remained stable at slightly over 32% over the past 10 years. Using primary and secondary literature published from 2010 to 2015, this review discusses how optimal CS rates were developed. In addition, we define a category of potentially avoidable CS (i.e., those conducted on nulliparous low-risk women who present with vertex infants at term) and explore how CS in this population appear to be one of the main drivers of high CS rates overall. The institutional, provider, and patient-related factors, which may be related to higher-than-recommended rates of CS, particularly those conducted in low-risk women, will be discussed. This review will then delve into clinician and patient-oriented interventions that have been shown to effectively reduce the rate of potentially avoidable CS. Our analysis showed that large-scale, multifaceted interventions that include audit and feedback cycles as well as peer review strategies were the most effective in decreasing rates of potentially avoidable CS. This review concludes with an agenda for future research into interventions that aim to achieve optimal CS rates.

Mode of delivery among Swedish midwives and obstetricians and their attitudes towards caesarean section

BACKGROUND

A knowledge gap exists around midwives' and obstetricians' mode of delivery in comparison to the general population, and if their personal experience influences their attitudes towards different modes of delivery.

OBJECTIVES

The aim of the present study was to investigate midwives' and obstetricians' mode of delivery compared to the population at large. The second aim was to see if their mode of delivery had been influenced by the expanded indications for caesarean section as described in medical literature. Thirdly, the differences between obstetricians' and midwifes' attitudes to caesarean section on maternal request was investigated.

MATERIAL AND METHOD

Textbooks from midwifery education and medical schools were reviewed using a structured protocol. A questionnaire for midwives and obstetricians containing questions on mode of delivery, attitudes towards patients' autonomy and performing caesarean sections on maternal request was sent to 380 midwives and 97 obstetricians born in 1935, 1955 or 1975 with an invitation to participate in the study. Two hundred and sixty three midwives and 55 obstetricians provided completed responses.

RESULTS

The review of textbooks identified that the number of indications for caesarean section has increased. Indications for caesarean section increased in medical textbooks from seven in the oldest books, from year 1955, to 11 in the textbook from 1993. The focus has shifted in more recently published textbooks to prevention of fatal deliveries. In earlier obstetric care they tend to learn to solve the catastrophe when it had occurred. No significant relationship between midwives' and obstetricians; own mode of delivery and their attitudes towards performing a caesarean section on maternal request (p = 0.191) was found. Thirty percent of the obstetricians reported that they would perform a caesarean section if the pregnant woman requested one. The study found a significant difference between the professions in the statement "the proportion of caesarean section is too high" where midwives to a greater extent agreed with the statement (p = 0.033). There were no significant differences between caesarean section as the mode of delivery for midwives and obstetricians as compared to the general population. Midwives born in 1975 had significantly lower rate of instrumental births compared to the population at large (p < 0.05).

CONCLUSIONS

Over the years, the indications for caesarean section have increased. The increase is shown in both the textbooks read during the different time periods as well as among the Swedish midwives and obstetricians born in 1955 and 1975.

Postmortem and perimortem cesarean section: historical, religious and ethical considerations

Guillimeau was the first to use the term cesarean section (CS) in 1598, but this name became universal only in the 20th century. The many theories of the origin of this name will be discussed.

This surgery has been reported to be performed in all cultures dating to ancient times. In the past, it was mainly done to deliver a live baby from a dead mother, hence the name postmortem CS (PMCS). Many heroes are reported to have been delivered this way.

Old Jewish sacred books have made references to abdominal delivery. It was especially encouraged and often mandated in Catholicism. There is evidence that the operation was done in Muslim countries in the middle ages. Islamic rulings support the performance of PMCS.

Now that most maternal deaths occur in the hospital, perimortem CS (PRMCS) is recommended for the delivery of a fetus after 24 weeks from a pregnant woman with cardiac arrest. It is believed that emergent delivery within four minutes of initiation of cardiopulmonary resuscitation (CPR) improves the chances of success of maternal resuscitation and survival and increases the chance of delivering a neurologically intact neonate.

It is agreed that physicians are not to be held legally liable for the performance of PMCS and PRMCS regardless of the outcome. The ethical aspects of these operations are also discussed including a discussion about PMCS for the delivery of women who have been declared brain dead.

Recognizing cesarean delivery on maternal request as a social problem: utilizing the public arenas model

Nearly one in three babies in the United States are now born surgically. While many causes for this surge in cesareans have been suggested, the phenomenon of cesarean delivery on maternal request (CDMR) has been the subject of the most controversy. Utilizing Hilgartner and Bosk's public arenas model, this article examines the ways in which CDMR has been framed and a collective definition of the problem established. Recognizing CDMR as a social problem is the first step to creating policies to ensure that the health and safety of mothers and babies are protected.