Increased Cesarean section rates in Turkey

Striking rise of cesarean section rates in Türkiye: there is a need for a whole new perspective

Since 2003, the Turkish Ministry of Health (TMOH) has activated a reformed system called Health Transformation Program (HTP) which has assertive goals. Health transformation program has brought about important improvements in many health topics. However, at the beginning of HTP, cesarean section (C-section) rate was approximately 30%, having exceeded 50% in 2013 which reflected the highest rate in Organization for Economic Cooperation and Development (OECD). Currently, most of the deliveries are carried out via C-section in Türkiye which started disputes about whether the high rate of C-section is Achilles' heel of HTP. To overcome high C-section rate, TMOH has been making intensive efforts and taking serious measures in recent years including passing a law to ban elective C-sections. Despite the strict measures taken C-section rate didn't decrease instead increased gradually. The current situation shows that the problem is more complicated than the authorities figure out, and a whole new perspective on the issue is needed.

Effect of Closure of Anterior Abdominal Wall Layers on Early Postoperative Findings at Cesarean Section: A Prospective Cross-sectional Study

OBJECTIVE

 To investigate the effect of closure types of the anterior abdominal wall layers in cesarean section (CS) surgery on early postoperative findings.

METHODS

 The present study was designed as a prospective cross-sectional study and was conducted at a university hospital between October 2018 and February 2019. A total of 180 patients who underwent CS for various reasons were enrolled in the study. Each patient was randomly assigned to one of three groups: Both parietal peritoneum and rectus abdominis muscle left open (group 1), parietal peritoneum closure only (group 2), and closure of the parietal peritoneum and reapproximation of rectus muscle (group 3). All patients were compared in terms of postoperative pain scores (while lying down and during mobilization), analgesia requirement, and return of bowel motility.

RESULTS

 The postoperative pain scores were similar at the 2^nd, 6^th, 12^th, and 18^th hours while lying down. During mobilization, the postoperative pain scores at 6 and 12 hours were significantly higher in group 2 than in group 3. Diclofenac use was significantly higher in patients in group 1 than in those in group 2. Meperidine requirements were similar among the groups. There was no difference between the groups' first flatus and stool passage times.

CONCLUSION

 In the group with only parietal peritoneum closure, the pain scores at the 6^th and 12^th hours were higher. Rectus abdominis muscle reapproximations were found not to increase the pain score. The closure of the anterior abdominal wall had no effect on the return of bowel motility.

Examining the role and relevance of the critical analysis and comparison of cesarean section rates in a changing world

Cesarean section (CS) is one of the most commonly performed surgical operations in the world and has resulted in improved maternal and neonatal morbidity and mortality rates internationally. However, concerns have been raised regarding the ever increasing CS rates to what has been described as 'epidemic' proportions. Global CS rates have increased from 6.7% in 1990 to 19.1% in 2014. However, there is a vast variation in the CS rates between countries with CS rates of 44.3% reported across Latin America & the Caribbean and CS rates as low as 4.1% in central and West Africa. There is much controversy regarding the optimal figure for CS in a population. The optimal CS rates for a population have been recommend in various studies, ranging from 10% to 19%, above which no reported improvement in maternal and neonatal mortality rates is observed. This review examines the evolution of the changing indications for CS and increasing CS rates in a world where family sizes are reducing and maternal age at first pregnancy is increasing. Efforts must be made to agree on an appropriate classification system whereby CS rates can be compared accurately between units and countries as a useful tool to audit and monitor our practice. Obstetricians should consider the indications for each CS performed, be conscious of the CS rate in our own countries and institutions and most importantly, be cognizant of how the CS rate impacts the maternal and perinatal morbidity and mortality rates and adjust our practice accordingly, to minimize harm.

Nonclinical predictors of caesarean section: a path analytic approach

The objective of this study was to explore nonclinical predictors of cesarean sections (CS) and how they interact with each other, specifically in Turkey. Data was gathered from official statistical records for the year 2017 from the 81 different provinces throughout Turkey. A path analytic model was constructed to examine the interrelationships between socioeconomic factors, utilization of health services, patient satisfaction, and number of CS procedures. The overall performance of the final path model was quite good (GFI = 0.98, AGFI = 0.93, and CFI = 0.96). The study results emphasize the substantial impact of an increase in the number of hospital admissions on the increase in the rate of CS procedures (PC = 0.70). Additionally, the increase in the number of hospital admissions mediates the interrelationship between geographic region, high education, and CS. The findings demonstrate the significant interrelationships among the several major nonclinical predictors of CS in Turkey.Impact StatementWhat is already known on this subject? There has been a considerable increase in the rate of CS in Turkey and the current study examined the nonclinical predictors of CS, and how they interact with each other, specifically in Turkey. The insights developed by this study are due to its scope and topicality. Although of course clinical factors associated with CS are reflected in the literature, this study focused on nonclinical predictors of CS.What the results of this study add? This study empirically clarifies the causal interrelationships among nonclinical predictors of CS, using data from Turkey where CS rates are very high, causing great concern by health professionals and decision-makers. The results of this study provide a stronger understanding of how nonclinical factors relate to CS in Turkey. Significant factors include the connective role of geographic region, the increasingly high level of education being received by women, and the total number of hospital admissions.What the implications are of these findings for clinical practice and/or further research? Study results empirically prove interconnection among geographic region, education, health services utilisation and the number of CS. Health decision makers need to consider the important indirect effects of region, education and number of hospital admissions on the demand for CS procedures.

Nonclinical Factors of Cesarean Section Birth: A Review of the Literature

The rate of cesarean section (CS) birth has increased dramatically across the world during the last few decades, mainly in high-income and middle-income countries. The aim of this study is to explore the nonclinical risk factors of CS birth and to look into its similarities and dissimilarities influencing CS birth between developed and developing countries. A search of the existing literature was conducted on electronic databases, such as PubMed, JSTOR, SpringerLink, ScienceDirect, and so forth. The maternal age is the most common factor of CS birth in almost all studies of developed and developing countries. Furthermore, type of hospitals is another predominant factor of CS birth as seen in more than half of the studies of developing countries and in several studies of developed countries. Nevertheless, it is also found that there is variation in main findings of CS birth according to the level of development. In most of the studies in developed countries, CS birth is highly associated with maternal age and birth weight of the baby. On the contrary, in developing countries, most of the studies show that CS birth is highly associated with maternal age, maternal education, type of hospitals, place of residence, number of antenatal care, and parity.

The incidence of and risk factors for postpartum depression at an urban maternity clinic in Turkey

OBJECTIVE

Postpartum depression (PPD) is an important health issue that affects not only mothers, but also entire families. Postpartum follow-up should address emotional and psychological issues, as well as physical issues, especially in those at risk. This study aimed to determine the incidence of PPD and the associated risk factors in a group of new mothers undergoing routine follow-up at an urban maternity clinic.

METHODS

This is a cross-sectional study investigating the relationship between PPD and various factors. A total of 187 women that presented to a university hospital for routine postpartum follow-up 4-6 weeks post delivery were recruited consecutively. The mothers were administered a sociodemographic form that included questions about the known risk factors (sociodemographic and sociocultural factors, and mother-related, pregnancy-related, and child-related factors) and the Edinburgh Postnatal Depression Scale (EPDS).

RESULTS

The incidence of PPD based on EPDS scores was 28.9% (scores > 12 were defined as PPD). Unplanned/unintended pregnancy, bottle-feeding only, mother's lack of satisfaction with the baby's sleep pattern, lack of family support for baby care, lack of satisfaction with the marital relationship, and family violence were significantly correlated with PPD (P < 0.05). Multiple logistic regression showed that bottle-feeding, lack of family support, lack of satisfaction with the marital relationship, and family violence were the primary factors that significantly increased the risk of PPD.

CONCLUSIONS

The findings show that the PPD occurs in almost one-third of women and that, among the risk factors, sociocultural factors were the most strongly associated with PPD.

Bioethics and Turkey: crossroads and challenges

Despite extraordinary improvements in medicine, health care worldwide continues to exhibit indefensible contradictions and extreme inequalities. "Health-for-all" campaigns, and development programs targeting welfare and social security have addressed these problems with limited success, but bioethicists, who by this point in the globalization era might have been expected to be addressing these problems urgently and persistently, have had little to say. We ask if bioethics, stalled at a crossroads, is prepared to alter course. We review the bioethics experience in Turkey as a case study, considering especially globalization and Turkey's application to join the European Union.

Mirena at caesarean section

The aim of the study was to audit the clinical experience of insertion of the Mirena intrauterine system at the time of a caesarean section. The Mirena apparatus was inserted into the fundus of the uterus after delivery of the foetus and placenta. Thirty-three patients were analysed in private practice over 32 woman-years. The audit revealed the device was extremely well tolerated. There were no contraceptive failures, no complications and no expulsions of the intrauterine device. Patient satisfaction was extremely high. At the conclusion of the audit, only one device had been removed; this descriptive study showed that the Mirena intrauterine device can be inserted into the uterus at caesarean section to provide an immediate, reliable and reversible contraceptive.