Cesareans: Are There Too Many or Too Few?

cesarean hero.jpgStatistics reveal that the cesarean section rate has doubled globally from 2000 to 2015. There are many instances where a cesarean birth saves the life of a parent, a newborn or both. But for people who live in high resource countries, many more cesareans are performed than may be necessary.  For those people who live in the Majority World, cesarean surgery is not available when needed.  A consequence of being unable to offer a cesarean when needed is that lives of both birthing people and babies are seriously impacted or lost unnecessarily.

In prior statements, the World Health Organization and in this new Lancet Series, a cesarean rate of approximately 10-15% is a recommended guideline.  Science & Sensibility has covered this topic before.  The Lancet Series shows that the global rate of cesarean birth has doubled in the past 15 years to 21%, and is increasing annually by 4%. It is estimated that there are 6.2 million unnecessary cesareans done each year. China and Brazil together make up half of this number.

The simple fact that there are wide variations in cesarean rates between different regions indicates that the differences are not based on evidence.  Variations in maternal age, parity, or obesity cannot explain away the differences in rates.  The World Health Organization (WHO) released new recommendations earlier this month that focused on non-clinical actions that could impact the cesarean rate.  It is often quicker to implement these non-clinical changes while waiting for protocols and practice management to catch up.

In some places, clinicians attending a vaginal birth is becoming a lost art. Newly prepared doctors feel more capable and ready to handle surgical births rather than the unpredictability of a vaginal birth.  Recommendations to remove financial incentives for cesareans are also needed. Setting up a midwifery-obstetrician shared care model where the providers collaborate and obstetricians are available for people who risk out of midwifery care is also offered as a solution.  According to the Lancet Series, studies show "midwifery care to be associated with more vaginal births, safer outcomes, positive maternal experiences, and lower costs..."

Aside from the immediate consequences of the surgery on parent and newborn, there are many downstream effects of cesarean surgery that can impact the reproductive health of parents who may give birth again, including a rising placenta accreta rate. Global researchers are exposing and clarifying every day why it is so important to prevent the primary cesarean. There is also the recognition that in many cases, the lack of access to safe and timely cesareans creates tragic repercussions for many who need but are denied this life-saving procedure.  I encourage you to review the Lancet Series in its entirety which you may find both encouraging and distressing at the same time.  Determine where you can lean in to help reduce unnecessary cesareans and increase access for those who currently do not have that option.

The entire Lancet Series includes the following (and there are additional comments sections and editorial pieces as well):

Resources

Betrán, A. P., Temmerman, M., Kingdon, C., Mohiddin, A., Opiyo, N., Torloni, M. R., ... & Downe, S. (2018). Interventions to reduce unnecessary caesarean sections in healthy women and babies. The Lancet, 392(10155), 1358-1368.

Boerma, T., Ronsmans, C., Melesse, D. Y., Barros, A. J., Barros, F. C., Juan, L., ... & Neto, D. D. L. R. (2018). Global epidemiology of use of and disparities in caesarean sections. The Lancet, 392(10155), 1341-1348.

Sandall, J., Tribe, R. M., Avery, L., Mola, G., Visser, G. H., Homer, C. S., ... & Taylor, P. (2018). Short-term and long-term effects of caesarean section on the health of women and children. The Lancet, 392(10155), 1349-1357.

The, L. (2018). Stemming the global caesarean section epidemic. Lancet (London, England), 392(10155), 1279.

World Health Organization. (2018). WHO recommendations non-clinical interventions to reduce unnecessary caesarean sections.

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