March of Dimes and an international team of doctors and scientists is calling on governmental bodies, the health care insurance industry, medical professionals, and women’s groups to help reverse the alarming rise in babies born by Cesarean section (C-section) around the world.
Three studies published today in The Lancet document the fact that global rates of C-sections have more than tripled from about 6 percent of all births in 1990 to 19 percent in 2014.
Salimah R. Walani, PhD, MPH, RN, vice president of Global Programs at March of Dimes, and colleagues at FIGO (The International Federation of Gynecology and Obstetrics), writing in a comment paper in the same issue, note the large variation in C-section rates in different parts of the world. Even as C-section rates are rapidly increasing in middle-income and high-income nations, particularly in urban areas, the rates are still too low in rural regions and in vulnerable groups in many low- and middle-income countries. They write, “In other words, lack of access in some regions of the world or countries, and over intervention in other countries or in other parts of the same country: ‘too little, too late and too much too soon.’”
The authors of all The Lancet reports and commentaries urge reductions in C-sections performed with no medical reason. An unnecessary C-section can do more harm than good for moms and babies, Dr. Walani says. When done without medical necessity, a C-section can greatly increase a woman’s risk of death in childbirth or serious complications, such as bleeding, hysterectomy and cardiac arrest, as well as risks to subsequent pregnancies. When the procedure is done before 39 weeks of pregnancy, a premature birth increases the baby's risk of death and lifelong disabilities.
Dr. Walani and her FIGO colleagues also state that women and babies in very low-income countries need more access to skilled care for labor and delivery; appropriate fetal surveillance; and assisted births or operative delivery.
The FIGO group recommends five actions to reduce unnecessary C-sections in areas where the procedure appears to be over-used:
- The delivery fees for physicians for undertaking C-sections and attending vaginal delivery should be the same, using a mean fee. This should also happen in private practice settings.
- Hospitals should be obliged to publish annual C-section rates, and financing of hospitals should be partly based on C-section rates. Risk-adjusted C-section rates should become available.
- Hospitals should use a uniform classification system for C-sections – the Robson/WHO classification.
- Women should be informed properly on the benefits and risks of a C-section.
- Money that will become available from lowering C-section costs should be invested in resources, better preparation for labor and delivery, and better care, adequate pain relief, practical skills training for doctors and midwives, and reintroduction of vaginal instrumental deliveries to reduce the need for C-section in the second stage of labor.
“FIGO position paper: how to stop the caesarean section epidemic” by Gerard H. A. Visser, Diogo Ayres-de-Campos, Eytan R. Barnea, Luc de Bernis, Gian Carlo Di Renzo, Maria Fernanda Escobar Vidarte, Isabel Lloyd, Anwar H. Nassar, Wanda Nicholson, P. K. Shah, William Stones, Luming Sun, Gerhard B. Theron, and Salimah Walani appeared in The Lancet, Vol. 392, October 13, 2018 and may be read free online at: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32113-5/fulltext