NEWS FOCUS:It is timely that high rates of Caesarean births are debated in Ireland – but attempts to set targets are fraught with difficulty
THE FIRST successful Caesarean section (CS) recorded in Ireland was performed in 1738 by Mary Donally, a midwife, on a farmer’s wife who had been in labour for 12 days. She resutured the uterus and skin, and dressed the wound with the white of an egg. Within four weeks post-operatively, the woman had recovered and was able to walk a mile. The survival of the mother after Caesarean section, however, was unusual. In 1884, a review of 134 operations reported a maternal mortality of 56 per cent internationally.
In 1948 in an article on Caesarean section in Dublin, JK Feeney analysed 45 annual reports from the Coombe, National Maternity and Rotunda Hospitals between 1932 and 1946 inclusive. Out of 165,036 total births, only 2,273 (1.4 per cent) Caesareans were performed and 61 (3 per cent) of these were associated with maternal death.
By the end of the 20th century Caesarean births had become much safer for the mother. In 1985, the World Health Organisation concluded: “There is no justification for any region to have CS rates higher than 10-15 per cent”. Yet, in the generation since remarkable differences in global, regional, national and hospital CS rates have evolved. In underdeveloped countries, particularly African, CS rates remain around 2-3 per cent, in part because there is often no obstetrician available to do the operation.
Maternal mortality rates in these countries remain stubbornly high due to the lack of resources. In a report from 119 countries between 1991 and 2003, only 3.4 per cent of high-income countries had a CS rate of less than 10 per cent compared with 76.3 per cent of low-income countries. The maternal mortality rate per 100,000 live births was 630 deaths in the low-income countries compared with 54 in the high- income countries.
The risk of maternal death per million births has been estimated at 17-20 for a vaginal delivery, 59 for an elective CS and 182 for an emergency CS. Mortality risks of CS are low, but they are dependant on the healthcare setting and are higher in resource-poor countries.
Rising CS rates increase foetal risks. Elective Caesarean births increase the risk of transient tachypnoea of the newborn and respiratory disease syndrome, especially if performed before 39 weeks’ gestation.
In developed countries, however, Caesarean birth has become so safe that rates have soared as women and their obstetricians strive to avoid the perceived risks and traumas of vaginal birth. In Ireland, the CS rate has increased from 13 per cent in 1999 to 26.2 per cent in 2007.
In the US, the CS rate increased from 20.7 per cent of all births in 1996 to 31.1 per cent in 2006. Similar increases have been reported in other developed countries and there is no evidence that CS rates have reached a plateau.
In many developing countries, Caesarean section rates are too low, resulting in preventable adverse outcomes for mothers and their babies. In developed countries, there are growing concerns that CS rates are too high, particularly in circumstances where there is little medical justification for the operation.
A Caesarean delivery in the current pregnancy also has long-term implications. For example, it increases the need for either emergency or elective Caesareans for future babies. It increases the future risk of catastrophic obstetric complications such as uterine rupture or peripartum hysterectomy. It makes future gynaecological surgery more hazardous.
Another concern about the rising CS rates is the impact on healthcare budgets with resources becoming more limited in the face of the economic recession. A Scottish study found that costs for Caesarean delivery were twice those for spontaneous vaginal delivery. It estimated that for each 1 per cent reduction in the CS rate in England, the health services would save £8.8 million (€10.3 million) annually. Avoiding a first Caesarean delivery will also reduce economic costs in the longer term by decreasing repeat Caesareans.
The main reasons for the rise in CS rates in developed countries are the safety of the procedure and the perceived risks of labour. It has been fuelled by the carpe diemmentality of modern life where women and their doctors focus on the short-term outcomes of the current pregnancy without considering the long-term consequences for a woman's health. This short-termism is more likely in circumstances where a woman is planning to have a small family.
Policymakers and public health commentators have suggested target CS rates, for example, the Health Service Executive (HSE) has recommended a CS rate of 20 per cent. However, such targets, including the WHO target, may be unrealistic. The optimum CS depends on local healthcare resources and service quality, and not on national or international recommendations. There is also a danger that, in attempting to meet hospital targets a Caesarean is not done in individual cases when it should have been done. This may have serious adverse consequences clinically and subsequent high financial costs medically and legally.
Optimising CS rates has yet to be achieved internationally and in Ireland it will not be easy. It needs to start with improvements in data collection and analysis to identify why Caesarean sections are done, and whether the results in some hospitals are outside an acceptable norm. There is also scant information nationally on the financial costs of Caesarean versus vaginal delivery and international costings cannot be extrapolated to our health system.
Any financial analysis also needs to consider the medico-legal costs of poor quality care. The CS rates cannot be considered in isolation, not just from the quality of clinical practices but also from the resources and organisation that underpin service delivery.
The development of national guidelines for obstetric practice may have a role to play, but attention will need to be paid to their crafting, dissemination and implementation. Caesarean birth, in many instances, is beneficial and potentially life-saving for either mother or child.
In some circumstances, however, it may increase risk and be potentially life-threatening. The art of obstetrics is getting the balance right. It is timely that high CS rates are debated in Ireland. If decisions are to be balanced, however, the debate needs to be informed by rigorous local and national analysis.
Michael Turner is professor of obstetrics and gynaecology at the Coombe Women and Infants University Hospital
This article appears in the current issue of
The Consultant
magazine
