Worldwide rise in cesarean section (CS) rate during the last
three decades, has been the cause of alarm and needs an in
depth study. CS is one of the most common major surgical
procedure in private sector health care services. The CS
epidemic is a reason for immediate concern and deserves
serious international attention. The procedure is not benign
and needs to be performed only when circumstances
distinctly require it.
The consensus recommendation for optimal CS rate of 10- 15% was made by WHO in 1985 1 . This recommendation was anything but arbitrary. The limitation issue is being debated by professionals and women’s groups in most parts of developed world based on risks and benefits 2 . This may compromise interests of mother and fetus exposing them to more risks from childbirth. Many are questioning the recommended optimal CS rate by suggesting that lowering the rate may be dangerous 3 . Efforts to bring down the rate have failed and it is on a steady rise.
In 2001 an estimated 21.4% of all deliveries in England and Wales were by CS, a five fold increase since 1971 4 . In 2002, more than one-fourth of all births (26.1%) in United States were CS deliveries a highest ever reported rate 5 . In 2004, rate of CS births for first pregnancies increased to 29.1% of all births, continuing a rising trend. Since 1996, CS deliveries have increased by more than 40% 6 . While the hospital CS rate is 22% in Egypt 7 , CS epidemic observed in Latin American countries is not yet evident in most of the Arab countries where CS rate ranges between 5-15% 8 . The rising trend in CS is definately not limited to USA and UK. In Brazil, there are hospitals with 100% CS rate, health districts with 85% CS rate, and an entire state with a CS rate of 47.7% 9 . The Brazilian Ministry of Health has imposed upper limit of CS rate at 35% in public hospitals while private sector rates of 70% and more are common in the country 10. In Delhi, CS rate in teaching hospitals currently ranges between 19-35%. In Sweden, Denmark and Netherlands, the CS rate is still close to 10% with some of the world’s lowest maternal and perinatal mortality rates 11
It is sad that CS are frequently and arbitrarily performed for fetal distress and prolonged labor without due respect to correct diagnosis and unbiased decision. During 1976-96, CS for singleton breech increased from 30% to 86% and for twin pregnancies from 13% to 47% 12. In 2001, 16.7% of all CS performed in UK, were on women previously delivered by CS 13. Recurrent sections for three or four or more times are now frequently performed for various reasons. A trial for vaginal birth after a previous CS (VBAC) is considered safer than a routine repeat CS. But, it is unfortunate that there is currently less enthusiasm for VBAC by trial of scar or of labor. It is evident that whereas CS is doctor friendly, VBAC is not. The rate of VBAC in USA is down from 17% in 1996 to 11% in 1999 10. RCOG recommended that all women previously delivered by one lower segment CS should be offered an opportunity to labor during their next pregnancy by promoting a trial of scar or of labor 13.
The rates for CS on demand in absence of any specific indication are increasing. Mackenzie et al 12 observed that maternal request was one of the main indication for CS (23%) in 1996. The introduction of this concept raises several questions. There are too many unknowns about the true risks and benefits of the procedure. The issue is being debated by professional and women’s groups in most parts of the developed world 2 . Inadequately informed women choose CS to avoid painful natural childbirth. Most of them like to maintain the vaginal tone of teenagers. But, this is more likely a benefit to the sexual partner than the woman herself. In India, the family sometimes demands that the baby be born on a auspicious date and time, obviously by CS, as dictated by horoscopic/astrological calculations. This happens to be a popular indication of CS in China. The right to choose CS involves many other important issues which are considered to be outside the domain of this review. The relative safety of an elective CS in developed world has given rise to another controversy. However, CS on demand threatens national resources, and is an expensive and dangerous luxury. Moreover, FIGO 14 states that performing CS for nonmedical reasons is ethically not justified.
Defensive obstetrics is another common reason for high rates of CS. It has been observed that 82% of physicians performed CS to avoid negligence claims 15. Defensive obstetrics violates the fundamental principle of medical practice. In any case it does not work. During the years that defensive obstetrics has grown in numbers, there has been no slowdown in litigation 12. This is closely related to daylight obstetrics for the obstetrician’s convenience. Elective CS is set in favor of weekdays and daylight. It takes usually 20-30 minutes to perform a CS while conducting a vaginal birth may need 12 hours or more heavily taxing on the obstetrician’s time and patience. In private health care services, CS is one of the most common major surgical procedures. Doctors and hospitals earn much more money from a CS than from a vaginal delivery. High CS rates financially benefit doctors, hospitals, and industries.
It is unfortunate that the option to choose or perform a CS is not so simple. Even elective CS carries serious risks for mother and child. The proponents of CS claim that CS is an extremely safe operation with a negligible mortality and morbidity. This could be open to question and there must be many potentially fatal problems which might occur unpredictably that are often not counted in any national audit. A fourfold increase in maternal mortality rate associated with CS was observed even after controlling for medical and obstetric complications, maternal age, and preterm delivery 17. Even elective CS had a 2.84 fold greater chance of maternal death as compared to vaginal birth. In UK, a twofold increase in mortality with CS was detected 18.
As regards immediate risks, all women undergoing CS are exposed to potential complications of anesthesia. Hawkins et al 19 found that 82% of anesthesia related maternal deaths occurred in women undergoing CS and general anesthesia was most prevalent among them (52% of 129 deaths). Overall intraoperative complications like uterocervical and bladder lacerations, blood loss greater than 1L and need for hysterectomy occur in 12-15% of cesarean deliveries 20. Major complications were almost double in emergency CS compared to those in elective CS. Overall postoperative complications – major (pelvic infection, sepsis, deep vein thrombosis etc.) and minor (fever, urinary infection, wound sepsis etc.) – occurred in 35.7% of cases 21. Abdominal delivery is also a significant risk factor for emergent postpartum hysterectomy, mainly for adherent placenta, uterine atony, uterine rupture, fibroids, sepsis, and extension of uterine scar 22.
Babies are also vulnerable to unnecessary risks from rising
CS rates. The first danger to the baby is the 1% to 9%
chance that the surgeon’s knife will accidentally lacerate the
fetus (6% in nonvertex presentation) 23. A much more serious
risk is respiratory distress syndrome (RDS). CS per se is a
potential risk factor for RDS in preterm infants and for other
forms of respiratory distress in mature infants 16. Another
distinct hazard is iatrogenic prematurity. Even with repeated
ultrasound scans, there may be errors in judging when to do
an elective CS. As CS rates rise, so do premature births.
While in USA more infants were born in 2004 by CS, more
were born prematurely and more were born with a low birth
weight in 2004 than in 2003 6
. Both RDS and prematurity.
Recurrent CS, scar rupture, hysterectomy, and maternal and fetal deaths are some of the future important risks. Previous CS increases the risk of multiple placental abnormalities like placental abruption, placenta previa, and adherent placentation in subsequent pregnancies 5 . First birth CS had a 30% increased risk for placental abruption in subsequent pregnancy 24. Numerous studies have confirmed the increased risk of placenta previa following CS. Women who had four or more deliveries with a single CS had a 1.7 fold increased risk of placenta previa whereas women with parity greater than four and four or more prior CS had almost a ninefold increased risk of placenta previa 25. Among women with placenta previa, the incidence of placenta accreta is almost 10% 26. Zaki et al 27 reported a 60% rate of placenta accreta with three or more cesarean deliveries. The leading indication for cesarean hysterectomy in USA is plaenta accreta 28. As the incidence of CS continues to rise worldwide, the problem of placenta previa and placenta accreta is likely to become more common. Obstetricians should be ready to face these future consequences of today’s decision of performing CS 29.
Women delivered by CS were less likely to have a subsequent
pregnancy (66.9%) compared with those having spontaneous
vaginal delivery (73.9%) and instrumental vaginal delivery
(71.6%). Women delivered by CS were also found more
likely to have an ectopic pregnancy in their next pregnancy
30. Maymon et al 31 reported eight cases of ectopic pregnancies
which developed in CS scars. The women at risk appear to
be those with a history of placental pathology, ectopic
pregnancy, multiple CS, and breech delivery by CS. Wang et
al 32 reported 14 cases of pregnancy on the cicatrix of
previous CS at the uterine isthmus in the 1st trimester. Six
cases of abdominal wall scar endometrioma after CS have
been recorded by Wasfie et al 34. One case of spontaneous
rupture of uterus following intercourse in a CS scarred
uterus was reported by Nassar et al 34 and the other by Tohlick et al 35.
