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Discusses Women's Health

As the New Year approaches, a plethora of medical articles are coming out with reviews of what has been recommended in the past and perhaps should be changed in the future. One of these was published in the December 1st issue of JAMA. It dealt with the relationship between cesarean delivery rates and maternal and neonatal mortality. I thought the statistics were extraordinarily interesting and even though I no longer practice obstetrics, many of my patients (and I) have children and grandchildren and we are concerned about their current and future pregnancies and deliveries…

In 1985 the World Health Organization (WHO) stated that, “There is no justification for any region to have a cesarean section rate higher than 10-15%”. The article cites a report on data gathered across 194 World Health Organization member states which examined the relationship between cesarean delivery rate and subsequent maternal and neonatal mortality rates. There was a huge variation in rates depending on the country. In 2013 almost 1/3 of deliveries in the United States were by cesarean section. Canada and Australia had cesarean section rates of 27.3% and 32.3% respectively. The proportion of cesarean delivery has increased to rates approaching 50% in South America. In Brazil it was approximately 90%!

A number of factors have caused increasing rates of cesarean delivery. Currently in North and South America almost no vaginal breech deliveries are conducted and any woman who has a breech presentation in which the baby cannot be turned has a C-section. In the U.S electronic fetal monitoring has become the standard in most prenatal care units and the increased level of fetal surveillance has led to an increased rate of concern about possible abnormalities in fetal status. If healthcare practitioners see worrisome changes in the fetal heartbeat they often rush to do a cesarean section. (Of note, the use of continuous electronic monitoring has not been shown to improve the overall rate of fetal death or cerebral palsy when compared with intermittent listening or recording of the fetal heartbeat… But in the world of malpractice no one seems to wants to take a chance!)

Many women want to schedule elective cesarean sections for convenience, fear of labor or future pelvic problems. In the United Kingdom the national guideline has reinforced the right of women to decide the mode of their delivery with appropriate counseling. The American College of Obstetrics and Gynecology counsels that patient should be advised that a primary C-section for convenience may not be advisable particularly among those women who desire several children. Failure to progress (FTP) is often used as a reason for cesarean section but again a ACOG has stated that too often this diagnosis is wrong. The first stage of labor can take a long time and many women and their doctors just give up. Three active labor occurs after the patient gets to 6 cm, if that goes no further a diagnosis of FTP is appropriate. (Well perhaps not in my family.)

So what did the authors of the article conclude after reviewing mortality and morbidity rates with delivery in mother and child? They stated that across all the 194 WHO states, cesarean delivery rates of approximately 19% were associated with optical levels of maternal and neonatal mortality. That means that that the 10 to 15% previous recommendations need to be raised. And according to this, we in North and South America are going too far…

But as usual in medicine nobody wanted to give a final and conclusive statement. The last paragraph of an editorial in JAMA states that “The optimal level of cesarean delivery cannot be as simple as a one-fits-all figure to be applied to all institutions in healthcare systems, and the obstetrical community must accept the fact that the appropriate cesarean delivery rate remains unknown. It is not whether the cesarean delivery rate is high or low that really matters but rather whether appropriate performance of cesarean delivery is part of a system that delivers optimal maternal and neonatal care. Just thought you might like to know…

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