Abstract
BackgroundImprovements in medical technologies have seen over-medicalization of childbirth. Caesarean section (CS) is a lifesaving procedure proven effective in reducing maternal and perinatal mortality across the globe. However, as with any medical procedure, the CS intrinsically carries some risk to its beneficiaries. In recent years, CS rates have risen alarmingly in high-income countries. Many exceeding the World Health Organisation (WHO) recommendation of a 10 to 15% annual CS rate. While this situation poses an increased risk to women and their children, it also represents an excess human and financial burden on health systems. Therefore, from a health system perspective this study systematically summarizes existing evidence relevant to the factors driving the phenomenon of increasing CS rates using Italy as a case study.MethodsEmploying the WHO Health System Framework (WHOHSF), this systematic review used the PRISMA guidelines to report findings. PubMed, SCOPUS, MEDLINE, Cochrane Library and Google Scholar databases were searched up until April 1, 2020. Findings were organised through the six dimensions of the WHOHSF framework: service delivery, health workforce, health system information; medical products vaccine and technologies, financing; and leadership and governance.ResultsCS rates in Italy are affected by complex interactions among several stakeholder groups and contextual factors such as the hyper-medicalisation of delivery, differences in policy and practice across units and the national context, issues pertaining to the legal and social environment, and women’s attitudes towards pregnancy and childbirth.ConclusionMitigating the high rates of CS will require a synergistic multi-stakeholder intervention. Specifically, with processes able to attract the official endorsement of policy makers, encourage concensus between regional authorities and local governments and guide the systematic compliance of delivery units with its clinical guidelines.
Highlights
Improvements in medical technologies have seen over-medicalization of childbirth
As most deliveries occur in hospital rather than at home, the routine use of technologies to monitor perinatal wellbeing during pregnancy and labor may lead to falsepositive diagnoses of fetal distress
In this study, we have considered the systemic complexities of increased Caesarean sections (CSs) rates in Italy, emphasizing how different drivers, including non-medical factors, have contributed to current trends
Summary
Improvements in medical technologies have seen over-medicalization of childbirth. Caesarean section (CS) is a lifesaving procedure proven effective in reducing maternal and perinatal mortality across the globe. In response to the risks and costs which comes with CS, in 1985, the World Health Health Organisation defined the optimal rate of CS to be 10 to 15% of the total number of deliveries per year [6] This rate was established using the best evidence available at that time and is still considered a standard obstetric target [4]. Despite this recommendation and the risks attributable to CS, the annual global CS rate has continued to rise at an alarming pace in high and middle-income countries [1, 7, 8]. As studies have continually shown that part of this situation arises from health system factors, this review aims to summarize and analyse these factors using the globally accepted WHO Building Blocks Health Systems Framework (WHOHSF)
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