National Cesarean Section Rate Research Articles

Rate of Cesarean Delivery among Physicians Practicing in A Teaching Hospital in Tigray Region, Northern Ethiopia

Abstract Introduction: The Ethiopian national cesarean section rate is about 5%. Rates of cesarean delivery (CD) vary widely among population segments in Ethiopia suggesting unequal access. Within this context, this study aimed to assess the rate of CD among physicians practicing at Ayder Comprehensive Specialized Hospital (ACSH). Methods: This was cross-sectional study. All female physicians who are parous (n = 15) and all male physicians whose spouses are parous (n = 86) were interviewed to evaluate the mode of delivery among them. Indications for CD were also assessed. Results: The overall CD rate among participants was 81 (44.3%). Thirteen out of 18 (87%) female obstetrician/gynecologists and male obstetrician/gynecologists' spouses delivered via CD. Cesarean delivery for maternal request (CDMR) accounted for 22.6% of primary CDs. Nearly all (95%) potential candidates for Trial of Labor after Cesarean delivery (TOLAC) opted for repeat elective CD. The driving factors for CD were: lack of confidence in the process of intrapartum fetal monitoring, “uncertainty” of outcome of vaginal delivery, fear of labor pain (due to absence of labor analgesia), and managing obstetricians' fear of blame for poor outcome by their colleagues. Conclusion: This study revealed a disparity in CD rates in physician community vs the general Ethiopian population. More revealing are the reasons why they underwent CD. Rate of CD may be decreased by winning the confidence of the parturient mothers through instituting international-standard intrapartum fetal monitoring and labor analgesia protocols. Key Words Mode of delivery, Cesarean delivery, maternal request, physicians

Clinicians' views regarding caesarean section rates in Switzerland: A cross-sectional web-based survey.

The caesarean section (CS) rate in Switzerland is currently 32 %, well above the WHO recommended rate of 15 %. The study aims were three-fold: to explore the perception of this high rate among Swiss obstetrics-gynecology (Ob-Gyn) professionals; to assess the factors associated with a perception of a too high national CS rate; and to describe professionals' opinions on measures to reduce this rate. A cross-sectional study was conducted between 1 May and 30 June 2021 using an online questionnaire sent to Ob/Gyn physicians and midwives at a university hospital and members of the Swiss Conference of Heads of Ob/Gyn Divisions. Survey participation was voluntary. The main outcome was the belief that CS was high. Associations were explored between different factors and the main outcome with logistic regression. Results were presented as odds ratios (OR) with 95 % confidence intervals (CIs). Multivariate logistic regression included adjustments for age, gender, place of work and profession. Of 226 health professionals invited, 188 completed the questionnaire (83.2 % participation rate). Among respondents, 50.3 % (n=94) were Ob/Gyn physicians and 49.7 % were midwives (n=93); 77.1 % were women (n=145). Most participants (74.7 % [n=139]) considered the Swiss CS rate as too high and that it should be reduced (79 % [n=147]) but, notably, they considered their own CS rate as correct (71.9 % [n=123]). Improving patient education (57.5 % [n=108]) and professional training (54.8 % [n=103]) were considered as strategies to reduce this rate. In multivariate analysis, only length of professional experience was significantly associated with a higher likelihood of considering the CS rate as too high (OR 3.07, 95 % CI 1.01-9.30; p=0.047). When specialty was added in the model, the length of professional experience disappeared and the perception of having a too high CS rate was associated with being a midwife and obstetrician rather than a gynecologist (OR 3.62, 95 % CI 1.72-7.63; p=0.001). Clinicians, particularly obstetricians, believed that the current rate of CS in Switzerland was too high and that actions were needed to reduce this rate. Improving patient education and professional training were considered as the main strategies to be explored.

Changes in cesarean section rates after introduction of a punitive financial policy in Georgia: A population-based registry study 2017-2019.

BackgroundThere is little research on how financial incentives and penalties impact national cesarean section rates. In January 2018, Georgia introduced a national cesarean section reduction policy, which imposes a financial penalty on hospitals that do not meet their reduction targets. The aim of this study was to assess the impact of this policy on cesarean section rates, subgroups of women, and selected perinatal outcomes.MethodsWe included women who gave birth from 2017 to 2019 registered in the Georgian Birth Registry (n = 150 534, nearly 100% of all births in the country during this time). We then divided the time period into pre-policy (January 1, 2017, to December 31, 2017) and post-policy (January 1, 2018, to December 31, 2019). An interrupted time series analysis was used to compare the cesarean section rates (both overall and stratified by parity), neonatal intensive care unit transfer rates, and perinatal mortality rates in the two time periods. Descriptive statistics were used to assess differences in maternal socio-demographic characteristics.ResultsThe mean cesarean section rate in Georgia decreased from 44.7% in the pre-policy period to 40.8% in the post-policy period, mainly among primiparous women. The largest decrease in cesarean section births was found among women <25 years of age and those with higher education. There were no significant differences in the neonatal intensive care unit transfer rate or the perinatal mortality rate between vaginal and cesarean section births in the post-policy period.ConclusionThe cesarean section rate in Georgia decreased during the 2-year post-policy period. The reduction mainly took place among primiparous women. The policy had no impact on the neonatal intensive care unit transfer rate or the perinatal mortality rate. The impact of the national cesarean section reduction policy on other outcomes is not known.

Patients’ Lived Experiences of the Care Provided Before and After Caesarean Sections in the City of Tshwane, Gauteng, South Africa

A caesarean section is an incision of the abdomen and uterine walls to deliver the foetus. An emergency caesarean section may be performed if complications during pregnancy or labour arise. Various indications such as abnormal presentation, a previous caesarean section, and other related conditions may need an elective caesarean section. In South Africa, the national average caesarean section rate between 2015 and 2016 was 26.2 per cent, whereas the rate in district hospitals was 24.1 per cent. At a community hospital in the City of Tshwane, the caesarean section rate of 32 per cent in 2015 was recorded as high. The aim of this research was to explore and to describe patients’ lived experiences of the care provided before and after a caesarean section in the City of Tshwane, Gauteng, South Africa. To achieve the aim of the study, a qualitative, exploratory, descriptive study was conducted. The sampling method used was purposive, and the sample size was determined by data saturation. An interview schedule was used to collect the data. The study concluded that some women were satisfied with the care provided, whereas the majority were dissatisfied. The need for strategies to improve such care provided by nurses and midwives was highlighted. Multidisciplinary teams have to acknowledge gaps and develop effective strategies to motivate nurses and midwives in the workplace to provide quality care. Research should be conducted to design an effective nursing framework for caesarean section care.

Delayed Initiation of Breastfeeding and Role of Mode and Place of Childbirth: Evidence from Health Surveys in 58 Low- and Middle- Income Countries (2012–2017)

Background: Timely initiation of breastfeeding is the first step towards achieving recommended breastfeeding behaviours. Delayed breastfeeding initiation harms neonatal health and survival, including infection associated neonatal mortality. Eighty percent of neonatal deaths occur in the low-and middle-income countries (LMICs), where delayed breastfeeding initiation is the highest. Place and mode of childbirth are important factors determining the time of initiation of breastfeeding. In this study, we report the prevalence of delayed breastfeeding initiation from 58 LMICs and investigate the relationship between place and mode of childbirth and delayed breastfeeding initiation in each country. Methods: We analysed data from the most recent Demographic and Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) collected between 2012 and 2017 and reported by 2019. The study sample comprised all women who had a live birth in the 24 months preceding the survey. ‘Delayed’ initiation of breastfeeding was defined using WHO recommendations as starting breastfeeding after one hour of birth. We coded the stratifying variable for the place and mode of childbirth as “vaginal birth at a facility (VBF)”, “caesarean section birth (CSB) “, and “vaginal birth at home (VBH)”. We used respondent-level sampling weights to account for individual surveys and de-normalised the standard survey weights to ensure the appropriate contribution of data from each country. We report the prevalence and population attributable fractions with robust standard errors. The population attributable risk identifies the proportion of delayed initiation that we could avert among VBH and CSB if everyone had the same risk of delaying breastfeeding as in VBF. Results: The overall prevalence of delayed initiation of breastfeeding was 53.8% (95% CI 53.3, 54.3), ranging from 15.0% (95% CI 13.8, 16.2) in Burundi to 83.4% (95% CI 80.6, 86.0) in Guinea. The prevalence of delayed initiation of breastfeeding was consistently high among women who experienced caesarean section births; however, there was no direct association with each country’s national caesarean section rates. The prevalence of delayed initiation among women who experienced VBF was high in Sub-Saharan Africa and South Asia, even though the CSB rates were low. In some countries, women who give birth vaginally in health facilities were more likely to delay breastfeeding initiation than women who did not. In many places, women who give birth by caesarean section were less likely to delay breastfeeding initiation. Population attributable risk percent for VBH ranged from −28.5% in Ukraine to 22.9% in Moldova, and for CSB, from 10.3% in Guinea to 54.8% in Burundi. On average, across all 58 countries, 24.4% of delayed initiation could be prevented if all women had the same risk of delaying breastfeeding initiation as in VBF. Discussion: In general, women who give birth in a health facility were less likely to experience delayed initiation of breastfeeding. Programs could avert much of the delayed breastfeeding initiation in LMICs if the prevalence of delayed initiation amongst women who experience CSB were the same as amongst women who experience VBF. Crucial reforms of health facilities are required to ensure early breastfeeding practices and to create pro-breastfeeding supportive environments as recommended in intervention packages like the Baby-friendly hospital initiative and Early essential newborn care. The findings from this study will guide program managers to identify countries at varying levels of preparedness to establish and maintain a breastfeeding-friendly environment at health facilities. Thus, governments should prioritise intervention strategies to improve coverage and settings surrounding early initiation of breastfeeding while considering the complex role of place and mode of childbirth.

Epidemiological analysis of peripartum hysterectomy across nine European countries.

IntroductionPeripartum hysterectomy is a surgical procedure performed for severe obstetric complications such as major obstetric hemorrhage. The prevalence of peripartum hysterectomy in high‐resource settings is relatively low. Hence, international comparisons and studying indications and associations with mode of birth rely on the use of national obstetric survey data. Objectives were to calculate the prevalence and indications of peripartum hysterectomy and its association with national cesarean section rates and mode of birth in nine European countries.Material and methodsWe performed a descriptive, multinational, population‐based study among women who underwent peripartum hysterectomy. Data were collected from national or multiregional databases from nine countries participating in the International Network of Obstetric Survey Systems. We included hysterectomies performed from 22 gestational weeks up to 48 hours postpartum for obstetric hemorrhage, as this was the most restrictive, overlapping case definition between all countries. Main outcomes were prevalence and indications of peripartum hysterectomy. Additionally, we compared prevalence of peripartum hysterectomy between women giving birth vaginally and by cesarean section, and between women giving birth with and without previous cesarean section. Finally, we calculated correlation between prevalence of peripartum hysterectomy and national cesarean section rates, as well as national rates of women giving birth after a previous cesarean section.ResultsA total of 1302 peripartum hysterectomies were performed in 2 498 013 births, leading to a prevalence of 5.2 per 10 000 births ranging from 2.6 in Denmark to 10.7 in Italy. Main indications were uterine atony (35.3%) and abnormally invasive placenta (34.8%). Relative risk of hysterectomy after cesarean section compared with vaginal birth was 9.1 (95% CI 8.0‐10.4). Relative risk for hysterectomy for birth after previous cesarean section compared with birth without previous cesarean section was 10.6 (95% CI 9.4‐12.1). A strong correlation was observed between national cesarean section rate and prevalence of peripartum hysterectomy (ρ = 0.67, P < .05).ConclusionsPrevalence of peripartum hysterectomy may vary considerably between high‐income countries. Uterine atony and abnormally invasive placenta are the commonest indications for hysterectomy. Birth by cesarean section and birth after previous cesarean section are associated with nine‐fold increased risk of peripartum hysterectomy.

Childbirth outcomes and ethnic disparities in Suriname: a nationwide registry-based study in a middle-income country

BackgroundOur study aims to evaluate the current perinatal registry, analyze national childbirth outcomes and study ethnic disparities in middle-income country Suriname, South America.MethodsA nationwide birth registry study was conducted in Suriname. Data were collected for 2016 and 2017 from the childbirth books of all five hospital maternity wards, covering 86% of all births in the country. Multinomial regression analyses were used to assess ethnic disparities in outcomes of maternal deaths, stillbirths, teenage pregnancy, cesarean delivery, low birth weight and preterm birth with Hindustani women as reference group.Results18.290 women gave birth to 18.118 (98%) live born children in the five hospitals. Hospital-based maternal mortality ratio was 112 per 100.000 live births. Hospital-based late stillbirth rate was 16 per 1000 births. Stillbirth rate was highest among Maroon (African-descendent) women (25 per 1000 births, aOR 2.0 (95%CI 1.3–2.8) and lowest among Javanese women (6 stillbirths per 1000 births, aOR 0.5, 95%CI 0.2–1.2). Preterm birth and low birthweight occurred in 14 and 15% of all births. Teenage pregnancy accounted for 14% of all births and was higher in Maroon women (18%) compared to Hindustani women (10%, aOR 2.1, 95%CI 1.8–2.4). The national cesarean section rate was 24% and was lower in Maroon (17%) than in Hindustani (32%) women (aOR 0.5 (95%CI 0.5–0.6)). Cesarean section rates varied between the hospitals from 17 to 36%.ConclusionThis is the first nationwide comprehensive overview of maternal and perinatal health in a middle income country. Disaggregated perinatal health data in Suriname shows substantial inequities in outcomes by ethnicity which need to be targetted by health professionals, researchers and policy makers.

Technocratic childbirth models

Not available.

A Population-Based Study on Association Between Cesarean Section and Neonatal Mortality in Nigeria

OBJECTIVETo examine the association between cesarean section and neonatal mortality Nigeria.METHODA retrospective analysis using Nigeria Demographic Health Survey 2013 national population-based cross-sectional survey. The national prevalence of cesarean section was calculated, and logistic regression was used to estimate the odds of neonatal mortality outcome following cesarean delivery.RESULTSThe national cesarean section rate for the 2009–2013 period was 2.1% among 31,495 deliveries. The odds of having a neonatal death was twice as high in cesarean deliveries in comparison to noncesarean deliveries (aOR = 2.56, 95% CI 1.75 to 3.74).CONCLUSIONCesarean section increases the odds of neonatal mortality in Nigeria. There is a need to scale up the quality and timeliness of emergency obstetric services offered to pregnant women.

Women\u2019s perspectives on health facility and system levels factors influencing mode of delivery in Tehran: a qualitative study

BackgroundIran has one of the highest national caesarean section rates worldwide. Few studies explored in-depth the health-facility and health-system level factors that affect women’s choices on mode of delivery in Iran. The aim of this study was to explore the health-facility and health-system level factors affecting women’s preferences on mode of delivery in Tehran.MethodsWe conducted a qualitative study using in-depth face-to-face interviews with women between October 2017 and May 2018. Study participants were sampled purposively from a range of health service settings to include women of varying experiences regarding childbirth. Eligibility criteria were Persian-speaking, women with or without childbirth experiences. All interviews were audio-recorded and lasted 30–45 min. After verbatim transcription of the interviews, we created a preliminary thematic framework to analyze the data. A combined inductive (themes emerging from the data) and deductive (key concepts across existing frameworks) approach was used during data analysis.ResultsIn total, 26 in-depth interviews were conducted. Five central themes influencing women’s preferences on mode of delivery emerged from the analysis: (1) health system conditions (important differences between the quality of care provided at private and public hospitals; staff shortages, skills, competency, motivation and also accessibility to staff during the longer time required for a vaginal delivery; policies and protocols on vaginal birth after cesarean, pain relief for vaginal birth, and having companion during labor; (2) standards of care in facilities (physical condition in facilities; physical examinations and procedures; continuous and organized care; ethics); (3) interaction between women and providers (communicating in a supportive manner with women and communication women’s partners/families); (4) preserving women’s dignity (delivering high quality and respectful care); (5) provision of information (education about pregnancy and childbirth including environment in facility, labor processes/procedures, and the risks and benefits of both vaginal delivery and caesarean section).ConclusionsOur study suggests, there are barriers to increasing demand for and satisfaction with vaginal birth, such as women’s perceived sub-optimal quality of care during labor and birth, understaffed facilities that lack standard protocols and have limited physical space, and lack of privacy and dignity. The multifactorial nature of the increase of unnecessary Cesarean section calls for multicomponent interventions to revert this trend. These interventions need to address the health-systems’ and health-facilities’ deficiencies behind women’s preference for Cesarean section.

Variation in caesarean section rates in Cyprus, Italy and Iceland: an analysis of the role of the media.

Cyprus has Europe's highest rate of births by caesarean section (CS). In 2015 56% of all babies were born by CS. This compares with 36% in Italy, and 16% in Iceland, which is among the lowest rates in Europe. There is some evidence that CS rates are partly driven by maternal request and media representation. The aim of this review is to explore the depiction of childbirth by CS in the media, and more specifically in newspapers, television, web and informational leaflets in Cyprus, Italy and Iceland. A thematic review of the depiction of CS in the media of Cyprus, Italy and Iceland was carried out through an examination of newspapers, television, web, and informational material published or presented in the included countries in 2017. Materials were identified by searches in PubMed and Google Scholar, using pre-determined key words, inclusion and exclusion criteria, and inclusion was agreed by at least two of the authors. Key themes in each data source were triangulated with each other and between the three countries. The review comprised 81 articles, 10 videos, six birth shows, two informational leaflets and one scientific paper. The central themes were: 1) CS as risky and unnecessary intervention, failure of maternity system; 2) CS as a necessary, life-saving intervention; 3) the ethical dimensions of CS; 4) the changing landscape of childbirth and medicalization; and 5) informed choices. In both Cyprus and Italy, the media focus was on a need to reduce high levels of CS. The focus in Iceland was on normal birth and midwife led care. The differing media messages in the three countries could partly explain the differing CS rates, suggesting that high CS rates are a social phenomenon, rather than a result of clinical need. The media may have a significant influence on the beliefs and choices of maternity service users, their families, and society in general, as well as health professionals and policy makers. Those working in the media have an ethical responsibility to critically examine the impact of high national CS rates, and to report on solutions that could optimize both the safety and the wellbeing of mothers and babies.

384: Safely lowering the emergency cesarean section (CS)/operative delivery (EOD) rates using the “Fetal Reserve Index” (FRI) to re-engineer EFM interpretation and manage labor

National CS rates have skyrocketed as obstetricians are caught in the vortex of demands to lower the CS rate but risking increased medicolegal exposure from not performing “timely” CSs for presumed fetal distress. Even “traditionalist” experts have now concluded that EFM cannot identify half of fetal acidemia. We have developed the FRI to incorporate components of EFM but adding hyperstimulation, maternal, obstetrical, and fetal risk factors into an algorithm and have recently demonstrated a much higher ability to discriminate CP cases (by reaching red zone) from controls than the ACOG category system and do so much earlier (p<.001). Here, we evaluate our ability to identify emerging trouble in labor early enough to allow intrauterine resuscitation (IR) techniques to impact the emergency (E) CS and EOD rates. We investigated 800 labors of singleton, vertex, term patients all of whom had normal neonatal outcomes. FRI scores were calculated retrospectively. In the “early” 400, no alterations from routine were used. In the “late” 400, one of us (RDE) helped manage the cases aggressively following FRI principles, but did not share specific scoring rationale with residents, etc. There were significantly fewer emergency deliveries in the late group than the early group (16 vs 69) (p<.001). A similar percentage of cases reached red zone, but more late cases had IR leading to lower emergency deliveries of all types. (Table) : Emergency deliveries, even with good fetal outcomes, produce havoc on L & D with higher complication rates and emotional stress for all. The FRI replaces the very subjective EFM interpretation with a quantifiable system for labor management. Our data suggest that the FRI, by providing earlier recognition of risk and allowing more time for IR to treat, may safely lower the ECS and EOD rates both improving fetal outcomes and reducing complications.

Cesarean section in Ethiopia: prevalence and sociodemographic characteristics

Objective The objective of this study was to assess the prevalence and sociodemographic characteristics of cesarean section in Ethiopia. Methods We used data collected for Ethiopia Demographic and Health Surveys (DHS) conducted in 2000, 2005, 2011, and 2016. A two-stage, stratified, clustered random sampling design was used to gather information from women who gave birth within the 5-year period before each of the surveys. We analyzed the data to identify sociodemographic characteristics associated with cesarean section using log-Poisson regression models. Results The national cesarean section rate increased from 0.7% in 2000 to 1.9% in 2016, with increases across seven of the eleven administrative regions of Ethiopia. Addis Ababa had the highest cesarean section rate (21.4%) in 2016 and the greatest increase since 2000. In the adjusted analysis, women who gave birth in private health facility had a 78.0% higher risk of cesarean section (adjusted prevalence ratio (aPR) (95% CI) 1.78 (1.22, 2.58)) compared with women who gave birth in public health facility. Having four or more births was associated with a lower risk of cesarean section compared with first births (aPR (95% CI) 0.36 (0.16, 0.79)). Conclusions The Ethiopian national cesarean section rate is about 2%, but the rate varies widely among administrative regions, suggesting unequal access. Cesarean sections were highest among urban mothers, first births, births to women with higher education, and births to women from the richest quintile of household wealth.

The effect of family policies and public health initiatives on breastfeeding initiation among 18 high-income countries: a qualitative comparative analysis research design

BackgroundThe objective of this study is to examine the effects of macro-level factors – welfare state policies and public health initiatives – on breastfeeding initiation among eighteen high-income countries.MethodsThis study utilizes fuzzy-set Qualitative Comparative Analysis methods to examine the combinations of conditions leading to both high and low national breastfeeding initiation rates among eighteen high-income countries.ResultsThe most common pathway leading to high breastfeeding initiation is the combination of conditions including a high percentage of women in parliament, a low national cesarean section rate, and either low family spending, high rates of maternity leave, or high rates of women working part-time. The most common pathway leading to low breastfeeding initiation includes the necessary condition of low national adherence to the Baby-Friendly Hospital Initiative.ConclusionThis research suggests that there is a connection between broad level welfare state polices, public health initiatives, and breastfeeding initiation. Compliance with the WHO/UNICEF initiatives depends on welfare regime policies and overall support for women in both productive and reproductive labor.

National Variation in Caesarean Section Rates: A Cross Sectional Study in Ireland.

ObjectiveInternationally, caesarean section (CS) rates are rising. However, mean rates of CS across providers obscure extremes of CS provision. We aimed to quantify variation between all maternity units in Ireland.MethodsTwo national databases, the National Perinatal Reporting System and the Hospital Inpatient Enquiry Scheme, were used to analyse data for all women delivering singleton births weighing ≥500g. We used multilevel models to examine variation between hospitals in Ireland for elective and emergency CS, adjusted for individual level sociodemographic, clinical and organisational variables. Analyses were subsequently stratified for nullipara and multipara with and without prior CS.ResultsThe national CS rate was 25.6% (range 18.2% ─ 35.1%). This was highest in multipara with prior CS at 86.1% (range 6.9% ─ 100%). The proportion of variation in CS that was attributable to the hospital of birth was 11.1% (95% CI, 6.0 ─ 19.4) for elective CS and 2.9% (95% CI, 1.4 ─ 5.6) for emergency CS, after adjustment. Stratifying across parity group, variation between hospitals was greatest for multipara with prior CS. Both types of CS were predicted by increasing age, prior history of miscarriage or stillbirth, prior CS, antenatal complications and private model of care.ConclusionThe proportion of variation attributable to the hospital was higher for elective CS than emergency CS suggesting that variation is more likely influenced by antenatal decision making than intrapartum decision making. Multipara with prior CS were particularly subject to variability, highlighting a need for consensus on appropriate care in this group.

Rates of caesarean section and total volume of surgery in Sierra Leone: a retrospective survey

BackgroundSurgical services are essential components of health-care systems. Monitoring of surgical activity is important, but resource demanding. Simpler tools to estimate surgical volume, particularly in low-income countries, are needed. Previous work hypothesises that the relative frequency of caesarean sections, expressed as a proportion of total operative procedures, could serve as a proxy measure of surgical capacity. We aimed to establish nationwide and district-wide rates of surgery and caesarean sections, and to explore correlations between districts rates for caesarean sections and corresponding rates for total volume of surgery in Sierra Leone in 2012. MethodsA nationwide, exhaustive, retrospective, facility-based study of all surgical providers and surgical procedures was performed in Sierra Leone. Between Jan 14, and May 20, 2013, four teams of 12 medical students collected data on the characteristics of the institutions and of the surgeries performed in 2012. Data were retrieved from operation, anaesthesia, and delivery logbooks. FindingsOf 60 facilities performing surgery, complete annual data for 2012 was collected from 58 (97%) institutions. 24 152 surgical procedures identified, gave a national rate of 400 surgeries per 100 000 inhabitants (district range 32–909 per 100 000 [IQR 95–502 per 100 000]). National caesarean section rate was 2·1% (district range 0·3–4·0% [IQR 0·8–2·1]). District caesarean sections rate significantly correlated with the rate of total surgical procedures per 100 000 population (p<0·01). With known caesarean section rate, total volume of surgeries per 100 000 can be calculated with the equation: −9·8 + 4·68 × caesarean sections per 100 000. InterpretationThe close correlation between rate of caesarean section and population rates of total volume of surgery at district level in Sierra Leone indicates that rate of caesarean section should be further explored as a proxy indicator for overall surgical volume in low performing settings. By collecting data from three sources, missing procedures was considered less likely. FundingNorwegian University of Science and Technology.

How useful are national caesarean section rates for monitoring quality of perinatal care?

Recommendations for the organisation and provision of perinatal care worldwide were published after a meeting of mostly European and American experts 30 years ago (Lancet 1985;2(8452):436–7). Among these recommendations, one—‘Countries with some of the lowest perinatal mortality rates in the world have caesarean section (CS) rates of <10%. There is no justification for any region to have a rate higher than 10–15%’—continues to generate discussions even today. Despite little empirical evidence, this rate became regarded as the ideal CS rate for a population. Guidelines on monitoring the availability of obstetric services published nearly 25 years later refer to an acceptable CS rate in the population of 5–15% (WHO, UNFPA, UNICEF, Mailman School of Public Health AMDD. Monitoring Emergency Obstetric Care: A Handbook. Geneva: WHO, 2009). The reality is different. Among 137 countries with national CS rates in 2008, 33 (mostly in Africa and Asia) had rates <5% and 54 had rates <10% (Gibbons et al. Am J Obstet Gynecol 2012;206:331.e1–19). In contrast, 69 countries had CS rates of >15%, with China and Brazil accounting for almost half of the total caesarean births in this category. Even among countries within the European region, CS rates vary widely (Macfarlane et al. BJOG 2016;123:559–568). Certainly CS can prevent maternal death in major-degree placenta praevia, certain malpresentations and major cephalopelvic disproportion with threatened uterine rupture. There may be additional indications, e.g. eclampsia, where early delivery is beneficial for the mother. With improvements in neonatal care and survival, fetal indications for CS have increased. Widespread introduction of electronic fetal monitoring without adequate assessment led to increasing diagnoses of fetal distress, fear of litigation and complaints about perinatal brain damage, and to acceleration in CS rates. In addition, breech presentation, worries about pelvic floor damage, personal choice and private care resulted in further increases in CS rates. ‘Once a Caesar, always a Caesar’ continues to be true in places where trial of vaginal birth after lower-segment CS is considered too risky. How well does a national CS rate reflect the quality of maternal and perinatal care in the country? A minimum number of CS is necessary for maternal survival. Therefore, very low national CS rates indicate poor overall access to life-saving facility-based maternal health interventions. In contrast, high rates may suggest inappropriate overuse of resources that does not directly contribute to reductions in maternal and perinatal mortality. Moreover, a national rate does not capture inequities in access to and use of CS within the country, nor does it help to identify where the problems lie. It is time to move on to using and publishing better information from facilities that perform CS: carefully defined information on why and when CS is performed and outcomes should be collected regularly. Analyses of data using a standardised classification system (Torloni et al. PLoS One 2011;6:e14566) with periodic review of the information will help to identify problems, and to develop and implement targeted solutions. Bringing about change in perceptions and practices is possible with strong leadership, consensus and commitment from all staff involved in maternity care, pregnant women, their families and communities. The author has no interests to disclose.

PLD.05 Audit of Informed Consent and Recall of Risks for Caesarean Section

BackgroundThe national caesarean section (CS) rate is 25%. Valid consent must be obtained for CS, after providing information on benefits, risks and burdens.ObjectiveTo audit the process of consent and recall...

Maternal Request Is not to Blame for an Increase in the Rate of Cesarean Section

The aim of this study was to establish whether Lithuanian women would request an elective cesarean section in a low-risk pregnancy and to compare how the women's opinion changed during the 5-year period. A study was conducted at the Hospital of Lithuanian University of Health Sciences from November 1 to December 31, 2006, and from January 1 to February 28, 2011. A total of 204 and 239 women were enrolled in 2006 and 2011, respectively. Self-administered anonymous questionnaires collected information on women's knowledge about the advantages of the different modes of delivery and their preferred type of birth in a low-risk pregnancy. Overall, 82.4% of the participants in 2006 and 74.5% in 2011 thought that women should be able to choose the mode of delivery in a low-risk pregnancy. If they had had such an opportunity, 15.2% of women in 2006 and 14.9% in 2011 would have chosen cesarean section without any medical indication. The most frequently mentioned advantage of vaginal delivery was that it is natural, while safety for the newborn and the possibility of avoiding delivery pain were the mentioned advantages of cesarean section. Approximately 15% of Lithuanian women would request an elective cesarean section, and this percentage did not change during the 5-year period. While the national cesarean section rate is increasing with every year, it seems that "maternal request" cannot be blamed for this phenomenon. Despite all the available information about the different modes of delivery, women still lack professional and reliable knowledge about it.

Re-audit of the use of fetal blood sampling prior to emergency caesarean section

AimTo determine the change in management of the pathological cardiotocograph (CTG) in labour with regards to the use of fetal blood sampling (FBS) prior to delivery by emergency Caesarean section.MethodsA...