Rising Caesarean Section Rate Research Articles

The Impact of Continuous Labor Support on Cesarean Section Rates among Nulliparous Women: A Randomized Controlled Trial

Cesarean section (CS) rates are increasing globally, raising concerns about maternal and neonatal morbidity. Continuous labor support (CLS) has been shown to reduce CS rates in some settings, but its impact in Indonesia remains understudied. This study aimed to evaluate the effect of CLS on CS rates among nulliparous women in Purwakarta Regency, Indonesia. A randomized controlled trial was conducted at the Purwakarta Regional Hospital from January 2022 to December 2023. Eligible nulliparous women in labor were randomized to receive either CLS (n=210) from a trained midwife or standard care (n=205). The primary outcome was the rate of CS. Secondary outcomes included duration of labor, use of analgesia, maternal satisfaction, and neonatal outcomes. The CS rate was significantly lower in the CLS group (18.1%) compared to the standard care group (29.3%) (p=0.02). Women in the CLS group also reported higher satisfaction with their birth experience. No significant differences were found in other secondary outcomes. Continuous labor support provided by a trained midwife significantly reduces CS rates among nulliparous women in Purwakarta Regency, Indonesia. Implementing CLS as a routine practice may help address the rising CS rates and improve maternal birth experiences in this setting.

Delivery after a previous cesarean section reviewed.

At the start of the 20th century, cesarean section (CS) was uncommon in obstetrics. By the end of the century, CS rates had increased dramatically worldwide. Although the explanation for the increase is multifactorial, a major driver in the ongoing escalation is the increase in women who are delivered by repeat CS. This is due, in part, to the fact that there has been a sharp fall in vaginal birth after CS (VBAC) rates as fewer women are offered a trial of labor after CS (TOLAC), due principally to fears of a catastrophic intrapartum uterine rupture. This paper reviewed international VBAC policies and trends. A number of themes emerged. The risk of intrapartum rupture and its associated complications is low and may sometimes be overestimated. Individual maternity hospitals in both developed and developing countries are inadequately resourced to safely supervise a TOLAC. Efforts to mitigate the risks of TOLAC by careful patient selection and good clinical practices may be underutilized. Given the serious short-term and long-term consequences of rising CS rates for women and for maternity services generally, a review of TOLAC policies worldwide should be prioritized and consideration given to convening a Global Consensus Development Conference on Delivery after CS.

A Quantitative and Qualitative Investigation of Factors Associated with Caesarean Section Deliveries in Sri Lanka Assessing National Trends and Views of Local Healthcare Professionals in Colombo in 2015

Background A caesarean section (CS) is an operation to deliver a baby through incisions made to the mother’s abdominal wall and uterus, either before or after labor has started. An emergency CS is performed for certain medical indications such as placenta praevia or umbilical cord prolapse, and it most frequently occurs once labor has started. Elective CS are planned CS. They could be performed for non-medical reasons such as maternal request. Aim CS rates in Sri Lanka have been rising over the past decades. This study investigates reasons for the rise in CS rates through qualitative and quantitative analyses. Methods Qualitative data analysis involved interviews which were conducted in a teaching hospital in Colombo, Sri Lanka. Twenty (20) healthcare professionals in Obstetrics and Gynecology were interviewed. A semi-structured questionnaire, consisting of 15 opened and closed questions, was the basis for the interview. Quantitative analysis was performed on Demographic and Health Survey (DHS) data from 2006-2007. Variables included mother’s age, education level and residence. Chi-squared (χ2) and regression analysis using statistical package for the social sciences version (SPSS) was performed to determine if these variables were associated with CS. Results From qualitative analyses of the interviews, the main themes identified were the healthcare professionals’ views on causes of the rising CS rates, parties involved in the decision-making process, benefits and risks of elective CS and availability of support or alternative options. Quantitative analysis of DHS data showed variables such as residence, province, and education level were significantly associated with CS (p<0.01). Urban residences, living in Colombo and extremes in education levels had the greatest likelihood of a CS. Age, although statistically not significant, is clinically important as literature reviewed showed that CS tend to be more prevalent in extremes of age. Conclusion Analysis revealed the importance of factors associated with CS. Targeting areas that showed the greatest prevalence of CS is an effective strategy to address rising rates

Behavioural factors associated with fear of litigation as a driver for the increased use of caesarean sections: a scoping review

ObjectiveTo explore the behavioural drivers of fear of litigation among healthcare providers influencing caesarean section (CS) rates.DesignScoping review.Data sourcesWe searched MEDLINE, Scopus and WHO Global Index (1 January 2001 to...

Clinicians' views of factors influencing decision-making for CS for first-time mothers-A qualitative descriptive study.

Clinicians' perspectives of the reasons for performing caesarean section (CS) are fundamental to deepening knowledge and understanding of factors influencing decision-making for CS. The aim of this study was to explore midwives' and obstetricians' views of factors influencing decision-making for CS for first-time mothers. A qualitative descriptive study with semi-structured one-to-one audio-recorded interviews was used to gather data from clinicians (15 midwives and 20 senior obstetricians). Following research ethics committee approval, clinicians, who were directly involved in the decision-making process for CS during the period of data collection, were purposively selected from three maternity units in the Republic of Ireland between June 2016 to July 2017. The interviews were transcribed verbatim and analysed thematically. Three interrelated themes with several subthemes reflective of clinicians' views and experiences emerged following data analysis. These were: 'A fear factor' describing clinicians' fear of adverse outcomes and subsequent litigation, 'Personal preferences versus a threshold-clinician driven factors emphasising the influence of clinicians' personal beliefs, and 'Standardised versus individualised care-a system perspective' explaining the effects of, or lack of, organisational policy and its direct and indirect impact on the decision-making process. Findings show that decisions to perform a CS are, on occasion, based on clinicians' personal beliefs and interpretation, similar to findings from other published literature. Consideration of broader issues related to organisational, socio-cultural and political context is essential when seeking solutions to the rising CS rates. The findings will enable clinicians to reflect on their day-to-day practice, in order to look for modifiable factors that influence their decision-making, and help women understand the multitude of factors that can lead to a decision to perform a CS. Findings will also contribute to the development of the 'next step action' and assist in devising future intervention studies to reduce any unnecessary CSs.

Midwives’ views of an evidence-based intervention to reduce caesarean section rates in Ireland

ProblemA worldwide increase of caesarean section (CS) rates has been estimated at a rate of 4% per year and numerous interventions to reduce the rates have not been successful, perhaps because they are not acceptable to clinicians. BackgroundA caesarean section (CS) can be a life-saving operation, but has been associated with short- and long-term risk factors and shown to affect subsequent pregnancies. AimTo explore midwives’ views on CS rates and evaluate the feasibility and acceptability of an evidence-based intervention programme (REDUCE) designed to decrease overall CS rates in Ireland by 7%. MethodsFollowing ethical approval, a qualitative exploratory design was used to seek midwives’ views of the evidence-based intervention. A total of 28 midwives from one large tertiary maternity hospital took part in four focus group interviews. Data were analysed using thematic analysis. FindingsFive themes emerged, illustrating the midwives’ views of what could be improved in the present system and how CS rates could be reduced in future. The themes included: (i) Induction of labour; (ii) Education; (iii) Auditing of practice; (iv) Clinical practice; (v) Midwife-Obstetrician collaboration. DiscussionThis study noted a rising CS rate year on year, with a rate of 37% at the time of the study, and the midwives voiced their very real concerns over the increased high rates. ConclusionThe study provided support for the evidence based ‘REDUCE’ intervention, which now needs to be tested empirically within this Irish population.

Factors contributing to rising cesarean section rates in South Asian countries: A systematic review

Rising cesarean section (CS) rates are a global public health problem. The systematic review investigates key indications for performing CS and factors significantly associated with the rising rate of CS in South Asia. Primary studies in South Asia published between January 2010 and December 2018 were searched using relevant electronic databases: MEDLINE, Scopus, PubMed, Web of Science, CINAHL, NepJOL, and BanglaJOL. A narrative synthesis of the indications for performing CS and factors significantly associated with the rising CS rates was performed using content analysis. A total of 68 studies were included in this review. The most common medical indication for CS was fetal distress, followed by previous CS, antepartum hemorrhage (including placenta previa/abruption), cephalopelvic disproportion, failed induction, hypertensive disorders in pregnancy, oligohydramnios, and non-progress of labor. Maternal request was the most common non-medical indication for conducting CS. Higher maternal age was the most common significant factor associated with the rising CS rate followed by higher maternal education, urban residency, higher economic status, previous CS, pregnancy/childbirth complications, and lower parity/nulliparity. Preference for CS and increasing private number hospital were also factors contributing to the rising rate. Several key indicators and factors significantly associated with rising CS rate are revealed. These key indicators and significant factors reflect the global trend. Reduction in the use of primary CS, unless medically warranted, would help stem rates of CS. Realistic and candid explanation to pregnant women and their families regarding the benefits of vaginal birth for women and babies should form an integral part of maternity care as these are issues of public health.

Analysis of caesarean section rates according to Robson's ten group classification system at a tertiary care teaching hospital in South India

Background: Robson’s ten-group classification system (RTGCS) is recommended by WHO as an analytical tool for effective monitoring of caesarean section (CS) rates. The overall CS rates are high but seldom, women are classified based on CS.Methods: Data was collected and reviewed retrospectively. All the pregnant women who delivered from January 2016 to December 2017 in the labour ward were classified according to RTGCS.Results: Total of 2951 women delivered- 1598 (54.15%) vaginally and 1353 (45.84%through CS. In this study, Group 5 was the largest contributor (30.08%), group 1 was second (28.15%).Conclusion: Reviewing the definition of failure to progress in labour and changing norms of fetal distress may lower CS rates in groups 1, 2 and5. RTGCS proves to be an effective tool that allows standardized comparison of data, time point and identifies the groups responsible for rising CS rates.

Accounting for the Rising Caesarean Section Rate in Canada: What Are the Roles of Changing Needs, Practices, and Incentives?

In most high-income countries, including Canada, the share of births by Caesarean section (C-section) has risen over the past decades to far exceed World Health Organization recommendations of the proportion justified on medical grounds (15 percent). Although unnecessary C-sections represent an important cost for health care systems, they are not associated with clear benefits for the mother and the child and can sometimes represent additional risks. Drawing on administrative records of nearly four million births in Canada, as well as macro data from the United States and Australia, we provide a comprehensive account of rising C-section rates. We explicitly consider the contributions of the main factors brought forward in the policy literature, including changing characteristics of mothers, births, and physicians as well as changing financial incentives for C-section deliveries. These factors account for at most one-half of the increase in C-section rates between April 1994 and March 2011. The majority of the remaining increase in C-sections over the period occurred in the early 2000s. We suggest that some event or shock in the early 2000s is likely the primary determinant of the recent strong increase in the C-section rate in Canada.

Caesarean section rates in primigravid women categorised by age and BMI

The rising caesarean section (CS) rate is a complex issue, particularly in an increasingly heterogenous nulliparous population. The study aim was to stratify the CS rate in nulliparous women by age and BMI to determine if any difference existed. This was a retrospective review of CS procedures of nulliparous women in two centres in Ireland (2014 through 2017). Data were obtained for 17,177 women from the hospital databases and CS procedures determined for each age and BMI category. Significant differences were observed when CS rates were stratified in this manner. The CS rates for women <20 years/BMI < 18.5 was 8.8 versus 57.6% for women 35 − 39 years/BMI 30 − 34 and 76 − 100% for all women >45 years (p<.005). The development of customised charts subdivided by age and BMI may be a useful counselling tool and assist in the comparison of rates between units. Impact statement What is already known on this subject? It is well known that along with rising CS rates globally, there have also been significant changes in maternal demographics—with increasing maternal age at first birth and increasing maternal BMI. It is well established that both of these factors affect the rate of CS in a population. What do the results of this study add? This study sought to stratify the CS rate in nulliparous women by age and BMI to determine if any difference existed. The results of the study showed an increasing CS rate for increasing age and BMI categories that was statistically significant. What are the implications of these findings for clinical practice and/or further research? Additional research using larger population data sets could allow the development of customised charts for nulliparous women subdivided by age and BMI which could act as a useful counselling tool in clinical practice, as well as assist in the comparison of CS rates between units.

Repeat Caesarean Sections: Complications and Outcomes

Background: The rising incidence of caesarean section all over the world has been of great concern both to the patients and obstetrician.1 Repeat caesarean section is one of the major reasons which have contributed greatly to high caesarean section (CS) rate.1,2 Although maternal death as a result of CS is now rare, reports of the short-and long-term consequences of the rising CS rate on the childbearing population are conflicting.3 Available data show that repeat caesarean section is associated with many maternal complications, specially intra-abdominal adhesions, central placenta praevia, uterine rupture, caesarean scar pregnancy, caesarean hysterectomy etc.4&#x0D; Objective: To evaluate outcome and complications of multiple repeat caesarean section.&#x0D; Methodology: This was a cross sectional prospective study conducted in Shaheed Suhrawardy Medical College Hospital (ShSMCH) from 1st June’2016 to 30th November’2016 for a period of six months. The study population were 102 patients, selected randomly who were admitted in ShSMCH for repeat caesarean section.&#x0D; Results: Out of 102 patients admitted with history of previous caesarean section, maternal morbidity was 26 (25.49%), which includes intra-abdominal adhesions 19 (18.62%), excessive blood loss 6(5.88%), placenta praevia 4 (3.94%), placenta accreta 1 (.98%), postpartum haemorrhage 11 (10.78%), wound infection 12 (11.76%) etc.&#x0D; Conclusion: As the rate of repeat caesarean section continue to rise, surgeons should be more judgemental in doing caesarean section.&#x0D; J Shaheed Suhrawardy Med Coll, December 2018, Vol.10(2); 74-79

Caesarean section rate and postnatal bed occupancy: a retrospective study replacing assumptions with evidence

BackgroundObstetric units across the UK face resource pressures alongside a rising rate of Caesarean section (CS). It is assumed that this places a further burden in the form of postnatal bed demands. The number of inpatient beds has fallen nationally, and this may be used to justify attempts to restrict the CS rate. We set out to replace such assumptions with evidence. We did not find any similar contemporary analysis in a literature search.MethodsThe postnatal length of stay (LOS) of women delivering at Watford General Hospital, a large unit hosting around 5500 deliveries per annum, was stratified by mode of delivery. Differences within and across time periods were analysed.ResultsThe CS rate rose from 14.5% in 1995 to 30.9% in 2015. The mean LOS post-CS declined from 4.2 to 2.4 days. These data were statistically significant to p < 0.001. Over this period the standardised total postnatal bed use for all delivery modes fell from 11083 days to 7894 days. A 113% rise in the CS rate was accommodated by only a 19.8% rise in postnatal bed use attributable to CS patients.ConclusionsWhatever pressures may be exacerbated by the rising CS rate, bed occupancy is not one of them. In discussion we widen our argument to suggest that resource pressures should not be used to justify limitations in the CS rate.

Rising Cesarean Section Rates in Nepal: Question of safety and Integrity on Obstetric Emergency Practice

Rising Cesarean Section Rates in Nepal: Question of safety and Integrity on Obstetric Emergency Practice

Rising Cesarean Section Rates: A Tertiary Hospital Perspective

Rising Cesarean Section Rates: A Tertiary Hospital Perspective

Development and Measurement of Guidelines-Based Quality Indicators of Caesarean Section Care in the Netherlands: A RAND-Modified Delphi Procedure and Retrospective Medical Chart Review.

BackgroundThere is an ongoing discussion on the rising CS rate worldwide. Suboptimal guideline adherence may be an important contributor to this rise. Before improvement of care can be established, optimal CS care in different settings has to be defined. This study aimed to develop and measure quality indicators to determine guideline adherence and identify target groups for improvement of care with direct effect on caesarean section (CS) rates.MethodEighteen obstetricians and midwives participated in an expert panel for systematic CS quality indicator development according to the RAND-modified Delphi method. A multi-center study was performed and medical charts of 1024 women with a CS and a stratified and weighted randomly selected group of 1036 women with a vaginal delivery were analysed. Quality indicator frequency and adherence were scored in 2060 women with a CS or vaginal delivery.ResultsThe expert panel developed 16 indicators on planned CS and 11 indicators on unplanned CS. Indicator adherence was calculated, defined as the number of women in a specific obstetrical situation in which care was performed as recommended in both planned and unplanned CS settings. The most frequently occurring obstetrical situations with low indicator adherence were: 1) suspected fetal distress (frequency 17%, adherence 46%), 2) non-progressive labour (frequency 12%, CS performed too early in over 75%), 3) continuous support during labour (frequency 88%, adherence 37%) and 4) previous CS (frequency 12%), with adequate counselling in 15%.ConclusionsWe identified four concrete target groups for improvement of obstetrical care, which can be used as a starting point to reduce CS rates worldwide.

Caesarean section should be available on request: AGAINST: Women need accessible evidence‐based information on caesarean section

Since the 1960s, worldwide trends have shown a dramatic rise in caesarean section (CS) rates, but with considerable variation between countries (0.4–46%) and healthcare settings (WHO Background Paper, 30). The contribution of CS on maternal request (CSMR) to overall CS rates ranges from 1–48% in public sector, and 60% in private sector healthcare systems, but diffferences in how CSMR is recorded limit reliability [Lavender et al., Cochrane Database Syst Rev 2012;(3):CD004660]. CSMR that are not medically indicated can do more harm than good, and should not be available ‘on demand’. A more woman-centred and evidence-based approach to maternity care is needed. FIGO has stated that CS without medical indication is ‘ethically unjustified’. Updated NICE clinical guidelines (CG132) have given more weight to CSMR: ‘if after discussion and support vaginal delivery remains unacceptable to a woman CS should be offered’. However, the RCOG emphasises that this is not a reason for CS being available ‘on demand’. Three primary reasons for CSMR exist (D'Souza, Best Pract Res Clin Obstet Gynaecol 2013;27:165–77): However, maternal case–fatality rates are estimated to be three times higher for CS than VB (Hall and Bewley, Lancet 1999;354:776). Moreover there are considerable short and long-term risks for mothers (increased anaesthetic risks, surgical complications, blood loss and pulmonary embolisms) and babies (increased neonatal admission, respiratory problems and stillbirth in the next pregnancy) [Lavender et al. Cochrane Database Syst Rev 2012;(3):CD004660]. Although we cannot accurately quantify the clinical impact of CSMR, these risks must not be overlooked. Clinical guidelines emphasise the importance of assessing the risk and benefits to mother and baby when considering CSMR. Given the balance of risks and benefits ACOG proposes that in the absence of maternal or fetal indications, a planned VB is the safest and most appropriate recommendation. We need to ask: ‘is the most appropriate response to psychological distress to offer surgery that carries risks for mother and baby?’ Tocophobia can be effectively treated with psychological therapies (up to 86% of women receiving therapy choose to have a VB (Nerum et al., Birth 2006;33:221–8). Therefore, an interprofessional approach to supporting women with tocophobia is needed, rather than simply offering CSMR. In some cases, psychological support will be insufficient to allay fears and a CS may be indicated. A woman's preference for a VB after a previous CS (VBAC) is greatly reduced (Mazzoni et al., BJOG 2011;118:391-9). However, previous CS should not dissuade women from choosing VBAC, or healthcare providers from offering it. VBAC is considered a safe option for the majority of women; 60–80% of women pursuing a VBAC will be successful (Obstet Gynecol 2010;115:1279–95). Planning a VBAC can be a difficult decision for women and additional support and information on associated risks and benefits should be provided. Health system factors are often neglected in this debate. A recent WHO World Report (Background Paper 29) implied that a demand-driven model exists, as regardless of medical need, the greater the capacity is to deliver surgical obstetric procedures, the more procedures will be delivered. Rising rates of CS have considerable cost implications; in the UK it has been estimated that every 1% reduction in CS could save the NHS ~£5 million (NICE; D'Souza, Best Pract Res Clin Obstet Gynaecol 2013;27:165–77). Healthcare provision should not be withheld on the basis of cost alone but it is impossible not to consider the economic implications of rising CS rates. In sum, rather than offering ‘CS on demand’, women should be offered accessible evidence-based information on CS risks, continuity of obstetric care and interprofessional support. Although we argue against CS on demand, we argue for tailored support and evidence-based information for women requesting a CS. In these circumstances we predict that the proportion of women favouring CS in the absence of medical reasons will decrease. I am grateful to Mary Newburn (Head of Research and Quality, NCT) and Elizabeth Duff (Senior Policy Advisor, NCT) for their helpful comments and feedback on drafts of this article. None declared. ■

The Impact of Payment Source and Hospital Type on Rising Cesarean Section Rates in Brazil, 1998 to 2008

High cesarean section rates in Brazilian public hospitals and higher rates in private hospitals are well established. Less is known about the relationship between payment source and cesarean section rates within public and private hospitals. We analyzed the 1998, 2003, and 2008 rounds of a nationally representative household survey (PNAD), which includes type of delivery, where it took place, and who paid for it. We construct cesarean section rates for various categories, and perform logistic regression to determine the relative importance of independent variables on cesarean section rates for all births and first births only. Brazilian cesarean section rates were 42 percent in 1998 and 53 percent in 2008. Women who delivered publicly funded births in either public or private hospitals had lower cesarean section rates than those who delivered privately financed deliveries in public or private hospitals. Multivariate models suggest that older age, higher education, and living outside the Northeast region all positively affect the odds of delivering by cesarean section; effects are attenuated by the payment source-hospital type variable for all women and even more so among first births. Cesarean section rates have risen substantially in Brazil. It is important to distinguish payment source for the delivery to have a better understanding of those rates.

Mode of Delivery and Offspring Body Mass Index, Overweight and Obesity in Adult Life: A Systematic Review and Meta-Analysis

BackgroundIt has been suggested that mode of delivery, a potentially powerful influence upon long-term health, may affect later life body mass index (BMI). We conducted a systematic review and meta-analysis of the effect of Caesarean section (CS) and vaginal delivery (VD) on offspring BMI, overweight (BMI>25) and obesity (BMI>30) in adulthood. Secondary outcomes were subgroup analyses by gender and type of CS (in-labour/emergency, pre-labour/elective).MethodsUsing a predefined search strategy, Pubmed, Google Scholar and Web of Science were searched for any article published before 31st March 2012, along with references of any studies deemed relevant. Studies were selected if they reported birth characteristics and long-term offspring follow-up into adulthood. Aggregate data from relevant studies were extracted onto a pre-piloted data table. A random-effects meta-analysis was carried out in RevMan5. Results are illustrated using forest plots and funnel plots, and presented as mean differences or odds ratios (OR) and 95% confidence intervals.ResultsThirty-five studies were identified through the search, and 15 studies with a combined population of 163,753 were suitable for inclusion in the meta-analysis. Comparing all CS to VD in pooled-gender unadjusted analyses, mean BMI difference was 0·44 kg·m-2 (0·17, 0·72; p = 0·002), OR for incidence of overweight was 1·26 (1·16, 1·38; p<0·00001) and OR for incidence of obesity was 1·22 (1·05, 1·42; p = 0·01). Heterogeneity was low in all primary analyses. Similar results were found in gender-specific subgroup analyses. Subgroup analyses comparing type of CS to VD showed no significant impact on any outcome.ConclusionsThere is a strong association between CS and increased offspring BMI, overweight and obesity in adulthood. Given the rising CS rate worldwide there is a need to determine whether this is causal, or reflective of confounding influences.Systematic review registrationAn a priori protocol was registered on PROSPERO (registration number: CRD42011001851)

Multidimensional Approaches to Reduce Rising Caesarean Section Rate in Nizwa Hospital

Multidimensional Approaches to Reduce Rising Caesarean Section Rate in Nizwa Hospital

Reasons behind decreasing trends in caesarean section (CS) rates – royal Bolton hospital (RBH)

IntroductionReasons for rising CS rates in the UK include rising maternal age at first pregnancy, improved safety of the procedure, changes in women's preferences and growing proportion of women with...