WASHINGTON, D.C.- The American College of Obstetricians and the Society for Maternal-Fetal Medicine released guidelines on February 19 which aim to decrease the number of cesarean sections (C-sections) in first-time mothers. The majority of C-sections are performed on women delivering their first child in a developed nation. Roughly one-third of American births are through C-section. In the developing world, the procedure is generally less common and in some places, it is rarely even an option.
The new guidelines state that women with low-risk pregnancies should be allowed to remain in labor and try to deliver vaginally for longer than is currently practiced in many hospitals.
C-sections in the United States have increased by 60 percent since the 1990’s, yet childbirth is not significantly safer for mothers or babies. Experts are increasingly discussing whether this trend indicates that the increase in C-sections has been medically unnecessary.
More women in the United States and other developed nations are electing to undergo what is major surgery, which can lead to complications and elevated risk in further pregnancies.
In 1985 the World Health Organization asserted “there is no justification for any region to have caesarean section rates higher than 10–15 percent,” which at the time was considered on the high end of acceptable for C-section rates.
Today, most regions of the developed world, excluding Eastern Europe, have C-section rates higher than 20 percent. At 40 percent, Italy has perhaps the highest rate of any developed nation. In the U.S., the rate is about 33 percent.
In the developing world, elective C-sections are also gaining popularity for people who can afford them.
China has the highest rate of C-section in the world at 46 percent of all births, with about 25 percent of those procedures deemed medically unnecessary. The C-section rate in Vietnam has reached as high as 36 percent.
Bangladesh’s C-section rate is also high, with many women choosing to have C-sections because they fear the pain of child birth and so they can plan the date of their labor. Most of the women getting C-sections in Bangladesh are middle and upper class, but poor women are increasingly electing to get the procedure as well.
Sister Gillian Rose, who runs Bollobhpur Hospital in West Bangladesh, finds the increase in C-sections to be of great concern. She states that doctors at private clinics are telling women that they need C-sections when it is actually medically unnecessary.
“Private clinics are just springing up like the plague with no government regulation, and the doctors basically are getting rich quick,” Rose explains.
A survey of 122 public and private hospitals in nine Asian countries in 2007 and 2008 revealed that 60 percent of hospitals were driven by financial motivations to perform surgeries.
Some Public Health experts also worry about the safety of performing unnecessary surgeries in environments that may lack the sanitary standards of a more regulated and developed health sector.
João Paulo Souza, an obstetrician for the WHO, studies the rising rates of C-sections in developing countries. He states, “In settings where surgery is not safe, what we have been seeing is increased risk of hysterectomy and other severe complications.”
In places like Bangladesh where healthcare can be rationed, another issue emerges surrounding elective C-sections. Dr. Shams El Arifeen, senior health researcher in Dhaka, Bangladesh, asserts that since poorer nations have limited infrastructure to provide safe surgical deliveries, those who actually need C-sections may not be able to get them.
According to the WHO, many nations do not sufficiently provide women who need them with C-sections. Roughly 270,000 women die globally every year during pregnancy and childbirth, and 30 to 60 percent of babies who experience obstructed delivery die. The child mortality rate during obstructed delivery drops to about zero when a C-section is possible.
A 2010 WHO report looked at developing countries and regions where C-sections were very low, such as in Sub-Saharan Africa, where the rate is about 9 percent. The report found that performing 2.8 million more C-sections in 49 countries would save 16,800 women’s lives and would prevent other women from living with chronic disabilities such as fistulas.
The cost of these C-sections would be about $140, with a $6 value earned for every dollar spent. This cost puts C-sections on roughly the same cost-effectiveness as the measles vaccine and HIV/AIDS antiretroviral treatments.
Given the widely disparate availability of C-sections based on which part of the world one lives and how much money one has, Blake Alkire, a clinical surgery fellow at Brigham and Women’s Hospital, emphasizes, “The conclusion is straightforward: surgery, or more specifically in this case, Caesarean delivery, is not a luxury that should be reserved for the developed world.”
– Kaylie Cordingley