New Evidence on Cesareans

Issues surrounding cesarean delivery feature in much of this issue of Birth. Several studies, a meta-analysis, a critical review of the literature, and an “In the Literature” commentary on the topic are included. This emphasis reflects the ongoing concern of researchers and practitioners worldwide about the epidemic of cesarean sections and the factors that have contributed to it. Green and Baston’s study, conducted in the United Kingdom, asks if women have become more willing to accept obstetric interventions and whether this factor may relate to mode of birth. They compared data collected in a 1987 study of 512 women with data collected on 977 women in 2000, and found that a shift had occurred between the two time periods toward a greater willingness of women to accept obstetric interventions, and that this attitude was related to a nearly twofold increase in having an operative or instrumental birth. Interestingly, epidural analgesia use was strongly related to mode of birth, in that women who received an epidural had a much higher odds of an operative or instrumental birth compared with those who did not receive an epidural. They conclude, therefore, “the findings suggest that epidural analgesia use mediates the link.” The study in Lebanon by Tamim and colleagues for the National Collaborative Perinatal Neonatal Network examined rates and predictors of cesarean delivery among 6,668 nulliparous women in 9 hospitals in Beirut. As in most other countries, cesarean section rates have increased in Lebanon. The authors found that one hospital (the control hospital) had a cesarean section rate of 12.5 percent, thereby meeting World Health Organization criteria for an acceptable rate (10–15%). In this hospital, midwives attended all laboring women and most physicians were females in contrast to the other 8 hospitals in which more male obstetricians practiced. The control hospital showed “no compromise in neonatal outcome.” The cesarean section rates in the other 8 study hospitals ranged from 25.2 to 42.2 percent. The authors reported that predictors of cesarean delivery in the 8 study hospitals were male obstetrician gender, day of the week (fewer cesareans on weekends), women who had private insurance, and women who had public insurance. Gagnon, Meier, and Waghorn’s investigation in Montreal, Canada, studied continuity of nursing care and its link to the cesarean birth rate in a group of 467 low-risk primiparous women. Together with data on length of labor, the authors calculated the proportion of the total labor for which the same nurse was responsible for each woman in labor. By examining patterns of nursing care, the authors reported that each additional nurse responsible for a woman in labor increased her risk of having a cesarean section by 4 to 32 percent, thus concluding that there was an association between the number of nurses caring for a laboring woman and risk of a cesarean delivery. As the authors note, “This study highlights the feasibility and importance of examining the association of nursing care responsibility patterns with health outcomes.” The United Kingdom study of women’s and obstetricians’ perceptions about cesarean section for nonclinical indications, conducted by Weaver, Statham, and Richards, asks “Are There ‘Unnecessary’ Cesarean Sections?” In this quantitative and qualitative study, participants included 64 women who completed an antenatal diary, 44 women and 29 obstetricians who were interviewed, and 785 obstetricians who completed a questionnaire. The study found that only a small minority of women request a cesarean section in the absence of a clinical indication, and such requests most often stemmed from anxiety or fear about the safety of themselves or their baby. Nevertheless, the authors reported, “Maternal request is perceived by obstetricians to be a major factor in driving the cesarean section rate upward.” Chaillet and Dumont in Montreal, concerned at the increase of cesarean deliveries in Canada, have completed a meta-analysis on “Evidence-Based Strategies for Reducing Cesarean Section Rates.” Ten studies were included in the analysis. Audit and feedback, quality improvement, and multifaceted strategies were effective for reducing the cesarean section rate; however, quality improvement based on active management of labor showed mixed effects. With respect to mode of delivery, no differences were found in perinatal and maternal morbidity, and with the exception of 1 study, no significant differences in neonatal and perinatal mortality were found. The authors conclude that the implementation of “complex interventions that involve health workers in analyzing and modifying their practice” can safely reduce the cesarean section rate. Updating the earlier critique of the literature on women’s request for a cesarean section conducted in 2000 by Australians Gamble and Creedy 1, a larger group of researchers from the United Kingdom and Australia, McCourt et al, have critically reviewed the literature on elective cesarean section and decision-making. A total of 17 research articles, using a range of designs and methods, met the criteria for review. The authors concluded that only very small numbers of women requested cesarean sections between the years 2000 and 2005, that maternal choice “does not constitute a major driver for rising cesarean section rates,” and that “a range of personal and societal reasons, including fear of birth and perceived inequality and inadequacy of care, underpinned these requests.” In addition, several studies were found to “conversely suggest that professional perceptions of women’s views, and their own personal preferences, may be emerging as an important factor in decision-making related to mode of birth.” “Patient-Choice Cesarean Delivery: Really a Choice?” is Bernstein’s In the Literature commentary, which reflects on the National Institutes of Health State-of-the-Science Conference report, Cesarean Delivery on Maternal Request 2. He expresses concern that the report’s authors “were so open to allowing for cesareans to be performed without a medical indication.” He expands on the significant risks of repeat cesarean sections, especially placenta previa, placenta accreta, uterine rupture, excessive blood loss, need for hysterectomy, and maternal death, pointing out that these risks rise with each subsequent cesarean. The patient-choice debate is “off target,” Bernstein writes, citing the extremely low number of women requesting a cesarean in a recent United States study 3. In fact, he claims that the elective delivery option “indicates failures of modern medicine and society in general,” and he fears the practice may never be undone. Readers will draw different conclusions from these diverse articles on cesarean delivery. However, some interesting parallels and contrasts are evident. Whereas Weaver et al and McCourt et al agree with the Listening to Mothers II U.S. survey 3 about only very small numbers of women requesting a cesarean with no medical indication, their findings are in contrast with those of the NIH report 2 and the perceptions of obstetricians in Weaver et al’s survey, who see patient requests as the driving force behind the increase in cesarean sections. The converse may be true, since McCourt et al’s review suggests that, instead, physicians’ perceptions of women’s views and physicians’ personal preferences may be factors in driving the rate upward. Women’s anxiety and fears may underlie their requests for a cesarean with no medical indication, according to both Weaver et al’s survey and McCourt et al’s review, and also a recent study by Nerum et al in Birth 4. The finding that higher rates of cesarean delivery do not confer benefit on perinatal and maternal outcomes, according to Tamim et al’s study of 9 Lebanese hospitals and Chaillet and Dumont’s meta-analysis of 10 studies, confirms that cesarean section rates can be reduced safely. Factors identified that contribute to the increase in cesarean deliveries include provider practice preferences and patterns (Tamim et al, Green and Baston, Chaillet and Dumont); type of practitioner and staff patterns (Tamim et al, Gagnon et al); and societal issues (McCourt et al, Bernstein). The studies and reviews in this issue of Birth not only provide new information, but they also confirm what other evidence has long shown. Reducing the cesarean birth rate worldwide is a complex and difficult task that must be tackled on many fronts using multiple strategies. These authors have made that clear.

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