The aim of this letter was a brief literature overview of recent publications on the cesarean section (CS)¹1 Filho MB, Rissin A. WHO and the epidemic of cesarians. Rev Bras Saúde Matern Infant. 2018; 18: 3-4. and cesarean tubal ligation, where CS is combined with tubal sterilization, analyzing this topic from the clinical and demographical viewpoints. The tubal sterilization is a reliable method of birth control. The cesarean tubal ligation has an advantage of avoiding additional incisions and anesthesia.²2 Mahadevappa K, Prasanna N, Channabasappa RA. Trends of various techniques of tubectomy: A five year study in a tertiary institute. J Clin Diagn Res. 2016; 10: QC04-7. A systematic performance of the cesarean tubal ligation could be an efficient birth control method, also counteracting the gender imbalance in some regions. For example, in China, the male-to-female ratio at birth is elevated, while the ratio was reported to increase considerably with the age and number of parities, being very high in non-primipara.³3 Huang Y, Tang W, Mu Y, Li X, Liu Z, Wang Y, Li M, Li Q, Dai L, Liang J, Zhu J. The sex ratio at birth for 5,338,853 deliveries in China from 2012 to 2015: a facility-based study. PLoS One. 2016; 11: e0167575. The gender imbalance at birth was reported also from India and other countries; more details and references are in.⁴4 Jargin SV. Overpopulation and modern ethics. S Afr Med J. 2009; 99: 572-3..⁵5 Jargin SV. Letter to the Editor. Int J Risk Saf Med. 2016; 28 (3): 171-4.

The majority of women are pleased with their decision to be sterilized.⁶6 Contraception by female sterilisation. Br Med J. 1980; 280: 1154-5. Patients are much more likely to regret declining a tubal ligation during unplanned CS (40%) than regret accepting one (2.5%).⁷7 Verkuyl DA. Sterilisation during unplanned caesarean sections for women likely to have a completed family -should they be offered? Experience in a country with limited health resources. BJOG. 2002; 109: 900-4. The female sterilization has been associated with a decreased risk of endometrioid and serous ovarian cancers⁸8 Walker JL, Powell CB, Chen LM, Carter J, Bae Jump VL, Parker LP, Borowsky ME, Gibb RK. Society of Gynecologic Oncology recommendations for the prevention of ovarian cancer. Cancer. 2015; 121: 2108-20. and probably has a positive impact upon sexuality.⁹9 Shah MB, Hoffstetter S. Contraception and sexuality. Minerva Ginecol. 2010; 62: 331-47. The advantage of elective CS is the relatively low risk of fetal injury as well as the negative association with neonatal mortality and morbidity. Some reports on enhanced maternal morbidity and mortality are probably biased as they confound CS with conditions related to maternal death not depending on the mode of delivery.¹⁰10 Kilsztajn S, Carmo MS, Machado LC Jr, Lopes ES, Lima LZ. Caesarean sections and maternal mortality in Sao Paulo. Eur J Obstet Gynecol Reprod Biol. 2007; 132: 64-9..¹¹11 Nomura RM, Alves EA, Zugaib M. Maternal complications associated with type of delivery in a university hospital. Rev Saúde Pública. 2004; 38: 9-15. Accordingly, CS may be a marker of pre-existing morbidities or older age rather than a risk factor of itself.¹²12 Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Cesarean delivery and postpartum mortality among primi-paras in Washington State, 1987-1996(1). Obstet Gynecol. 2001; 97: 169-74. Moreover, in regard to certain maternal complications e.g. pelvic floor injury and urinary incontinence, elective CS was reported to be protective compared to vaginal delivery and emergent CS.¹³13 Salim R, Shalev E. Health implications resulting from the timing of elective cesarean delivery. Reprod Biol Endocrinol. 2010; 8: 68..¹⁴14 Di Stefano M, Caserta D, Marci R, Moscarini M. Urinary incontinence in pregnancy and prevention of perineal complications of labour. Minerva Ginecol. 2000; 52: 307-12. Admittedly, CS is more costly and associated with higher risks in conditions of limited medical facilities. The bleeding associated with CS is a problem that still requires attention; CS is a potential underlying factor in puerperal sepsis, thromboembolism and eclampsia.¹⁵15 Moodley J, Fawcus S, Pattinson R. Improvements in maternal mortality in South Africa. S Afr Med J. 2018; 108(3 Suppl. 1): S4-S8. However, surgical procedures generally tend to improve. In more developed countries, CS is widely regarded as a safe intervention owing to mastered surgical techniques, improved anesthesia, infection and thrombosis prophylaxis.¹⁶16 Stordeur S, Jonckheer P, Fairon N, De Laet C. Elective caesarean section in low - risk women at term: consequences for mother and offspring. Health technology assessment. KCE Report 275, 2016. Finally, granted requests for elective CS were reported to be associated with decreased postpartum depression rates.¹⁷17 Olieman RM, Siemonsma F, Bartens MA, Garthus-Niegel S, Scheele F, Honig A. The effect of an elective cesarean section on maternal request on peripartum anxiety and depression in women with childbirth fear: a systematic review. BMC Pregnancy Childbirth. 2017; 17: 195.

There seems to be some conservatism and bias in favor of vaginal delivery also in the professional literature. For example, it was claimed that the "overuse of SC adversely affects the health of the mother and the child"¹⁸18 Liang J, Mu Y, Li X, Tang W, Wang Y, Liu Z, Huang X, Scherpbier RW, Guo S, Li M, Dai L, Deng K, Deng C, Li Q, Kang L, Zhu J, Ronsmans C. Relaxation of the one child policy and trends in caesarean section rates and birth outcomes in China between 2012 and 2016: observational study of nearly seven million health facility births. BMJ. 2018; 360: k817. with references.¹⁹19 Blustein J, Liu J. Time to consider the risks of caesarean delivery for long term child health. BMJ. 2015; 350: h2410.^,2020 Belizan JM, Althabe F, Cafferata ML. Health consequences of the increasing caesarean section rates. Epidemiol. 2007; 18: 485-6. However, there are no such or similar statements in the articles.¹⁹19 Blustein J, Liu J. Time to consider the risks of caesarean delivery for long term child health. BMJ. 2015; 350: h2410.^,2020 Belizan JM, Althabe F, Cafferata ML. Health consequences of the increasing caesarean section rates. Epidemiol. 2007; 18: 485-6. Analogously, it was stated that "morbidity and mortality [associated with CS is] more often than [that associated with] vaginal delivery"²¹21 Dhai A, Gardner J, Guidozzi Y, Howarth G, Vorster M. Vaginal deliveries - is there a need for documented consent? S Afr Med J. 2011; 101: 20-2. with references, among others, to the sources.²²22 Rageth JC, Juzi C, Grossenbacher H. Delivery after previous cesarean: a risk evaluation. Obstet Gynec. 1999; 93: 332-7..²³23 Hibbard JC, Ismail MA, Wang Y, Te C, Karrison T, Ismail MA. Failed vaginal birth after a cesarean section: how risky is it? Maternal morbidity. Am J Obstet Gynecol. 2001; 184: 1365-71. These articles are about the vaginal birth after SC,²²22 Rageth JC, Juzi C, Grossenbacher H. Delivery after previous cesarean: a risk evaluation. Obstet Gynec. 1999; 93: 332-7..²³23 Hibbard JC, Ismail MA, Wang Y, Te C, Karrison T, Ismail MA. Failed vaginal birth after a cesarean section: how risky is it? Maternal morbidity. Am J Obstet Gynecol. 2001; 184: 1365-71. which is a different topic. An indirect evidence in favor of a biased attitude to CS is the frequently mentioned association of CS with long-term offspring outcomes such as asthma, diabetes mellitus type 1 and gastrointestinal diseases, although the evidence is poor.¹⁶16 Stordeur S, Jonckheer P, Fairon N, De Laet C. Elective caesarean section in low - risk women at term: consequences for mother and offspring. Health technology assessment. KCE Report 275, 2016. The proposed mechanisms through which CS could impact the immune system are obscure and largely hypothetical e.g. impaired bacterial colonization of the intestine.¹⁶16 Stordeur S, Jonckheer P, Fairon N, De Laet C. Elective caesarean section in low - risk women at term: consequences for mother and offspring. Health technology assessment. KCE Report 275, 2016. If it is so indeed, the lacking exposure to certain microorganisms at CS could be compensated by probiotics.²⁴24 Hashemi A, Villa CR, Comelli EM. Probiotics in early life: a preventative and treatment approach. Food Funct. 2016; 7: 1752-68.

Conclusion

The cesarean tubal ligation should be generally considered for women not planning further pregnancies. Certainly, the latest delivery is not necessarily the last one, since circumstances may change after the delivery, including socio-economic settings or death of a child. The age, attitude of the male partner etc. should be taken into account in decisions about recommendations. However, CS on maternal request must be available also in the absence of contraindications for attempting vaginal delivery. This pertains also to Russia, where CS is normally not performed on a maternal request.²⁵25 Likhachev VK. Operative obstetrics with a phantom course. Moscow: MIA; 2014 (Russian). Certain experts reported that they had performed CS on maternal request and that countrywide CS is performed more frequently when the procedure is paid on by patients.²⁶26 Cherhukha EA. Is cesarean section at a pregnant woman's will justified? Akush Ginekol (Mosk); 2002; (6): 3-7 (Russian). Others insist that SC must be done only in accordance with indications. In the author's opinion, the tripling of the global index of deliveries performed by CS over the period 1980-2016 (from 6 to 18.6%)! is a positive development. A more frequent use of the cesarean tubal ligation would be especially favorable for overpopulated regions with a gender imbalance.

References

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History