Editorial

What is the right number of caesarean sections?

Most maternal deaths occur in low-income countries where access to appropriate medical care is restricted.

To evaluate rates of cesarean deliveries and identify barriers to this mode of delivery in low-income countries.

A review of Medline and PubMed was performed to identify reports published in English or French using the keywords “cesarean section,” “maternal mortality,” and “developing countries.”

Studies investigating the obstacles to cesarean delivery and plans to overcome them in low-income countries were included.

Data from included studies were extracted and analyzed.

Studies from 16 countries in Sub-Saharan Africa were included. The average rate of cesarean delivery was 3.6% (range 1.5%–7.1%). The rate was negatively correlated with the maternal mortality ratio (r = –0.63; P = 0.005), neonatal mortality rate (r = –0.81; P < 0.001), and infant mortality rate (r = –0.80; P < 0.001). Major barriers to achieving higher rates of cesarean deliveries include poverty, limited access to healthcare services, and a shortage of skilled providers.

Maternal and infant mortality rates could be lowered by increasing access to cesarean delivery. Additional education of patients and providers, establishment of more heath facilities, and governmental support of obstetric care could help to reach this goal.

Identificar los grupos de mujeres en los que cambian las tasas de cesáreas durante dos periodos comparativos.

Revisamos los partos del Hospital de Manacor en 2000-1 y 2005-6, mediante el análisis retrospectivo de las historias clínicas, agrupándolos según la Clasificación de Robson.

El porcentaje de cesáreas aumentó del 14 al 18,6%, con un incremento significativo entre las mujeres con feto único en cefálica a término inducidas, o sometidas a cesárea electiva, que son quienes más contribuyen al porcentaje de cesáreas del hospital.

Ha aumentado el porcentaje de cesáreas. Con la Clasificación de Robson sabemos qué pacientes contribuyen a ese incremento.

To identify groups of women with changes in cesarean rates in two different periods.

Deliveries in the Manacor Hospital in 2000-2001 and 2005-2006, were analyzed through a retrospective review of clinical records and were grouped using Robsońs classification.

The cesarean rate increased from 14 to 18.6% with a statistically significant increase among women with a single cephalic pregnancy at term who underwent labor induction or elective cesarean section. These two groups were the major contributors to the cesarean rate at our hospital.

A trend towards an increase in the rates of cesarean section was found during the study period. Robson's Classification allowed us to identify the groups of women contributing to this increase.

In India, as in other parts of the world with high birthrates, there is an imbalance between maternal expectations and provision of labor pain services. Maternal experience may have an impact on attitudes toward the mode of future deliveries and on cesarean section rates. Maternal expectations regarding labor and delivery, and attitudes towards cesarean section were assessed in women of mixed parity during an antenatal visit at a charitable non-governmental hospital in Calcutta.

Structured interviews based on a questionnaire were conducted with 205 women.

The majority of the 205 women were nulliparous (71%); the average previous cesarean section rate among the parous minority (29%) was 38.8%. Expectation of labor pain was very common. In the absence of an idea of its severity (78%), a majority were ready to tolerate it as a natural phenomenon (71%). For most interviewees, information about epidural labor analgesia was new (97%), although they were prepared to ask for effective pain relief (98%) and pay for epidural analgesia, if available (95%). Nearly a quarter (24%) of subjects considered cesarean section as an option to avoid labor pain, while most (99%) perceived cesarean section to be safer for the baby than vaginal delivery.

This study indicates that information on what to expect during labor and delivery, the potential role of epidural labor analgesia, and the impact of cesarean section on neonatal outcome should be the focus of services instituted to improve antenatal and perinatal care.