Cesarean section should only be done when medically indicated: Results from the WHO global maternal survey

January 11, 2010

Data from the WHO global survey on maternal and perinatal health shows that risk of maternal death and serious complications is higher for women undergoing caesarean section that is not medically indicated than for those where there is a medical indication. Thus, to improve medical outcomes, caesarean section should be done only when there is a medical indication. The findings of the survey are reported in an Article Online First (www.thelancet.com) and in an upcoming edition of The Lancet, written by Dr A Metin Gülmezoglu, Department of Reproductive Health and Research, WHO, Switzerland, and colleagues.

The survey took data from nine Asian countries: Cambodia, China, India, Japan, Nepal, Philippines, Sri Lanka, Thailand, and Vietnam. In each country, the capital city and two other regions or provinces were randomly selected. A detailed description of each health facility, and its resources for obstetric care, was obtained. Women's medical records were also scrutinised to summarise obstetric and perinatal events.

Data was obtained for 109 101 of 112 152 deliveries reported in 122 recruited facilities (97% coverage), and 107 950 deliveries were studied. The overall rate of caesarean section was 27.3% . The overall rate of operative vaginal delivery (which includes vacuum and forceps assisted vaginal deliveries) was 3.2%. Risk of maternal mortality and morbidity index (at least one of: maternal mortality, admission to intensive care unit [ICU], blood transfusion, hysterectomy, or internal iliac artery ligation) was increased for both operative vaginal delivery and caesarean section in various scenarios. The increased risk, compared with normal birth, was for operative vaginal delivery 2.1 times, antepartum caesarean without indication 2.7; antepartum caesarean with indication 10.6, intrapartum without indication 14.2; intrapartum with indication 14.5. For breech presentation, caesarean section reduced the risk of perinatal mortality--both for antepartum (by 80%) and intrapartum (by 70%) caesarean deliveries; but caesarean section in this situation also increased risk of stay in neonatal ICU (doubled for both antepartum and intrapartum deliveries).

The authors say: "In the 122 Asian health facilities studied, more than one in four women underwent caesarean section. Facilities in China, Sri Lanka, Vietnam, and Thailand had higher aggregated rates of caesarean section than did those in Cambodia, India, Japan, Nepal, and the Philippines. Operative vaginal delivery and caesarean section were independently associated with increased risk of maternal mortality and morbidity index. Caesarean section without a medical indication was associated with increased risk of maternal mortality and morbidity. Caesarean section for breech presentation was associated with improved perinatal outcomes."

They conclude: "Caesarean section should be done only when there is a medical indication to improve the outcome for the mother or the baby. Women and their carers who plan to undertake caesarean section delivery should discuss the potential risks to make an informed decision if they still wish to have a caesarean delivery."

In an accompanying Comment, Dr Yap-Seng Chong, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, and Dr Kenneth Y C Kwek, Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore, say: "There is little wrong with medical interventions when indicated, but for those who are still inclined to consider caesarean delivery a harmless option, they need to take a cold hard look at the evidence against unnecessary caesarean section."
Dr A Metin Gülmezoglu, Department of Reproductive Health and Research, WHO, Switzerland. T) +41 22 791 3417 E) gulmezoglum@who.int

Dr Yap-Seng Chong, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore. T) +65 98219326 E) obgcys@nus.edu.sg

For full Article and Comment, see: http://press.thelancet.com/whoasia.pdf


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