Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study

doi:10.1136/bmj.39363.706956.55

BMJ, doi: 10.1136/bmj.39363.706956.55, (Published 30 October 2007)

Research

Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study

José Villar, senior fellow¹, Guillermo Carroli, director², Nelly Zavaleta, senior researcher³, Allan Donner, professor⁴, Daniel Wojdyla, statistician², Anibal Faundes, professor⁵, Alejandro Velazco, director⁶, Vicente Bataglia, senior adviser⁷, Ana Langer, president⁸, Alberto Narváez, senior researcher⁹, Eliette Valladares, director¹⁰, Archana Shah, scientist¹¹, Liana Campodónico, statistician², Mariana Romero, senior investigator¹², Sofia Reynoso, investigator¹³, Karla Simônia de Pádua, research coordinator⁵, Daniel Giordano, computer analyst², Marius Kublickas, obstetrician-gynaecologist¹⁴, Arnaldo Acosta, professor¹⁵, World Health Organization 2005 Global Survey on Maternal and Perinatal Health Research Group

¹ Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Oxford OX3 9DU, ² Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina, ³ Instituto de Investigación Nutricional, Lima, Peru, ⁴ Department of Epidemiology and Biostatistics, Faculty of Medicine and Dentistry, University of Western Ontario, London, Canada, ⁵ Centro de Pesquisas em Saúde Reprodutiva de Campinas (Cemicamp), Campinas, SP, Brazil, ⁶ Hospital Docente Ginecobstétrico "América Arias," La Habana, Cuba, ⁷ Department of Obstetrics and Gynaecology, Hospital Nacional de Itauguá, Itauguá, Paraguay, ⁸ EngenderHealth, New York, NY, USA, ⁹ Fundación Salud, Ambiente y Desarrollo, Quito, Ecuador, ¹⁰ Universidad Nacional Autónoma de Nicaragua, León, Nicaragua, ¹¹ Department of Making Pregnancy Safer, World Health Organization, Geneva, Switzerland, ¹² CONICET/Centro de Estudios de Estado y Sociedad (CEDES), Buenos Aires, Argentina, ¹³ Population Council Regional Office for Latin America and the Caribbean, Mexico City, Mexico, ¹⁴ Karolinska Institutet, Stockholm, Sweden, ¹⁵ Department of Obstetrics and Gynaecology, Universidad Nacional de Asunción, Asunción, Paraguay

Correspondence to: J Villar jose.villar{at}obs-gyn.ox.ac.uk

Objective To assess the risks and benefits associated with caesareandelivery compared with vaginal delivery.

Design Prospective cohort study within the 2005 WHO global surveyon maternal and perinatal health.

Setting 410 health facilities in 24 areas in eight randomlyselected Latin American countries; 123 were randomly selectedand 120 participated and provided data

Participants 106 546 deliveries reported during the three monthstudy period, with data available for 97 095 (91% coverage).

Main outcome measures Maternal, fetal, and neonatal morbidityand mortality associated with intrapartum or elective caesareandelivery, adjusted for clinical, demographic, pregnancy, andinstitutional characteristics.

Results Women undergoing caesarean delivery had an increasedrisk of severe maternal morbidity compared with women undergoingvaginal delivery (odds ratio 2.0 (95% confidence interval 1.6to 2.5) for intrapartum caesarean and 2.3 (1.7 to 3.1) for electivecaesarean). The risk of antibiotic treatment after deliveryfor women having either type of caesarean was five times thatof women having vaginal deliveries. With cephalic presentation,there was a trend towards a reduced odds ratio for fetal deathwith elective caesarean, after adjustment for possible confoundingvariables and gestational age (0.7, 0.4 to 1.0). With breechpresentation, caesarean delivery had a large protective effectfor fetal death. With cephalic presentation, however, independentof possible confounding variables and gestational age, intrapartumand elective caesarean increased the risk for a stay of sevenor more days in neonatal intensive care (2.1 (1.8 to 2.6) and1.9 (1.6 to 2.3), respectively) and the risk of neonatal mortalityup to hospital discharge (1.7 (1.3 to 2.2) and 1.9 (1.5 to 2.6),respectively), which remained higher even after exclusion ofall caesarean deliveries for fetal distress. Such increasedrisk was not seen for breech presentation. Lack of labour wasa risk factor for a stay of seven or more days in neonatal intensivecare and neonatal mortality up to hospital discharge for babiesdelivered by elective caesarean delivery, but rupturing of membranesmay be protective.

Conclusions Caesarean delivery independently reduces overallrisk in breech presentations and risk of intrapartum fetal deathin cephalic presentations but increases the risk of severe maternaland neonatal morbidity and mortality in cephalic presentations.

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Read all Rapid Responses

A prospective study is still needed: Maureen Treadwell
bmj.com, 1 Nov 2007 [Full text]
Definition of "elective" is misleading: Amy B. Tuteur, et al.
bmj.com, 2 Nov 2007 [Full text]
Avoid interfering with physiology when possible: David JR Hutchon
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Term and preterm deliveries: Gordon C S Smith
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Not much help, really: Robert G Buist
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Somewhat misleading: Zhong-Cheng Luo
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Caesarean section risks and maternal choice: Jonathan H West
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Elective Caesarean section safest form of childbirth: Michael P Wyldes
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Anesthesia Effects: Martin Dauber
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