Letters

Caesarean section controversy

The rate of caesarean sections is not the issue

Brazilian obstetricians are pressured to perform caesarean sections

Women choose caesarean section

A debate is needed on caesarean section rates in India

Elective caesarean can increase the risk to the fetus

Further research is needed on why rates of caesarean section are increasing

Authors' reply

The caesarean culture of Brazil

The rate of caesarean sections is not the issue

EDITORBelizán et al show that the richest countries in Latin America have the highest rates of caesarean section, yet they fail to point out that these countries also have the lowest perinatal, infant, and maternal mortality.¹ Using their figures we found a significant negative correlation between rate of caesarean section and each of these (figure) (perinatal mortality rs=0.498, p=0.035; infant mortality rs =0.506, p=0.032; maternal mortality rs =0.903, p=0.001). This does not prove cause and effect, but their claim that 850 000 excess caesarean sections represent an unnecessary increased risk for women and their babies is speculative.

View larger version (17K): [in this window] [in a new window]   Relation between infant, perinatal, and maternal mortality and caesarean section rate

Rates of caesarean section differ hugely within and between countries and reflect numerous variables. To investigate this area properly we must take an impartial view in order to establish the best principles for practice in each situation. To suggest that one caesarean section rate (15%) is optimal for all populations in all countries cannot be sound.² As found in the United States, the recent drive to reduce the overall rate to 15% is causing problems of its own.³

What matters most is that those women who need a caesarean section get one under optimum conditions and that those who do not need a section get appropriate care and support through labour. Only then will we minimise damage and maximise satisfaction.

Katie Groom, clinical research fellow. 
katie.groom{at}ukgateway.net

Sara Paterson Brown, consultant in obstetrics and gynaecology. 
Queen Charlotte's Hospital, London W6 0XG

Brazilian obstetricians are pressured to perform caesarean sections

EDITORI am a Brazilian obstetrician and have worked for more than 10 years as an "on call" obstetrician. During this time, I have been put under pressure to perform caesarean section many times, from patients, husbands, and relatives. Some unjustified fears cause this situation, including the fear of fetal distress during labour, the notion that labour lasting more than six hours is unbearable for the mother, the fear that a vaginal delivery will ruin the woman's sex life, and the idea that a caesarean section is better and more "modern," since it is the preferred form of delivery for rich women in our country. The patients also want to plan the day of the birth, choosing a relative's birthday or avoiding a holiday, for instance.

I think that the population should be alerted to the risks of unnecessary caesarean sections, including the death of the mother.¹ In some private hospitals, where most patients have their own obstetrician, the rate of caesarean sections reaches 80%.

Luis G A Quadros, visiting professor. 
Department of Obstetrics and Gynaecology, Federal University of São Paulo, Brazil quadros.toco{at}epm.br

Women choose caesarean section

EDITORThe paper by Belizán et al shows the link between gross national product and caesarean sections, indicating that wealthier women are more likely to have caesarean sections.¹

In their commentary to the paper Showalter and Griffin argue for women to have the opportunity to choose caesarean section as the mode of delivering their babies. As the Chelsea and Westminster Hospital is in an affluent area of London, we audited our indications for caesarean section for 1999 to assess the contribution of women's choice to elective caesarean section.

Out of 420 elective caesarean sections (10.6%, from a total of 3971 births) recorded in the planning book in our labour ward, the major indications were previous caesarean section (186, 44%), maternal request alone (no other indication) (59, 14%), and breech delivery (55, 13%). All women who had previously had a caesarean section or who had a breech presentation were given the opportunity to try vaginal delivery, so the ultimate decision in these cases was arguably also maternal request. Thus, 300 (72%) of all our elective caesarean sections were because of either purely or mainly maternal request (7.6% of all births).

It is clear from these data that maternal choice is now a major factor influencing the mode of delivery, at least in affluent areas in the United Kingdom, and should be taken into account in resource planning for the maternity services.

Kathy Eftekhar, medical student. 
University of New South Wales, Sydney, Australia

Philip Steer, head of maternal fetal medicine. 
Imperial College School of Medicine, Chelsea and Westminster Hospital, London SW10 9NH p.steer{at}ic.ac.uk

A debate is needed on caesarean section rates in India

EDITORThe issue of increasing rates of caesarean section, its impact, and methods of control have been well researched and discussed in developed countries. In comparison, work in developing countries is limited. In this context, the study by Belizán et al is relevant and important.¹

In India, unfortunately, we do not have any national estimates of the rate of caesarean section. In fact, hardly any population based data exist in India. We have just reported our observations on the rate of caesarean section from a population based survey in Madras city, India.² This study, the first of its kind in India, was published along with an editorial³ by the National Medical Journal of India, to open up the debate.

Our survey was an expanded programme on immunisation, 30-cluster survey in an urban, educated, middle and upper class population in Madras city. Some 45% of the babies had been delivered by caesarean section. We also found some evidence (though it was not conclusive) that caesarean sections adversely affected breastfeeding practices in this community.

I hope that there will be a wider debate in India on this issue, and that attempts will be made to estimate our national rate. The Latin American study would serve as a useful guide in this effort.

Madhukar Pai, consultant, community medicine and epidemiology. 
Sundaram Medical Foundation, Madras, India madhupai{at}vsnl.com

Elective caesarean can increase the risk to the fetus

EDITORIn their commentary on the paper by Belizán et al Showalter and Griffin correctly identify the recent improvement in the safety of caesarean section and the improvement in birth weight associated with better maternal health and nutrition.¹ In cases where normal vaginal delivery incurs considerable risk to the mother and fetus, elective caesarean section may be justified, but decisions must take into account the risk to the infant associated with delivery before 39 weeks' gestation.

It is now clear that respiratory distress syndrome is indeed seen in "term" infants and is a considerable source of morbidity and mortality in this group.² A recent article by Madar et al shows that mechanical ventilation to treat presumed surfactant deficiency is 120 times more likely to be needed after elective delivery at 37-38 weeks than after delivery at 39-41 weeks.³

We recently revisited this issue as part of a departmental audit. We reviewed those infants born by elective caesarean section at or after 37 completed weeks' gestation who were admitted to the neonatal intensive care unit with a diagnosis of transient tachypnoea of the newborn or respiratory distress syndrome, on the basis of clinical and radiological findings, from 1996 to 1999. A total of 762 elective caesarean sections at term were carried out. Of these, nine infants were admitted to the neonatal intensive care unit with a diagnosis of respiratory distress syndrome (an incidence of 11.8/1000) and 11 with transient tachypnoea of the newborn (an incidence of 14.4/1000). In these 20 infants there were no deaths, although one baby with the respiratory distress syndrome developed pneumothorax. The average admission was 6.9 days for infants with respiratory distress syndrome (range 3-13 days) and 3.6 days for those with transient tachypnoea of the newborn (range 1-9 days).

These findings are consistent with the findings of previous studies⁴ and confirm that babies delivered before 39 weeks' gestation are at increased risk of respiratory distress and that for term infants caesarean section before the onset of labour results in a considerably greater risk of neonatal respiratory morbidity than delivery by any other means. Moreover, the risk of respiratory morbidity is halved with each completed week of gestation between 37 and 41 weeks.

Evidence based guidelines should be established so that when there is no clear benefit to mother or fetus elective caesarean section before 39 weeks' gestation is avoided.

Nilofer Sabrine, specialist registrar. 
Neonatal Unit, South Cleveland Hospital, Middlesbrough TS4 3BW nilofer.sabrine5{at}virgin.net

Further research is needed on why rates of caesarean section are increasing

EDITORBelizán et al's article highlights important health issues which are not confined to Latin America.¹ We have looked at the rates of caesarean section in the United Kingdom for 1993, 1994, and 1997-8. The 1993 and 1994 figures were obtained from the annual statistical returns of the Royal College of Obstetricians and Gynaecologists, and the 1997-8 figures were obtained through a manual search of the Royal College of Obstetricians and Gynaecologists' returns from 221 individual units in the United Kingdom. ^{2 3} The annual returns for 1995 and 1996 are not yet published. The figure compares the rates of caesarean section in Northern Ireland, Scotland, England, and Wales. Clearly, the rates rise over the period studied. If we subject these data to an analysis similar to Belizán's, using the World Health Organization figure of 15% as the maximum desirable rate of caesarean section,⁴ then in 1993 the excess number of caesarean sections in the United Kingdom would have been 4723, and it would have been 5765 in 1994 and 19 470 in 1997-8. The 1997-8 figure may well be an underestimate because only 221 of the units had returned data when we created our database.

View larger version (17K): [in this window] [in a new window]   Caesarean section rates in the United Kingdom

Although we agree that there is an overall increase in rates of caesarean section, unlike the figures for Latin America this increase is consistent for the four countries analysed. The range for rates of caesarean section was 14.33-16.61% in 1993, 15.08-17.19% in 1994, and 18.22-18.97% in 1997-8.

These trends confirm the need for a detailed audit of rates of caesarean sections in the United Kingdom, to identify the reasons for the increase. The audit is being organised by the Royal College of Obstetricians and Gynaecologists. Once the results become available then we will be in a position to target the specific areas that are responsible for any increase in rate of caesarean section and so deal with the issue in a more scientific manner.

M P O'Connell, clinical research fellow. 
W Lindow, senior lecturer in perinatology. 
Hull Maternity Hospital, Hull HU9 5LX

Authors' reply

EDITORWe agree that caesarean section is one of the "most politically fraught of operations"¹ and hope that the different opinions on this issue may contribute to its more rational use.

In ecological studies (as in any study) it is not appropriate to perform statistical analysis without bibliographic or rational support. Populations with better socioeconomic conditions, and therefore higher rates of caesarean section, will generally have better health indicators. We agree that the World Health Organization's suggested figure of a limit of 15% should be analysed and adapted to different scenarios, but to draw attention to problems related to this figure they unfortunately quote an article where the authors gave only their beliefs, with no scientific support.² Everybody agrees with Groom and Paterson Brown that the option is to deliver the best care possible, but everybody knows how difficult it is to achieve and audit the "best care." It is hard to accept that Quadros's figure of 80% for caesarean sections could be associated with good or even sensible care.

We agree with Quadros that people have many beliefs about the benefits of caesarean section, but he should know that in his country those beliefs mainly originate from physicians "justifying" their behaviour and their preference for caesarean section.

We agree with Showalter and Griffin in their commentary to our paper that women should be involved in the decision about mode of delivery.³ However, we consider that the data presented by Eftekhar and Steer should be interpreted with caution. In Latin America at least, doctors strongly influence women's decisions; therefore to distinguish between free maternal choice and maternal choice induced by doctors is difficult.

Pai wishes to improve the information on caesarean section in India. A major weakness of developing countries is a lack of knowledge about their situationand consequently about their main problems and priorities. Improved knowledge about our situation would improve the use of our scarce resources. The epidemic of caesarean sections in countries with so many constraints is an example of how a risky fashion, which has been initiated in countries with more resources, has been translated to the entire population.

José M Belizán, director. 
Fernando Althabe, researcher. 
Fernando Barros, consultant. 
Latin American Centre for Perinatology, Pan American Health Organization, World Health Organization, Montevideo, Uruguay

Sophie Alexander, lecturer. 
Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium

The caesarean culture of Brazil

EDITORLast year the debate on whether women should be charged for a caesarean on request was also aired in the BMJ.¹

As an anthropologist I have spent the past two years researching caesarean section in Vitoria, a coastal city in south east Brazil, where the caesarean rate is currently around 25% in public hospitals and around 98% for women who have access to private medicine (mainly through health insurance schemes). The caesarean culture took hold in Brazil over 30 years ago (in 1970 the caesarean rate was 20.2%).

The reasons are complex and concerned not only with the history of obstetric procedures but also with the following cultural issues specific to Brazil.

• All births are attended by obstetricians; although an increasing number of nurse-midwives are being trained, they find it difficult to obtain employment.
• Obstetricians receive little training and practice in handling even marginally difficult vaginal deliveries because caesarean section rates have been high for so long, and they therefore choose caesareans owing to lack of experience.
• Doctors are currently paid the same rate for a normal vaginal delivery as for a caesarean section by both the public health system and private health insurance schemes; they are, however, not prepared to wait hours for their patients to deliver when they can do a caesarean section in an hour.
• Delivery by caesarean section has a certain status. Brazilian society values modernity and technology highly, and caesarean section is equated with these qualities. Normal delivery is thus seen as "alternative" if chosen by middle class women.
• In Brazil, as in most Catholic countries, the maternal role is revered. However, women's bodies are perceived as sexual rather than maternal and the genitals as being for sexual intercourse rather than for childbearing.

I find it worrying that childbirth in the United Kingdom is being discussed in some of the same terms. In world terms, most European countries are considered as still laying importance on the social and physiological values of normal birth, and it would be ironic if childbirth in the United Kingdom were to follow the Brazilian path, especially with the increase in private medicine. While Brazil is held up as an extreme example, many obstetricians acknowledge the high caesarean section rate, even if they have no intention of trying to reduce it.

Christine Nuttall, independent researcher. 
Rua Dr Dorio Silva 7, Mata da Praia, Vitoria 29066-100, Espirito Santo, Brazil CLNuttall{at}pop.ig.com.br