Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
The high rate of caesarian sections in Brazil is not only doctors' blame
- Luis G A Quadros (20 April 2002)
-
Consumer demand for caesarean section: Problem is global and causes are multiple
- Shashi Tripathi (27 April 2002)
-
Caesarean section (CS) and patient’s demand
- Heloisa Bettiol, Marco A. Barbieri, Antônio A. M. Silva and Roberto J. Rona (17 May 2002)
-
Inconsistent data?
- Milorad Z Letic (22 May 2002)
-
Maternal Request for Caesarean Section
- Michael J. Turner (27 May 2002)
|
|
|||
|
Luis G A Quadros, Consultant Gynaecology Department, Federal University of Sao Paulo
Send response to journal:
|
The high rate of Caesarean sections (CSs) in Brazil reflects not only the obstetrician’s decision, but also the pressure that some patients and relatives put on Doctors, due to the “general belief” that a CS would be better for both the mother and the child. Why do many Brazilian women prefer CSs? Because they fear vaginal delivery, not only due to the pain and discomfort of labour, but also because they are afraid that foetal distress can occur during labour and have the wrong idea that a vaginal delivery will ruin their sexual life! They think that a CS is more "modern" and "safe", since it is the preferred form of delivery for the rich and famous women in our country (like TV artists that schedule their CSs to broadcast it on prime time news). Regarding the obstetricians, of course it is more convenient to make elective CSs, considering that they receive the same (low) payment from health plans when staying long hours beside a patient in labour, and may also reduce the risk of malpractice litigation (that is common in Brazil when some problem occurs during vaginal delivery). To change this scenario, I think that first the population should be alerted about the risks of unnecessary caesarean sections, including the death of the mother, before choosing or accepting to have a CS. Continuing medical education is also crucial, because Brazilian obstetricians common sense is that a CS is usually better that vaginal delivery (that includes episiotomy in most cases). |
|||
|
|
|||
|
Shashi Tripathi, Registrar Stepping Hill Hospital, Stockport
Send response to journal:
|
Dear Editor I read with great interest the article by Béhague et al. It brings to fore a problem, which, as a matter of fact, may be multifactorial in origin, and I believe that the reasons for such a problem vary from place to place. I will like to share my experience in this matter with regard to women in India. It has been my experience over last few years that women from lower socio-economic background still consider caesarean section a “major” surgery and prefer having a normal vaginal delivery, if possible. Moreover, the cost involved and prolonged convalescence, which may affect domestic duties, do also they always consider a factor. On the other hand, more and more educated women from higher socio-economic group are showing a preference for elective caesarean section and the main reasons for this are avoiding a painful delivery, having a “say” in when to have the baby. Some even go to the extent of planning the date of birth of their child on the basis of astrological predictions. Surprisingly, there is also a relatively small group of women in whom the decision is mainly taken by the male partner who does not want to “compromise” his sex life after the normal vaginal delivery. Obviously these reasons are not strong enough to expose a woman to a surgical delivery, if she is capable of having a safe normal vaginal delivery. The published study, while effectively highlighting a current problem, suffers from the fact that it is a small regional study and not true representative of the global pattern of the problem. I believe that a larger multicentre, multiregional study should be undertaken to identify the causes for a recent sudden worldwide rise in the incidence of caesarean sections. It is the duty of the medical fraternity to properly counsel these women and try to cut down the number of unnecessary caesarean sections. Also, there is a need to encourage vaginal birth after previous caesarean section, if possible. Shashi Tripathi MRCOG Stepping Hill Hospital Stockport |
|||
|
|
|||
|
Heloisa Bettiol, Assistant professor University of São Paulo. Avenida Bandeirantes 3900. 14049-900 - Ribeirão Preto, SP, Brazil, Marco A. Barbieri, Antônio A. M. Silva and Roberto J. Rona
Send response to journal:
|
Béhague et al. highlighted the importance of mother’s preferences for CS based on the perception of poor quality of care for vaginal deliveries(1). Data from two birth cohorts born 15 years apart (1978/79 and 1994) in Ribeirão Preto, one of the richest areas in Brazil, showed that CS increased from 30.3% to 50.8%(2). Over the same period, low birthweight increased from 7.2% to 10.6% and preterm births from 7.6 to 13.6%(3). Thus maternal beliefs that CS is good quality care may not be supported by evidence. We were concerned that Béhague et al.(1) did not fully explore the influence of physicians’ convenience on mother’s preferences. In our studies CS was more commonly performed in daylight hours and evenings, among those attended by the same physician in prenatal care and delivery and who had a higher number of antenatal visits(2). Similar results were found in 1997 in São Luís, the capital of Maranhão state, one of the poorest regions in Brazil(4). The CS rate was 33.7% and the risk was higher for primiparous, married and more educated mothers, those attended by the same physician during prenatal care and delivery, deliveries held in private hospitals, daylight hours or evenings, and for those who had adequate prenatal care. These findings are consistent with a recent report showing that despite the higher CS rates among women attended in private sector (72%) than in the public one (31%), nearly all women wanted a vaginal delivery, contrary to popular belief(5). The differences in CS births between the two groups were due to higher rates of unwanted CS among private patients rather than to differences in preferences regarding type of delivery. We believe that Béhague et al’s focus on maternal preferences is dealing with the effect rather than the cause of the problem. Maternal preferences on CS delivery may be related to her perception of doctors’ behaviour during the antenatal and delivery period. Scheduling CS is the manner how obstetricians accommodate their working and leisure time. Although the phenomenon is commoner in private patients, the trend may have a knock-on effect on the socially unprivileged women seeking for what they perceive to be good health care regarding delivery. We believe that efforts should be made to change doctors’ behaviour and the health care context in which they operate. We fear that education alone, regardless of target population, professionals or mothers to be, will be ineffective. Heloisa Bettiol, Assistant Professor
Antônio Augusto Moura da Silva, Associate Professor
Roberto Jorge Rona, Professor
Corresponding author: Heloisa Bettiol. References 1. Behágue DP, Victora CG, Barros FC. Consumer demand for caesarean sections in Brazil: population based birth cohort study linking ethnographic and epidemiological methods. BMJ 2002; 324: 942-5. 2. Gomes UA, Silva AAM, Bettiol H, Barbieri MA. Risk factors for the increasing caesarean section rate in Southeast Brazil: a comparison of two births cohorts, 1978-1979 and 1994. Int J Epidemiol 1999; 28: 687-94. 3. Bettiol H, Rona RJ, Chinn S, Goldani M, Barbieri MA. Factors associated with preterm births in southeast Brazil: a comparison of two births cohorts born 15 years apart. Paediatr Perinat Epidemiol 2000; 14: 30-8. 4. Silva AAM, Lamy-Filho F, Alves MTSSB, Coimbra LC, Bettiol H, Barbieri MA. Risk factors for low birthweight in Northeast Brazil: the role of caesarean section. Paediatr Perinat Epidemiol 2001: 5. Potter JE, Berquó E, Perpétuo IHO, Leal OF, Hopkins K, Souza MR, Formiga MCC. Unwanted caesarean sections among public and private patients in Brazil: prospective study. BMJ 2001; 323: 1155-8. |
|||
|
|
|||
|
Milorad Z Letic, Asst lecturer Department of Biophysics, University School of Medicine, 11 000 Belgrade, Yugoslavia
Send response to journal:
|
Results presented in the article by Béhague et al (1) include tables which seam to contain inconsistent data and if so need either explanation or correction.
When each characteristic in table 1 is considered the sum of numbers of women in each category is supposed to equal 5304 (number of participants). For the characteristic "No of antenatal visits" this sum is 5292 and for the characteristic "Gestational risk" 5303. Characteristic "Parity" records 3444 multiparous women, but the sum of numbers of women in each category for the characteristic "Birth history" (women with previous deliveries namely multiparous) is 3177. There were 80 women in subsample, but for the characteristic "Maternal power" the sum is 78. In table 4 of the version of the article posted on the BMJ website to which the readers of the paper BMJ are also directed some inconsistencies are apparent as well. Total number of women considered for each of the four characteristics: "Family income", "Maternal schooling", "No of antenatal visits" and "Gestational risk" is different being 5190, 4914, 5292 and 5303 respectively. However in the text of the article it is stated that there were 5304 women in the epidemiological sample. Numbers of induced vaginal deliveries in table 4 for mentioned characteristics are 1395, 1433, 1428 and 1433 respectively. Numbers of not induced vaginal deliveries for mentioned characteristics are 2208, 2251, 2247 and 2250 respectively. Therefore total numbers of vaginal deliveries in table 4 considered for mentioned characteristics are 3603, 3684, 3675 and 3683 respectively. Numbers of caesarean sections (induced) for mentioned characteristics are 258, 258, 262 and 262 respectively. Numbers of caesarean sections (not induced) for mentioned characteristics are 1329, 968, 1355 and 1358 respectively. Therefore total numbers of caesarean sections in table 4 considered for mentioned characteristics are 1587, 1230, 1617 and 1620 respectively. In textual part of the article it is stated that number of caesarean sections is 1619. Described inconsistencies are those which have been noticed in portions of data which were analysed. 1. Béhague DP, Victora , Barros FC. Consumer demand for caesarean sections in Brazil: population based cohort study linking ethnographic and epidemiological methods. BMJ 2002; 324: 942-945 |
|||
|
|
|||
|
Michael J. Turner, Consultant Obstetrician & Gynaecologist Dublin, Ireland
Send response to journal:
|
Editor, The paper from Brazil by Dr. Behague and her colleagues confirms the complexity of consumer demand for caesarean section (1). Maternal request for elective section appears to be on the increase, for example, nearly 1 in 5 of elective sections in Scotland were associated with maternal request (2). In England and Wales, 69% of consultant obstetricians surveyed said they would agree to a maternal request and the majority of these claimed their practice had changed recently (3). It is, in my opinion, important to draw a sharp distinction between women requesting elective section who had an adverse experience of childbirth previously, either physical or psychological, and those women who had not. Even though the risks of labour may be low, I believe that it is reasonable for an obstetrician to accede to a maternal request for section if she has been previously traumatised. However, agreeing to the mother's request in normal circumstances may reflect the obstetrician's inability or unwillingness to communicate to the woman the advantages of vaginal delivery. Any increase in the incidence of caesarean section solely for maternal request, when there is no history of obstetric complications, should be a cause for concern. Michael J. Turner, Consultant Obstetrician and Gynaecologist, Coombe Women's Hospital, Dublin 8, Ireland. REFERENCES: 1. Consumer demand for caesarean sections in Brazil: population based birth cohort study linking ethnographic and epidemiological methods. Dominique P. Behague, Cesar G. Victoria, Fernando C. Barros. BMJ 2002; 324: 942-5. 2. Is a rising caesarean section rate inevitable? Wilkinson C., McElwaine G., Boulton-Jones C., Cole S. Br J Obstet Gynaecol 1998; 105: 45-52. 3. Obstetricians say yes to maternal request for elective caesarean section: a survey of current opinion. Cotzias C.S., Paterson-Brown S., Fisk N.M. Eur J Obstet Gynecol Reprod Biol 2001; 97: 15-6. |
|||