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Maternal and fetal risk factors for stillbirth: population based study

BMJ 2013; 346 doi: (Published 24 January 2013) Cite this as: BMJ 2013;346:f108

Re: Maternal and fetal risk factors for stillbirth: population based study

In his Rapid Response above,(1) Dr. Vlachadis talks about the recent increase in Greece’s stillbirth rate. Following an historic low of 3.31 in 2008, by 2010 it had increased by 32% to 4.36. Vlachadis suggests this increase is likely associated with the country’s economic crisis, and increasing numbers of pregnant women being excluded from obstetric care. But there was another, possibly coincidental, occurrence around this time too. In 2008, a concerted effort began to inform Greek women about the benefits of natural birth; a new organization was formed(2), researchers wrote about “the CS epidemic” and “importance of performing more vaginal birth after CS”,(3) and Greek midwives called for “reorganizing the health education antenatal services”; they described “frightened women” as “obedient consumers” who were “products of a technocratic medical system [and] likely to choose intervention”.(4) Three years later, a shift away from intervention was reportedly(2) “not a particularly strong trend”, but shifting “mostly due to the crisis, because some benefits for birth in public hospitals and under the national health system have been cut.”

Certainly the culture of caesarean birth in Greece is somewhat unique. Greek mythology tells the story of Asklepios, the god of medicine whose mother died in labour, but whose father Apollon ‘rescued’ him by cutting him from her womb(5), and the word tokophobia stems from the Greek ‘ tokos’ and ‘phobia’, which mean birth and fear. Most notably, Greece is reported to have very high caesarean rates,* especially in the private sector,(2) but it’s the types of caesareans that is perhaps most interesting. In a 2011 university hospital study,(6) an overall caesarean rate of 29.2% over five years consisted of 18.2% elective and 11% emergency. That’s a reversal of England’s much lower 10.2% elective and higher 14.8% emergency rates,(7) and furthermore, just 6% of births were instrumental deliveries, compared with our 13%. This is important because this Greek hospital is managing to keep its riskiest births to a minimum.

Conversely, the ratio of obstetricians to pregnant women is reportedly far greater in Greece than here, with numbers historically rising alongside a falling birth rate.(8) By comparison, and despite 2004 British research that a “higher intervention score and higher number of consultant obstetricians per 1000 births were both independently and significantly associated with lower stillbirth rates”(9), the UK doesn’t have nearly enough obstetricians, and birth rates are increasing. Finally, Greece has one of the lowest maternal mortality rates in the world, and in 2010, with just 3 deaths per 100,000 live births, it ranked joint second out of 183 countries.(10)

Yet in 2011, an Organisation for Economic Co-operation and Development report began, “caesarean delivery continues to result in increased maternal mortality, maternal and infant morbidity, and increased complications for subsequent deliveries.”(11) In its report, the OECD lists the lowest caesarean rate (14.3%) as being in the Netherlands, and specifically mentions its 30% homebirth rate for “low risk” women. Greece’s caesarean rate is absent from the list, but so is the fact that in 2009, the Netherlands had one of the highest perinatal mortality rates in Europe (9.8 infant deaths in every 1000 live births), and was one of three named countries to have utilized the category of “unknown” most heavily (18.8%), in answer to why maternal deaths occurred.(12)

This is all very important in light of recent maternity care recommendations in the UK, emphasizing the need for higher rates of ‘normal’ birth, and lower rates of medical intervention (unless the intervention aids vaginal birth, i.e. instrumental delivery, but certainly fewer caesareans and epidurals),(13) and the fact that the 2011 Birthplace study, which is being passionately communicated to women to encourage birth outside obstetric units, excludes rates of stillbirth prior to onset of labour.(14)

That said, the decision about when to do a caesarean can undoubtedly be a difficult one; for those women with very high BMIs for example, the 40% and 60% increased stillbirth risk(1) must be weighed against the maternal risks associated with surgery. Similarly, the risk of stillbirth versus preterm morbidity is challenging too. Researchers have described increasing rates of late preterm births in Greece as a “rising concern”, although stillbirth rates fell in a constant way regardless of the maturity index.(15) Meanwhile in the U.S., a policy limiting elective delivery before 39 weeks of gestation “was associated with a small reduction in NICU admissions; however, macrosomia and stillbirth increased."(16)

It is not the aim of this response to present Greece, or high caesarean rates, as an ideal model of maternity care, but rather to highlight the need to look beyond blanket caesarean rates as an inherent value or marker for good health outcomes, and the need for stillbirth research to step outside its comfort zone. Caesarean league tables should be made redundant, unless they can specify emergency and planned rates alongside other critical facts such as perinatal and maternal mortality. And this is because for most women, what matters more than anything else is that their pregnancy ends with a live, healthy baby.

*the European Statistical Data Support Centre of Greece advised me that the country’s caesarean rate is not available through its service.

1) February 4, 2012 Increase of stillbirth rate in Greece.
2) December 8, 2011. “Greece ranks first in the world in number of Caesarean births”, Anastasia Balezdrova. GRReporter
3) Aust N Z J Obstet Gynaecol. 2008 Apr;48(2):142-6. doi: 10.1111/j.1479-828X.2008.00839.x. Current caesarean delivery rates and indications in a major public hospital in northern Greece. Dinas K, Mavromatidis G, Dovas D, Giannoulis C, Tantanasis T, Loufopoulos A, Tzafettas J.
4) Caesarean Section: The Underpinning Choice? Vivilaki, Antoniou. Volume 2, Issue 2 (2008) HSJ
5) The Theoi Project : Greek Mythology. Aaron J. Atsma, Auckland, New Zealand. 2000–2011.
6) Epidemiological Characteristics and Trends of Caesarean Delivery in a University Hospital in Northern Greece. Kalogiannidis et al. WAJM 2011; 30(4): 250–254.
7) Health and Social Care Information Centre HSCIC's NHS Maternity Statistics, 2011-12.
8) *Are Operative Delivery Procedures in Greece Socially Conditioned? Skalkidis et al. IntaMhbnalJorvnol for Qucrliry in Hmlth Cur, Vol. 8, NO. 2. pp. 15%165, 1996 * Eur J Public Health (June 2005) 15 (3): 288-295. doi: 10.1093/eurpub/cki002 First published online: May 27, 2005 An investigation of Caesarean sections in three Greek hospitals. The impact of financial incentives and convenience. E. Mossialos et al.
9) R Joyce, R Webb, and J L Peacock, “Associations between perinatal interventions and hospital stillbirth rates and neonatal mortality,” Archives of Disease in Childhood. Fetal and Neonatal Edition 89, no. 1 (January 2004): F51-56
10) CIA World Factbook - page is accurate as of July 26, 2012
11) OECD (2011), “Caesarean sections”, in Health at a Glance 2011: OECD Indicators, OECD Publishing.
12) Meagan Zimbeck, Ashna Mohangoo, and Jennifer Zeitlin, “The European perinatal health report: delivering comparable data for examining differences in maternal and infant health,” European Journal of Obstetrics, Gynecology, and Reproductive Biology 146, no. 2 (October 2009): 149-151.
13) New RCOG guidance urges CCGs to increase births without epidurals and reduce caesarean rates to 20%. August 24, 2012, published by
14) April 30, 2012 Concerned that flawed analysis may be used to restrict birth choices, Pauline M Hull
15) Preterm birth trends in Greece, 1980- 2008: A rising concern. Baroutis et al. Acta Obstet Gynecol Scand. 2013 Jan 29. doi: 10.1111/aogs.12089.
16) Neonatal Outcomes After Implementation of Guidelines Limiting Elective Delivery Before 39 Weeks of Gestation, Ehrenthal et al. Obstetrics & Gynecology: November 2011 - Volume 118 - Issue 5 - p 1047–1055

Competing interests: Co-author of Choosing Cesarean, A Natural Birth Plan (Prometheus Books 2012) and editor of
14 February 2013
Pauline M Hull
Author and editor
Surrey, UK
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