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

BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39363.706956.55 (Published 15 November 2007) Cite this as: BMJ 2007;335:1025
  1. José Villar, senior fellow1,
  2. Guillermo Carroli, director2,
  3. Nelly Zavaleta, senior researcher3,
  4. Allan Donner, professor4,
  5. Daniel Wojdyla, statistician2,
  6. Anibal Faundes, professor5,
  7. Alejandro Velazco, director6,
  8. Vicente Bataglia, senior adviser7,
  9. Ana Langer, president8,
  10. Alberto Narváez, senior researcher9,
  11. Eliette Valladares, director10,
  12. Archana Shah, scientist11,
  13. Liana Campodónico, statistician2,
  14. Mariana Romero, senior investigator12,
  15. Sofia Reynoso, investigator13,
  16. Karla Simônia de Pádua, research coordinator5,
  17. Daniel Giordano, computer analyst2,
  18. Marius Kublickas, obstetrician-gynaecologist14,
  19. Arnaldo Acosta, professor15
  20. World Health Organization 2005 Global Survey on Maternal and Perinatal Health Research Group
  1. 1Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Oxford OX3 9DU
  2. 2Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina
  3. 3Instituto de Investigación Nutricional, Lima, Peru
  4. 4Department of Epidemiology and Biostatistics, Faculty of Medicine and Dentistry, University of Western Ontario, London, Canada
  5. 5Centro de Pesquisas em Saúde Reprodutiva de Campinas (Cemicamp), Campinas, SP, Brazil
  6. 6Hospital Docente Ginecobstétrico “América Arias,” La Habana, Cuba
  7. 7Department of Obstetrics and Gynaecology, Hospital Nacional de Itauguá, Itauguá, Paraguay
  8. 8EngenderHealth, New York, NY, USA
  9. 9Fundación Salud, Ambiente y Desarrollo, Quito, Ecuador
  10. 10Universidad Nacional Autónoma de Nicaragua, León, Nicaragua
  11. 11Department of Making Pregnancy Safer, World Health Organization, Geneva, Switzerland
  12. 12CONICET/Centro de Estudios de Estado y Sociedad (CEDES), Buenos Aires, Argentina
  13. 13Population Council Regional Office for Latin America and the Caribbean, Mexico City, Mexico
  14. 14Karolinska Institutet, Stockholm, Sweden
  15. 15Department of Obstetrics and Gynaecology, Universidad Nacional de Asunción, Asunción, Paraguay
  1. Correspondence to: J Villar jose.villar{at}obs-gyn.ox.ac.uk
  • Accepted 9 September 2007

Abstract

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

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

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

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

Main outcome measures Maternal, fetal, and neonatal morbidity and mortality associated with intrapartum or elective caesarean delivery, adjusted for clinical, demographic, pregnancy, and institutional characteristics.

Results Women undergoing caesarean delivery had an increased risk of severe maternal morbidity compared with women undergoing vaginal delivery (odds ratio 2.0 (95% confidence interval 1.6 to 2.5) for intrapartum caesarean and 2.3 (1.7 to 3.1) for elective caesarean). The risk of antibiotic treatment after delivery for women having either type of caesarean was five times that of women having vaginal deliveries. With cephalic presentation, there was a trend towards a reduced odds ratio for fetal death with elective caesarean, after adjustment for possible confounding variables and gestational age (0.7, 0.4 to 1.0). With breech presentation, caesarean delivery had a large protective effect for fetal death. With cephalic presentation, however, independent of possible confounding variables and gestational age, intrapartum and elective caesarean increased the risk for a stay of seven or more days in neonatal intensive care (2.1 (1.8 to 2.6) and 1.9 (1.6 to 2.3), respectively) and the risk of neonatal mortality up 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 of all caesarean deliveries for fetal distress. Such increased risk was not seen for breech presentation. Lack of labour was a risk factor for a stay of seven or more days in neonatal intensive care and neonatal mortality up to hospital discharge for babies delivered by elective caesarean delivery, but rupturing of membranes may be protective.

Conclusions Caesarean delivery independently reduces overall risk in breech presentations and risk of intrapartum fetal death in cephalic presentations but increases the risk of severe maternal and neonatal morbidity and mortality in cephalic presentations.

Footnotes

  • We thank P Bergsjö, E O Akande, and D Oluwole, who participated during the preparatory phase of the survey and provided advice and support during its implementation; S Marthinsson for technical support to the on-line data entry system; M E Stanton and P F A Van Look for continuous support for the survey; M Taljaard for her statistical comments on an advanced version of the manuscript; and I MacKenzie for his ideas for the intended method of delivery analysis.

    Steering committee: A Faundes (chairman), L S Bakketeig, E O Akande, A Kosia, A Langer, G Carroli, P Lumbiganon, D Oluwole, M Lydon-Rochelle, ex officio J Villar, A Shah, L Campodónico (regional data manager), D Giordano, J Villar, A Shah.

    Data analysis subcommittee: D Wojdyla, J Villar, A Donner, M Taljaard, L Campodónico, F Burgueño, R Zanello.

    Country collaborators

    Argentina: M Romero, M Molinas, B Petz; R Votta, R Winograd, S Bulacio (Hospital General de Agudos “Cosme Argerich”); P Saposnik, N J Bruno, L Acuña, M Pared, G Perez Giambriani (Hospital General de Agudos “José María Penna”); P Justich, R Luca, S Mazzeo, M Marinelli (Hospital General de Agudos Donación F Santojanni); J D Argento, L Flores, M V Secondi (Hospital Materno Infantil Ramón Sarda); J Falcón, A Brondolo, G Musante (Clínica y Maternidad Suizo Argentina); A Lambierto, J Pascual, H Bergondo, L Bouyssounadea Agüero (Sanatorio Otamendi); H Marchitelli, L Otaño, M Sebastiani, J Ceriani Cernadas, J Saadi (Hospital Italiano); R Rizzi; M E Jofre, D Cerda, MF Rizzi (Hospital Universitario de Maternidad y Neonatología); H E Bolatti, L M Ramallo, J Mainguyague, F Crespo Roca (Hospital Materno Neonatal); M J Figueroa, J M Olmas, E Villar, J Oviedo, Z Maldonado, V González, M I Viale, P Feier, L Rodriguez, F Rolon, C Barbieri, M García Salguero (Hospital Materno Provincial); F Andion, P Panzeri (Hospital Misericordia); J Nores Fierro, M Jofre, D Santoni, I Maggi, F Bazan Flett, S Aodassio, L Ret Davalos, G Goldsmorthi (Sanatorio Allende Privado Cordoba); R T Garcia; S M Adla, A Gomel, S S Cataldi, J Mema, R Segura, M Chandia, S Guzman, S Montecino, V Villanueva, S Ciancia, C Pepino, M A Rolon, M C Uria, A Moreno, A B Pedron (Hospital Area Programa “Dr Francisco López Lima”); S S Parsons, MI Giraudo, N N Rebay, NB Menna, J Cortés Alvarado, C M Gonzalez (Hospital Area Programa “Dr Ramón Carrillo”).

    Brazil: A Faúndes, K S de Pádua, M J D Osis, A H Barbosa, O B Moraes Filho, J Nunes, C Barros, V Zotareli (Centro de Pesquisa em Saúde Reprodutiva de Campinas, Cemicamp); L D C da Motta, J P da Silva Netto, A H Barbosa, H M Nishi, C A N Neves, R C Viana, J Alves Neto, A S Carvalhinho Neto, C K Hueb, C Mariani Neto, E Santana, M Ymayo, R Abreu Filho, R A A Prado, C F G Gonçalves, R C V Valverde, E Araújo Filho, A I de Souza, O B Moraes Filho; A R Batista, B P P Antunes, D Gomes, M Vieira, R G Vasconcelos, J P da Silva Netto, A A Rezende, C A A Rocha, C M da Silva, G Marcelo, M Arcanjo, L C Muniz, L Mondes, M S Barros, E T Rodrigues, R C Viana, M B Dal Cal, M R Ramalho, R M Teixeira, E M Martin, D F Noventa, A L F Gonçalves, S M Nascimento, A C Oliveira, M C Bernardo, F T Santos, C S Moreno, A Vidal, D A M de Souza, G A C Ângelo, R L Garcia, R Carrasco, R Iannitta, L C Motta, L F Ripino, A G R Berrocoso, J L Caneppele, R P de Souza, A A de Oliveira, P C Gonçalves, G B dos Santos, A K Malaquias, F R B Silva, L S Viegas, M I M da Silva, R H M Kubota, V D Fogaça, D B B Ziziotti, R Buonacorso, K C G da Silva, V P da Silva, C F G Gonçalves, M D Silva, M F S Araújo, T L C Fernandes, R C V Valverde, C F V dos Santos, A C F de Figueiredo, A F F de Albuquerque, I F de Melo, R L C de Lima, G de Moraes, M C Beuquior, R Alves.

    Cuba: A Velasco Boza, U Farnot, J Martinez, A Rguez Cárdenas (Hospital America Arias); A Ortusa Chirino (Hospital Ramon Gonzalez); D Dueñas (Hospital Materno 10 de Octubre); C R Fuentes Paisán (Hospital Enrique Cabrera); V Hojoy Rivalta (Hospital Eusebio Hernandez); I Barrio Rivero (Hospital Materno Guanabacoa); C M Corral Marzo, I Díaz García (Maternidad Norte Tamra Bunke); Y Fayat Saeta (Hospital General Santiago); M Vensan Massó (Maternidad Sur Mariana Grajales); B Filgueira Argote (Hospital Orlando Pantoja Tamayo); L Vázquez Fernández (Hospital Palma Soariano); L Munder Benítez (Hospital General San Luis); E Verdecia; J P Martínez Silva (Hospital Vladimir I Lenin); J Martínez Rodriguez (Maternidad Infantil Banes); L Vega Estévez (Hospital Martires de Mayari); E Abad Brocard (Hospital Guillermo Luis); J Hiraldo Martínez (Hospital Juan Paz Camejo).

    Ecuador: R Cantos; I Cantos, A Quevedo, K Márquez, J González, N Rosales (M E Sotomayor); M Falcones (Hospital Guayaquil); R Cordero (Hospital Mat Guasmo); I Guerra (Hospital Mariana de J); M Palma (Hospital Libertad); H Orrala (Hospital Salinas); C Velasco (Hospital Milagro); F Barba; N Carrión (Hospital Isidro Ayora); N Ochoa (Hospital Isidro Ayora); P Ordóñez (Hospital Civil de Macara); L Astudillo (Hospital Vilcabamba); S Hidalgo (Hospital IESS y Clínica S José); P Jácome; A Villacrés, F Reyes, P Basantes (Hospital Mat Isidro Ayora); E Amores (Hospital Enrique Garcés); N Amores, M Duran, C Hinojosa, R Villalba (Hospital Enrique Garcés); F Delgado, A Estrada, A Meza (Hospital Pablo A Suárez); N Laspina (Hospital Patronato San José); V Dávalos (Hospital Del IESS); M Cortés (Hospital Del IESS); P Narváez, H Pozo (Funsad); A Narváez (MSP); B Vera (Funsad); N Pozo (MSP).

    Mexico: E Becerra Muñoz, P Cruz Garcia, M G Santiago Ramos, M G Lizaola Díaz (Hospital Materno Infantil de Inguarán); C Vargas Garcia, M López Maldonado, A González Galavíz (Hospital de la Asoc Hispano Mexicana CIMIgen Tláhuac); J L Garcia Benavides, A Gómez Mendieta, L M Alvarado Bárcenas, M L León Hernández, C Espinoza De los Monteros y Guzmán, M Ruíz Muñóz (Hospital de la Mujer); O A Martínez Rodríguez, I Peralta García, S Hernández Porras, E Nava Granados, P Pineda López, J Pozos Garcia (Hospital La Raza IMSS); J C Izquierdo Puente, M Moreno Camacho, R Sauer Ramírez, G Jiménez Solís, J A Ayala Méndez, A L Lara González, M Villa Guerrero, R M Arce Herrera (Hospital Dr Luis Castelazo Ayala); M T Martínez Meza, M Díaz Sánchez, A F Vargas, J A Martínez Escobar, P Pérez Bailón, E López González, O D Balvanera Ortiz, L del Carmen Alvarado Vilchis, M T Valencia Villalpando, M C Rodríguez Sánchez, J A Vázquez Garcia, G Tinoco Jaramillo, A A Santos Carrillo, R M Toledano Cuevas, R J Jasso Ramos, J Ruíz Cristóbal, G Torres Palomino, É E Ochoa Ruíz, L Pérez Rodríguez, R Quizaman Martínez, O Ramírez Garcia (Hospital del Paso y Troncoso); (Guanajuato) E Lowenberg Fabela, E Lowenberg Bolaños, E Mares Martínez (Hospital Tehuantepec); J J Rios, A Patiño Ramirez, A Meneses Rivas, C D Tafoya Zavala, J I Durán Bañuelos, A Vega Negrete, S Vázquez González, V H Rocha Ortiz (Hospital General de Zona No 2 Irapuato IMSS); R M Zavala Gónzález, D Flores Hernández, J Manríquez Mejía, Y Espinoza Balcazar, R Rivera Colín, C Guadiana Pantoja, R López Aguilera, R Valencia Escogido, I Torres Aguirre, G Jiménez Cervantes, E Badillo Garza, M de los Angeles Rivera Rayón, M P Almaguer Ibarra, D A Jaime Trujillo, JL Arteaga Domínguez, M Tinajero Ramítez, M Del Rosario Pérez Roque, R Herrera Patiño (Hospital General de Zona No 4 Celaya); L M Vera Candanedo, MA Ramírez López (Hospital General de Zona No 3 Salamanca) A Estrada Escalante, L Fernando Huerta, F J Avelar Ramírez, V Godínez (Hospital de Gineco Pediatría No 48); M de Gracia Roque Díaz de León, R Garcia Araujo, J R Torrero Solorio (Hospital General de Irapuato); T Puga Rodríguez, JA Vázquez Rojas, M de la Luz Ruíz Jaramillo (Hospital General de León); M M Moraila Ochoa, J de Jesús Rivera Huerta, Enf Liliana Herrera Santana, José Alfredo López, Enf Norma Leticia Morales Serrano, Enf Rosa Elena Rodríguez Sahui (Hospital General del Estado); F Castillo Menchaca, L Pérez Perales, JL Barrera Azuara, M A Robles Mejia (Hospital General de Tampico); V Garcia Fuentes, G García Salinas, R I Ayala Leal, E Romero Alvarez, O Sepúlveda Ruvalcaba, N L Paulín González, L Munguía Rodríguez, L Ramírez Arreola, J A Cerda López, W C Martínez Brambrilia (Hospital General de Matamoros); J G Saucedo Lerma, J A Ramos, M A Sánchez, J A Ramos Flores, J M Compean González, E Ramírez Elías, N Y Montoya Hernández, C O Sosa González, G D Maciel Palos, P Y Cristobal Coronado, E Cavazos Moreno, L De Souza Pagocauco, Y L Cortazo Gómez, L Espino Vázquez, RA Ruíz López, H F Gómez Estrada, J J Flores Pulido, B C Rodríguez López, N Hernández Sánchez (Hospital General de Zona No 15); P Cuauhtémoc Cruz Gómez, C Sánchez Toledo, A M Conti Briceño, M A Alvarez Raso, M A Avila Escobar, A Colas, L F Cuevas Lezama, O Hernández Robles, A Ibarra Rodríguez, R Moctezuma Rodríguez, O M Torres, J M Robles Reyes, E Vázquez Mora, E Bouchan Rivera, F J Camacho González, F E Escobar Loe, M García Guzmán, O A García Ruíz, M L Guemez Rivera, K Guevara González, A L Medina Zaragoza, E I Pérez Cástro, B W Ruíz Hernández (Hospital General Regional No 6); C R Aguirre, J Gutiérrez González, J S Rodríguez Córdoba, C Rangel Aranda, G Bennet Lara, A Velázquez Escamilla, A Bernal Salazar, S Pastor Chao, J Murillo Cruz, N López Garza, F Baeza Estrella, JC Decilos García, E Caro Rojas, L López Hernández, F J Lara Vázquez (Hospital General de Zona No 3); J L Landero Reyes, G Juárez Jiménez, S Gallardo Cruz, C Medeles Gómez, J Pérez Castillo, D E Hernández Caballero, M A Diego Andrade, J M Zamora Cabrera (Hospital General de Zona No 11); U Pizarro Esquivel, G Martínez del Bosque, L R Herrera Pérez, O Pérez Covian, S Márquez de los Santos, T A Rodríguez Parra, G Rodríguez Garza, M S Cabañas Rodríguez, J A Rodríguez García, L Hernández Hernández, A R Gómez González, D González Cruz, M I Castillo Walle, U E Martínez Eufragio, E M Sánchez Mendoza, S Vázquez López, S Castillo Martínez, A Ruíz Lemus, J A Elizalde Barrera, B Márquez Carranza, M Chávez Velásquez (Hospital General de Zona No 13); J Azuara Rebordea, F G Galván González, A Navarrete Escobar, A M Hernández Sánchez, R A Aguirre Ledesma, V Turrubiates Conde; R Rodríguez González, M Díaz Córdoba, I Aquino Cerero, C Mártinez Moreno, R Rodríguez Martínez, S Del R Reynoso Delgado.

    Nicaragua: J Flores Martinez, M Hernandez Muñoz, J J Almendarez (Hospital Fernando Velez Paiz); D Arguello Pallais, V Mantilla, DA Pallais, C Amuretti (Hospital de la Mujer Bertha Calderon Roque); A Villanueva, C Cerrato, J Bonilla Lao (Hospital Aleman Nicaraguense); C E Nicaragua Darce, C E Nicaragua Darce (Centro De Salud Julio Buitrago Urroz); S Benavidez Lanuza, S Benavidez Lanuza (Centro De Salud Yolanda Mayorga); M E Miranda Molina F Guevara Garcia (Hospital Militar Alexandro Davila Bolaños); A Gonazales Rojas (Hospital Escuela Oscar Danilo Rosales Arguello); R Olivas Montiel J Canales (data collector) (Hospital Luis Felipe Moncada).

    Paraguay: C V Urdapilleta, C Wiens, P Palacios, V Battaglia, M V Corna, R Sosa, R Gimenez, R Ruttia, E Szott, C Gonzales, C Godoy, A Acosta.

    Peru: N Zavaleta, M Inga, D Galvez, B Cama, S Rico, C Tizón, T Jara, S Cabrera, J Silva, A Calero, O Chumbe, A Farro, S Palomino, A Iyo, S García-Angulo, A Vereau, R Ponce, B Paredes, R Villalta, O Requena, P Flores, F Sandoval, E Zapata; V Bazul, J Torres, R Chávez, J Arias, R Hinojosa, J Lí, P Wong, C Mendoza, R Rafael, J Ramirez, M Rivera, J Villar, T Hiromoto, C Puescas, M Vásquez, P Pacora, J Alva, E Llanos, R Lip, L Neciosup, B Liñán, R Chambi, M Sialer, M Huatuco; J Arango, L Hernández, G Rojas, J Rodríguez, E Aguirre, C Morales, V Chávez, R Gamarra, E Lazo, S Chávez, L Haro, A Gutiérrez, M P Quiróz, M E Arévalo, L Aquino.

  • Contributors: JV, GC, AF, AD, Leiv Bakketeig and AS were responsible for the idea and conception of the survey. JV, AS, GC, and AD prepared the protocol. LC, GC, JV, and AS supervised and coordinated the survey's overall execution in the Americas Region. DW, LC, JV, AD, DG, and MK were responsible for data management. DW, AD, and JV conducted the analysis. EV, NZ, AV, VB, AL, AN, MR, SR, KSdeP, and AA collaborated in the preparation of the protocol and the survey and implemented it in their respective countries; they actively contributed to the overall undertaking of the study. JV, GC, AD, DW, and AF wrote this paper with input from all the investigators. All the investigators read the report and made substantive suggestions on its content. JV is guarantor.

  • Funding: UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research (RHR), WHO, and the US Agency for International Development (USAID).

  • Competing interests: None declared.

  • Ethical approval: The protocol was approved by the research ethics review committee of WHO and that of each participating country

    Provenance and peer review: Not commissioned; externally peer reviewed.

  • Accepted 9 September 2007
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