Malcolm John Dickson consultant obstetrician and gynaecologist, Maheshie Obeysekera specialty trainee year 4 in obstetrics and gynaecology
Dickson M J, Obeysekera M.
When unusual circumstances become accepted as normal
BMJ 2019; 367 :l6990
doi:10.1136/bmj.l6990
C-section in Pakistan; a need or a business
Dear Editor,
Despite global efforts to improve maternal health, many developing countries including Pakistan have failed to achieve the target of a 75% reduction in maternal deaths. Pakistan is the fifth-largest contributor to global maternal mortality where 6% of the world’s maternal deaths occur [1]. The maternal mortality rate in Pakistan is 276 deaths per 100000 live births [2] while maternity-related complications are a major cause of maternal and infant morbidity and mortality [3].
The reduction in maternal mortality observed in high-income countries has been achieved by providing access to skilled care during pregnancy and childbirth and by the provision of safe interventions such as assisted vaginal delivery and cesarean section (C-section), which are also achievable in developing countries [4]. Over the years, the World health organization (WHO) reports C-section rates have been on the rise in both the developed and developing nations [5]. According to the WHO, the ideal rate for C-section should be below 10 to 15 percent. When the rate of C-section exceeds 10 percent, there is no significant evidence to suggest improvement in maternal mortality [5, 6].
In Pakistan, medically unnecessary C-section births have more than doubled over the past two decades because hospitals are not working under the rules and regulations set by the government [7]. C-section rates are higher in private hospitals as compared to public hospitals [8, 9]. The doctors in private hospitals are performing unnecessary C-section in order to fulfill the demands of private hospital’s owners as well as financial incentives. Additionally, most of the women prefer to give birth through C-section in order to eliminate the fear of long labor and vaginal delivery pain
Although performing C-section has become safer but still accounts for higher rates of maternal and neonatal morbidity and more costs as compared to vaginal deliveries. A 2015 study of Pakistan states that a substantial increase in C-section rates was not due to medical indications, but rather were performed as unnecessary surgical procedures, including nonevidence-based indications, economic gains, ever terminated pregnancy, professional convenience, and maternal requests [10].
The large increases in C-section use – mostly observed in the richest, highly educated, and urban-living women for non-medical purposes – are concerning for mothers and babies because C-sections is linked with short term and long-term health hazard/risk including increased risk of uterine rupture, abnormal placentation, ectopic pregnancy, stillbirth, and preterm birth, which can outspread over many years [11]. “We call on healthcare professionals, hospitals, funders, women, and families to only intervene in this way when it is medically required.”
The Government should facilitate access to healthcare facilities in areas that are easily accessible, especially, to rural women. From the programme and policy perspectives of healthcare interventions, it is imperative to investigate further the disparities among administrative divisions. Confronting health challenges at a microgeographic level will help to develop public policy that better meets the goals of Punjab Health Sector Plan 2018 [12], Punjab Economic Growth Strategy 2018 [13] and Federal Government Vision 2025 [14].
References:
1. Hogan, Margaret C., Kyle J. Foreman, Mohsen Naghavi, Stephanie Y. Ahn, Mengru Wang, Susanna M. Makela, Alan D. Lopez, Rafael Lozano, and Christopher JL Murray.. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet. 2010 May 8; 375 (9726): 1609–23. (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%296...)
2. Abbas, Faisal, Rafi Amir ud Din, and Maqsood Sadiq. "Prevalence and determinants of Caesarean delivery in Punjab, Pakistan." Eastern Mediterranean Health Journal 24, no. 11 (2018): 1058-1065. (http://www.emro.who.int/emhj-volume-24-2018/volume-24-issue-11/prevalenc...)
3. Bhutta ZA, Hafeez A. What can Pakistan do to address maternal and child health over the next decade? Health Res Policy Syst. 2015, 13 (1) Suppl 1:49. (https://doi.org/10.1186/s12961-015-0036-5 PMID:26792061)
4. Leone T, Padmadas SS, Matthews Z. Community factors affecting rising caesarean section rates in developing countries: an analysis of six countries. Soc Sci Med. 2008 Oct;67(8):1236–46.(https://doi.org/10.1016/j.socscimed.2008.06.032 PMID:18657345)
5. World Health Organization. Maternal deaths data by country. 2015 (http://apps.who.int/gho/data/view.main.GSWCAH01v)
6. World Health Organization. WHO statement on cesarean section rates. 2015(https://apps.who.int/iris/bitstream/handle/10665/161442/WHO_RHR_15.02_en...)
7. Haider G, Zehra N, Munir AA, Haider A. Frequency and indications of cesarean sections in a tertiary care hospital. Pakistan Journal of Medical Science, 2009;25(5): 791-796 (https://www.pjms.com.pk/issues/octdec109/article/article17.html).
8. Shahid J. Private hospital thriving on cesarean sections. DAWN (25 Nov). 2013. (https://www.dawn.com/news/1058406)
9. C-section; a need or a business. The Nation. (https://nation.com.pk/23-May-2018/c-section-a-need-or-business)
10. Souza JP, Betran AP, Dumont A, De Mucio B, Gibbs Pickens CM, Deneux‐Tharaux C, Ortiz‐Panozo E, Sullivan E, Ota E, Togoobaatar G, Carroli G. A global reference for caesarean section rates (C‐Model): a multicountry cross‐sectional study. BJOG: An International Journal of Obstetrics & Gynaecology. 2016 Feb; 123(3): 427-36. (https://doi.org/10.1111/1471-0528.13509)
11. Sandall, Jane, Rachel M. Tribe, Lisa Avery, Glen Mola, Gerard HA Visser, Caroline SE Homer, Deena Gibbons et al. "Short-term and long-term effects of caesarean section on the health of women and children." The Lancet 392, no. 10155 (2018): 1349-1357. (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31930-5/fulltext)
12. Punjab Health Sector Strategy 2012-2020. (http://www.phsrp.punjab.gov.pk/healthdept/phsp/Draft_Punjab_Health_Secto...)
13. Punjab growth strategy-2018 (https://www.theigc.org/wp-content/uploads/2015/04/Punjab-Growth-Strategy...)
14. Pakistan vision-2025, (https://www.pc.gov.pk/uploads/vision2025/Vision-2025-Executive-Summary.pdf)
Competing interests: No competing interests