Caesarean sections in Mexico: are there too many?

Abstract

This paper seeks to quantify the magnitude of caesarean sections in Mexican public health-care institutions in recent years, to characterize the evolution of caesarean section rates (CSR) during the last decade, and to estimate the possible economic cost caused by the excess of caesareans performed in these institutions. The study is based on data obtained from the health sector, both for Mexico in the 5-year period 1993-97 and for the Mexican State of Jalisco between 1983 and 1998. Linear regression analysis was used to evaluate time series, and "excess of caesareans" was considered the number of caesarean deliveries performed above the admissible 15% CSR. The results reflect that on the national level, more than one-quarter of the deliveries handled by public institutions ended in caesarean section for each analyzed year, and if the deliveries performed in private institutions are included, the national rate is around 30%. A marked increase in CSR can be observed in Jalisco between 1983 and 1998 (almost 50%); and the cost for the nation of this CSR excess in financial terms is highly significant: several millions of dollars--obtained from public funds--are spent annually and unnecessarily by health services. The findings suggest that the increase in CSR is a public health problem that has not been satisfactorily faced by the health sector authorities. Many unnecessary caesareans would undoubtedly be avoided if the policies of these public health-care institutions were to consider, as a priority, both the known higher risk implicit in a caesarean for the health of the mother and child, and the economic impact on the country and its health institutions of the excessive number of caesareans performed yearly.

Características sociodemográficas y reproductivas asociadas con el aumento de cesáreas en México

“…Si bien esta situación podría sorprender, no deja de apuntar a la argumentación hecha en otras investigaciones de que en una y otra institución lo que prevalece para la realización de cesárea incluye tanto razones médicas como razones no médicas, entre las que destacan la "comodidad" que esta intervención supone tanto para ellas, como para las usuarias, patrones particulares de práctica clínica de las instituciones, la interpretación del proveedor de las condiciones del trabajo de parto, la protección médico-legal de los proveedores y los incentivos económicos, particularmente en las instituciones privadas. 2,8,16,30,31,[34][35][36] Otro hallazgo relevante obtenido en el estudio es la posibilidad de cesárea cuando las mujeres tienen nivel socioeconómico alto. Este resultado coincide con otros en donde se señala que en las mujeres este estatus la operación cesárea es considerada como una práctica ideal para el nacimiento de un hijo y de ahí su demanda frecuente.…”

“…8,18,30 Se tiene la percepción errónea de que la cesárea es un modo favorable, seguro y rápido para el nacimiento, y no así el parto vaginal, el cual además es percibido por algunos proveedores y mujeres como un "método anticuado". 34,37 Dicha percepción posiblemente esté influyendo en el incremento de esta práctica a solicitud materna, 8,13,18 argumento que en muchos casos ha sido fomentado por los médicos. 8,18,31,38 Otro factor que resultó relevante para la práctica de la operación cesárea fue el peso del recién nacido; esta observación de alguna forma podría ofrecer un indicio de la aplicación de criterios médicos justificados para su realización, 20 ya que diversas investigaciones han dado cuenta de las prerrogativas de este procedimiento en productos prematuros 39,40 o macrosómicos.…”

The policy environment encouraging C-section in Lebanon

“…(1) Physician-specific factors include physician training and/or professional experience [14,15], gender -with male physicians found in the UK, for example, to be more likely to perform C-section than their female colleagues [7,16] -, age [15], time-convenience, fear of litigation and defensive medicine [9,15], as well as a widespread belief among physicians that C-section is safe and implies few risks [8,9]. (2) Woman-specific factors include the socioeconomic status of the woman and her or her family's payer status.…”

“…The few studies documenting women's views of C-section postpartum indicate that their satisfaction with their delivery experience depended largely on the level of information they had prior to the delivery about a possible C-section and the extent to which they were involved in the decision-making process concerning their delivery [9,17]. (3) Financial factors: a number of studies have indicated that the nature of health financing and rewards to physicians implicit in Ministry of Health, insurance or hospital reimbursement policies for C-section versus normal delivery are key factors in explaining high C-section rates [8,19,20]. Interviews with obstetricians in a study in Chile [21] found that financial incentives were also a major factor for high C-section rates in that country.…”

“…Although there are methodological difficulties in establishing an "acceptable" level of C-section rates across countries [8], there is no evidence that rates over 15% at the population level improve maternal health or newborn outcomes [9].…”