Pathways to a rising caesarean section rate: a population-based cohort study

Abstract

ObjectivesTo determine whether the obstetric pathways leading to caesarean section changed from one decade to another. We also aimed to explore how much of the increase in caesarean rate could be attributed to maternal and pregnancy factors including a shift towards delivery in private hospitals.DesignPopulation-based record linkage cohort study.SettingNew South Wales, Australia.ParticipantsFor annual rates, all women giving birth in NSW during 1994 to 2009 were included. To examine changes in obstetric pathways two cohorts were compared: all women with a first-birth during either 1994–1997 (82 988 women) or 2001–2004 (85 859 women) and who had a second (sequential) birth within 5 years of their first-birth.Primary outcome measuresCaesarean section rates, by parity and onset of labour.ResultsFor first-births, prelabour and intrapartum caesarean rates increased from 1994 to 2009, with intrapartum rates rising from 6.5% to 11.7%. This fed into repeat caesarean rates; from 2003, over 18% of all multiparous births were prelabour repeat caesareans. In the 1994–1997 cohort, 17.7% of women had a caesarean delivery for their first-birth. For their second birth, the vaginal birth after caesarean (VBAC) rate was 28%. In the 2001–2004 cohort, 26.1% of women had a caesarean delivery for their first-birth and the VBAC rate was 16%. Among women with a first-birth, maternal and pregnancy factors and increasing deliveries in private hospitals, only explained 24% of the rise in caesarean rates from 1994 to 2009.ConclusionsRising first-birth caesarean rates drove the overall increase. Maternal factors and changes in public/private care could explain only a quarter of the increase. Changes in the perceived risks of vaginal birth versus caesarean delivery may be influencing the pregnancy management decisions of clinicians and/or mothers.

Rates and trends in cesarean sections between 2008 and 2012 in Iraq

“…The recent global increase in the cesarean section rate can be largely attributed to different factors including advances in technologies to detect fetal distress and the attitudes of clinicians and women toward cesarean sections such as the avoidance of labor pain [26]. In Iraq, there is a lack of clear evidence of the main factors attributing to the reported high cesarean section rate.…”

Reducing caesarean section rates – No easy task

“…The most obvious example is how the increase in women birthing by caesarean sections in their first pregnancy has led to an ongoing increase in repeat caesarean births. 6 An analysis which models the contingent effects of particular changes in practice has not been undertaken. Hence, it is unclear where the greatest achievable potential lies for reducing the caesarean delivery rates.…”

Cesarean Section Rate in a Sample of Primigravida Women in the Public Maternity Hospital in Erbil City, Iraq

“…No specific data on each of the public or private sectors were available for Erbil governorate (10). The increased rates of cesarean section in the private health care sector were attributed to provider-induced demand (11). Presence of a large number of private hospitals in Iraq might be partially responsible for the increased rates of cesarean section potentially due to provider-induced demand (9).…”

“…However, the World Health Organization (WHO) stated that the "ideal rate" for cesarean section is to be between 10% and 15%, but when the rate goes above 10%, there is no evidence that maternal and neonatal mortality rates improve (1). Identifying and addressing these risk factors need setting policies to reduce surgical deliveries (4,11).…”