From 2000 to 2015 the number of Caesarean sections, commonly known as a C-section, has approximately doubled in the world. This is according to a dossier published in the medical journal The Lancet, under the title Global epidemiology of use of and disparities in Caesarean sections at the XXII World Congress of the International Federation of Gynecology and Obstetrics (FIGO), held in Rio de Janeiro from October 14-19, 2018.
According to the research, based on data from 169 countries and covering 98.4 percent of all births in the world, about 29.7 million children in 2015 (or 21.1 percent of the 140.6 million live births) have been birthed by C-section. That is almost double the number in 2000, when there were about 16 million (12.1 percent of the 131.9 million born alive).
The study, coordinated by Belgian gynecologist Marleen Temmerman, of Ghent University (UGent) in Belgium, and in affiliation with the Aga Khan University in Kenya, shows that the use of the scalpel to give birth to children was up to 10 times more frequent in the countries of Latin America and the Caribbean, where it was used in almost half of the births (44.3 percent), compared to central and western Africa, where the C-section was used only in 4.1 percent. In South Sudan, Cesarean delivery is used in only 0.6 percent of all births, while in the Dominican Republic the percentage jumps to 58.1 percent, the highest rate overall.
There are 15 countries where births by C-section exceed 40 percent of the total; among these are Brazil and Egypt (both 55.5 percent), Turkey (53.1 percent), Iran (45.6 percent), and Cuba (40.4 percent). Scoring lower than 40 percent—but still well above what is considered the “ideal” or “optimal” rate of 10-15 percent—are North America (32 percent) and Western Europe (26.9 percent). In 2000 the rate was 24.3 percent in the US and 19.6 percent in Europe.
While over the period from 2000 to 2015 an increase in the use of C-sections has occurred in all regions of the world, it had the most growth in the regions of Eastern Europe and Central Asia (with an average annual variation rate of 5.5 percent) and South Asia (6.1 percent).
On the other hand, the slowest increase occurred in the regions of central and western Africa (an average annual variation rate of 2.1 percent) and southern and eastern Africa (2.0 percent). In both cases, according to the report, these are regions where in 2015 the use of the C-section was still less than 10 percent . According to the authors of the report, two developments have contributed to the generalized increase in the number of C-sections. On the one hand, there has been an increase in the percentage of births occurring within healthcare facilities, which in itself accounted for 66.5 percent (two thirds) of the increase, since C-sections are generally performed in clinical environments; on the other hand, facilities in question also started to perform C-sections with greater relative frequency (the other 33.5 percent).
Causes or forms of disparity
According to the dossier, the proportion of births by Caesarean section was “significantly” higher in countries with higher levels of socioeconomic development, of women with secondary education, and of urbanization, with a resultant higher density of doctors and lower fertility.
Regarding the relationship between getting a C-section and access to higher education, data for Brazil, for example, shows that less than one fifth (19.4 percent) of the less educated women (i.e. with fewer than eight years of education) have resorted to the scalpel, compared to more than half of women with a high level of education (54.4 percent).
It also affects another form of disparity within a single nation or region. For example, in Ethiopia the frequency of C-sections is only 2 percent at the national level; that number however rises to 21.4 percent in the capital, Addis Ababa, reveals the dossier. Among the various provinces of China, the birth rate by C-section varies between 4 percent and 62 percent, while between the various states of India the rate varies between 7 percent and 49 percent.
Another form of disparity is that found between private and public healthcare services. The use of the C-section is 1.6 times higher in private clinics (18.3 percent) than in public ones (11 percent), according to data from 69 of the 82 low and middle income countries included in the dossier. In 12 countries, he use of the C-section in private institutions exceeded half of the births, the study goes on to say; however, it observes that the great majority of C-sections performed in the 69 countries in question take place in public facilities: on average 81 percent.
Source of concern
The lead researcher of the dossier, Marleen Temmerman, did not hide a certain level of concern. “Pregnancy and labor are normal processes, which occur safely in most cases,” said the gynecologist, who was quoted by ScienceAlert, and who expressed concern about the increase in Caesarean sections “for non-medical reasons,” as they involve risks for both pregnant women and unborn children.
“C-section is a type of major surgery,” Jane Sandall said. The risks associated with the C-section “require careful consideration,” continued the maternal health expert at King’s College London. “C-section should only be used when it is medically required,” she warned. Although the C-section remains a life-saving tool when complications occur during birth, such as hemorrhages or fetal stress, it is not without risks, says the World Health Organization (WHO), which for this reason has published a set of guidelines to accompany the dossier.
“Compared with women having a vaginal birth, those having a C-section for the first time have 3.1 times greater risk of blood transfusions, a 5.7 times greater risk of an unplanned hysterectomy and a six times greater risk of being admitted into intensive care,” warns the Guardian (October 4, 2017).
Placenta accreta, a condition that can cause hemorrhaging for the woman after childbirth, is now about 600 times more widespread than in the 1950s, an increase that scientists connect to the growth in the number of C-sections. For example, patients with placenta accreta constitute 38 percent of hysterectomies related to C-sections, and up to 7 percent of women affected by the condition die, recalls the Guardian.
As the majority of women who prefer a C-section consider it a safer practice for themselves and the unborn child, young doctors have become experts in Caesarean sections, but at the same time they are losing the necessary skills to safely assist the vaginal births, observes the dossier in the final section.
If in many parts of the world there is an excessive use of C-sections, in some other regions this type of intervention remains practically unavailable, a situation that primarily affects sub-Saharan Africa and the poorest of women.
“In several countries, the proportion of births by CS in poor and vulnerable women is close to 0 percent, implying that some women die because they cannot access life-saving surgery during childbirth,” the report emphasizes.
“In cases where complications do occur, c-sections save lives, and we must increase accessibility in poorer regions, making c-sections universally available,” concluded Marleen Temmerman, “but we should not overuse them.”