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Tuesday
Jan122010

WHO Survey on Cesareans and Pregnancy Outcomes in Asia

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Associated Press released an article today about the China’s high cesarean rate.

Nearly half of all births in China are delivered by cesarean section, the world’s highest rate, according to a survey by the World Health Organization — a shift toward modernization that isn’t necessarily a good thing.

The boom in unnecessary surgeries is jeopardizing women’s health, the U.N. health agency warned in the report published online Tuesday in the medical journal The Lancet.

Unnecessary C-sections are costlier than natural births and raise the risk of complications for the mother, said the report surveying nine Asian nations. It noted C-sections have reached “epidemic proportions” in many countries worldwide.

Read more of the article…

 

The study, Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007—08, is available online.

The first paragraph of the introduction details a few key factors associated with the worldwide unnecessary cesarean trend. [Emphasis mine]

Several factors, including the increased perception of safety, have contributed to a worldwide increase in rates of caesarean section. In many countries, these rates have reached epidemic proportions, motivating a debate about whether the high rates are appropriate. Unnecessary caesarean section is a classic example of the mismatch between evidence and practice in obstetrics. This debate also draws attention to the complexities that attempts to change practice entail. On the one hand, some are concerned about possible additional maternal and perinatal morbidity caused by unnecessary caesarean sections. On the other hand, assessment of whether the caesarean section operation poses an intrinsic risk to the mother or the baby is difficult. Ethical and practical constraints prevent assessment of intrinsic risks related to caesarean sections with use of a randomised controlled trial.

Table 1 (modified here to fit on page) shows numbers of women by country and method of delivery

 

The discussion of how risk was calculated in the absence of an RCT was interesting.

Intrinsic risk associated with the caesarean section operation is not easy to separate from the medical and obstetrical indications that lead to the procedure. In the previous survey, the intrinsic risk was investigated by dividing the method of delivery into three categories: vaginal, elective caesarean section, and intrapartum caesarean section with elective caesarean section as a proxy.

Instead of three categories, this survey used six categories (see above table).

We identified six categories as described in the results. Assisted vaginal delivery represents a high-risk situation, and combination of such deliveries with spontaneous vaginal deliveries as the reference group might not be appropriate. Second, we noticed that several births that were recorded as elective had an indication for caesarean section. The group with no medical indication therefore is probably a more appropriate group to assess the intrinsic risk associated with this procedure.

The following is considered the most important finding of the survey.

The most important finding of the survey is the increased risk of maternal mortality and severe morbidity, which was analysed as a composite outcome (the maternal mortality and morbidity index), in women who undergo caesarean section with no medical indication. The findings for the individual outcomes that make up the composite outcome suggest that the increased risk is mainly attributable to increased admission to ICU and blood transfusion. Although we acknowledge that both ICU admission and blood transfusion depend on the availability of those services and the potentially differing thresholds for giving blood and for admission of women to ICU or referral to higher levels of care, this outcome is nevertheless important.

 


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Reader Comments (14)

Funny thing is, the safest form of birth turned out to be C-section, particularly C-section in the absence of medical indications.

January 12, 2010 | Unregistered CommenterAmy Tuteur, MD

Not for mothers.

When I was reading this earlier, I blew straight past cephalic presentations (Table 5) because ORs for breech and other presentations caught my eye. Antepartum c/s without indication is the safest in this study and if what they said in the discussion about several births that were recorded as elective having an indication for c/s, then that number (c/s with no indications) might look even better. Wow.

January 12, 2010 | Registered CommenterJill

Actually, it's safest for mothers, too. The authors tried to obscure this fact by hiding outcomes in a perinatal "index."

An index of outcomes can be useful if there are a great deal of possible complications, all of approximately the same severity. So an index might have been useful had the possible complication of surgery been for example: transfusion, ICU admission, wound infection, IV antibiotics, hospital readmission, etc.

An index is inappropriate if there are only a few outcomes (as in this paper) or if it combines outcomes of wildly different severity (as in this case). In such situations and index is often use to OBSCURE outcomes. The WHO group desperately wanted to conclude that vaginal delivery was "safer" than C-section with no indications. The data, of course, show otherwise. There were fewer hysterectomies and maternal deaths in the C-section group, so they added in transfusions and ICU admissions to create an "index" that made vaginal delivery look better.

January 13, 2010 | Unregistered CommenterAmy Tuteur, MD

The first sentence should read:

Actually, it's safest for mothers, too. The authors tried to obscure this fact by hiding outcomes in a maternal morbidity "index."

January 13, 2010 | Unregistered CommenterAmy Tuteur, MD

The index doesn't seem that inappropriate or sneaky to me, but I hadn't considered that they might not be grouping like with like (or "like enough"). There were a few other things in there that I thought sounded like potential gray areas, like relying on proxies. With a survey this huge, I don't know how they would adjust for everything anyway. It's quite an undertaking.

So... I gave the WHO the benefit of the doubt because it seems really strange to me that there would be such transparent obfuscation of data. Do you have a good theory?

If you can resist the urge to insult large groups of people just to stir up a debate, I'd like to hear Professor Amy's take on it if you have a minute.

January 13, 2010 | Unregistered CommenterJill--Unnecesarean

Honestly, I can't figure out what the WHO thought they were doing in this study and why anyone would publish it. If we want to find out the safety and efficacy of a procedure (like C-section) we identify specific conditions or risk factors and divide patients into the treatment group (C-section) and the control group (vaginal delivery). We certainly don't compare all women who had C-sections with all women who had vaginal deliveries because they are going to differ in very important ways.

I just don't get it. This is a poorly designed study that can't possibly yield any valid results. The authors compounded their error by misinterpreting (basically ignoring) the results that they got and instead reached a conclusion decrying C-section that seems to have been pre-determined before the study began.

January 13, 2010 | Unregistered CommenterAmy Tuteur, MD

...and the World Health Organization would want to deliberately lie and get the media hyped about curtailing unnecessary surgical procedures because...? Or are you just baffled as to why the study was published and promoted in the first place?

January 14, 2010 | Unregistered CommenterSara

"and the World Health Organization would want to deliberately lie and get the media hyped about curtailing unnecessary surgical procedures because...? Or are you just baffled as to why the study was published and promoted in the first place?"

Both. More importantly, I don't understand the structure of the study. Typically if you are looking at an intervention (like C-section) you compare those who have a specific indication for receiving the intervention and then you compare those who received the intervention with those who didn't. So, for example, a typical study might be looking women with babies in the breech position and comparing the outcomes for C-section an vaginal delivery.

I can't understand why anyone would do a study comparing women who had C-sections for medical reasons with women who had vaginal deliveries and never had any reason to have a C-section.

January 14, 2010 | Unregistered CommenterAmy Tuteur, MD

I haven't read the study yet, but it's on my list of things to do. But I have to say WHY IN THE WORLD would China have nearly a 50% C-section rate?! Does it say any more than "with indication" and "without indication"? My guess is that substantial numbers of these women were pregnant with their prized boy, and jumped at a C/s without indication or at the first hint of "indication." Does anybody honestly think that half of all women in China had a real medical reason for a C/s? Or is it the Chinese doctors' style that drives the C/s rate so high? Just doesn't make sense to me.

January 14, 2010 | Unregistered CommenterKathy

China had a planned (antepartum, no indications) c/s rate of 9.3%. As the authors noted, “…several births that were recorded as elective had an indication for caesarean section.” This is shown on Table 2 but is not broken down by country.

They also state, “Several factors, including the increased perception of safety, have contributed to a worldwide increase in rates of caesarean section.”

The AP article reporter noted: “The study did not discuss specific reasons for the high number of C-sections, but it noted that more than 60 percent of the hospitals studied were motivated by financial incentives to perform surgeries.”

Maternal request or doctor behest? Who knows?

January 14, 2010 | Registered CommenterJill
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