‘Demographic, socio-economic and institutional factors determine the rate of caesarean delivery’

Although the WHO considered the ideal rate of Caesarean sections to be between 10% and 15%, we are now witnessing a global and a regional rise in the trend of Lower segment Caesarean section (LSCS) not only across the state and nation but also across the world

'Demographic, socio-economic and institutional factors determine the rate of caesarean delivery'
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Latin America and the Caribbean which had the highest C-section rate in 1990 (22.8%) is also the region with the largest rate in 2014 and the largest absolute increase in the Caesarean section (CS) rate (19.4 points). The region with the second largest absolute increase was Asia going from a CS rate of 4.4% in 1990 to 39.5% in the latest estimates The trend analyses show that, except for two countries (Guinea and Nigeria) in which CS rates decreased and one (Zimbabwe) that maintained the same rate, all other countries have increased the use of CS at different levels.

A combination of demographic, socioeconomic changes and institutional factors determine the rate of caesarean section delivery in any region.

  • It is well known that WHO also concludes that Caesarean sections are effective in saving maternal and infant lives. Based on the WHO systematic review, increases in caesarean section rates up to 10-15% at the population level are associated with decreases in maternal, neonatal and infant mortality.
  • Healthcare centre rates of caesarean births vary widely depending on differences in the cases, transport availability in those regions, a mix of the obstetric populations they serve, and the clinical management protocols.
  • Therefore, a population-based recommended caesarean section rate cannot be applied as the ideal rate at the hospital level, especially tertiary care centre, because  these are referral centres ,wherein very high risk cases are brought in sometimes at the last minute
  • Socially, the delaying of the age of marriage for various reasons and subsequent maternal age at pregnancy is globally on the rise, which has increased tremendously the infertility problems amongst couples, stress and bad obstetric history, which in turn has made many conceptions as precious.
  • Further, these socioeconomic factors, along with increasing age and weight at pre-pregnancy time  with of course near absence of exercise and physical fitness levels in teenage girls ,  has brought in many ‘medical disorders with pregnancy’ in the limelight, such as increasing gestational diabetes mellitus , thyroid-hypothyroidism, obesity, hypertension, etc.
  • In India, the population pressure is so high and the proper vaginal delivery related infrastructure (For example – bed, electronic foetal monitoring system, skilled neonatal intensive care, blood transfusion facility, etc.) is so lacking in many remote private as well as public health institutions that doctors sometimes favour LSCS over vaginal delivery to achieve good outcomes.
  • In India, doctors are accounted for any delivery. To avoid harassment and litigation, they may choose caesarean delivery.
  • A small percentage of females with increasing wealth index and years of schooling make mothers prefer LSCS over vaginal delivery. Such Caesarean deliveries on maternal request (CDMR) currently are on a rise.
  • Patient education and involvement in decisions during pregnancy and so the patient’s preference is also taken as most important.
  • Medico-legal reasons, scheduling issues (muhurat LSCS), provider- and patient-driven medicalisation of birth (patient gives and insists her choices for admission), increased labour induction rates, and a broader perception that Caesareans are safe.
  • The difficulty in arranging for an emergency Caesarean section within short period is another factor that may be important in the Indian context.
  • While Caesarean delivery rates that are too low are associated with increased adverse events, potential risks and benefits of both vaginal and Caesarean delivery should be considered, before blaming the hospitals and doctors.

Thus, the Indian scenarios and overall socio-economic trends of population should be considered while thinking of rise in LSCS rates.

The author is an MBBS, M.D (OBGYN) Consulting Obstetrician and Gynaecologist, Joint Secretary IMA Pune, Chairman PCPNDT committee, IMA Pune, Master Trainer FOGSI – VAW Cell