What should we do to decrease high Cesarean Section rates ?

1. Prof.Dr.S.Cansun DEMİRTurkishSociety of ObstetricsandGynecologyÇukurova UniversityFaculty of Medicine Whatshouldwe do todecrease highCesareanSection rates ?

2. Labor American Journal of Obstetrics & Gynecology. 195(1):121-128, July 2006. • Natural and Normal Physiological Process • Dystocia : % 23.6 • Functional Dystocia: % 11.1 • Failure in Dilatation and Descensus • Arrest Dilatation and Descensus • Ineffective Expulsion • Mechanical Dystocia: %12.5 • Cephalo-pelvic Disproportion • Fetal Macrosomia • Pelvic Anatomic Problems • Fetal Malpresentation

3. Published rates • W.H.O.: 1 • 15 % • Maximum desirable rate of cesarean section • No benefit for mother and the fetus for medical reasons 1World Health Organisation. Appropriate technology for birth. Lancet 1985;436­7.

4. Optimum C/S Rate ? • Some authors have proposed an “ideal rate” of all cesarean deliveries (such as 15 percent) for a population. • There is no consistency in this ideal rate, and artificial declarations of an ideal rate should be discouraged. • Goals for achieving an optimal cesarean delivery rate should be based on maximizing the best possible maternal and neonatal outcomes,taking into account available medical and health resources and maternal preferences. • Thus, optimal cesarean delivery rates will vary over time and across different populations according to individual and societal circumstances.

5. Healthy People 2000 1 • Department of Health and Human Services • 15 % by the year 2000 “....the advantages of a safe vaginal delivery over a cesarean delivery are clear: a vaginal delivery is associated with lower maternal and neonatal morbilidity and it costs less...” 1Healthy People 2000; DHHS publication Nº. (PHS) 91-50212.

6. C/S Rates Rises all over the World.

7. The Total cesarean, Primarycesarean and vaginal birth after cesarean rates in the United States from 1989 to 2006. Source: U.S. National Center for Health Statistics

8. Betran AP, Merialdi M, Lauer JA, et al. Rates of cesarean section: analysis of global, regional and national estimates. Paediatr Perinat Epidemiol. 2007;21:98–113.

9. Why has the rate of cesarean delivery climbed so dramaticallyin the past 25 years? • Lower tolerancefor taking risks • Fear of malpractice - litigation • Increaseduse of epidural anesthesia ? • Increased use of electronic fetalmonitoring • The convenience of physicians Sachs BP et al., NEJM 1999;340:54 – 57

10. Factors of taking C/S

11. C/S RATES IN TURKEY,2009

16. Cesarean on Demand • In 2005; • The C/S rate in USA is 30.3% among all deliveries. • 62% of these cases were Primary Elective C/S . • C/S Rates varies by mother’s request or demand was 4-18%.

17. What is C/S on Demand? Definition: • The incidence of cesarean delivery without medical or obstetric indications is increasing in the World, and a component of this increase is cesarean delivery on maternal request. • Given the tools available,the magnitude of this component is difficult to quantify.

18. Cesarean section on demand • Until quality evidence becomes available, any decision to perform a cesarean delivery on maternal request should be carefully individualized and consistent with ethical principles.

19. Cesarean section on demand • Given that the risks of placenta previa and accreta rise with each cesarean delivery, cesarean delivery on maternal request is not recommended for women desiring several children.

20. Cesarean section on demand • 31% of female obstetricians would prefer a cesarean delivery for themselves 1 1 Al-Muffti et al. Eur J Obstet Gynecol Reprod Biol 1997:73:1-4

21. Rising C/S rate in Turkey.The reasons: 1 Physician’s attidutes; C/S easy access and lower risk Time saving procedure ( 12-16 hours-vs 35-45 minutes); To avoid from intrapartum long-term follow-up of parturient in labor ward;and not to take any responsibility of labor complications. Malpractice and fear of litigation pushes them to take more Sections.Elective Caserean Section as an indication recorded into the statistical data. Not to able to control the unset of labor during very heavy clinical work in the day time,and also the extra and out of time.

22. Rising C/S rate in Turkey.The reasons ..2 Tobelievethat C/S is minimizingperinatalneurologicinjuryandalsopreventsmaternaladverseoutcomes as pelvicrelaxationsyndromwithurinaryincontinance. Thereflexion of physicianspreference on thegravidas as todirectthemforSectionseemsto be anotherimportantfactor. Normal deliveryneedsmorelabour-intensivework but not satisfactory rate of return .

23. Rising C/S rate in Turkey.The reasons..3 The Social Background and Communal Factors; IVF-ET cycles and pregnancies.Multiple gestation. Higher prevalence of maternal obesity and related obstetric problems as hypertansion, diabetes,systemic diseases and dystocia. Extensive use of Electro-fetal Monitorization and prenatal ultrasonography (Fetal Macrosomia-15% false positive) Cesarean rates are higher among the gravidas cared by obstetricians ,when compared by midwifery during antenatal period.

24. Rising C/S rate in Turkey.The reasons ..4 Maternalattidutes; Inadequateantenatalbookingandlack of antenatalclinicsresultsmisunderstanding at choosingthemode of delivery; Not toshowenoughrespecttotheparturient’sconfidenceduringlabour in theward,frequency of painfulvaginalexams ,Lack of privateseperationsandroomsforlabour; Negativeapproachandthequality of correspondanceduringadmissiontothelaborward Thepatientsandalsotheobstetriciansadverselyaffectedagaints normal deliverybecause of badconsequences of obstetriccomplicationswhichrecognizedbycommunity.

25. Conclusion The cesarean section should not be used asan indicator of quality of obstetrical care We do not have a good definition of unnecesary c-section

26. Comments – 1 High quality of Maternal Schooling.Prenatal Courses on training how to manage spontanous delivery and experienced trainers must be on this field. Encouragement and Education. Normal labor should be cared and followed by Obstetricians or Midwifes whose only is focused on this subject.Certification and Responsibility. Physical Conditions of Labor wards and hospital must be modernized and Patient Friendly Structure could be built.

27. Comments – 2 Gravida must be treated honestly as she feels herself in confidence at labor. During the delivery the criterias which declared by WHO should be applied. ( No Routine enema,limited number of vaginal exams for low risk pregnants,unnecessary Kristeller Manoeuvre,No restriction to take fluids during labor). Midwifery System should be progressed and rebuilt as they will be responsible of normal spontanous deliveries .The Education of Midwifes must be in the responsibility of University and Teaching Hospitals which updated and upgraded.

28. Comments - 3… Continuous Professional and Postgraduate Education for midwifes and labor staff . Obligatory Intrapartum Fetal Monitorization. Physicians and Midwifes must be educated on IFM. The responsibility of labor Ward must belongs to Academic Staff (Obstetricians and Midwifes ). Full Physicological Support and Obstetric follow-up .

29. Comments – 4 • Facility of Rapid consultation of parturient with obstetrician if necessary because of dystocia and other complications appeared at delivery. • Guidelines about Normal Vaginal Delivery and Labor Care must be setup in the labor Wards. • Induction of Labor

30. Thank you very much for your attention