Do we have a definition of an unnecessary cesarean section?

1. Do we have a definition of an unnecessary cesarean section? -Dr. Mario Sebastiani- Asociación Argentina de Ginecología y Obstetricia Psicosomática Servicio de Obstetricia. Hospital Italiano de Buenos Aires. Argentina

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

3. Sweden: 1 Outcome based study • 59 hospitals • 1988 - 1992 • Perinatal mortality • Rate of asphixia No benefit Minimum cesarean section rate is optimal 1 Eckerlund I, et al.,Int J Technol Asses Health Care 1999;15:123 - 35

4. England 1 Outcome based study • 17 maternity units (one health region) • 1988 • 36.727 singleton pregnancies • CS rates should be 10 - 12 % • More intervensionist approach in low birth weight infants 1 Joffe M, et al., J Epidemiol Community Health 1994;48:406 - 11

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...” 1 Healthy People 2000; DHHS publication Nº. (PHS) 91-50212.

6. Latin America

7. Grafic I: Incidence of ceasarean secton in Latin American W.H.O. Belizán JM, et al, BMJ 1999;319:1397 -402

8. Grafic I: Incidence of ceasarean secton in Latin American W.H.O. Belizán JM, et al, BMJ 1999;319:1397 -402

9. “Rates and implications of caesarean sections in Latin America: ecological study” Belizán JM, et al, BMJ 1999;319:1397 -402 • 12 of 19 Latin American countries • 81% of the deliveries • C-S rates above 15% (16,8% - 40%) • Better socioeconomic conditions = higher C-S rates • Over 850.000 unnecesary c-sections are performed each year in LA

10. 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

11. Difficulties for the analysis • Which is the optimun cesarean rate? • Many stategies to reduce the rates

12. Caserean Section = Clasical indicaton or failure Vaginal Birth = Quality Difficulties for the analysis • Which is the optimun cesarean rate? • Many stategies to reduce the rates Medical and non medical reason

13. Caserean Section = Clasical indicaton or failure Vaginal Birth = Quality Difficulties for the analysis • Which is the optimun cesarean rate? • Many stategies to reduce the rates Is there a different view ?

14. FETUS MOTHER Childbirth Who are involved ?

15. FETUS MOTHER Obstetricians Health system Childbirth Midwives Obstetrical Uni-Hospital Society Who are involved ?

16. Factors involved in decision • Fetal mortality and morbidity • Newborn health • VBAC • Cost • Pelvic floor damage • Maternal mortality • Cultural factors • Autonomy - C-section on demand?

17. “Unexplained fetal deaths” Cotzias C, Paterson-Brown S, Fisk N. BMJ, 319,31 july 1999

18. Could C-S reduce fetal death rate? • 5 times more frequent than SIDS • Termination of pregnancy when fetal risks in útero are larger than the risks of the newborn: 1/500 • Most of fetal deaths occur in non-malformed fetuses Cotzias C, et al., BMJ, 319,31 july 1999

19. Could C-S reduce fetal death rate? • 5 times more frequent than SIDS • Termination of pregnancy when fetal risks in útero are larger than the risks of the newborn: 1/500 • Most of fetal deaths occur in non-malformed fetuses • Women’s preference: C-section of the risk is > 1:4000 1 Cotzias C, et al., BMJ, 319,31 july 1999 • 1 Thornton E, et al., J Obstet Gynecol 1989;9:283-8

20. Factors involved in decision • Fetal mortality and morbidity • Newborn health • VBAC • Cost • Pelvic floor damage • Maternal mortality • Cultural factors • Autonomy - C-section on demand?

21. “Effect of Mode of Delivery in Nulliparous Women on Neonatal Intracranial Injury” Towner D et al., NEJM 1999;341:23 • 1: 664 forceps • 1: 860 vacuum extraction • 1: 907 c-section during labor • 1: 1900 delivered spontaneously • 1: 2750 c-section with no labor Conclusion: The common risk factor for hemorrhage is abnormal labor

22. Factors involved in decision • Fetal mortality and morbidity • Newborn health • VBAC • Cost • Pelvic floor damage • Maternal mortality • Cultural factors • Autonomy - C-section on demand?

23. Frequency of cesarean section, primary cesarean and vaginal birth post-c-section between 1989 - 2001 VBAC All c-sections Primary c-section Martin JA, et al., National Center for Health Statistics. 2002

24. Recomendations • The most conservative recomendations. • ACOG Technical Bulletin. Vaginal delivery after a previous cesarean birth. • Int J Gynecol Obstet 48:127 – 129; 1995. • ACOG Vaginal birth after a previous cesarean. • ACOG Practice Bulletin N° 5:1 – 8; 1999.

25. VBAC • Over 1000 reports: not one RCT

26. VBAC • Over 1000 reports: not one RCT • Economic forces rather than patient well-being, are driving the goal of fewer cesarean sections ? 1 1 Clark S., et al., Am J Obstet Gynecol 2000;182:599-602

27. Factors involved in decision • Fetal mortality and morbidity • Newborn health • VBAC • Cost • Pelvic floor damage • Maternal mortality • Cultural factors • Autonomy - C-section on demand?

28. Costs of deliveries • Cesareandelivery: • Costs more than a vaginal delivery • Longer hospital stay • Use of an operating room. • Laborunit:a prolonged and difficult labor, even when it results in a vaginaldelivery, is more costly to an institution than a cesarean delivery.

29. Costs of deliveries Beth Israel Deaconess Medical Center, Boston, USA • Electiverepeated cesarean delivery $ 7.700 • Normal vaginal delivery $ 6.800 • Intrapartum Cesarean: $ 10.000

30. Costs of deliveries Beth Israel Deaconess Medical Center, Boston, USA • Electiverepeated cesarean delivery $ 7.700 • Normal vaginal delivery $ 6.800 • Intrapartum Cesarean: $ 10.000 • Complication • Mother: + $ 4.000 • Child: + $ 2.000

31. Difficulties in the estimation of costs • Poor quality: what resources were included in their cost estimate • Lack of progress of labor > more hospital lenght > medical costs > nursing costs • Charges are not the same as costs • Long term sequelae: Pelvic floor - Fetal mortality - Newborn trauma Malkin J, et al., Birth 2001;28:208-9

32. Factors involved in decision • Fetal mortality and morbidity • Newborn health • VBAC • Cost • Pelvic floor damage • Maternal mortality • Cultural factors • Autonomy - C-section on demand?

33. Pelvic floor • Urinary incontinence • Fecal incontinence • Sexual dysfunction • Organ prolapse

34. Pelvic floor • Pudendal nerve damage • Soft tissue trauma • The levator musculature trauma • Anal sphincter trauma

35. Pelvic floor • Pudendal nerve damage • Soft tissue trauma • The levator musculature trauma • Anal sphincter trauma “...neurophysiologic studies have demonstrated the etiologic role of parturition-related nerve damage in development of pelvic floor disfunction...”1 1 Davila GW, et al., Int Urogyneocl J 2001;12:289-291

36. Reduction of pelvic floor damage • Minimizing forceps deliveries • Minimizing episiotomies • Allowing passive descent in the second stage • Selectively recomending elective cesarean delivery Davila GW, et al., Int Urogyneocl J 2001;12:289-291

37. Prevention of pelvic floor damage • Avoid labor • Avoid passage of the fetus through the pelvis • Shorten second stage • Avoid routine episiotomy • Forget the forceps specially in macrosomia • Repair perineal damage Devine II, Contemporary Ob/Gyn 1999:119

38. Factors involved in decision • Fetal mortality and morbidity • Newborn health • VBAC • Cost • Pelvic floor damage • Maternal mortality • Cultural factors • Autonomy - C-section on demand?

39. Risk of maternal death “...the presumed increased risk of maternal death with elective cesarean delivery traditionally has been the most compelling reason to reject a policy of universal cesarean delivery or "cesarean on demand." However, good evidence is accumulating that this is no longer true; the maternal morbidity and mortality from elective cesarean delivery at term before the onset of labor appear to be similar to those associated with vaginal birth....” Hannah ME, Lancet 2000;356:1375-83.

40. Factors involved in decision • Fetal mortality and morbidity • Newborn health • VBAC • Cost • Pelvic floor damage • Maternal mortality • Cultural factors • Autonomy - C-section on demand?

41. Cultural phenomena - Brazil • All birth are attended by obstetricians • Training • Doctors work in the public and private health system • Status of c-section: modern and technical • Women’s body are perceived as sexual than maternal • Genitals are perceived for sexual activity than for childbearing Nuttall C., et al., BMJ 2000;320:1072

42. Factors involved in decision • Fetal mortality and morbidity • Newborn health • VBAC • Cost • Pelvic floor damage • Maternal mortality • Cultural factors • Autonomy - C-section on demand?

43. 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

44. Cesarean section on demand • 31% of female obstetricians would prefer a cesarean delivery for themselves 1 • Italian law mandates that women be given the option of an elective cesarean, and about 4% of pregnant women choose it. 2 1 Al-Muffti et al. Eur J Obstet Gynecol Reprod Biol 1997:73:1-4 2 Tranquilli AL, et al., Am J Obstet Gynecol 1997;177:245-246

45. Autonomy • Is the governing principle in medicine • We respect with better eyes a woman’s right to refuse a cesarean delivery • Nobody is interested in respecting woman’s desire to refuse vaginal delivery Wagner M et al., Lancet 2000;356:1677-80

46. Autonomy and informed consent • Full and umbiased information (better=efficacy and worse=risks) • Do we have the time to inform ? • Male dominated obstetric model • Does a woman have an inalienable “right” to choose a C-S ? Wagner M et al., Lancet 2000;356:1677-80

47. Autonomy and informed consent “...performing cesarean section for non medical reasons is ethically not justified....” Committee for the Ethical Aspects of Human Reproduction and Women’s Health of FIGO (1999)

48. Ambiguity of terms • Natural as desirable • Natural as hazardous • C-section as safe • C-section as beneficial for doctors

49. Natural (phylosophy of terms) • To approve or excuse a behavior. Unnatural • Ecologist’s feeling against the danger of the nature • Natural is everything that belong to the Universe (animate or liveless, rational o irrational) (Stuart Mill) • Dynamic and historical concept

50. Artificial (phylosophy of terms) • What is produced by the arts and human technics • Learned, modified. Natural is biologic. • Natural in humans is not to be as much. (Savater) • Artificial is better than natural. Which is the meaning of arts? (Savater) • Human Life is precisely to be different from nature