Worldwide caesarean section use has nearly doubled over two decades and has reached “epidemic” proportions in some countries, doctors said yesterday, highlighting a huge gap in childbirth care between rich and poor mothers.
Millions of women each year might be putting themselves and their babies at unnecessary risk by undergoing c-sections at rates “that have virtually nothing to do with evidence-based medicine,” the doctors said.
In 2015, the most recent year for which complete data is available, doctors performed 29.7 million c-sections worldwide — 21 percent of all births and up from 16 million, or 12 percent of all births, in 2000, a research paper published in The Lancet said.
It is estimated that the operation — a vital surgical procedure when complications occur during birth — is necessary in 10 to 15 percent of births.
However, the research found wildly varying national rates of c-section use, often corresponding to economic status: In at least 15 countries, more than 40 percent of births were performed using the practice, often on wealthier women in private facilities.
In Brazil, Egypt and Turkey, more than half of all births were done via c-section. The Dominican Republic had the highest rate of any nation, with 58.1 percent of all babies delivered using the procedure.
However, in close to a quarter of nations surveyed, c-section use was significantly lower than average.
The authors pointed out that while the procedure is generally overused in many middle and high-income settings, women in low-income situations often lack necessary access to what can be a life-saving procedure.
“We would not expect such differences between countries, between women by socioeconomic status or between provinces/states within countries based on obstetric need,” said Ties Boerma, a professor of public health at the University of Manitoba, Winnipeg, and lead author on the study.
Jane Sandall, a professor of social science and women’s health at King’s College London and an author on the study, told reporters that women are increasingly opting for surgery for a variety of reasons.
They include “a lack of midwives to prevent and detect problems, loss of medical skills to confidently and competently attend a vaginal delivery, as well as medico-legal issues,” she said.
Doctors are often tempted to organize c-sections to ease the flow of patients through a maternity clinic and medical professionals are generally less vulnerable to legal action if they choose an operation over a natural birth, Sandall said.
She also said there are often “financial incentives for both doctor and hospital” to perform the procedure.
The study warned that in many settings, young doctors are becoming “experts” in c-section, while losing confidence in their abilities when it comes to natural birth.
It also identified an emerging gap between wealthy and poorer regions within the same country.
In China, c-section rates diverged from 4 percent to 62 percent; in India the range was 7 to 49 percent; and while the US saw more than a quarter of all births performed by c-section, some states used the procedure more than twice as often as others.
“It is clear that poor countries have low c-section use because access to services is a problem,” said Sandall. “In many of those countries, however, richer women who live in urban areas, have access to private facilities have much higher c-section use.”
C-sections might be marketed by clinics as the “easy” way to give birth, but they are not without risks.
Maternal death and disability rates are higher after c-section than vaginal birth. The procedure scars the womb, which can lead to bleeding, ectopic pregnancies — where the embryo is stuck in the ovaries — as well as still and premature subsequent births.
The authors suggested better education, more midwifery-led care and improved labor planning as ways of ensuring that c-sections are only performed when medically necessary, as well as ensuring that women properly understand the risks involved with the procedure.
“C-section is a type of major surgery, which carries risks that require careful consideration,” Sandall said.
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