Maternal Health Task Force

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The Global Epidemic of Unnecessary Cesarean Sections (Part 1)

By: Sarah Hodin, Project Coordinator II, Women and Health Initiative, Harvard T.H. Chan School of Public Health

Cesarean section surgery, when medically indicated and performed by trained staff with the necessary equipment and supplies, can be a life-saving procedure for the mother and baby. However, compared to vaginal delivery, cesareans are associated with a higher risk of maternal and neonatal death; numerous maternal morbidities including infection, uterine rupture and amniotic fluid embolism; neonatal morbidities often related to iatrogenic prematurity; and potential complications in subsequent pregnancies. Studies have also observed that children born via cesarean are more likely to develop respiratory problems, diabetes and obesity later in life. Therefore, cesareans should be considered a major surgical intervention and only be performed when clinically necessary. Furthermore, to minimize the risks associated with cesarean section, the surgery should only be performed by skilled health workers in high quality facilities.

For many years, researchers have debated the optimal cesarean rate for maximizing maternal and infant health outcomes. Since 1985, the World Health Organization has estimated the ideal population-level cesarean rate at 10-15%, although some scientists have suggested a higher figure. Further investigation of an optimal rate is certainly warranted. Theoretically, the optimal population-level cesarean rate should be calculated based on the proportion of laboring women who have a medical indication for cesarean delivery. But, unfortunately, the high and increasing levels of cesarean delivery rates around the world illustrate that the procedure is not always medically indicated.

Clinicians sometimes disagree about what constitutes a medical indication, and in some cases lack the necessary tools to identify a complication. For example, fetal distress is a commonly reported reason for performing a cesarean—but how exactly does one measure fetal distress? How long should a provider wait for an abnormal fetal heartbeat to return to normal before deciding to perform a cesarean? How can clinicians in low-resource settings without access to fetal monitoring technology accurately assess these situations?

Before developing consensus on the optimal population-level rate, the global maternal health community must agree upon the medical indications for cesarean delivery and ensure that clinicians around the world are adhering to standardized, evidence-based guidelines.

Read Part 2 and Part 3.

Read a statement about the prevention of primary cesareans from the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine.

Categories: Maternal Health

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