Local efforts can stem the increasing unnecessary cesarean sections

Caesarean section rates are steadily increasing globally. Requiring two doctors to agree that a Caesarean section is the best way to deliver a baby, rather than just needing one opinion, providing internal feedback to doctors on the number of operations performed and seeking support from local opinion leaders may reduce the use of this procedure. For low-risk pregnancies, nurse-led relaxation classes for women with a fear or anxiety of childbirth and birth preparation classes for mothers may decrease caesarean sections.

On the other hand, providing prenatal education and support programs, computer patient decision-aids, decision-aid booklets and intensive group therapy to women have not been shown to decrease Caesarean sections effectively. Likewise, insurance reform, legislative changes, external feedback to doctors on their performance and training of public health nurses to provide mode of delivery information in childbirth classes do not decrease caesarean section rates.

These were the findings of a systematic review carried out by researchers in Thailand and Australia and published in The Cochrane Library.

"Around the world more and more women are opting to deliver their babies by a Cesarean section rather than have the discomfort and perceived greater risk of a standard vaginal delivery," says study leader Suthit Khunpradit, who works in the department of Obstetrics and Gynaecology at Lamphun Hospital, in Thailand. He points out that while reported Caesarean section rates vary, studies have shown that in England, Scotland, Norway, Finland, Sweden and Denmark Caesarean section rates rose from around 4% to 5% in 1970 to 20% to 22% in 2001. Furthermore, in 1997 up to 40% of women in Chile opted for a Cesarean section and current figures show that 46.2% of deliveries in China are by Caesarean section.

"In 1985 an expert panel of the World Health Organization suggested that you could expect up to 15% of women to benefit from a Cesarean section, but if more were having them, then many were unnecessary," says Khunpradit.

While it can be a life-saving procedure for both the mother and the unborn child, Caesarean sections are also used in situations when neither the mother nor the unborn child has a greater risk of complications than the rest of the peripartum population. Caesarean section itself has risks, including maternal infections, haemorrhage, transfusion, other organ injury, anaesthetic complications and psychological complications. "In some settings, maternal mortality associated with caesarean section has been reported to be two to four times greater than that associated with vaginal birth," says Khunpradit.

"There is a clear need to halt the escalating use of Caesarean sections, and from the studies published so far the strategies that had clearest evidence of reducing the proportion Caesarean sections were those that focused on the clinicians," says Khunpradit. He believes there is clear need for further studies that get higher quality evidence about interventions that could help women see whether a Caesarean really is the best option or whether a natural birth would be better.

Full citation: Khunpradit S, Tavender E, Lumbiganon P, Laopaiboon M, Wasiak J, Gruen RL. Non-clinical interventions for reducing unnecessary caesarean section. Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD005528. DOI:10.1002/14651858.CD005528.pub2.
URL: http://doi.wiley.com/10.1002/14651858.CD005528.pub2

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