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An analysis of the indications for cesarean section in a teaching hospital in China
European Journal of Obstetrics & Gynecology and Reproductive Biology 170 (2013) 414–418
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
An analysis of the indications for cesarean section in a teaching hospital in China Yanyun Gao a, Qinqin Xue a, Gang Chen a, Peter Stone c, Min Zhao b,*, Qi Chen b,c a
Department of Obstetrics & Gynaecology, Yulin First Hospital, Yanan Medical University, Shanxi Province, China Wuxi Maternity and Child Health Hospital, Nanjing Medical University, China c Department of Obstetrics & Gynaecology, The University of Auckland, New Zealand b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 25 March 2013 Received in revised form 17 July 2013 Accepted 2 August 2013
Objectives: Cesarean delivery rates have increased remarkably worldwide. The indications for this increase are not fully understood and there may be regional, ethnic or health system differences in quoted indications which may explain, at least in part, the observed changes. In 2008 China was cited as having one of the highest rates of cesarean delivery in the world, but there was no accurate information about the indications for the high rate. This study sought to provide some information about the high cesarean section rate in China. Study design: Data on all births in a university teaching hospital in northern China serving a general obstetric population, excluding premature births, were collected from the hospital database from January 2009 to September 2012. All indications on the mode of delivery were analyzed for live births. Results: There were 5267 births and the cesarean delivery rate was 41.4% in the study period. There was no significant trend in the cesarean delivery rate from 2009 to 2012. Fetal indications contributed most to the rate. More than 50% of all cesarean deliveries were due to nuchal cord, previous cesarean delivery, fetal distress and malpresentation. The rate of cesarean delivery on maternal request was 9.07%. Smaller contributions to the indications for cesarean delivery came from cephalopelvic disproportion, preeclampsia, prolonged labor, uterine rupture and other obstetric conditions. Conclusion: The data show increased fetal or maternal risk assessments are the main indications for cesarean delivery rather than cesarean delivery on maternal request in China. ß 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Cesarean delivery Fetal indications Maternal indications Nuchal cord China
1. Introduction Worldwide cesarean delivery rates have increased remarkably over the last two decades [1]. Although cesarean delivery is recommended when vaginal delivery might pose a significant risk to the mother or baby, more cesarean sections are performed in both developing and developed countries than would seem to be justified by established risk factors alone. The World Health Organisation (WHO) has suggested a rate around 15% as being appropriate [2]. Despite variations globally in cesarean section delivery rates, this increasing trend has occurred for women of all ages, races, geographic areas and gestational ages, although some studies have suggested that the cesarean delivery rate is likely to be in part associated with the ethnicity of the mothers [3]. Based on a survey by the WHO, the cesarean delivery rate in
* Corresponding author at: Wuxi Maternity and Children Health Hospital Affiliated Nanjing Medical University, 48 Huaishu Street, Wuxi, Jiangsu Province, China. Tel.: +86 13861688600; fax: +86 510 82725094. E-mail address: [email protected] (M. Zhao). 0301-2115/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejogrb.2013.08.009
China or other Asian countries reached 46% and 27% respectively in 2008 [4]. The indications for the increased cesarean delivery rate are not clear. It may be because cesarean delivery is perceived to be lifesaving and may prevent birth trauma to the fetus and mother [5,6]. A number of studies have attempted to explain the trends, including an increase in non-medically indicated cesarean section for maternal request in situations where birth would be expected to occur naturally. In addition, increases in previous cesarean delivery, the number of expectant mothers with risk factors such as obesity, delays in childbirth, reduced parity, and changes in the obstetrical medicolegal environment are all likely to contribute to the soaring rates. The indications for increased cesarean delivery, however, also appear to be dependent on the regions and ethnicity studied [7,8]. One study suggested that currently the changes in maternal risk profile rather than increased cesarean delivery on request should be taken account in the assessment of indications for increased cesarean delivery [9], although another recent study suggested that cesarean delivery on maternal request had increased by 20% resulting in the increased cesarean delivery rates [10]. Based on the
Y. Gao et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 170 (2013) 414–418
WHO survey in 2008, it was suggested that the increased cesarean delivery rate in China may be mainly due to increased cesarean delivery on maternal request [4]. Less evidence was provided in that survey, however, as to what the actual indications for the increased cesarean section delivery rates in China might be. To date, only a few studies have reported the actual indications for increased cesarean delivery. These studies suggest that maternal or fetal risk profiles are the main indications for increased cesarean delivery both in the United States and SubSaharan Africa [11,12]. This prompted us to prospectively collect detailed data on indications for cesarean delivery in a region in China. In this study we analyzed the indications for cesarean delivery from 2009 to 2012, based on the medical records of the mother and the newborn at a university teaching hospital which serves a diverse urban and rural population. 2. Materials and methods This retrospective analysis of prospectively acquired data was based in the Department of Obstetrics and Gynaecology, Yulin First Hospital, which is a general teaching hospital serving a diverse urban and rural population. The birth rate in Yulin City was 1.1% in 2011. In this study, data on all births in the Yulin First Hospital were collected from January 2009 to September 2012 according to the medical records of mother and newborn. Data included the type of delivery and the indications for cesarean delivery. All primary indications for cesarean delivery were recorded in the medical records of the mother and newborn. The data were then further divided into four categories: maternal indications, fetal indications, maternal and fetal indications, and maternal request where there was no stated medical or obstetric reason for cesarean section. Maternal indications are defined as maternal conditions that could complicate delivery. They include previous cesarean delivery, complications of pregnancy such as preeclampsia, labor dystocia, maternal infection, elderly primigravida (over 40 years old), pregnant women with a tumor and maternal cardiac diseases. Although preeclampsia, maternal infection and maternal tumor are not traditional indications for cesarean section, it is common to have a cesarean section for these complications in China and we therefore included these in the maternal indications category. Fetal indications included nuchal cord, malpresentation, fetal distress, macrosomia and multiple births. Nuchal cord was diagnosed by a transabdominal ultrasound scan in the third trimester when the umbilical cord appeared wrapped around the fetal neck twice, i.e. with two loops. Transabdominal ultrasound scanning is commonly performed before delivery in China, and is usually performed three to four times during pregnancy. Fetal distress was defined on cardiotocography (CTG) alone: fetal scalp blood sampling was not used. Macrosomia is defined as a fetus or
infant that weighs above 4000 g based on an ultrasound estimate following a guideline from the Chinese College of Obstetrics and Gynecology. Multiple births include all twins and higher multiples. Cephalopelvic disproportion was diagnosed by the combination of ultrasound and abdominal examination by obstetrician assessing head descent into the pelvic brim prior to labor. Prolonged pregnancy was defined as gestation length 42 completed weeks. Malpresentation included breech and shoulder presentation or transverse lie. Maternal and fetal indications were defined as conditions affecting both the mother and the fetus, and included placenta previa and polyhydramnios or oligohydramnios. The statistical difference in maternal age, length of gestation, multiparity and birth weight between vaginal and cesarean delivery were assessed by the Mann–Whitney U-test using the Prism software package. The statistical differences in cesarean delivery rate and indications for cesarean delivery in the study period were assessed by the Chi-square test using Prism software. The statistical difference in fetal indications, maternal indications, fetal and maternal indications and cesarean delivery on maternal request were assessed by Poisson regression which analyzed the difference between four groups using SAS software. P-values of <0.05 were considered significant. 3. Results During the study period the total number of live births was 5267. Of these live births, 2181 (41.4%) were delivered by cesarean section. The cesarean delivery rate among all live births was 44.9% in 2009, 42.0% in 2010, 42.3% in 2011 and 38.8% in 2012. There was no significant difference in the cesarean delivery rates over the 4 years (p = 0.4148). Of 2181 women with cesarean section, 1404 were planned cesarean sections and 777 were emergency cesarean sections (Fig. 1). There were no data available in the hospital database regarding the distinction between emergency cesarean delivery in labor or not in labor. All unplanned cesarean sections were termed emergency. The documented indications for all cesarean sections are shown in Table 1. Overall, nuchal cord was the single most frequent reason for cesarean delivery (19.3%), followed by previous cesarean delivery (13.6%), fetal distress (11.8%), malpresentation (11.0%) and cesarean delivery on maternal request (9.1%). Macrosomia (5.8%), cephalopelvic disproportion (4.9%), preeclampsia (4.8%), prolonged labor (3.3%) and uterine rupture (3.3%) accounted for similar percentages. Less frequent indications (between 1 and 3%) were maternal cardiac disease, multiple births, polyhydramnios or oligohydramnios and placenta previa. Prolonged pregnancy, elderly primigravida, maternal tumors including uterine fibroids and malignancy, maternal infection, idiopathic thrombocytopenic purpura (ITP), failed labor induction, umbilical cord prolapse and
Cesarean section (N=2181)
Planned (N=1404)
No labor (N=1370)
In labor (N=34)
415
Emergency (N, 811=777+34)
Fig. 1. Flow diagram showing the numbers of planned and emergency cesarean sections in the study population.
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Y. Gao et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 170 (2013) 414–418
Table 1 Detailed leading indications for cesarean delivery during the 4 years of the study. Indications Nuchal cord Previous cesarean Fetal distress Malpresentation Cesarean delivery on maternal request Macrosomia Cephalopelvic disproportion Preeclampsia Prolonged labor (dystocia) Placenta abruption Maternal cardiac diseases Multi births Polyhydramnios or oligohydramnios Placenta praevia Prolonged pregnancy Elderly primigravida, tumor Infection ITP Failed labor induction Varices Umbilical cord prolapse Others Total
Total N = 2181 423 297 259 240 198 127 109 106 73 72 57 52 40 26 20 21 19 7 7 6 5 1 16
(19.3%) (13.6%) (11.8%) (11.0%) (9.1%) (5.8%) (4.9%) (4.8%) (3.3%) (3.3%) (2.6%) (2.4%) (1.8%) (1.2%) (0.9%) (0.9%) (0.8%) (0.3%) (0.3%) (0.2%) (0.2%) (0.1%) (0.7%)
2181 (100%)
others contributed to the indications for cesarean delivery by less than 1% in total population (Table 1). The trend for the indication for cesarean delivery due to previous cesarean delivery significantly increased from 7.22% (24 out of 332) in 2009, 8.25% (39 out of 473) in 2010, 13.1% (91 out of 693) in 2011 to 20.9% (143 out of 683) in 2012 (p = 0.002). Cesarean delivery due to nuchal cord, however, decreased significantly from 26.8% (89 out of 332) in 2009, 22.2% (105 out 473) in 2010, 16.8% (117 out of 693) in 2011 to 16.39 (112 out of 683) in 2012 (p = 0.04). There was no significant difference in other indications for cesarean delivery from 2009 to 2012 (p > 0.05). The average maternal age was 26.72 4.2 years old, the average gestation was 39+1 weeks, and the average birth weight was 3299 526 g. There was no difference in maternal age, gestation weeks, multiparous and birth weight between vaginal delivery and cesarean delivery. Parity was not recorded in 136 of the 3086 women who delivered vaginally. In the remaining 2947 vaginal births, 1705 (57.8%) were nulliparous. In the group of 2181 women delivered by cesarean section, 1522 (69.8%) were nulliparous. Significantly more nulliparous women were delivered by cesarean section than vaginally (p = 0.001). During the study period, of the 2181 women delivered by cesarean section, a primary fetal indication contributed to 1124 births or 51.5% of the cesareans. This was significantly higher than maternal indications (31.3%) or maternal and fetal indications (8.1%) or cesarean delivery for maternal request (9.1%) (p < 0.001, Table 2). The maternal indications for cesarean delivery (684 women) were also significantly higher than maternal and fetal indications or cesarean delivery on maternal request (p < 0.001, Table 2). Over the 4 years of the study, 57 pregnant women with maternal cardiac disease had a cesarean delivery. All these mothers
Table 2 Indications for cesarean delivery. N = 2181 Fetal indications Maternal indications Maternal & fetal indications cesarean delivery on maternal request
1124 684 175 198
(51.5%) (31.3%) (8.1%) (9.1%)
had pre-existing cardiac disease. A total of 19 women with cancer including cervical and ovarian malignancies also had cesarean deliveries. 4. Comments Cesarean delivery may, in appropriate circumstances, significantly reduce maternal and perinatal mortality [13], but the cesarean delivery rate has significantly increased worldwide in the last two decades at a rate higher than could be accounted for by previously accepted indications likely to be associated with adverse outcomes with a vaginal birth. A WHO survey showed that the cesarean delivery rate in China was 46% in 2008 and is higher than most other countries [4]. In this current study, we found the overall cesarean delivery rate in a relatively small-sized city with a population of 3.5 million was 41.4%, which is slightly lower than the cesarean delivery rate by WHO survey. This difference could be because the WHO survey was done in hospitals which are located in the capital cities (large cities in China) where it is reported that maternal request is higher. It may also reflect regional differences in rates [7,8,14]. There is no agreed international standard classification of indications for cesarean delivery [15,16] because definitions are not standardized and indications can be multiple or interrelated. In China, it has been reported that the main indications for cesarean section are fetal distress, failure of progress, malpresentation, cephalo-pelvic disproportion, and pregnancy complications such as preeclampsia and maternal request (articles in Chinese). In our study, we summarized indications into four categories: maternal, fetal, maternal and fetal, and cesarean delivery on maternal request. Our data show that fetal indications were the commonest reason for cesaraen section in the region studied. These data are consistent with a recent study which showed fetal indications to be the leading reason for cesarean delivery in the United States [12]. Among the fetal indications, nuchal cord was recorded as a major problem (19.39%), followed by fetal distress (11.87%) in China, while fetal distress (32%) was recorded as the leading problem in a major academic medical center in the United States [12]. Comparing the leading four individual indications for cesarean delivery in the United States, which were prolonged labor (dystocia), previous cesarean, breech presentation and fetal distress [17], we found in this study that the leading four indications for cesarean delivery in China were nuchal cord, previous cesarean, fetal distress and malpresentation. Unlike Western countries, prolonged labor only accounted for 3.35% of all cesarean deliveries in China. This could be because of the very high cesarean section rate, differences in definitions or clinical practices before labor, or because some indications were multiple or interrelated. Nuchal cord is a common finding at delivery and occurs in 10–37% of all births [18]. The presence of a nuchal cord can be identified before induction of labor by prenatal ultrasound examination [18]. It is very common to perform an ultrasound examination in late gestation or before delivery in China and this has become a practice protocol. Although nuchal cord alone is not a common indication for cesarean delivery in most western countries and not associated with the adverse perinatal outcome [19], it is one of the commonest indications for cesarean delivery in China for perceived safety reasons. Retrospective studies of over 182,000 births with adequate statistical power also suggested that nuchal cord may be associated with cesarean delivery in births in some countries [20,21]. In China, due to social pressures of a medicolegal nature, physicians commonly fear failure of vaginal delivery or poor fetal outcome when a nuchal cord is present. In such circumstances, cesarean delivery may be convenient for the physicians although in this study nuchal cord as a primary indication showed a reducing the trend from 26.8% in 2009 to
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16.39% in 2012. The reason for this reduction is unclear, especially as there is no formalized medical indemnity system for doctors in China and defensive clinical actions contribute to many of the obstetric practices. Similar to other reports [17], in this study previous cesarean delivery was one of the main indications for cesarean delivery in China (13.6%). This is likely due to increasing cesarean rates and low rates of trial of vaginal birth after cesarean section. The percentage of pregnant women who had a previous cesarean delivery has increased from 18% in 1992 to 40% in 2000 in urban China [22]. In this study we also found that the percentage of pregnant women who had had previous cesarean delivery was significantly increased from 7.22% in 2009 to 20.9% in 2012. In SubSaharan Africa, a multinational study also showed that 14% of cesarean deliveries were due to previous cesarean delivery [11], which is very similar to the results found in this study. The increasing numbers of repeat cesarean section are of particular interest. China instituted a ‘‘one child policy’’ at the end of the 1970s. In practice, this policy was implemented and had more effect in the urban rather than rural areas. After 30 years of strict enforcement with financial sanctions to those families not adhering to this policy, it has recently become apparent that there has been relaxation in the application of the policy throughout the country. Specific examples where more than one child has been accepted included where the couple themselves both came from a single child family and also where a child may have been disabled. Vaginal delivery after cesarean delivery (VBAC) has significantly reduced from 28% in 1996 to 9.2% in 2004 in the United States [23]. Trial of vaginal delivery after previous cesarean delivery may increase the risk of an emergency cesarean delivery although the risk is not high [24,25], and a recent study has suggested that VBAC is a reasonable choice for the majority of women who had a previous cesarean section [26]. Consistent with other studies, the trend for VBAC also significantly reduced in this study suggesting more and more physicians or pregnant women choose repeat cesarean delivery instead of trial of VBAC. We reviewed seventeen papers in Chinese, specifically about VBAC, and the rates of repeat cesarean section ranged from 42% to 98% with the median being 80.51%. Based on the WHO survey in 2008, it was suggested that the increased cesarean delivery rate in China may be mainly due to increased maternal request [4]. Studies indicated that 5–40% of pregnant women fear childbirth in western countries [24,27]. This fear of childbirth may also be relevant to Chinese women, because Chinese women fear painful natural birth or worry that the vagina may be stretched or damaged by a normal delivery [4]. In addition, social pressures may influence the desire to have a cesarean delivery. A common belief in Chinese society and reinforced in the media is that cesarean delivery is a more convenient way to give birth [28]. This impacts on Chinese women and their family feeling that it is safer for the mother and child to have a cesarean delivery. A recent study suggested that rates of cesarean delivery for maternal request have increased by 20% [10] which may contribute to the overall increased cesarean delivery rate. In this study, however, we found it is not the case in a relatively small sized city in China. We found the overall average rate of cesarean delivery on maternal request was only 9.1% over the 4 years. These data are consistent with another study which suggests that maternal request for cesarean delivery is not the main reason for increased cesarean delivery rates [29]. We also found that the rate of cesarean delivery on maternal request was not increased during the study period (the rates of cesarean delivery on maternal request in 2009, 2010, 2011 and 2012 were 6.0%, 10.9%, 9.5% and 5.7%, respectively). Although a large national wide survey in the United States showed that only 2.5% of all cesarean deliveries
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appear to be due to maternal request [30], a more recent study [12] in a single hospital in the United State showed the rate of cesarean delivery on maternal request was 8%, similar to our findings. There are some limitations to this study in terms of generalizing the findings to China as a whole. Data were obtained from a hospital in a relatively small-sized city in China over a 4-year period. This limited the sample size. Indications for cesarean delivery may vary amongst regions and economic levels in China. Therefore whilst our data may not be representative of China as a whole they could provide some information for indications for cesarean section in China, which has one of the highest cesarean section rates in the world. A recent Chinese article with 4281 live births from 24 hospitals in 2005 showed that the average cesarean section rate was 57.8% (range from 45.7% to 78.1%). Of this 57.8% cesarean section rate, 20.9% was recorded as maternal request. The main clinical indications for cesarean section were cephalopelvic disproportion (11.5%), fetal distress (11.3%), malpresentation (7%), pregnancy complications (6.1%) and macrosomia (5.25%). In conclusion, in this study we have described the indications for all cesarean deliveries in a small city in the northwest of China. Our data show that the average cesarean delivery rate is 41.44%, and the leading indications for cesarean delivery are nuchal cord, previous cesarean delivery, fetal distress and malpresentation. Our data also showed that cesarean delivery on maternal request was not the main indication for cesarean delivery. Conflict of interest statement None of the authors has a conflict of interest. References [1] Betran AP, Merialdi M, Lauer JA, et al. Rates of caesarean section: analysis of global, regional and national estimates. Paediatr Perinat Epidemiol 2007; 21:98–113. [2] WHO. Appropriate technology for birth. Lancet 1985;2:436–7. [3] Braveman P, Egerter S, Edmonston F, Verdon M. Racial/ethnic differences in the likelihood of cesarean delivery, California. Am J Public Health 1995;85:625–30. [4] Lumbiganon P, Laopaiboon M, Gulmezoglu AM, et al. Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007–08. Lancet 2010;375:490–9. [5] Lee YM, D’Alton ME. Cesarean delivery on maternal request: the impact on mother and newborn. Clin Perinatol 2008;35:505–18. x. [6] Hankins GD, Clark SM, Munn MB. Cesarean section on request at 39 weeks: impact on shoulder dystocia, fetal trauma, neonatal encephalopathy, and intrauterine fetal demise. Semin Perinatol 2006;30:276–87. [7] Rio I, Castello A, Barona C, et al. Caesarean section rates in immigrant and native women in Spain: the importance of geographical origin and type of hospital for delivery. Eur J Public Health 2010;20:524–9. [8] Malin M, Gissler M. Maternal care and birth outcomes among ethnic minority women in Finland. BMC Public Health 2009;9:84. [9] Reddy UM, Ko CW, Willinger M. Maternal age and the risk of stillbirth throughout pregnancy in the United States. Am J Obstet Gynecol 2006;195: 764–70. [10] Fuglenes D, Oian P, Kristiansen IS. Obstetricians’ choice of cesarean delivery in ambiguous cases: is it influenced by risk attitude or fear of complaints and litigation? Am J Obstet Gynecol 2009;200:48e1–8. [11] Chu K, Cortier H, Maldonado F, Mashant T, Ford N, Trelles M. Cesarean section rates and indications in Sub-Saharan Africa: a multi-country study from Medecins sans Frontieres. PLoS ONE 2012;7:e44484. [12] Barber EL, Funai EF, Bracken MB, Illuzzi JL. Interpretation of 2002 Centers for Disease Control guidelines for group B streptococcus and evolving provider practice patterns. Am J Perinatol 2011;28:97–102. [13] Weil O, Fernandez H. Is safe motherhood an orphan initiative. Lancet 1999;354:940–3. [14] Zhang J, Liu Y, Meikle S, Zheng J, Sun W, Li Z. Cesarean delivery on maternal request in southeast China. Obstet Gynecol 2008;111:1077–82. [15] Torloni MR, Betran AP, Souza JP, et al. Classifications for cesarean section: a systematic review. PLoS ONE 2011;6:e14566. [16] Stanton C, Ronsmans C. Recommendations for routine reporting on indications for cesarean delivery in developing countries. Birth 2008;35:204–11. [17] Tita AT. When is primary cesarean appropriate: maternal and obstetrical indications. Semin Perinatol 2012;36:324–7. [18] Peregrine E, O’Brien P, Jauniaux E. Ultrasound detection of nuchal cord prior to labor induction and the risk of Cesarean section. Ultrasound Obstet Gynecol 2005;25:160–4.
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[19] Sheiner E, Abramowicz JS, Levy A, Silberstein T, Mazor M, Hershkovitz R. Nuchal cord is not associated with adverse perinatal outcome. Arch Gynecol Obstet 2006;274:81–3. [20] Schaffer L, Burkhardt T, Zimmermann R, Kurmanavicius J. Nuchal cords in term and postterm deliveries—do we need to know. Obstet Gynecol 2005;106:23–8. [21] Mastrobattista JM, Hollier LM, Yeomans ER, et al. Effects of nuchal cord on birthweight and immediate neonatal outcomes. Am J Perinatol 2005;22:83–5. [22] Tang S, Li X, Wu Z. Rising cesarean delivery rate in primiparous women in urban China: evidence from three nationwide household health surveys. Am J Obstet Gynecol 2006;195:1527–32. [23] Yang YT, Mello MM, Subramanian SV, Studdert DM. Relationship between malpractice litigation pressure and rates of cesarean section and vaginal birth after cesarean section. Med Care 2009;47:234–42. [24] Kringeland T, Daltveit AK, Moller A. What characterizes women in Norway who wish to have a caesarean section. Scand J Public Health 2009;37:364–71.
[25] Hildingsson I, Radestad I, Rubertsson C, Waldenstrom U. Few women wish to be delivered by caesarean section. BJOG 2002;109:618–23. [26] Guise JM, Denman MA, Emeis C, et al. Vaginal birth after cesarean: new insights on maternal and neonatal outcomes. Obstet Gynecol 2010;115:1267–78. [27] Nieminen K, Stephansson O, Ryding EL. Women’s fear of childbirth and preference for cesarean section—a cross-sectional study at various stages of pregnancy in Sweden. Acta Obstet Gynecol Scand 2009;88:807–13. [28] Walker R, Turnbull D, Wilkinson C. Increasing cesarean section rates: exploring the role of culture in an Australian community. Birth 2004;31:117–24. [29] MacDorman MF, Menacker F, Declercq E. Cesarean birth in the United States: epidemiology, trends, and outcomes. Clin Perinatol 2008;35:293–307. v. [30] De Vries RG, Low LK, Bogdan-Lewis E. Choosing surgical birth: desire and the nature of bioethical advice. In: Lindemann H, Verkerk M, Urban Walker M, editors. Naturalized bioethics. Cambridge: Cambridge University Press; 2008. p. 42–64.
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
An analysis of the indications for cesarean section in a teaching hospital in China Yanyun Gao a, Qinqin Xue a, Gang Chen a, Peter Stone c, Min Zhao b,*, Qi Chen b,c a
Department of Obstetrics & Gynaecology, Yulin First Hospital, Yanan Medical University, Shanxi Province, China Wuxi Maternity and Child Health Hospital, Nanjing Medical University, China c Department of Obstetrics & Gynaecology, The University of Auckland, New Zealand b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 25 March 2013 Received in revised form 17 July 2013 Accepted 2 August 2013
Objectives: Cesarean delivery rates have increased remarkably worldwide. The indications for this increase are not fully understood and there may be regional, ethnic or health system differences in quoted indications which may explain, at least in part, the observed changes. In 2008 China was cited as having one of the highest rates of cesarean delivery in the world, but there was no accurate information about the indications for the high rate. This study sought to provide some information about the high cesarean section rate in China. Study design: Data on all births in a university teaching hospital in northern China serving a general obstetric population, excluding premature births, were collected from the hospital database from January 2009 to September 2012. All indications on the mode of delivery were analyzed for live births. Results: There were 5267 births and the cesarean delivery rate was 41.4% in the study period. There was no significant trend in the cesarean delivery rate from 2009 to 2012. Fetal indications contributed most to the rate. More than 50% of all cesarean deliveries were due to nuchal cord, previous cesarean delivery, fetal distress and malpresentation. The rate of cesarean delivery on maternal request was 9.07%. Smaller contributions to the indications for cesarean delivery came from cephalopelvic disproportion, preeclampsia, prolonged labor, uterine rupture and other obstetric conditions. Conclusion: The data show increased fetal or maternal risk assessments are the main indications for cesarean delivery rather than cesarean delivery on maternal request in China. ß 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Cesarean delivery Fetal indications Maternal indications Nuchal cord China
1. Introduction Worldwide cesarean delivery rates have increased remarkably over the last two decades [1]. Although cesarean delivery is recommended when vaginal delivery might pose a significant risk to the mother or baby, more cesarean sections are performed in both developing and developed countries than would seem to be justified by established risk factors alone. The World Health Organisation (WHO) has suggested a rate around 15% as being appropriate [2]. Despite variations globally in cesarean section delivery rates, this increasing trend has occurred for women of all ages, races, geographic areas and gestational ages, although some studies have suggested that the cesarean delivery rate is likely to be in part associated with the ethnicity of the mothers [3]. Based on a survey by the WHO, the cesarean delivery rate in
* Corresponding author at: Wuxi Maternity and Children Health Hospital Affiliated Nanjing Medical University, 48 Huaishu Street, Wuxi, Jiangsu Province, China. Tel.: +86 13861688600; fax: +86 510 82725094. E-mail address: [email protected] (M. Zhao). 0301-2115/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejogrb.2013.08.009
China or other Asian countries reached 46% and 27% respectively in 2008 [4]. The indications for the increased cesarean delivery rate are not clear. It may be because cesarean delivery is perceived to be lifesaving and may prevent birth trauma to the fetus and mother [5,6]. A number of studies have attempted to explain the trends, including an increase in non-medically indicated cesarean section for maternal request in situations where birth would be expected to occur naturally. In addition, increases in previous cesarean delivery, the number of expectant mothers with risk factors such as obesity, delays in childbirth, reduced parity, and changes in the obstetrical medicolegal environment are all likely to contribute to the soaring rates. The indications for increased cesarean delivery, however, also appear to be dependent on the regions and ethnicity studied [7,8]. One study suggested that currently the changes in maternal risk profile rather than increased cesarean delivery on request should be taken account in the assessment of indications for increased cesarean delivery [9], although another recent study suggested that cesarean delivery on maternal request had increased by 20% resulting in the increased cesarean delivery rates [10]. Based on the
Y. Gao et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 170 (2013) 414–418
WHO survey in 2008, it was suggested that the increased cesarean delivery rate in China may be mainly due to increased cesarean delivery on maternal request [4]. Less evidence was provided in that survey, however, as to what the actual indications for the increased cesarean section delivery rates in China might be. To date, only a few studies have reported the actual indications for increased cesarean delivery. These studies suggest that maternal or fetal risk profiles are the main indications for increased cesarean delivery both in the United States and SubSaharan Africa [11,12]. This prompted us to prospectively collect detailed data on indications for cesarean delivery in a region in China. In this study we analyzed the indications for cesarean delivery from 2009 to 2012, based on the medical records of the mother and the newborn at a university teaching hospital which serves a diverse urban and rural population. 2. Materials and methods This retrospective analysis of prospectively acquired data was based in the Department of Obstetrics and Gynaecology, Yulin First Hospital, which is a general teaching hospital serving a diverse urban and rural population. The birth rate in Yulin City was 1.1% in 2011. In this study, data on all births in the Yulin First Hospital were collected from January 2009 to September 2012 according to the medical records of mother and newborn. Data included the type of delivery and the indications for cesarean delivery. All primary indications for cesarean delivery were recorded in the medical records of the mother and newborn. The data were then further divided into four categories: maternal indications, fetal indications, maternal and fetal indications, and maternal request where there was no stated medical or obstetric reason for cesarean section. Maternal indications are defined as maternal conditions that could complicate delivery. They include previous cesarean delivery, complications of pregnancy such as preeclampsia, labor dystocia, maternal infection, elderly primigravida (over 40 years old), pregnant women with a tumor and maternal cardiac diseases. Although preeclampsia, maternal infection and maternal tumor are not traditional indications for cesarean section, it is common to have a cesarean section for these complications in China and we therefore included these in the maternal indications category. Fetal indications included nuchal cord, malpresentation, fetal distress, macrosomia and multiple births. Nuchal cord was diagnosed by a transabdominal ultrasound scan in the third trimester when the umbilical cord appeared wrapped around the fetal neck twice, i.e. with two loops. Transabdominal ultrasound scanning is commonly performed before delivery in China, and is usually performed three to four times during pregnancy. Fetal distress was defined on cardiotocography (CTG) alone: fetal scalp blood sampling was not used. Macrosomia is defined as a fetus or
infant that weighs above 4000 g based on an ultrasound estimate following a guideline from the Chinese College of Obstetrics and Gynecology. Multiple births include all twins and higher multiples. Cephalopelvic disproportion was diagnosed by the combination of ultrasound and abdominal examination by obstetrician assessing head descent into the pelvic brim prior to labor. Prolonged pregnancy was defined as gestation length 42 completed weeks. Malpresentation included breech and shoulder presentation or transverse lie. Maternal and fetal indications were defined as conditions affecting both the mother and the fetus, and included placenta previa and polyhydramnios or oligohydramnios. The statistical difference in maternal age, length of gestation, multiparity and birth weight between vaginal and cesarean delivery were assessed by the Mann–Whitney U-test using the Prism software package. The statistical differences in cesarean delivery rate and indications for cesarean delivery in the study period were assessed by the Chi-square test using Prism software. The statistical difference in fetal indications, maternal indications, fetal and maternal indications and cesarean delivery on maternal request were assessed by Poisson regression which analyzed the difference between four groups using SAS software. P-values of <0.05 were considered significant. 3. Results During the study period the total number of live births was 5267. Of these live births, 2181 (41.4%) were delivered by cesarean section. The cesarean delivery rate among all live births was 44.9% in 2009, 42.0% in 2010, 42.3% in 2011 and 38.8% in 2012. There was no significant difference in the cesarean delivery rates over the 4 years (p = 0.4148). Of 2181 women with cesarean section, 1404 were planned cesarean sections and 777 were emergency cesarean sections (Fig. 1). There were no data available in the hospital database regarding the distinction between emergency cesarean delivery in labor or not in labor. All unplanned cesarean sections were termed emergency. The documented indications for all cesarean sections are shown in Table 1. Overall, nuchal cord was the single most frequent reason for cesarean delivery (19.3%), followed by previous cesarean delivery (13.6%), fetal distress (11.8%), malpresentation (11.0%) and cesarean delivery on maternal request (9.1%). Macrosomia (5.8%), cephalopelvic disproportion (4.9%), preeclampsia (4.8%), prolonged labor (3.3%) and uterine rupture (3.3%) accounted for similar percentages. Less frequent indications (between 1 and 3%) were maternal cardiac disease, multiple births, polyhydramnios or oligohydramnios and placenta previa. Prolonged pregnancy, elderly primigravida, maternal tumors including uterine fibroids and malignancy, maternal infection, idiopathic thrombocytopenic purpura (ITP), failed labor induction, umbilical cord prolapse and
Cesarean section (N=2181)
Planned (N=1404)
No labor (N=1370)
In labor (N=34)
415
Emergency (N, 811=777+34)
Fig. 1. Flow diagram showing the numbers of planned and emergency cesarean sections in the study population.
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Table 1 Detailed leading indications for cesarean delivery during the 4 years of the study. Indications Nuchal cord Previous cesarean Fetal distress Malpresentation Cesarean delivery on maternal request Macrosomia Cephalopelvic disproportion Preeclampsia Prolonged labor (dystocia) Placenta abruption Maternal cardiac diseases Multi births Polyhydramnios or oligohydramnios Placenta praevia Prolonged pregnancy Elderly primigravida, tumor Infection ITP Failed labor induction Varices Umbilical cord prolapse Others Total
Total N = 2181 423 297 259 240 198 127 109 106 73 72 57 52 40 26 20 21 19 7 7 6 5 1 16
(19.3%) (13.6%) (11.8%) (11.0%) (9.1%) (5.8%) (4.9%) (4.8%) (3.3%) (3.3%) (2.6%) (2.4%) (1.8%) (1.2%) (0.9%) (0.9%) (0.8%) (0.3%) (0.3%) (0.2%) (0.2%) (0.1%) (0.7%)
2181 (100%)
others contributed to the indications for cesarean delivery by less than 1% in total population (Table 1). The trend for the indication for cesarean delivery due to previous cesarean delivery significantly increased from 7.22% (24 out of 332) in 2009, 8.25% (39 out of 473) in 2010, 13.1% (91 out of 693) in 2011 to 20.9% (143 out of 683) in 2012 (p = 0.002). Cesarean delivery due to nuchal cord, however, decreased significantly from 26.8% (89 out of 332) in 2009, 22.2% (105 out 473) in 2010, 16.8% (117 out of 693) in 2011 to 16.39 (112 out of 683) in 2012 (p = 0.04). There was no significant difference in other indications for cesarean delivery from 2009 to 2012 (p > 0.05). The average maternal age was 26.72 4.2 years old, the average gestation was 39+1 weeks, and the average birth weight was 3299 526 g. There was no difference in maternal age, gestation weeks, multiparous and birth weight between vaginal delivery and cesarean delivery. Parity was not recorded in 136 of the 3086 women who delivered vaginally. In the remaining 2947 vaginal births, 1705 (57.8%) were nulliparous. In the group of 2181 women delivered by cesarean section, 1522 (69.8%) were nulliparous. Significantly more nulliparous women were delivered by cesarean section than vaginally (p = 0.001). During the study period, of the 2181 women delivered by cesarean section, a primary fetal indication contributed to 1124 births or 51.5% of the cesareans. This was significantly higher than maternal indications (31.3%) or maternal and fetal indications (8.1%) or cesarean delivery for maternal request (9.1%) (p < 0.001, Table 2). The maternal indications for cesarean delivery (684 women) were also significantly higher than maternal and fetal indications or cesarean delivery on maternal request (p < 0.001, Table 2). Over the 4 years of the study, 57 pregnant women with maternal cardiac disease had a cesarean delivery. All these mothers
Table 2 Indications for cesarean delivery. N = 2181 Fetal indications Maternal indications Maternal & fetal indications cesarean delivery on maternal request
1124 684 175 198
(51.5%) (31.3%) (8.1%) (9.1%)
had pre-existing cardiac disease. A total of 19 women with cancer including cervical and ovarian malignancies also had cesarean deliveries. 4. Comments Cesarean delivery may, in appropriate circumstances, significantly reduce maternal and perinatal mortality [13], but the cesarean delivery rate has significantly increased worldwide in the last two decades at a rate higher than could be accounted for by previously accepted indications likely to be associated with adverse outcomes with a vaginal birth. A WHO survey showed that the cesarean delivery rate in China was 46% in 2008 and is higher than most other countries [4]. In this current study, we found the overall cesarean delivery rate in a relatively small-sized city with a population of 3.5 million was 41.4%, which is slightly lower than the cesarean delivery rate by WHO survey. This difference could be because the WHO survey was done in hospitals which are located in the capital cities (large cities in China) where it is reported that maternal request is higher. It may also reflect regional differences in rates [7,8,14]. There is no agreed international standard classification of indications for cesarean delivery [15,16] because definitions are not standardized and indications can be multiple or interrelated. In China, it has been reported that the main indications for cesarean section are fetal distress, failure of progress, malpresentation, cephalo-pelvic disproportion, and pregnancy complications such as preeclampsia and maternal request (articles in Chinese). In our study, we summarized indications into four categories: maternal, fetal, maternal and fetal, and cesarean delivery on maternal request. Our data show that fetal indications were the commonest reason for cesaraen section in the region studied. These data are consistent with a recent study which showed fetal indications to be the leading reason for cesarean delivery in the United States [12]. Among the fetal indications, nuchal cord was recorded as a major problem (19.39%), followed by fetal distress (11.87%) in China, while fetal distress (32%) was recorded as the leading problem in a major academic medical center in the United States [12]. Comparing the leading four individual indications for cesarean delivery in the United States, which were prolonged labor (dystocia), previous cesarean, breech presentation and fetal distress [17], we found in this study that the leading four indications for cesarean delivery in China were nuchal cord, previous cesarean, fetal distress and malpresentation. Unlike Western countries, prolonged labor only accounted for 3.35% of all cesarean deliveries in China. This could be because of the very high cesarean section rate, differences in definitions or clinical practices before labor, or because some indications were multiple or interrelated. Nuchal cord is a common finding at delivery and occurs in 10–37% of all births [18]. The presence of a nuchal cord can be identified before induction of labor by prenatal ultrasound examination [18]. It is very common to perform an ultrasound examination in late gestation or before delivery in China and this has become a practice protocol. Although nuchal cord alone is not a common indication for cesarean delivery in most western countries and not associated with the adverse perinatal outcome [19], it is one of the commonest indications for cesarean delivery in China for perceived safety reasons. Retrospective studies of over 182,000 births with adequate statistical power also suggested that nuchal cord may be associated with cesarean delivery in births in some countries [20,21]. In China, due to social pressures of a medicolegal nature, physicians commonly fear failure of vaginal delivery or poor fetal outcome when a nuchal cord is present. In such circumstances, cesarean delivery may be convenient for the physicians although in this study nuchal cord as a primary indication showed a reducing the trend from 26.8% in 2009 to
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16.39% in 2012. The reason for this reduction is unclear, especially as there is no formalized medical indemnity system for doctors in China and defensive clinical actions contribute to many of the obstetric practices. Similar to other reports [17], in this study previous cesarean delivery was one of the main indications for cesarean delivery in China (13.6%). This is likely due to increasing cesarean rates and low rates of trial of vaginal birth after cesarean section. The percentage of pregnant women who had a previous cesarean delivery has increased from 18% in 1992 to 40% in 2000 in urban China [22]. In this study we also found that the percentage of pregnant women who had had previous cesarean delivery was significantly increased from 7.22% in 2009 to 20.9% in 2012. In SubSaharan Africa, a multinational study also showed that 14% of cesarean deliveries were due to previous cesarean delivery [11], which is very similar to the results found in this study. The increasing numbers of repeat cesarean section are of particular interest. China instituted a ‘‘one child policy’’ at the end of the 1970s. In practice, this policy was implemented and had more effect in the urban rather than rural areas. After 30 years of strict enforcement with financial sanctions to those families not adhering to this policy, it has recently become apparent that there has been relaxation in the application of the policy throughout the country. Specific examples where more than one child has been accepted included where the couple themselves both came from a single child family and also where a child may have been disabled. Vaginal delivery after cesarean delivery (VBAC) has significantly reduced from 28% in 1996 to 9.2% in 2004 in the United States [23]. Trial of vaginal delivery after previous cesarean delivery may increase the risk of an emergency cesarean delivery although the risk is not high [24,25], and a recent study has suggested that VBAC is a reasonable choice for the majority of women who had a previous cesarean section [26]. Consistent with other studies, the trend for VBAC also significantly reduced in this study suggesting more and more physicians or pregnant women choose repeat cesarean delivery instead of trial of VBAC. We reviewed seventeen papers in Chinese, specifically about VBAC, and the rates of repeat cesarean section ranged from 42% to 98% with the median being 80.51%. Based on the WHO survey in 2008, it was suggested that the increased cesarean delivery rate in China may be mainly due to increased maternal request [4]. Studies indicated that 5–40% of pregnant women fear childbirth in western countries [24,27]. This fear of childbirth may also be relevant to Chinese women, because Chinese women fear painful natural birth or worry that the vagina may be stretched or damaged by a normal delivery [4]. In addition, social pressures may influence the desire to have a cesarean delivery. A common belief in Chinese society and reinforced in the media is that cesarean delivery is a more convenient way to give birth [28]. This impacts on Chinese women and their family feeling that it is safer for the mother and child to have a cesarean delivery. A recent study suggested that rates of cesarean delivery for maternal request have increased by 20% [10] which may contribute to the overall increased cesarean delivery rate. In this study, however, we found it is not the case in a relatively small sized city in China. We found the overall average rate of cesarean delivery on maternal request was only 9.1% over the 4 years. These data are consistent with another study which suggests that maternal request for cesarean delivery is not the main reason for increased cesarean delivery rates [29]. We also found that the rate of cesarean delivery on maternal request was not increased during the study period (the rates of cesarean delivery on maternal request in 2009, 2010, 2011 and 2012 were 6.0%, 10.9%, 9.5% and 5.7%, respectively). Although a large national wide survey in the United States showed that only 2.5% of all cesarean deliveries
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appear to be due to maternal request [30], a more recent study [12] in a single hospital in the United State showed the rate of cesarean delivery on maternal request was 8%, similar to our findings. There are some limitations to this study in terms of generalizing the findings to China as a whole. Data were obtained from a hospital in a relatively small-sized city in China over a 4-year period. This limited the sample size. Indications for cesarean delivery may vary amongst regions and economic levels in China. Therefore whilst our data may not be representative of China as a whole they could provide some information for indications for cesarean section in China, which has one of the highest cesarean section rates in the world. A recent Chinese article with 4281 live births from 24 hospitals in 2005 showed that the average cesarean section rate was 57.8% (range from 45.7% to 78.1%). Of this 57.8% cesarean section rate, 20.9% was recorded as maternal request. The main clinical indications for cesarean section were cephalopelvic disproportion (11.5%), fetal distress (11.3%), malpresentation (7%), pregnancy complications (6.1%) and macrosomia (5.25%). In conclusion, in this study we have described the indications for all cesarean deliveries in a small city in the northwest of China. Our data show that the average cesarean delivery rate is 41.44%, and the leading indications for cesarean delivery are nuchal cord, previous cesarean delivery, fetal distress and malpresentation. Our data also showed that cesarean delivery on maternal request was not the main indication for cesarean delivery. Conflict of interest statement None of the authors has a conflict of interest. References [1] Betran AP, Merialdi M, Lauer JA, et al. Rates of caesarean section: analysis of global, regional and national estimates. Paediatr Perinat Epidemiol 2007; 21:98–113. [2] WHO. Appropriate technology for birth. Lancet 1985;2:436–7. [3] Braveman P, Egerter S, Edmonston F, Verdon M. Racial/ethnic differences in the likelihood of cesarean delivery, California. Am J Public Health 1995;85:625–30. [4] Lumbiganon P, Laopaiboon M, Gulmezoglu AM, et al. Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007–08. Lancet 2010;375:490–9. [5] Lee YM, D’Alton ME. Cesarean delivery on maternal request: the impact on mother and newborn. Clin Perinatol 2008;35:505–18. x. [6] Hankins GD, Clark SM, Munn MB. Cesarean section on request at 39 weeks: impact on shoulder dystocia, fetal trauma, neonatal encephalopathy, and intrauterine fetal demise. Semin Perinatol 2006;30:276–87. [7] Rio I, Castello A, Barona C, et al. Caesarean section rates in immigrant and native women in Spain: the importance of geographical origin and type of hospital for delivery. Eur J Public Health 2010;20:524–9. [8] Malin M, Gissler M. Maternal care and birth outcomes among ethnic minority women in Finland. BMC Public Health 2009;9:84. [9] Reddy UM, Ko CW, Willinger M. Maternal age and the risk of stillbirth throughout pregnancy in the United States. Am J Obstet Gynecol 2006;195: 764–70. [10] Fuglenes D, Oian P, Kristiansen IS. Obstetricians’ choice of cesarean delivery in ambiguous cases: is it influenced by risk attitude or fear of complaints and litigation? Am J Obstet Gynecol 2009;200:48e1–8. [11] Chu K, Cortier H, Maldonado F, Mashant T, Ford N, Trelles M. Cesarean section rates and indications in Sub-Saharan Africa: a multi-country study from Medecins sans Frontieres. PLoS ONE 2012;7:e44484. [12] Barber EL, Funai EF, Bracken MB, Illuzzi JL. Interpretation of 2002 Centers for Disease Control guidelines for group B streptococcus and evolving provider practice patterns. Am J Perinatol 2011;28:97–102. [13] Weil O, Fernandez H. Is safe motherhood an orphan initiative. Lancet 1999;354:940–3. [14] Zhang J, Liu Y, Meikle S, Zheng J, Sun W, Li Z. Cesarean delivery on maternal request in southeast China. Obstet Gynecol 2008;111:1077–82. [15] Torloni MR, Betran AP, Souza JP, et al. Classifications for cesarean section: a systematic review. PLoS ONE 2011;6:e14566. [16] Stanton C, Ronsmans C. Recommendations for routine reporting on indications for cesarean delivery in developing countries. Birth 2008;35:204–11. [17] Tita AT. When is primary cesarean appropriate: maternal and obstetrical indications. Semin Perinatol 2012;36:324–7. [18] Peregrine E, O’Brien P, Jauniaux E. Ultrasound detection of nuchal cord prior to labor induction and the risk of Cesarean section. Ultrasound Obstet Gynecol 2005;25:160–4.
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