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CAESAREAN SECTION — CHANGING TRENDS DURING LAST TWO DECADES
CAESAREAN SECTION CHANGING TRENDS DURING LAST TWO DECADES Col M ALAM*, Brig RP ARORA+ ABSTRACf Changing trends of caesarean section during last twenty years have been studied. There seems to be a gradual increase in the incidence of caesarean section over the years with a simultaneous decline in the perinatal mortality rate. The incidence of caesarean section has slowly been increasing for post-caesarean pregnancy, breech presentation and foetal distress. This opens up a debate as to what extent this increase is justifiable. The trend needs a close observation. MJAFI 1995; 51 : 183·185
KEY WORDS: Cesarean section; Trends.
Introduction
T
h is study is an analysis ofthe changing trends of caesarean section at our service hospitals over the last 20 years. It is mainly based on the observations of the authors and the operations performed by them. The mother's life is important but the new born has also the right to be physically, mentally and emotionally "well born". There can always be a conflict between maternal mortality/morbidity rate versus perinatal mortality/morbidity. In civil practice, the rate of caesarean delivery is touching new heights. There is a growing concern among patients and obstetricians about the rising trend of caesarean deliveries. This study tries to find out the causes and justification for this increase. Material and Methods
The study covers the period from Jan 1974 to Dec 1993. The obstetric records of various service hospitals where the authors were posted and worked were carefully studied. The incidence and indications of caesarean section with maternal and perinatal mortality
rate were studied. The data have been divided into four 5-year periods for ease of understanding and analysis. Results There has been a gradually progressive increase in the incidence of caesarean section over the years (Table 1). The incidence which was only 2.5% during 1974-78 has become 14.12% during 1989-93, a nearly six-fold increase in two decades. Similarly we observe that maternal mortality due to caesarean section has dropped from 0.9% to 0.12%, nearly seven-fold during the same period (Fig 1). TABLE 1 Incidence of caesarean 1100 deliveries Indication
1974-78
5-year period 79-83 84-88
Post-caesarean Breech Foetal distress Dystocia APH Miscellaneous
0.6 0.1 0.2 0.8 0.2 0.6
1.0 0.4 0.6 1.2 0.4 3.8
Total
2.5
7.4
89-93
2.2
2.5
0.9
0.95
1.2 1.8 0.3 4.4
2.5 1.6 0.4 6.17
10.8
14.12
*Senior Adviser (Obst and Gynae), 166 Military Hospital Clo 56 APO. +Commandant, Base Hospital. Delhi Canlt 110010.
184 ALAM and ARORA
MJAFI, 51: 3, July 1995
~.--.
0'8
120
....f I8
,
roo
0'6
eo 0'4
60
, ",72
62
"
~-"
"~41
40 0'12 1974- 78
79-53
84, 88
'--
'-'0,:0
20
' . _,15
1974076
89 - 93
OVERALL
"t CAESAREIIN
19-83
84'8e
89-93
Fig. 1: Maternal mortality rate!100 caesarean section.
Fig, 2: Perinatal mortality rate/t 000 births,
Overall perinatal mortality rate has been showing a gradual decline over the years (Fig 2). But there is a marked and phenomenal decline of perinatal mortality associated with caesarean deliveries. Table 1 shows the trends in caesarean section rates according to the specific indications. Since the primary caesarean section rate has been increasing during last two decades, it is but natural that the repeat caesarean section rate has gone up nearly four-fold. Many more caesarean sections are being performed for breech now-a-days, more so in primigravida. The rate of caesarean section for foetal distress is also fast increasing due to introduction of doppler, cardiotocography and electronic foetal monitoring and more safety consciousness among obstetricians. The rate of caesarean section for dystocia was gradually increasing till about five years ago, but now seems a bit static, possibly due to more cases being taken up for active management of labour. Miscellaneous group of indications for caesarean is also on the rise, which comprises of caesarean section for elderly primigravida, pregnancy after prolonged period of infertility, pregnancy induced hypertension and intrauterine growth retardation.
increase from 2.5% to 14.12% in service hospitals during the last 20 years, while Arora and Oumachigui [1] from Pondicherry, India reported a doubling of the caesarean section rate in just 6 years. The increasing safety of caesarean section is well demonstrated in Fig 1 and the absolute decrease in perinatal mortality in Fig 2. However, a cause and effect relationship between these two parameters cannot be established unequivocally. In 1984, Gulstrap et al [2], showed concern about the rising caesarean section rates particularly for dystocia, breech presentation, foetal distress and repeat caesarean section. O'Driscoll and Foley [3] have shown that improvement in the perinatal mortality rates parallel to those seen in the United States could be achieved without parallel escalation
Discussion This study shows clearly that there is a gradually increasing trend in caesarean deliveries in service hospitals. These trends are also visible throughout the world as shown in Table 2. There has been a nearly six-fold
TABLE 2
Caesarean section (changing trends] Author
Country
Earlier incidence
Later incidence
Notzon et al [4] Notzon etal [4] Ciltrap et al [21 Shiono et al [5] Arora & Oumachlgul [1] Present study
England! 5.0% (1970) Wales 5.7% (1970) Canada
10.1 % (1983)
USA
8.2% (1970)
15.2% (1981)
USA
9.1 (1974)
21.2% (1984)
India
12.3% (1981)
27.6% (1989)
India
15.9% [1980)
2.5% (1974) 14.12% (1993)
MJAFI, 51 : 3, July 1995
in the caesarean section rates. They identified the two main problems as dystocia and repeat caesarean section. They advocated management of labour in primigravida using a partegram, with early detection and prompt treatment of dystocia by non -8 urgical means. They advocated a liberal use of intravenous oxytocin in primigravidae. In our study (Table 1) the last 5-year figures show a declining trend for dystocia. due to practice of active management of labour in our service hospitals as well. It is possible that we can reduce or check the increasing trend of caesarean by active management of labour in primigravidae, by delivering selected breech cases (those with average expected baby weight and adequate pelvis) vaginally, and also by allowing vagi-
Caesarean Section 185
nal deliveries in poslcaesarean pregnancy with non-recurrent indications. In the latter instance the patients consent must be obtained and the labour closely supervised by the obstetrician. REFERENCES 1. Arora RR. Oumachigui A. Caesarean section : A
review. Journal of Obstetrics Gynaecology India 1991; 41 : 192-4.
2. Gilstrap LC, Hauth JC, Toussant S. Rising trend of caesarean deliveries. Obstet Gynecol1984; 63 : 2058.
3. O'Driscoli K, Folley M. Perinatal mortality and caesarean section. Obstet Cyneccl 1983; 161 : 1-3. 4. Notazon FC, Placek DJ. Raffel SM. Changing indications of caesarean. New Eng J Mad 1987: 43 : 316-9. 5. Shinono PH. Mc Nellis D, Rhoads GG. How safe is caesarean section? Obstot Gynecol1987; 69 : 696·3.
KEY WORDS: Cesarean section; Trends.
Introduction
T
h is study is an analysis ofthe changing trends of caesarean section at our service hospitals over the last 20 years. It is mainly based on the observations of the authors and the operations performed by them. The mother's life is important but the new born has also the right to be physically, mentally and emotionally "well born". There can always be a conflict between maternal mortality/morbidity rate versus perinatal mortality/morbidity. In civil practice, the rate of caesarean delivery is touching new heights. There is a growing concern among patients and obstetricians about the rising trend of caesarean deliveries. This study tries to find out the causes and justification for this increase. Material and Methods
The study covers the period from Jan 1974 to Dec 1993. The obstetric records of various service hospitals where the authors were posted and worked were carefully studied. The incidence and indications of caesarean section with maternal and perinatal mortality
rate were studied. The data have been divided into four 5-year periods for ease of understanding and analysis. Results There has been a gradually progressive increase in the incidence of caesarean section over the years (Table 1). The incidence which was only 2.5% during 1974-78 has become 14.12% during 1989-93, a nearly six-fold increase in two decades. Similarly we observe that maternal mortality due to caesarean section has dropped from 0.9% to 0.12%, nearly seven-fold during the same period (Fig 1). TABLE 1 Incidence of caesarean 1100 deliveries Indication
1974-78
5-year period 79-83 84-88
Post-caesarean Breech Foetal distress Dystocia APH Miscellaneous
0.6 0.1 0.2 0.8 0.2 0.6
1.0 0.4 0.6 1.2 0.4 3.8
Total
2.5
7.4
89-93
2.2
2.5
0.9
0.95
1.2 1.8 0.3 4.4
2.5 1.6 0.4 6.17
10.8
14.12
*Senior Adviser (Obst and Gynae), 166 Military Hospital Clo 56 APO. +Commandant, Base Hospital. Delhi Canlt 110010.
184 ALAM and ARORA
MJAFI, 51: 3, July 1995
~.--.
0'8
120
....f I8
,
roo
0'6
eo 0'4
60
, ",72
62
"
~-"
"~41
40 0'12 1974- 78
79-53
84, 88
'--
'-'0,:0
20
' . _,15
1974076
89 - 93
OVERALL
"t CAESAREIIN
19-83
84'8e
89-93
Fig. 1: Maternal mortality rate!100 caesarean section.
Fig, 2: Perinatal mortality rate/t 000 births,
Overall perinatal mortality rate has been showing a gradual decline over the years (Fig 2). But there is a marked and phenomenal decline of perinatal mortality associated with caesarean deliveries. Table 1 shows the trends in caesarean section rates according to the specific indications. Since the primary caesarean section rate has been increasing during last two decades, it is but natural that the repeat caesarean section rate has gone up nearly four-fold. Many more caesarean sections are being performed for breech now-a-days, more so in primigravida. The rate of caesarean section for foetal distress is also fast increasing due to introduction of doppler, cardiotocography and electronic foetal monitoring and more safety consciousness among obstetricians. The rate of caesarean section for dystocia was gradually increasing till about five years ago, but now seems a bit static, possibly due to more cases being taken up for active management of labour. Miscellaneous group of indications for caesarean is also on the rise, which comprises of caesarean section for elderly primigravida, pregnancy after prolonged period of infertility, pregnancy induced hypertension and intrauterine growth retardation.
increase from 2.5% to 14.12% in service hospitals during the last 20 years, while Arora and Oumachigui [1] from Pondicherry, India reported a doubling of the caesarean section rate in just 6 years. The increasing safety of caesarean section is well demonstrated in Fig 1 and the absolute decrease in perinatal mortality in Fig 2. However, a cause and effect relationship between these two parameters cannot be established unequivocally. In 1984, Gulstrap et al [2], showed concern about the rising caesarean section rates particularly for dystocia, breech presentation, foetal distress and repeat caesarean section. O'Driscoll and Foley [3] have shown that improvement in the perinatal mortality rates parallel to those seen in the United States could be achieved without parallel escalation
Discussion This study shows clearly that there is a gradually increasing trend in caesarean deliveries in service hospitals. These trends are also visible throughout the world as shown in Table 2. There has been a nearly six-fold
TABLE 2
Caesarean section (changing trends] Author
Country
Earlier incidence
Later incidence
Notzon et al [4] Notzon etal [4] Ciltrap et al [21 Shiono et al [5] Arora & Oumachlgul [1] Present study
England! 5.0% (1970) Wales 5.7% (1970) Canada
10.1 % (1983)
USA
8.2% (1970)
15.2% (1981)
USA
9.1 (1974)
21.2% (1984)
India
12.3% (1981)
27.6% (1989)
India
15.9% [1980)
2.5% (1974) 14.12% (1993)
MJAFI, 51 : 3, July 1995
in the caesarean section rates. They identified the two main problems as dystocia and repeat caesarean section. They advocated management of labour in primigravida using a partegram, with early detection and prompt treatment of dystocia by non -8 urgical means. They advocated a liberal use of intravenous oxytocin in primigravidae. In our study (Table 1) the last 5-year figures show a declining trend for dystocia. due to practice of active management of labour in our service hospitals as well. It is possible that we can reduce or check the increasing trend of caesarean by active management of labour in primigravidae, by delivering selected breech cases (those with average expected baby weight and adequate pelvis) vaginally, and also by allowing vagi-
Caesarean Section 185
nal deliveries in poslcaesarean pregnancy with non-recurrent indications. In the latter instance the patients consent must be obtained and the labour closely supervised by the obstetrician. REFERENCES 1. Arora RR. Oumachigui A. Caesarean section : A
review. Journal of Obstetrics Gynaecology India 1991; 41 : 192-4.
2. Gilstrap LC, Hauth JC, Toussant S. Rising trend of caesarean deliveries. Obstet Gynecol1984; 63 : 2058.
3. O'Driscoli K, Folley M. Perinatal mortality and caesarean section. Obstet Cyneccl 1983; 161 : 1-3. 4. Notazon FC, Placek DJ. Raffel SM. Changing indications of caesarean. New Eng J Mad 1987: 43 : 316-9. 5. Shinono PH. Mc Nellis D, Rhoads GG. How safe is caesarean section? Obstot Gynecol1987; 69 : 696·3.