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  • Title: Caesarean birth rates worldwide. A search for determinants.
    Author: van Roosmalen J, van der Does CD.
    Journal: Trop Geogr Med; 1995; 47(1):19-22. PubMed ID: 7747325.
    Abstract:
    High caesarean birth rates are an issue of international public health concern. Determinants of caesarean birth are reviewed in order to formulate strategies to reduce these high rates. A strong independent profession of highly qualified midwives, who care for women with low-risk pregnancies, may contribute to a relatively low caesarean birth rate. Different clinical policies which influence the intervention rate, are discussed for the most frequent reasons to perform caesarean section: dystocia, repeat caesarean birth, breech delivery and foetal distress. The risks and safety of caesarean birth differ from place to place in this world. As the relative safety of the procedure is an important factor contributing to the rise of caesarean birth, the fact that this has only been achieved in some parts of the world should restrict the indications to perform the operation in the best interests of pregnant women. High cesarean birth rates are a matter of concern to international public health. Determinants of cesarean birth are reviewed and different clinical policies are discussed for the most frequent reasons to perform cesarean section: dystocia, repeat cesarean birth, breech delivery, and fetal distress. The most frequent indication for cesarean section is dystocia, although in some cases of the lesser degrees of cephalopelvic disproportion, symphysiotomy can be practiced. Repeat cesarean births account for a high percentage of the total number of operations. Of 45,425 births to women with previous cesarean sections in California in 1986, 89% had a repeat cesarean birth in subsequent pregnancies. However, a trial of vaginal labor is safe for women with a history of cesarean birth. The risks involved in breech delivery have led to an increasing number of elective cesarean sections. The use of the operation should be less liberal when the maternal mortality rate after the operation exceeds 1-2/1000. For that reason, one should be reluctant to perform an operation for fetal distress, which often cannot be diagnosed properly. Strong arguments call for reluctance in applying new indications for cesarean section, for instance, in all triplets pregnancies, in order to prevent vertical transmission of HIV-infection, or a transverse lie in a second twin. The mortality rate after cesarean section in women in a Nigerian teaching hospital (0.6%) is still six times higher than the mortality rate after the operation in the West (0.1%). Serious maternal morbidity after the operation occurs in 9-15% of cesarean sections in the Third World. Cesarean section can also lower fertility rates compared to vaginal birth. In other parts of the world, cesarean section has not yet become the safe procedure as it is considered in the West, thus alternative procedures should be performed such as version and extraction, vaginal breech or instrumental delivery, and symphysiotomy.
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