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Caesarean section--a woman's right to choose: ICM Central Europe Region workshop: regional representative Renske Drejer reports on a workshop held in Vienna, Austria, April 2004, to address an important issue for midwives.

Midwives in the Central Europe Region, along with many others around the world in both developed and developing countries, are very much concerned about the ongoing increase of the Caesarean section rate.

Facts and figures about Caesarean section rates in the member countries of this particular region have been reported and are shown in Table 1. These data have been collected by midwives from their own national sources.

What can midwives do?

Knowing these figures, we asked ourselves what we can do to influence the phenomenon of rising CS rates within the region. It was decided to organise a workshop on the subject of Caesarean section: eventually this was arranged to he held in Vienna on 3rd April 2004. Twelve ICM delegates attended.

The subject 'Caesarean section' was considered too wide, so we chose a more specific theme: 'Caesarean section: a woman's tight to choose?'. Mary Sidebotham, a member of the Association of Supervisors of Midwives in the UK, offered her help and her skills as a workshop moderator.

The following questions, to which we hoped to find some answers, were selected as the guidelines through the workshop:

* Is the worldwide rise in the Caesarean section rate something we as midwives are concerned about?

* What are our concerns?

* Why is it happening?

* Are women concerned?

* Can we do anything about it?

Divided into two groups for discussion, we were given eight case histories to study, taken from a Dutch survey looking for obstetricians' views on elective Caesarean section.

Emerging from these histories were some of the reasons why certain women ask for a delivery by Caesarean section.

* Fear of perineal trauma

* Fear of fetal distress

* No motivation to choose a vaginal delivery

* Previous delivery experienced as very traumatic, pelvic pain

* Obesity

* Previous elective Caesarean section because of a not engaged breech: now afraid for uterine rupture.

The groups were asked to identify what empowered midwives could do in each of the cases to help the women to make their decision. Two important conclusions were among those reached after the discussions were:

* In discussions with obstetricians, midwives need to be well informed about actual research findings.

* Midwifery teachers must ensure that the new members of the profession learn the essence of their job: being with women and being pro-active in supporting normal birth.

Action plan

We agreed on the following action plan:

1. To write a new position paper for ICM Council in Brisbane, supported by all the Europe regions and eventually FIGO

2. To prepare a scientific paper based on the minutes of the workshop for presentation in Brisbane

3. To establish a plan of action for the delegates in their own countries

We will keep you informed of our progress.


The author thanks Penny Held of the Swiss Federation of Midwives for the use of her notes on the meeting.
Table 1. Selected data on Caesarean section (CS) rates in Central

Country CS rate and comments

Austria National CS rate 15%-30%, depending on the hospital

Belgium CS rate was 20% in 2003 and is rising every year.
 Almost 100% of women presenting with breech will be
 delivered by CS.

Croatia National average CS rate 15% and rising at 1% a
 year. It is possible to have a CS on demand.

Czech Republic National average CS rate was 14% in 2002, ranging
 from 11%-18%. Tertiary centres did not have rates
 any higher than 18%

Germany CS rate shows a national average of 22%. There is a
 difference between the former west and east Germany:
 in the west the rate is higher. (In general hospitals
 are paid 1500 Euros for a spontaneous delivery and
 3800-4800 Euros for a CS)

The Netherlands There is a rise in the CS rate although there is a
 strict division between primary and secondary care
 and midwives carry out the risk selection. For
 example the rate at the Amsterdam medical centre went
 up in 2003 from 24% to 27%. *

Slovenia National average CS rate is only 11%. In tertiary
 units, e.g. the hospital in Ljubljana where there are
 5000 deliveries a year, the CS rate is 14%.

Switzerland No national perinatal database. Large tertiary units
 are estimated to have a CS rate of 25%-27%. Hospitals
 which have received 'Baby Friendly' awards must
 publish their rates and these are 18%. Private
 clinics do not have to publish their figures and
 their CS rates are estimated to be 40%-50%.

* The rise in the Netherlands follows the report of the 'Term
Breech Trial' in 2000 (1) in which data were collected from 121
centres in 26 countries. The results of the study indicate that
planned Caesarean delivery has better outcomes than planned
vaginal delivery for foetuses in the breech position at term.


(1.) Hannah ME, Hannah WJ, Hewson SA, et al. (The Term Breech Trial Collaborative Group). 2000. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. The Lancet, vol 356, 1375-1383.

Note: the current ICM Position Statement, 'Promoting vaginal delivery in preference to Caesarean section', is accessible on the ICM website
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Article Details
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Author:Drejer, Renske
Publication:International Midwifery
Geographic Code:4E
Date:Jul 1, 2004
Previous Article:Midwifery in the Netherlands: a prospect for future development in Europe.
Next Article:Nordic conference brings together 500 midwives in Reykjavik, Iceland, May 2004.

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