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Reducing c-sections may require multifaceted approach.

Latin America has some of the highest rates of cesarean section in the world, involving 25-30 percent of all deliveries. The World Health Organization recommends a safe target rate for c-section of 15 percent. Researchers with the Latin American Cesarean Section Study Group, including Population Council regional director Ana Langer, investigated whether instituting mandatory second opinions in hospital obstetric wards would reduce the rate of unnecessary cesarean sections. A similar intervention on a smaller scale in Ecuador had resulted in an 18.5 percent reduction in c-sections.

Consequences of c-sections

As compared to vaginal deliveries, cesarean section deliveries are associated with increased maternal death, injury, and infection. In some cases, scheduled cesarean sections can result in babies being delivered prematurely, with undeveloped lungs. Cesarean deliveries are also more costly than vaginal deliveries and require longer hospital stays.

The Latin American Caesarean Section Study Group conducted a trial between October 1998 and June 2000. The study involved 36 hospitals (18 in Argentina, eight in Brazil, four in Cuba, two in Guatemala, and four in Mexico) and nearly 150,000 women. The hospitals were paired off and assigned randomly to experimental and control groups. One of the hospitals closed during the study, hence the hospital it was matched with was excluded from the trial. At all hospitals the researchers collected baseline data on the rate of c-sections for six months. Then, at the experimental hospitals, obstetricians and other staff underwent training for one month to prepare for the intervention. Finally, the investigators observed the outcome of the intervention for six months.

At the experimental hospitals a policy, of mandatory second opinions was instituted for all elective and other nonemergency cesarean sections. Physicians often suggest that women get elective cesarean sections if they have undergone a c-section for a previous pregnancy. C-sections are also proposed when labor progresses slowly or when there is evidence of fetal distress. Emergency c-sections, such as those involving maternal hemorrhage, umbilical cord prolapse, or uterine rapture, required no second opinion because delaying surgery might endanger the mother or infant. At the control hospitals the standard of care remained unchanged.

The researchers assessed whether the intervention would be effective under routine conditions. Therefore, strategies to improve compliance with the intervention were left to hospital coordinators. In the end, second opinions were obtained for 88 percent of eligible c-sections.

Small reductions

The second-opinion policy was associated with a 7.3 percent reduction in the rates of cesarean section, a small but statistically significant decline. The researchers' analysis revealed that the decrease was seen mostly in the case of unplanned cesareans, usually those suggested for failure of labor to progress and for possible fetal distress. Here the reduction was 12.6 percent. The intervention and control hospitals were not perfectly matched. The baseline findings revealed that experimental hospitals had a larger proportion of women expecting their first child. First births are more likely than later births to be problematic. The women at the experimental hospitals were also more likely to have excessively heavy babies, which may be harder to deliver. Adjusting for these differences further reduced the rate of cesarean sections.

Although the decline in c-section was statistically significant, it was not large enough to justify a change in current protocol. Instituting such a change in procedure would require a substantial effort. The cost of implementing the intervention on a large scale would potentially exceed the savings gained by avoiding a small number of c-sections.

"There are no easy answers about what strategies will effectively reduce the rate of c-section," asserts Langer. "My hunch is that a multifaceted approach is likely needed."

Langer suggests three potential targets for interventions to reduce the rate of c-sections: the medical system, women and families, and the culture. Educating senior physicians and medical school professors in evidence-based medicine will make them less likely to recommend c-sections in cases when it may not be necessary. These physicians can tutor younger doctors. Educating and empowering women and other family members about the risks and benefits of cesarean sections will make them better advocates for their own care. Finally, tackling the perception of c-section as a status symbol and addressing insurance policies that favor c-section will help to give proper prominence to vaginal delivery and its benefits.

A similarly comprehensive campaign, the UNICEF/World Health Organization's Baby Friendly Hospital Initiative, successfully increased the rate of breastfeeding in the 1990s.


Althabe, Fernando, Jose M. Belizan, Jose Villar, Sophie Alexander, Eduardo Bergel, Silvina Ramos, Mariana Romero, Allan Donner, Gunilla Lindmark, Ana Langer, Ubaldo Farnot, Jose G. Cecatti, Guillermo Carroli, Edgar Kestler, for the Latin American Caesarean Section Study Group. 2004. "Mandatory second opinion to reduce rates of unnecessary caesarean sections in Latin America: A cluster randomised controlled trial," Lancet 363(9425): 1934-1940.


The European Union, the Pan American Health Organization, the Research Support Fund of Sao Paulo State, Brazil, and the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development, and Research Training in Human Reproduction of WHO
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Title Annotation:Safe Motherhood
Publication:Population Briefs
Geographic Code:0LATI
Date:Sep 1, 2004
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