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Trends in caesarean section rates at a maternity hospital in Mumbai, India.

INTRODUCTION

What has already been described as the "caesarean birth epidemic" (1) may now well be considered a true pandemic emerging issue in mother-child healthcare. A recent leading editorial stressed that the rise in caesarean section is now a matter that deserves international attention (2), since the trend is no longer confined to western industrialized countries.

Noteworthy in this respect is the study by Belizan et al. reporting on caesarean section rates in 19 Latin American countries, revealing caesarean section rates ranging from 16.8% up to 40% in 12 of these countries (3).

Other reports from developing countries, albeit scarce, are often based on vital statistics in providing crude population-based caesarean birth rates. However, caesarean rates tend to vary widely with clinical and sociodemographic factors of patients and attitudes of health providers. Hence, it has been suggested that national caesarean delivery rates do not reflect what is happening locally (4), supporting the trend toward monitoring rates at the level of individual hospital or physician (5).

The use of caesarean rate as a clinical indicator for healthcare quality has been the subject of an ongoing debate (6-12), albeit much of the controversy has focused on high caesarean rates in the USA and the UK. Yet, from a public-health perspective, WHO (13) endorsed the principle that there is no region in the world where a population-based caesarean section rate exceeding 15% of all live-births is justified. Even when the rate put forward by WHO was set as an arbitrary upper limit, it is an interesting concept in itself, as it may be considered a 'threshold', beyond which the benefits of performing caesarean section are no longer outweighing short- and long-term morbidity and mortality associated with the actual procedure.

An assessment of the patterns and trends over time in caesarean section rates and maternal-perinatal mortality rates might be useful to analyze the past, current and future caesarean section scenario, which may help in advising healthcare providers about optimal caesarean section rates. With this background, a study was undertaken to assess and compare time-trends in caesarean section rates and their association with maternal case-fatality rates and perinatal mortality since 1957 at the Nowrosjee Wadia Maternity Hospital, Mumbai, India.

MATERIALS AND METHODS

The Nowrosjee Wadia Maternity Hospital (NWMH), a semi-private teaching hospital in obstetrics and gynaecology, is the single largest maternity facility in Mumbai (Bombay), accounting for approximately 5% of all births in the district of Mumbai. Nearly 10,000 births were registered anually throughout the study period. The precise catchment area is difficult to delineate, as women attending the NMWH virtually come from all over the city of Mumbai. Ninety-nine percent of these women are booked in the antenatal clinic of the NWMH, while 0.3% receive antenatal care elsewhere, and another 0.7% arrive for an unbooked 'emergency delivery.' The number of NWMH antenatal-care attenders who deliver at home or elsewhere is unknown, but is considered low by the health staff. As the hospital does not have a maternal intensive care unit, pregnant women with obstetrical, medical or surgical complications are referred to the K.E.M. Hospital, a tertiary care-level municipal teaching hospital. However, the NWMH has good emergency obstetric services, including blood-bank facilities and anaesthetic services. Its Newborn Intensive Care Unit is adequate, and round-the-clock service is guaranteed.

Relatively small percentages of poor women come to the hospital. The hospital rather caters to the need of mainly rich, low-middle to mid-middle classes of the population. The literacy rate of women attending the NWMH is over 90%, with the majority having secondary or higher-level education. The educational status of the parturients shows that 8.9% did not have any formal education, 3.7% had primary-level only, 54.4% had secondary-level education, and 33.0% had higher education.

All basic obstetric, perinatal and neonatal data of 1957-1998 as recorded in the hospital files were compiled in annual reports throughout the entire study period. Published materials on these (interim analyses) were also-used as an additional source to the current analysis (21,22). Separate analyses were made for 1991 to 1998 based on the 'Minimum Obstetric-Neonatal Record' database from Sir Ness Wadia Research Centre of the NMWH. All information was collected by the first author, who is a physician at the NWMH.

From the early 1990s, data were stored in a computer database on 'Minimum Obstetric-Neonatal Record' at Sir Ness Wadia Research Centre of the hospital. Data from earlier registers were entered into a database. Data were analyzed using the EPI Info[c] (version 7.0) statistical package. When found appropriate, simple Pearson's chi-square test of significance was applied for time-trend analysis.

RESULTS

From the late 1950s to the mid-1970s, only a small but discernable rise in the caesarean section rate was observed, when the caesarean section rates rose from less than 2% to just over 3% (Fig. 1). This slowly-evolving trend was followed by a far sharper incline in the late 1970s onward. Where caesarean sections at this maternity facility remained at a rather steady rate during the first half of 1970s at about 3%, the caesarean section rate reached a level of more than 8% of all births by the end of 1980s. However, from 1990s onward, even a more accelarated rise in the caesarean section rate was observed from 9% to 16% in less than a decade.

During the first half of the study period, rates of instrumental vaginal delivery (through forceps or vacuum extraction) were comparable to caesarean rates and showed similar trends (Fig. 2). These rates were less than 2% during the late 1950s and increased to about 3% during the mid-1970s. During this period, vacuum extraction was not performed at the NWMH. Hence, forcep-aided deliveries entirely accounted for the observed operative vaginal delivery rates. From the mid-1970s to the early 1990s, the operative vaginal delivery rate increased from 3% to over 6%. Vacuum extraction was introduced in practice in the early 1980s, and its application gradually increased at the NMWH till its rate nearly equalled the forcep-aided delivery rate in the beginning of 1990s. The slow but steady rise in instrumental vaginal deliveries has generally been attributed to more active management of the second stage of labour with intrapartum foetal distress as the major indication.

[FIGURE 2 OMITTED]

Figure 3 presents the overall perinatal mortality rate (PNMR) per 1,000 births and the caesarean-related PNMR (perinatal mortality rate per 1,000 caesarean sections).

Overall, the PNMR showed a slow but steady decline over the entire study period. However, the decline was most pronounced during the first half, reflecting general achievements and improvement in both obstetrical and neonatal care. During the same period, i.e. from the late 1950s to the mid-1970s, when caesarean section was mainly performed for maternal indications, the caesarean-related PNMR showed an even sharper decline.

[FIGURE 3 OMITTED]

It was not until the late 1970s that a distinct transition could be seen when foetal survival became an indication for caesarean section, followed by a significant reduction in the PNMR, particularly in the caesarean section cases.

While the reduction in perinatal mortality continued and perinatal outcome in caesarean section cases showed dramatic improvement, it is important to note that from the late 1980s to the end of the study period, the spectacular rise in caesarean section rate was not associated with any improvement in the PNMR. In fact, the PNMR in the caesarean section cases increased slightly. Hence, we observed no reduction at all in the PNMR over the past decade despite the significant rise in caesarean rates at this centre.

[FIGURE 4 OMITTED]

Finally, as shown in Fig. 4 and Table 1 and 2, both case-fatality rate and maternal mortality rate have changed to a considerable extent over the study period. As mentioned above, technical aspects relating to the actual obstetrical procedure, such as improved acquaintance with the surgical procedure, increasing availability of peroperative IV antibiotics, better blood-bank facilities, and safer aneasthesia, undoubtedly played a pivotal role in the latter observations. Although there was an apparent lowering of the overall maternal mortality rate over the years, one cannot draw any clear conclusions as the overall number of maternal deaths was relatively low. Since most critical patients were transferred to the K.E.M. Hospital for intensive care, maternal deaths in these transferred women were not recorded at the NMWH. Thus, both maternal mortality rate and case-fatality rate at this hospital did not give accurate assessment of maternal mortality at the NMWH. It would be interesting and worthwhile to maintain a separate register for recording of follow-up and outcome details of these transferred women, as this information would be useful in evaluating case fatalities at the NWMH.

DISCUSSION

At the NWMH, the caesarean section rate increased from 1.9% to 16% in 40 years, but without any improvement in overall perinatal outcome beyond a caesarean section rate of 10%. The figures provided are hospital-based and do not necessarily reflect what is happening in the community. The percentage of hospital deliveries in Mumbai is unknown, and the people attending the NWMH are probably not a representative cross-section of the overall population. Hence, comparison with settings of other countries is difficult. However the strength of these data rests on the extended period of time with consistent data collection on large numbers of women giving birth at the same place. Weaknesses include potential selection biases because of more middle-class women attending the NWMH, calculation errors because of missing denominators, and the different registration methods used over time. Nevertheless, we are reasonably confident that the figures on their own are interesting and concur with trends in other countries.

Caesarean section rates have increased also in many other countries. In the USA, caesarean birth rate rose from 5.7% to over 21% during 1970-1984, followed by a levelling of phase at about 24% in the early 1990s (23-25), and in Brazil, rates of over 40% have been reported recently (3). On the contrary, caesarean deliveries remained constant at around 4% at the National Maternity Hospital, Dublin, from 1965 to 1975, and increased only marginally to nearly 5% in the early 1980s (25). At the NWMH, the caesarean section rate was initially lower than that in Dublin, equalled the caesarean section rate in Dublin by the mid-1970s, and even surpassed it in the early 1980s. A remarkable feature of the Dublin experience was a considerable reduction in perinatal mortality from 42 per l,000 births in 1965 to 16.8 per 1,000 in 1980 despite the steady caesarean section rate. The extent of rise and the pattern of trends, over time, in caesarean sections have shown considerable variations from country to country, depending on many determinants of caesarean delivery.

The overall trend in caesarean sections at the NWMH, especially the initial slow incline during the first half of the study period, is undoubtedly related to better obstetrical procedures (improved acquaintance with the surgical procedure, increasing availability of peroperative IV antibiotics, better blood-bank facilities, safer aneasthesia, etc.). Yet, technical factors alone are unlikely to account for the rise over the second half of the study period. Other non-medical factors have probably contributed to a far larger extent to the increasing performance of this procedure. Of particular interest in the NWMH setting is the impact of 'private class of patients' on the management of labour and the caesarean rate. While this group of women is at a lower risk and has better antenatal care than the background population, the trend toward caesarean section seems to be higher, probably as a result of factors relating to both patients and physicians.

Monitoring time-trends in caesarean deliveries has to take the risk-adjusted rates of caesarean births (rates standardized by patient characteristics) into account (14). Hence, in this study, further analysis of time-trends in clinical risk factors for caesarean delivery may improve the attributable risk calculation to the overall observed time-trend in caesarean rates. However, since the NMWH serves as a maternity facility with an almost continuous patient flow from its own antenatal clinic (over 99% of all patients are booked) and since patients with major obstetrical pathologies are referred to a nearby tertiary centre, the NMWH mainly operates at the primary and secondary levels. Therefore, we believe that time-trends in clinical risk factors are unlikely to have biased the observed trend in caesarean rates to a considerable extent, especially since the steepest incline was observed over a single 10-year period. Various clinical risk factors have been associated with caesarean section, the 'major' indications being dystocia or cephalopelvic disproportion, breech presentation, and 'non-reassuring' foetal heart-rate tracings. 'Minor' risk factors, epidural analgesia, and induction of labour, in particular, are more prone to have added some bias, especially in the overall rise over the entire 40-year study period.

With regard to communities experiencing the urban transition in developing countries, two risk factors, both enhancing accessibility to the medical intervention under study, are of particular interest here. First, obstetrical care in the light of increasing prosperity is characterized by a tendency toward a greater patient involvement in clinical decision-making (15-20). Sachs et al., for instance, stated that "a couple's expectation of a perfect baby, as well as a women's previous experience of difficult labor, undoubtfully also plays a part in the decision to perform a cesarean delivery" (6). Second, mode of reimbursement and type of medical insurance have been quite consistently found to affect caesarean rates, in the direction of patients with better financial means and of physicians getting larger fees for caesarean than vaginal deliveries, leading to a higher performance of operative birth. We believe that both the factors (non-medical) may have considerably contributed to the observed trend at the NMWH, although further investigation is desirable to prove this assumption. The institution being a private nursing home with patients paying an additional fee to senior medical staff may have enhanced this tendency, but potential bias is less likely to have confounded the observed trend in the steep rise over the last 10-year study period.

The perinatal mortality rate decreased significantly over three decades, but remained stable in the 1990s. In fact, an upward trend was noted with a higher PNMR in caesarean births since the early 1990s, which seems to be explained by various factors, such as privatization of care and a more liberal use of caesarean section in women with a compromised foetus.

It is concluded that the caesaran section rate has increased substantially over the last four decades in the NWMH in Mumbai up to 16% since the early 1990s. No improvements, either in maternal or in perinatal outcome, have been observed with caesarean section rates over 10%. On the contrary, the PNMR seems to increase as a consequence of trying to improve the perinatal outcome of the very low-birth-weight children by a liberal caesarean section policy.

ACKNOWLEDGEMENTS

The authors are thankful to Dr. Vandana Walvekar, Dean of Nowrosjee Wadia Maternity Hospital, Bombay, for allowing the hospital data for this publication. We are very grateful to Dr. Ajit Mehta, an honorary consultant in epidemiological studies at Sir Ness Wadia Research Centre, for providing all the invaluable information and data from the Nowrosjee Wadia Maternity Hospital, Bombay.

REFERENCES

(1.) Porreco RP, Thorp JA. The cesarean birth epidemic: trends, causes, and solutions. Am J Obstet Gynecol 1996;175:369-74.

(2.) Caesarean section on the rise (editorial). Lancet 2000;356:1697.

(3.) Belizan JM, Althabe F, Barros FC, Alexander S. Rates and implications of caesarean section in Latin America: ecological study. Br Med J 1999;319: 1397-400.

(4.) Richman VV. Lack of local reflection of national changes in cesarean rates: the Canadian experience. Am J Obstet Gynecol 1999;180:393-5.

(5.) Gregory KD. Monitoring, risk adjustment and strategies to decrease cesarean rates. Curr Opin Obstet Gynecol 2000;12:481-6.

(6.) Sachs BP, Kobelin C, Castro MA, Frigoletto F. The risks of lowering the cesarean-delivery rate. N Engl J Med 1999;340:54-7.

(7.) DeMott RK, Sandmire HF. The risks of lowering the cesarean-delivery rate (letter). N Engl J Med 1999;341:53.

(8.) Halpern SH, Leighton BL. The risks of lowering the cesarean-delivery rate. N Engl J Med 1999;341:54-7.

(9.) DeJoy S, O'Grady JP, Burkman RT. The risks of lowering the cesarean-delivery rate. N Engl J Med 1999;341:53-54 [comment appears in: N Engl J Med 1999;340:54-7].

(10.) Sirio CA. The risks of lowering the cesarean-delivery rate. N Engl J Med 1999;341:54 [comment appears in: N Engl J Med 1999;340:54-7].

(11.) Satcher D. The risks of lowering the cesarean-delivery rate. N Engl J Med 1999;341:53-55 [comment appears in: N Engl J Med 1999;340: 54-7].

(12.) Sachs BP, Kobelin C, Castro MA, Frigoletto F. The risks of lowering the cesarean-delivery rate. N Engl J Med 1999;341:54-7 [comment appears in: N Engl J Med 1999;341:53; discussion 54-5].

(13.) World Health Organisation. Appropriate technology for birth. Lancet 1985;2:436-7.

(14.) American College of Obstetricians and Gynecologists. Task Force on Cesarean Delivery. Considerations in evaluating the incidence of cesarean delivery. Washington, DC: American College of Obstetricians and Gynecologists, 2000.

(15.) Irvine LM. Patient education is way to influence maternal requests for caesarean section (letter). Br Med J 1999;319:190.

(16.) Showalter E, Griffin A. Commentary: all women should have choice. Br Med J 1999;319:1401.

(17.) Cruishank DP. Informed consent, patient choice, and physician responsability. Obstet Gynecol 1999;94:142-3.

(18.) Quinlivan JA, Petersen RW, Nichols CN. Patient preference: the leading indication for elective cesarean section in public patients-results of a 2-year prospective audit in a teaching hospital. Aust NZ J Obstet Gynaecol 1999;39:207-14.

(19.) Paterson-Brown S, Fisk NM. Caesarean section: every woman's right to choose? Curr Opin Obstet Gynecol 1997;9:351-5.

(20.) Elective caesarean section on request (letter). Br Med J 1999;318:120-2.

(21.) Bhide AG. Cesarean section: how safe is it? J Obstet Gynecol Ind 1992;42:330-3.

(22.) Bhide AG. Changing trends of cesarean section. J Obstet Gynecol Ind 1993;43:539-54.

(23.) Shiono PH, McNellis D, Rhoads GG. Reasons for rising cesarean delivery rates: 1978-1984. Obstet Gynecol 1987;69:696-700.

(24.) Centers for Disease Control. Rates of caesarean delivery: United States. MMWR 1993;42:285.

(25.) Bottoms SF, Rosen MG, Sokol RJ. The increase in the cesarean birth. N Engl J Med 1980;302:559-63.

Correspondence and reprint requests should be addressed to:

Dr. Marleen Temmerman

International Centre for Reproductive Health

Ghent University Hospital

De Pintelaan 185, P3, Ghent

Belgium

Email: marleen.temmerman@rug.ac.be

Fax +32 9 240 3867

A. Mehta [1], L. Apers [2], H. Verstraelen [2], and M. Temmerman [2]

[1] Department of Gynaecology and Obstetrics, Nowrosjee Wadia Maternity Hospital, Bombay, India; and [2] International Centre for Reproductive Health, Ghent University, Belgium
Table 1. Trends in caesarean section rate, perinatal mortality rate,
and case-fatality rate at NWMH, 1957-1998

Year        CS     Overall PNMR   PNMRin CS cases   Case-fatality rate
            rate    (per 1,000    (per 1,000 CS)    (per 100,000 CS)
                     births)

1957-1961    1.9        69              131                1100
1962-1966    2.6        68              106                 800
1967-1971    3.1        63               71                 860
1972-1976    3.2        56               38                 700
1977-1981    5.3        46               30                 320
1982-1986    7.3        45               20                 120
1987-1991    8.9        45               16                 210
1992-1996   13.5        36               26                  --
1997-1998   16.0        34               27                  --

NWMH = Nowrosjee Wadia Maternity Hospital; CS = Caesarean section;
PNMR = Perinatal mortality rate

Table 2. Trends in caesarean section rate, maternal
mortality rate, and perinatal mortality rate at
NWMH, 1991-1998

Year        Caesarean      Maternal    Perinatal
            section rate   mortality   mortality rate

1991-1991    1.7             80           33.3
1992-1991    1.5             60           32.5
1993-1991    2.6             40           43.3
1994-1991    3.4             60           35.0
1995-1991    4.6             30           35.3
1996-1991    6.2             20           35.9
1997-1991    6.0             50           34.0
p value     <0.00001       0.10518        0.08

Fig.1. Time-trends in caesarean rates at NMWH, 1957-1998

1957-61    1.9
  62-66    2.6
  67-71    3.1
  72-76    3.2
  77-81    5.3
  82-86    7.3
  87-91    8.9
  92-96   13.5
  97-98   16

Note: Table made from line graph.
COPYRIGHT 2001 International Centre for Diarrhoeal Disease Research Bangladesh
No portion of this article can be reproduced without the express written permission from the copyright holder.
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Article Details
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Author:Mehta, A.; Apers, L.; Verstraelen, H.; Temmerman, M.
Publication:Journal of Health Population and Nutrition
Article Type:Report
Geographic Code:9INDI
Date:Dec 1, 2001
Words:3338
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