C-sections without medical indication increase morbidity and mortality risk

[kkmalaysia]

Women undergoing cesarean sections (C-sections) are at an increased risk of maternal death and serious complications if the operation is not medically indicated, according to findings from a WHO global maternal survey.

Researchers analyzed data from 107,950 deliveries in 122 health facilities from nine Asian countries and found that compared to spontaneous vaginal delivery, C-sections were associated with an increased risk of maternal mortality and morbidity index (defined as the presence of at least one of the following: maternal death, intensive care unit admission, blood transfusion, hysterectomy, or internal iliac artery ligation). The increased risk compared to normal birth was 2.7 times for antepartum C-section without medical indication, 10.6 times for antepartum C-section with indication, 14.2 times for intrapartum without indication and 14.5 times for intrapartum with indication. [Lancet 2010 DOI:10.1016/S0140-6736(09)61870-5]

“The most important finding of the survey is the increased risk of maternal mortality and severe morbidity… in women who undergo cesarean section with no medical indication,” wrote Dr. A. Metin Gülmezoglu, of the department of reproductive health and research, WHO, Switzerland, and colleagues who conducted the study.

“C-section should be done only when there is a medical indication to improve the outcome for the mother or the baby. Women and their carers who plan to undertake C-section delivery should discuss the potential risks to make an informed decision if they still wish to have a cesarean delivery,” the authors wrote.

In an editorial about the study, Dr. Yap-Seng Chong, of the department of obstetrics and gynecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, and Dr. Kenneth Y.C. Kwek, of the department of maternal fetal medicine and chairman of the medical board at KK Women’s and Children’s Hospital, Singapore, stated that the risk of ICU admission was 10 times more likely for antepartum C-section without medical indication and 67 times more likely for intrapartum C-section without medical indication compared to spontaneous vaginal deliveries. “Clearly,” they wrote, “cesarean deliveries, even in mothers with no underlying medical issues, can be life-threatening.” [Lancet 2010 DOI:10.1016/S0140-6736(10)60055-4]

Controversy about the ideal rate of
C-section and the place of maternal choice has been protracted and “many obstetricians have become accustomed to the practice of medical interventions for non-medical reasons,” wrote Chong and Kwek.

The survey, which involved health facilities from Cambodia, China, India, Japan, Nepal, the Philippines, Sri Lanka, Thailand and Vietnam, also revealed that 62 percent of the health facilities surveyed received financial incentives for carrying out C-sections.

“Financial incentives for doing these procedures should be removed or kept to a minimum,” Chong and Kwek stated.

Dr. Ravindran Jegasothy, senior consultant and head of the department of obstetrics and gynecology at Hospital Kuala Lumpur, Malaysia, stated that the “doctor’s duty is to counsel patients and always state the fact that C-sections are four times more risky than vaginal delivery, as shown by the Cochrane database.” He added that birth plans and the patient’s concerns should be addressed before labor and that counseling should be detailed and recorded in notes. “What should a doctor do if the patient still requests a cesarean? One should be prepared to do it or refer to someone else for a second opinion. Definitely, C-section without indication should not be done in labor,” Jegasothy said.