How to reduce cesarean section rate?. It touches the causes, and complications if increased CS rate. It provides some strategies on how to reduce it.

1. Reducing Cesarean Section
Rate:
A National Demand
Prof/ Mahmoud Abdel-Aleem
Professor of Obstetrics and Gynecology. Assiut university.

2. Introduction

3. Born by knife: In Egypt, C-sections are sold as
the only way to give birth
• Cesarean section is a life saving procedure
(reducing maternal and perinatal risks).
• It should have the following components:
• Valid obstetric indication.
• Under ideal conditions
• Must be accessible to women who need the
procedure.
• Safe for the mother (Short term- Long term)
• Safe for the neonate (Short term- Long term)

4. Why this topic?
• Quality health care during deliveries and births is essential for
reducing maternal and neonatal morbidity and mortality.
• Birth should not be treated as a set of medical procedures, but as a
physiological act, an important family and cultural event.
• Women and babies are being exposed to avoidable risks (unnecessary
CS) as well as increasing the burden of cost on health systems.

5. ‫العالمية‬ ‫الصحة‬»‫القيصرية‬ ‫الوالدات‬ ‫من‬ ‫بالحد‬ ‫مصر‬ ‫توصي‬
‫الثالثاء‬15/‫سبتمبر‬/2015-10:16‫ص‬
‫أ‬‫الرسمم‬ ‫المتحدث‬ ،‫الغفار‬ ‫عبد‬ ‫حسام‬ ‫الدكتور‬ ‫علن‬
‫ممممممممممممممممممممممممممممممممممممممر‬‫م‬‫ي‬ ‫ال‬ ‫دا‬ ‫ممممممممممممممممممممممممممممممممممممممو‬‫م‬‫لل‬ ‫مممممممممممممممممممممممممممممممممممممم‬‫م‬ ‫وم‬ ‫مممممممممممممممممممممممممممممممممممممم‬‫م‬ ‫ل‬ ‫ممممممممممممممممممممممممممممممممممممممك‬‫م‬ ‫ت‬ ‫ممممممممممممممممممممممممممممممممممممممن‬‫م‬‫ع‬ ، ‫ممممممممممممممممممممممممممممممممممممممح‬‫م‬‫الي‬ ‫ق‬‫ار‬ ‫ممممممممممممممممممممممممممممممممممممممو‬‫م‬‫ل‬.
‫م‬ ‫مهور‬ ‫مه‬ ‫هما‬ ‫توب‬ ‫مكمن‬ ‫مه‬‫م‬‫الت‬ ‫يمر‬ ‫ال‬ ‫دق‬ ‫المو‬ ‫ما‬ ‫عمل‬ ‫ات‬‫ر‬‫م‬ ‫ع‬ ‫ااء‬‫و‬‫م‬‫م‬‫ط‬ ‫م‬ ‫ا‬ ‫وم‬ ‫م‬ ‫ا‬‫ر‬‫لم‬ ‫م‬ ‫الل‬ ‫وتهمد‬‫مر‬‫م‬‫مي‬‫المتاحم‬ ‫ما‬ ‫لممكا‬ ‫ما‬ً‫وا‬ ‫رب‬ ‫ال‬‫ا‬ ‫مف‬‫م‬ ‫المست‬ ‫مه‬
‫المير‬.

6. Rate In Egypt
Alarming… Increasing…Frightening

7. • A C-section rate: 52%
• The rise started since 2005 with doubling (from 26.7 to 51.8%)
between 2008-2014.
• Ranked third in the world, after Brazil and the Dominican
Republic.
• Ranked first in the Middle East.
• Doctors who performed C-sections reported that 10 % of these
cases could have been delivered normally,” UNFPA study.
• This increase has no positive effect on maternal or fetal health
in the future. United Nations (UN).

8. Egypt:
DHS_2014

10. Arab countries
Cesarean Section rate in Arab countries
(Khawaja et al, 2009)

11. Of the 6158 institutional-based c-sections done in
EDHS-2014:
- 77.3% were performed in the private sector.
- X 3.46-time in trend of c-sections in EDHS 2014
relative to EDHS-2005.
- X 4.19- time increase in trend of c-sections was
higher in private sector relative to public.

12. Cairo

13. AinShams
The leading causes were repeat C-sections (42.84%), failure to progress in labor (13%), PROM (7%),
preeclampsia/eclampsia (6.17%), multiple pregnancy (5.64), malpresentations (4.75%) , medical disorders
complicating pregnancy (4.25%). Vaginal birth after caesarean (VBAC) was attempted in 3158 women and
was successful in 36.57%.

14. Tanta
The Rate of cesarean section
(1049/3592) 41% in 2013
(1004/2332) 45% in 2014
(1057/3320) 46% in 2015

15. Assiut

16. Economic burden
• Egypt is a resource limited-setting, where 26.3% of Egyptians live below the
poverty line
• Direct money spent:
• In 2008, the WHO estimated that 253,890 unnecessary c-sections had been
performed with a total cost of US$ 41,085,585 per year.
• In 2014, this study assumes that the unnecessary c-sections and its associated
spending at least would double the ones estimated in 2008 = 85 million/ year.
• After 2016, it is about 255 million/ year.
• Indirect:
• Increasing adverse outcomes associated with c-sections in a country already
burdened with a relatively high MMR and NMR
• Increasing infectious diseases mainly hepatitis C virus that infect nearly 15% of the
15 to 59 years old Egyptian people.
UNDP. UNDP human development report 2015, Egypt central Agency for Public Mobilization and Statistics – CAPMAS. 2015.

17. 27
reasons
C-section rate
drivers in
Egypt

18. 1-Maternal issues
1. Fear of labour pains
2. Intolerance of labour pains
3. Misconception about genital damage after vaginal delivery.
4. Misconception about safety of CS delivery for the baby.
5. Lower tolerance to any complications or outcomes other than the perfect baby.
6. Cesarean section on request (CDMR)
Women who had C-section may have not received complete informed choice to make
the right decision about the method of delivery.
• 67 %of women were told of the causes of undergoing a cesarean delivery.
• 14 % were informed of positive information.
• Only 6 % knew the negatives of the cesarean operation.

19. 2- Medico-legal issues
1. Medical litigations for complications either fetal or maternal
2. Negligence and medical reports
3. Compensations
4. Insurance
• 70% of litigation relates to obstetrics
• The bill for medical negligence has doubled to $5.9bn since 1997
• 99% of these claims relate to “failure to intervene” or “delay in
intervention.”

20. 3- Social factors
• Social factors control the time and type of delivery.
• Choosing specific birthdate 01/01/20--

21. 4- Health professional
• Financial issues: A shift towards delivery in private health-care facilities.
• This assumption was backed by the UNFPA study which analyzed 13 governmental hospitals
and three privately-owned ones. Number of C-section surgeries is
• 66 % in privately-owned hospitals.
• 44 % in governmental hospitals.
• Obstetrician’s greed, as the average cost of a cesarean delivery in Egypt is worth LE 1,076,
while a natural delivery costs only LE 664. costs more money and saves time and effort.
• Lack of compliance with regulations by private practitioners and inadequate
enforcement of the law, public’s perception that medical services in private sector
due to the availability of necessary medical technology and better inpatient
quality care services for this surgical intervention, particularly in presence of near
birth complications, as well as obstetricians’ predisposition to manage their time,
are suggested.

22. • Ignorance of vaginal delivery arts
• Ignorance of how to anticipate complications in vaginal delivery
• Ignorance of CTG, Partogram
• Intolerance to long lasting deliveries
• Fear of rupture uterus in TOLACS
• Malpractice

23. Natural delivery scene is a nightmare for Egyptian
women !!!
Vaginal Birth
• A screaming lady trying to catch
her intermittent breathe, a
terrified husband holding her
hand, a crying mother patting
her back, tears falling from
people’s eyes all around, and the
sound of a baby’s heartbeats
could be heard amid doctor’s
observations.
Cesarean Section
• Egyptian woman prefer to take
the anaesthetic, sleep for a
while, wake up and find their
baby beside them regardless any
surgical pain afterwards.
--- making them resort to a C-section (cesarean) to avoid any such experiences.

24. A YEAR ago a hospital in
São Paulo announced that
its maternity ward would
henceforth only admit
clients from 10am to 4pm,
Monday to Friday. The
message was clear: births
by appointment only—that
is, by Caesarean section.

25. Moms’ wording after CS
• “….I can’t judge the doctor’s intentions, but I can acknowledge that there were some medical
complications. But 90% of the doctor’s decision is based on money”.
• “……I remember feeling shaky and cold due to anaesthesia. I can recall the incision’s pain very
well, it was unbearable, and the worst moment was when the nurse asked me to get up and
walk around, suddenly I felt if time stopped for few seconds. The pain was excruciating, I was
not able to move my legs.”
• “……C-section was my obstetrician’s choice. She kept saying that she would prefer to go
though natural delivery but her physician refused”.
• “….Actually I did not feel my case needed a cesarean, but he insisted”
• “…Actually until this moment I don’t know the actual reason”
• “ … I was pressured into a costly C-section by my doctor”.

26. On the other hand, Moms also say:
• “…I gave birth to my first baby girl through a C-section, and if I will give birth
to six babies I will strongly go for C-section. I decided earlier and I genuinely
loved the experience.
• “…I think C-section is much better because natural delivery ends up with
some complications”.
• “…Upon my experience, I advocate strongly C-section as I went through a
very painful and tiring natural delivery, I stayed more than 12 hours
experiencing labor contractions, my cervix did not open so I told my doctor to
go through a C-section”.

27. Maternal satisfaction
We as doctors
1- promoted CS
2- neglected Vaginal
birth

28. When to do C section?
Medically justifiable and non-justifiable.

29. I. Medically justifiable
II. Medically Not- justifiable
1- Patient Preference
2- Physician Preference
CS has greater risk of
maternal morbidity and
mortality than VD
CS is Safe with Lower
complications than VD

30. Ideal C- section Rate
A matter of debate: 10-15 %
Up to 22% is accepted

31. WHO statement 2015
• There is a lack of agreement on what an appropriate c-section rate is.
• WHO recommends that the ideal c-section rate should be 10-15%.
• When c-section rates in a country move towards 10%, there is a
significant decrease in maternal and newborn deaths.
• When the rate goes over 10%, there is no evidence that death rates
improve – therefore the risks outweigh the benefits.
• Every effort should be made to provide caesarean sections to women
in need, rather than striving to achieve a specific rate.

32. C section and Complications
3-6 fold risk of severe morbidity
Sholapurkar SL. Long-term complications of caesarean section - an inevitable consequence? BJOG. 2014; 121: 1445-1446.
Cunningham F, Leveno K, Bloom S, Spong CY, Dashe J. Williams Obstetrics, 24e. Mcgraw-hill; 2014.

35. ACOG,
2014

36. CS and Maternal Mortality
The past 20 years in the US, the maternal mortality rate keeps
rising and rising while the rate of C section continues to rise.

37. Severe acute maternal morbidity
• It is the presence of complications
such as haemorrhage, requiring
hysterectomy or blood transfusion,
any hysterectomy, uterine rupture,
anaesthetic complications (including
those arising from administration of
a general or local anaesthetic,
analgesic, or other sedation during
labour &delivery), obstetric shock,
cardiac arrest, acute renal failure,
assisted ventilation or intubation,
puerperal VTE, major puerperal
infection, in-hospital wound
disruption, and haematoma
Canadian study: more women in the planned CS group had SAMM
(2·7%) than those in the planned vaginal birth group (0·9%).
Dutch study: (371 000 pregnancies) found that birth by planned or
emergency CS is associated with a 5 times increased risk of SAMM
(risk ratio [RR] 5·2, 95% CI 4·8–5·6).
This increased risk also applied to CS without labour (4·6, 4·2–5·0).

38. Immediate complications. Thx God !!
6102 CS 1 extra thromboembolic event
632 CS to prevent 1 transfusion
37 CS 1 extra operative trauma
159 CS 1 extra infection
435 CS 1 extra case sepsis/DIC
4330 CS 1 extra maternal death

39. Intermediate and long term
156 CS 1 extra readmission
444 CS 1 extra abruption
489 CS 1 extra ectopic
230 CS 1 extra placenta previa
694 CS 1 extra invasive placenta
2667 CS 1 extra hysterectomy
Poorer outcomes in subsequent births for baby—increase stillbirth,
prematurity and low birth weight

40. Remote complications
1. Complications in
subsequent pregnancy
• Rupture uterus
• Placental
abnormalities
• Ectopic pregnancy
• Perinatal
complications
2. Scar complications
• Scar defect or
niche
• Scar pregnancy
• Incisional hernia
• Keloid formation
• Sinus/fistula
formation
• Endometriosis
3. Pelvic adhesions
• Chronic pelvic
pain
• Bowel obstruction
• Secondary
infertility
2. Neonatal
complications
• Prematurity
• Asthma.
• Obesity.

41. C- section and Placenta Previa/
Accreta
Strong link…Hazardous outcome.

42. • The incidence of placenta accreta spectrum
• Overall 1.7 per 10000 women.
• Previous CS and PP: 577 per 10000 women.
• CS increases risk of placenta praevia in subsequent pregnancies.
• This risk rises as the number of prior caesarean sections increases. RCOG. 2018
• No CS: risk of hysterectomy: 0.6%
• 3%: 1 CS
• 11%: 2 CS
• 40%: 3 CS
• 61%: 4 CS
• 67%: 5 CS
• The Dutch study
• A risk of one event in 25 000 pregnancies for hysterectomy due to abnormal placentation
in women without previous CS.
• One event in 500 pregnancies for women with one previous CS.
• One event in 20 pregnancies for women with three or more previous CSs.

43. Cesarean Section and Infertility

45. All types of C section are associated with a reduced
subsequent birth rate.
There is no or only a slight effect of C section on future
fertility. The clinical and social circumstances leading to the
C section have a greater effect on future fertility than the C
section itself.

46. Interventions to Reduce C-section
Starts by auditing birth then applying evidence –based clinical and non-
clinical effective interventions

47. Auditing birth
Robson ten group classification system

48. Robson Ten Group Classification
System defines 10 groups on the basis
of 4 obstetric concepts:
 Category of pregnancy (single/
multiple pregnancy, fetal
presentation)
 Obstetric history (nulliparous,
multiparous with/without uterine
scar)
 Course of labor and delivery
(spontaneous labor/induced labor/
cesarean before labor)
 Gestational age at the time of
delivery
• It can be applied at an institutional level to monitor the rate of cesarean delivery.
• Plan effective strategies targeted at specific subgroups of women to prevent an increase in the rate of cesarean delivery and to
improve maternal and neonatal outcomes.

50. • The most common cesarean
delivery indication in Group 1 in
the present study was dystocia
and/or failure of progress.
(30%) to (70%).
Adherence to the guidelines for diagnosing
failure of progress and dystocia.
A second opinion before performing a
primary cesarean
The most common indication for
cesarean delivery in group 4 was
other obstetric complications (for
example bad obstetric history,
PROM, oligohydramnios)
followed by fetal distress.
Update of the guidelines for labor induction.
Proper monitoring during induction of labor.
Better education of CTG
A second opinion may be helpful

51. • Encouragement of vaginal delivery is very important to limit the steady rise
in C-sections in Egypt.
• Single most important factor that will reduce CSR is physician motivation to
make a change
• Educating mothers about risks associated with c-section.
• Initiatives to raise peoples’ and health professionals’ awareness
about the adverse outcomes
• Midwifery training.
• Establishment of birthing centers.

52. Non-clinical
1- Legislations
• New laws by Parliament for
safe medical practice
• Ministry of health:
• Follow rate of C. deliveries
• Put manual guidelines for each
conditions to limit liberal use of
CS
• Birthing campaigns
• Distribution of flyers to be
aware about hazards of CS
2- Education
• Workshops for vaginal
delivery arts
• Assisted vaginal delivery
techniques
• Contact of people to
increase the knowledge
about CS hazards.

53. 3- Organizational
1- The delivery fees for physicians for undertaking CS and attending
vaginal delivery should be the same, using a mean fee. This should also
happen in private practice settings.
2- Hospitals should be obliged to publish annual CS rates, and financing
of hospitals should be partly based on CS rates. Risk-adjusted CS rates
should become available.
3- Hospitals should use a uniform classification system for CSs
(Robson/WHO classification).
4- Provision of evidence based guidelines for labour management.

54. 5- Money that will become available from lowering CS costs should be
invested in resources (better care- pain relief- skills training for doctors
and midwives- reintroduction of vaginal instrumental deliveries).
6- Acuity-adjusted physician-specific C Section rate.
7- Organizational, Hospital actions
• Second opinion for performing all except emergency CS.
• Auditing birth.
• Feedback.

55. Clinical Interventions
1. Continuous labor and delivery support presence of continuous one-on-one
support during labor and delivery:
2. Correct diagnosis of labour: The diagnosis of labor is made within 1 hr of
presentation.
1. Spontaneous contractions at least 2/15 min & at least 2 of the following:
1. Complete effacement of cervix
2. Cervical dilation 3 cm or greater
3. SROM
3. Routine amniotomy should be discouraged.
4. A partogram with a 4-hour action line should be used to monitor progress of
labour of women in spontaneous labour with an uncomplicated singleton
pregnancy at term
5. Consultant obstetricians should be involved in the decision making for CS
6. Use of electronic fetal monitoring should be restricted to high risk pregnancy and
better understanding of the fetal monitor & what actually constitutes fetal
distress

56. Induction of labor
at 39 weeks in low-
risk nulliparous
women results in a
lower frequency of
c section

57. Pregnant women
should be physically
and psychologically
prepared for natural
delivery

59. C-section and
neonate/child
Definite Link

61. Neonatal complications
• Cesarean deliveries with
no labor complications or
procedures remained at a
69 % higher risk of
neonatal mortality than
planned vaginal deliveries.

63. Newborn benefits that favor cesarean
• Cesarean vs vaginal birth
22,641 CS prevent 1 subdural/intracranial bleed
19,601 CS prevent 1 IVH
10,613 CS prevent 1 neonatal convulsion
7,549 CS prevent 1 subarachnoid hemorrhage
5,666 CS prevent 1 newborn CNS depression
2,164 CS prevent 1 brachial plexus injury
The increase in cesarean section rate isn’t associated with
measurable improvement in the baby outcome.

64. Prematurity
• A dramatic increase in C-section deliveries in the United States is largely
responsible for an equally dramatic rise in preterm births.
• One in 8 babies in the U.S. is born prematurely each year, and close to one in
three births overall is delivered by cesarean section.
• The analysis revealed an increase of nearly 60,000 preterm deliveries among
single-birth pregnancies between 1996 and 2004, with more than 9 out of 10 of
these deliveries performed by C-section.
• There is concern that at least some of these early deliveries may not be medically
warranted.

65. ‫مصر‬ ‫في‬ ‫الوضع‬
‫المركزة‬ ‫العناية‬ ‫حضانة‬ ‫تكلفة‬ ‫متوسط‬ ‫إن‬(1500‫جنيه‬)‫الثالث‬ ‫بالمستوى‬ ‫الواحد‬ ‫اليوم‬ ‫خالل‬ ،
‫خطو‬ ‫األقل‬ ‫للحاالت‬ ‫مخصص‬ ‫الثانى‬ ‫المستوى‬ ‫أن‬ ‫إلى‬ ‫ا‬ً‫ت‬‫الف‬ ،‫خطورة‬ ‫األكثر‬ ‫للحاالت‬‫وتكلفة‬ ‫رة‬
‫بين‬ ‫تتراوح‬ ‫اليوم‬900‫و‬1000‫ال‬ ‫في‬ ‫التكلفة‬ ‫تبلغ‬ ‫األول‬ ‫المستوى‬ ‫أن‬ ‫حين‬ ‫في‬ ،‫جنيه‬‫متوسط‬
500‫ي‬ ‫التي‬ ‫المستلزمات‬ ‫أسعار‬ ‫الثالثة‬ ‫المستويات‬ ‫في‬ ‫المبالغ‬ ‫لهذه‬ ‫مضافا‬ ،‫جنيه‬‫دفعها‬
‫المستشفى‬.
‫عدد‬‫عام‬ ‫كل‬ ‫مصر‬ ‫في‬ ‫المواليد‬2.5‫من‬ ‫حضانات‬ ‫منهم‬ ‫يحتاج‬ ‫تقريبا‬ ‫مليون‬5‫الي‬10%‫اي‬
‫بنسبة‬150‫الي‬250‫من‬ ‫يحتاج‬ ‫الطفل‬ ‫ان‬ ‫الي‬ ‫مشيرا‬ ، ‫طفل‬ ‫ألف‬3‫داخل‬ ‫أسبوع‬ ‫الي‬ ‫ايام‬
‫عام‬ ‫منذ‬ ‫الفترة‬ ‫في‬ ‫انه‬ ‫موضحا‬ ‫حالته‬ ‫حسب‬ ‫الحضانة‬2008‫الي‬2012‫عدد‬ ‫في‬ ‫العجز‬ ‫كان‬
‫حوالي‬ ‫الحضانات‬50.%

66. Pediatrics
• Not all babies have “drunk” from their mothers during
birth.
• Cerebral palsy is over-diagnosed and Vaginal birth is
always accused wrongly.
• Presence of light meconium isn’t a problem.

67. Take Home message
• CS epidemic is annoying to the whole medical societies.
• Despite the rise in CS rate, there is no appreciable improvement in the
maternal or fetal benefits
• CS isn’t a simple operation as it appears but it has many “uncommon” but
“disastrous” complications. Rising rate= rising rate of complications.
• CS shouldn’t be done for physician preferences but for clear medical
maternal or fetal indications.
• The option of “when in doubt, cut it out” should not be adopted.

68. • The medical profession on its own cannot reverse this trend. Joint
actions with governmental bodies, the health care insurance industry,
and women's groups are urgently needed to stop unnecessary CSs
and enable women and families to be confident of receiving the most
appropriate obstetric care for their individual circumstances.