Cesarean section rate: navigating the gap between WHO recommended range and current obstetrical challenges

Abstract

The cesarean section (CS) rate is very heterogeneous all over the world, reflecting the differences in the access to healthcare services. In higher-income countries, changes observed in the obstetrical population brought to an increased rate of cesarean section for maternal request. Besides, clinicians are facing an increasing number of induction of labor, with the consequent risk of CS if the management is inappropriate. Analyzing the rate of primary CS, the interpretation of intrapartum CTG and a tailored management of labor are also red flags that must be considered. In this optic, the implementation of obstetrics training and simulation programs and the improvement of clinical protocols with the latest evidence can lead to the reduction of unnecessary CS.

Keywords:

• Cesarean section
• CTG interpretation
• labor induction
• maternal request
• medical simulation training

The cesarean section (CS) rate influences our perception of obstetrical health care quality. This number is pondered as a negative phenomenon that needs to be limited in order to guarantee the physiology and nature of vaginal delivery [1,2].

The World Health Organization (WHO)’s affirmations “no justification for any region to have a cesarean section rate higher than 10–15%” dates back to1985 [1].

The worldwide cesarean section (CS) rate stands at 21.1% [3]. The lowest rate is observed in sub-Saharan Africa at 5.0%, while the highest rate is prevalent in Latin America and the Caribbean, reaching 42.8% [3]. In Europe, the rate hovers at around 25%, while in North America, it is approximately 30% [3]. In many low-income countries, access to healthcare services and the availability of cesarean sections may be limited compared to higher-income countries. As a result, the cesarean section rate may be lower in some low-income regions due to these barriers. However, this phenomenon corresponds to worse maternal and neonatal outcomes underlining that forced underuse of CS contributes to increased maternal and perinatal mortality and morbidity [4].

One possible explanation for these findings is that in low-income countries fewer cesarean sections are performed than those needed for their population at risk and higher rates of cesarean sections are linked to a reduction in neonatal and maternal mortality [4].

On the other hand, in many high-income countries the required number of cesarean sections is typically performed for their at-risk population, and the higher rate may reflect the use of unwarranted cesarean sections in healthy populations as well as the use of cesarean sections to prevent non-severe morbidity. In fact, in medium- and high-income countries, the rise in cesarean section rate does not show a significant impact on mortality rates [4]. Many developed countries with advanced healthcare systems have relatively higher C-section rates but lower maternal and neonatal mortality. In a Norwegian cohort study, a reduction in the cesarean section rate below 17% was observed between 2008 and 2018, with a simultaneous decrease in fetal and neonatal mortality [5]. In a recent study, no important association between the cesarean section rate and maternal and neonatal mortality was reported when the cesarean section rate exceeded 10% [6].

In past decades, there has been a significant shift in the population of women seeking to have a baby. This includes a trend toward having a single baby, often at an advanced maternal age, pregnancies with assisted reproductive technologies, variations in Body Mass Index, and an improvement in the management of preexisting maternal health conditions that have allowed these women to have a pregnancy. Additionally, maternal choice has played a crucial role in this changing scenery. Maternal-request cesarean section (MRCS) has represented an increasing phenomenon in recent years [7]. It appears to be influenced by economical and socio-cultural factors [8–10] and the generalized perception that this modality of delivery is devoid of risks, compared to vaginal delivery. In a retrospective observational study, Masciullo et al. [11] demonstrated how women that undergo MRCS show common characteristics such as advanced maternal age (>35 years), higher educational level, assisted reproduction technology, primiparity, history of previous miscarriage or operative vaginal delivery. This further underlines how social changes can modify women’s desires, expectation and information. Women who undergo this procedure should be properly informed of the possible short- and long-term sequelae, especially regarding future pregnancies, with an increased risk of morbidly adherent placenta (PAS, Placenta Accreta Spectrum) [12,13]. However, clinicians’ efforts to guarantee adequate information are not sufficient to modify patients’ choices as these depend to a great degree on personal experiences and individual features, so it would be desirable to have at least one professional figure covering this role in each Birth Center.

Comprehension of this phenomenon rather than its minimization represent an ever-increasing challenge for clinicians. Indeed, even if not universally accepted [14,15], MRCS is equalized to maternal and fetal indications for CS, as different guidelines explicitly indicate [16–19]. The major concern is how to combine the acceptance of MRCS with the aim of reducing the global CS rate.

The CS rate of a specific Delivery Unit is internationally calculated using the TGCS (Ten Group Classification System or Robson’s Classification) [20,21]. This classification owns intrinsic characteristics that make it extremely easy to use, replicate and apply in a prospective way, leaving it devoid of subjective observations [22]. This allows an immediate interpretation of each institute’s results and objective comparison with other delivery units; however in order to analyze the rate and indication of “unnecessary intervention,” the TGCS is insufficient. It lacks some fundamental information that allows a deep evaluation of CS rates. The CS statistic acquires a new meaning when its evaluation is enriched with information such as: indication for CS, epidemiologic and demographic characteristics of patients, and lastly, perinatal outcomes and complications. In fact how can we classify maternal request in this system?

An important indicator of obstetrical health care quality is primary cesarean delivery.

This statistic can be easily inferred through the Robson classification, but again, it lacks important information, for example the indications for CS and consequently the evaluation of clinical attitude and applied protocols.

If we analyze the indications for primary cesarean sections in detail, we can observe that a large number of them are related to labor arrest and intrapartum cardiotocography [23].

The absolute value of the CS rate, without including the topic of clinical behavior, could be run as an inflexible statistic that does not allow the full evaluation of all the parameters related to obstetrical health care quality.

Definition and understanding of the CS rate and its relationship with short- and long-term outcomes are now more important than ever.

The perinatal mortality rate is an important indicator for quality and consistency of a good clinical practice. Fetal surveillance during the late third trimester and a plan for labor induction in selected cases seem to be efficient in the reduction of the perinatal mortality rate [24,25].

For example, conditions such as late fetal intrauterine growth restriction (late IUGR), if not properly detected, can lead to the undervaluation of the feto-neonatal risk and consequently to a deficiency in obstetrical decision making [24]. Recently, also fetal echocardiography has been demonstrated as a valid tool in fetal surveillance, both in normal and complicated pregnancies. In fact, monitoring fetal wellbeing through fetal echocardiography over a period of several weeks, with the last examination performed shortly before delivery, the condition of the newborn in the first hours and days of extrauterine life can be reliably predicted [26].

The changes in the population and the ability to recognize pathological conditions have shifted the balance from low risk to high-risk pregnancies, determining a higher rate of labor induction.

Changes in clinical practices have also been identified as potential contributors to these trends. These changes involve a more permissive approach to induction (whether medically warranted or elective), the inclination of healthcare practitioners, expectant mothers, and families to arrange the timing of childbirth, expanded utilization of cervical ripening agents, shifting perspectives on elective labor induction, and greater accessibility of routine ultrasound examinations in the early and mid-stages of pregnancy. Sociodemographic elements have also been linked to the increasing use of induction. Additionally, the location and the tier of hospitals play a role as contributing factors [27,28].

Induction of labor is undoubtedly one of the most commonly performed obstetric procedures worldwide. Recent data show induction rates as high as 24.5% in the United States, and ranging from 6.8% to 33% in Europe [29], in particular 32% in Italy [30]. There is a lack of data regarding labor induction in low-income countries. However, among facility deliveries in 22 Low- and Middle-Income Countries (LMICs) as part of the WHO Global Survey on Maternal and Newborn Health, the rate of labor induction was comparatively lower. It stood at 11.4% in 8 Latin American countries, 4.4% in 7 African countries, and 12.1% in 9 Asian countries [31].

Labor induction is a growing phenomenon in many countries around the world, particularly in high-income countries. Calculating the prevalence of elective labor induction from national birth statistics is generally not feasible because indications are not consistently recorded, and healthcare workers may be hesitant to document the lack of an indication [31].

When the induction of labor is necessary, variations in the management of the methods can be responsible for CS related to the failure of induction. In recent years new mechanical methods to obtain cervical ripening have reduced pharmacological exposure to prostaglandin, implementing the increase in the Bishop score without significant feto-maternal risks and ensuring a higher success rate in terms of vaginal delivery. Numerous RCTs, reviews, and meta-analyses have demonstrated that the use of mechanical cervical ripening methods such as Foley catheter, double-balloon catheter, laminaria, and hygroscopic dilators used alone or in combination with pharmacological agents have led to a higher rate of vaginal deliveries in shorter time frames [32–35].

Dilapan-S, a synthetic hygroscopic cervical dilator, has been used before the termination of pregnancy for decades [36] and recently was shown not to be inferior to the Foley balloon for preinduction cervical ripening at term [37]. Advantages of Dilapan-S over Foley include better patient satisfaction [37].

Recent advances in methods and approaches to the induction of labor have significantly improved safety, effectiveness, and patient satisfaction. With a range of options available, healthcare providers can tailor labor induction to each patient’s unique circumstances, minimizing risks and optimizing outcomes for both mother and baby, also including the reduction of “unnecessary CS.”

In the last few years, recent studies have demonstrated how changes in the clinical activity of delivery rooms, in the operators’ training and in taking charge of patients can result in a reduction of the absolute number of CS [23,38]. In these studies, the importance of certain aspects was underlined: the appropriate knowledge about first and second stage timing of labor and how to manage their abnormal progression, the ability to perform an operative vaginal delivery correctly and the ability to recognize both physiological and pathological features of cardiotocography. Even today, the accurate definition of labor duration, the proper use of oxytocin and the interpretation of intrapartum cardiotocography remain nebulous topics in which the physician must navigate to achieve the goal of vaginal delivery while minimizing risks for the mother and the fetus.

The 2020 WHO Guidelines for Intrapartum Care [39] introduced changes to the partogram. It moved beyond the concept of a cervical dilation curve, introducing a time limit for each centimeter of cervical dilation starting from 5 cm. The scientific evidence that led to the modification of the cervical dilation curve in the 2020 WHO Guidelines is substantial.

The active phase of labor is characterized by regular, painful uterine contractions, significant cervical effacement, and an acceleration of cervical dilation from 5 cm to full dilation [40].

The 1 cm/hour cervical dilation threshold in women with spontaneous labor, corresponding to the alert line, is inaccurate for identifying women at risk of adverse birth outcomes [41] and slower progression is not an indication for obstetric intervention [40]. Augmentation of labor before 5 cm, using oxytocin or resorting to cesarean section, is not recommended if maternal and fetal conditions are reassuring [40].

Oxytocin is a commonly used medication in obstetrics, and there is significant diversity in its administration protocols. When integrated into care in a well-considered manner, oxytocin becomes an essential tool for induction and augmentation of labor. Oxytocin regimens should be individualized for each patient to minimize the occurrence of pathologically prolonged labor, reduce the rates of clinical chorioamnionitis, and decrease the need for cesarean deliveries [42].

In recent years, the interpretation of CTG during labor has evolved thanks to a better understanding of the physiopathological mechanisms of fetal response to hypoxic stimulus during labor [43]. Correctly interpreting these features can also lead to improved labor management.

The capabilities to manage various aspects of labor can be acquired by pursuing and attending, on a regular basis, master classes, practical training sessions for the simulated management of obstetrics complications and clinical audits [23,38]. The implementation of obstetrics training and simulation programs and the improvement of clinical protocols with the latest evidence can lead to the reduction of unnecessary CS.

The team’s inclination in deciding whether or not to perform a cesarean section is strongly influenced by experience. Simulations play a crucial role in training for obstetric emergencies. The integration of this training method has demonstrated enhancements in patient outcomes and should be integrated into delivery units staff training to enhance skills in labor management and improve teamwork abilities [44].

In this way, the optimum rate of CS for each specific delivery unit can be achieved, by personalizing it, meaning that, diversely from what has been announced by the WHO, this rate could be different among institutes and change over time. Reaching the optimum rate can demonstrate the ability to adequately manage this number in the general population and, at the same time, demonstrate the ability to collect data, acquire information and, consequently, apply the needed changes.

In this optic, is always the vaginal delivery risk-free? We have to consider that also planned vaginal delivery could have potential risks compared to planned cesarean delivery. In a recent systematic review by Adewale et al. [45], planned CD was associated with significant benefits in terms of less low neonatal umbilical artery pH, less need for tube feeds, less birth trauma, and less neonatal hypotonia; and significant decreases in chorioamnionitis, urinary incontinence, and painful perineum. However, the authors concluded that their results could not be generalized to the general population, because data from RCTs showed that mostly in high-risk patients there is no significant difference in perinatal or maternal mortality. Moreover, none of the included RCTs reported on a future pregnancy, and as we previously highlighted, a prior CS is a major risk factor for future placenta accreta spectrum disorders complications, and is associated with an increase in stillbirths and preterm/early term births resulting in an increased rate of admission to the neonatal unit [45].

In conclusion, is a CS rate of 10–15% really the number that expresses the obstetrical quality and safe care of delivery units?

A cultural revolution in our delivery rooms is needed, a revolution that does not simply look at statistics with a negative eye but which brings a strong awareness toward the numbers. This deeper reasoning on our delivery rooms’ data should allow us to consider statistics in all their complexity and to avoid the concept of a race for a downward trend just to appear top of the class in national and international audits.

New studies, dense training courses, also through programs for simulated management of obstetric complications, and tools for cultural divulgation seem to represent the starting point in order to guarantee adequate behavior and to achieve the best possible maternal and neonatal outcomes.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Data supporting these findings are available from the corresponding author upon request.

Additional information

Funding

This research received no external funding.