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Caesarean Section rates worldwide WHO Recommendations/approach to reducing unnecessary caesareans
Istanbul, 29 Ekim 2016
Dr Lale Say, Dr Ana Pilar Betran, Dr A. Metin Gülmezoglu
CS trends worldwide since 1990
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CS rates worldwide
Source: Betrán et al: The increasing trend in Caesarean section rates. PLoS ONE 2016
IS THERE AN IDEAL CAESAREAN SECTION RATE?
CAESAREAN SECTION RATES AT THE POPULATION LEVEL
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2015 WHO Statement on Caesarean Section Rates
At population level, CS rates >10% are not associated with reductions in maternal
and neonatal mortality
Least developed countries(n=41)
Association between CS rates vs. maternal and neonatal mortality Without adjustment and adjusting for HDI
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Results
There is a strong inverse association between CS rates and mortality outcomes:
as CS rates increase, up to a certain threshold, maternal and neonatal mortality decrease
above this threshold, the association no longer exists and further increases in CS rates are not associated with
improved mortality outcomes
Point of inflection for the association between CS rates and mortality outcomes: CS rates at about 10% (9-16% for the systematic review)
Correlation does not mean causation
Limitations
Current data does not enable us to assess the link for CS rates >30%
Is mortality the only relevant outcome?
The effects of CS rates on other outcomes, such as maternal and perinatal morbidity, paediatric outcomes, and
psychological or social well-being are still unclear.
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Caesarean Section – WHO Statements
1985 Statement
There is no justification for any region to have a CS rate higher than 10-15%
2015 Statement
At population level, CS rates higher than 10%
are not associated with reductions in maternal and newborn mortality rates
WHO proposes the use of the Robson (10- group) classification
CS are effective in saving maternal and infant lives, but only when they are required for
medically indicated reasons.
2015 WHO Statement on Caesarean Section Key messages
CS can cause significant complications, disability or death
particularly in settings that lack the facilities to conduct safe surgery and treat complications.
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WHO STATEMENT – PART II
GLOBAL STANDARD FOR MONITORING C-SECTION RATES
Filename
The Robson classification
(10-group classification)
• Parity
• Onset of labour
• Gestational age
• Fetal lie and presentation
• Number of fetuses
• Previous CS
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Shifting focus
From the search of an “optimal”
CS rate to
prioritize and promote facility-
level understanding of CS rates by using a common tool
Challenge: most recurrent question!
How can I reduce the unnecessary caesarean
deliveries in my…. ?
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2006: NIH Statement on Caesarean Delivery on Maternal Request
Acknowledged the increasing trend of CS without medical
indication in US and “maternal request” as a component of this increase
Reviewed risks and benefits of CS vs. VD concluding that there is insufficient evidence
Did not propose interventions to reduce CS.
2011: NICE Guidelines on CS
Interventions which may reduce CS
Involve consultant obstetricians in the decision making for CS
Offer ECV if breech at 36 weeks when appropriate
Facilitate continuous companionship during labour and childbirth
Offer induction of labour beyond 41
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2011: NICE Guidelines on CS
Interventions which may reduce CS
Perform fetal blood sampling before CS for abnormal CTG in labour when appropriate
Use a partogram with a 4-hour action line for women in spontaneous labour with an uncomplicated singleton
pregnancy at term.
2011: NICE Guidelines
Interventions which may reduce CS
Auditing using the 10-group classification system may result in reduced CS rates
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2014: ACOG and SMFM Obstetric Care Consensus:
Safe Prevention of the Primary CS
Revisit the definition of labor dystocia because recent data show that contemporary labor progresses at a slower rate than
historically taught
Improve and standardize fetal heart rate interpretation and management
Increase women’s access to nonmedical interventions during labor, such as continuous labor and delivery support by a lay companion
ECV for breech presentation and a trial of labour for women with twin gestations when the first twin is in cephalic
presentation
WHO Guideline for reducing unnecessary
Caesarean Sections – UNDER DEVELOPMENT
The GOAL of this guideline will be to consolidate guidance for effective interventions to reduce the unnecessary use of caesarean section
The specific OBJECTIVE will be to develop evidence-
based recommendations on interventions for the
reduction and prevention of unnecessary caesarean
sections
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