Epidemiology, trends in use of Cesarean section

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1 February, 2010

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3 Source Michelangelo Epidemiology, trends in use of Cesarean section Siri Vangen National Resource Centre for Women s Health, Department of Obstetric and Gynaecology, Oslo University Hospital siri

4 Trends in use of cesarean section The global situation Useof cesarean section in Norway Data from Rikshospitalet, a tertiary referral hospital in the capital of Oslo, Norway

5 The global situation, CS % Population based CS rates in ~1995 and most recent available figures Health Statisitics in respective regions Cyntia K et al. Stud Fam Plann 2006.

6 Cesarean section in the USA

7 Primary Cesarean delivery in the US

8 Change in indication subtype Dystocia Fetal distress Breech Other* No indication *Medical or obstetric indications other than breech, dystocia and fetal distress

9 Cesarean section in Latin America 33% Villar J et al.the WHO global survey on maternal and perinatal Health in Latin America. Lancet 2006.

10 Complications after Cesarean Section Maternal Fetal * * Maternal death, Admission to ICU, Blood transfusion, Hysterectomy Prolonged hospital stay Villar J et al.the WHO global survey on maternal and perinatal Health in Latin America. Lancet Villar J et al. BMJ, 2007;335:1025.

11 Cesarean section in Brazil Freitas PF et al. Inequalities in cesarean delivery rates by ethnicity and hospital accessibility in Brazil. Int J Gynaecol Obstet Dec;107(3): Epub 2009 Sep 26.

12 Cesarean section in Asia 27% Lumbiganon P et al. Method of delivery and pregnancy outcomes in Asia: The WHO global survey on maternal and perinatal health. Lancet 2010; 375:

13 Maternal morbidity and mortality index * % Adj. OR (95% CI) Spontaneous Operative vaginal ( ) Antepartum CS without indication Antepartum CS with indication Intrapartum CS without indication Intrapartum CS with indication ( ) ( ) ( ) ( ) *Maternal death, Admission to ICU, Blood transfusion, Hysterectomy Lumbiganon P et al. Method of delivery and pregnancy outcomes in Asia: The WHO global survey on maternal and perinatal health. Lancet 2010; 375:

14 Ssvvvvvvvvvvvvvvvvvvvvv Cesarean sections in Africa vvvvvvvvvvv

15 CS at KCMC, Moshi, Tanzania Previous caesarean section Total Caesarean section 35 Percent of total deliveries % 13 % 32 % 21 % Year of birth Sørby I et al. Submitted

16 Cesarean section in Europe, 1995 and per 100 children born Finland Sweden Norway Denmark Latvia Romania England Bulgaria Austria Germany Turkey Portugal Italy Country

17 Factors associated with the increase Medical/demographic Non medical Broadened medical indications Maternal age In vitro fertilisation Multiple gestations Induction of labour Maternal request Fear of litigation Health care organisation Economic factors Previous Cesarean section

18 Trends in use of cesarean section The global situation Useof cesarean section in Norway Data from Rikshospitalet, a tertiary referral hospital in the capital of Oslo, Norway

19 Cesarean section in Norway % Percent of children born Keisersnitt i % Medical Birth Registry

20 Cesarean section rates, ,6 Cesarean section, total Planned 21,2 Hordaland Rogaland Sogn og Fjordane Troms Vestfold Nordland Sør-Trøndelag Finnmark Vest-Agder Akershus Oslo Aust-Agder Møre og Romsdal Telemark Hedmark Buskerud Oppland Nord-Trøndelag Østfold County 17,1% 6,8 % per 100 children born

21 Emergency and elective CS and elective Caesarian section In % of children born % Elective CS 40 % 10 Emergency CS Period

22 Before and after labour start Before After Percent of children born Year

23 Indications for Cesarean Section Per 100 deliveries 0 Failed induction Preeclampsia/eclmpsia Maternal request Breech Previous CS Failure to progrss Fetal distress Kolås T et al. Indications for cesarean deliveries in Norway. Am J obstet Gynecol 2003;

24 CS in breech delivery Breech, % CS in Breech, % Year Breech CS in Breech Medical Birth Registry of Norway

25 CS in Breech delivery, % 37.1% Hordaland Vestfold Sør-Trøndelag Oppland Nord-Trøndelag Rogaland Østfold Troms Akershus Vest-Agder Nordland Telemark Oslo Mørd-Tr Buskerud Hedmark Finnmark Aust-Agder Sogn og Fjordane ,3 38,8 Country 67,4 Per 1000 breech deliveries

26 Complications (%) after CS Maternal 30weeks 29 weeks Intraoperative Blood loss 1000ml Hematoma Newborn Plannedvaginal Planned CS Tranfer to NICU Tachypnea or RDS Häger R et al Am J Obstet Gynecol 2004 Kolås T et al Am J Obstet Gynecol 2006

27 Complications * in subsequent pregnancies Condition Uterine rupture Placenta accreta Placental abruption Preeclampsia Placenta previa SGA Infertility % increased risk ~370 ~ 90 ~ 70 ~ 70 ~ 40 ~ 30 ~ 20 * Compared with women with a previous vaginal delivery Daltveit AK et al, 2008 Tollåned M et al

28 Cesarean section among immigrants in Norway ** (45) ** ** (24) ** ** 10 ** 26 ** (46) ** **p<0,001 Vangen s et al. Acta Obstyet Gynecol, 2001

29 Indications of caesarean section * Unknow n Diabetes, hypertension/preeclampsia/eclampsia, tw ins and low birth w eight Breech presentation Prolonged labor Fetal distress Foeto-pelvic disproportion Emergency Elective Cesarean section, % Horn of Africa Sri Lanka/India Philippines Chile/Brazil Norway Philippines Chile/Brazil Sri Lanka/India Horn of Africa Norway Vangen s et al. Acta Obstet Gynecol, 2001

30 Trends in use of cesarean section The global situation Useof cesarean section in Norway Data from Rikshospitalet, a tertiary referral hospital in the capital of Oslo, Norway

31 Cesarean section at Rikshospitalet Per 100 births ,8 24, Year Data from Obstetrics

32 Previous Cesarean section, % 13 Per 100 births , Year Data from Obstetrics, Anne Hedvig Mellbye Pfeffer

33 Vaginal Birth After Cesarean section 50 43% 40 Per 100 births Year Data from Obstetrics, Anne Hedvig Mellbye Pfeffer

34 CS in women with previous CS Per 100 births Year CS total Elective repeat CS Data from Obstetrics, Anne Hedvig Mellbye Pfeffer

35 CS in women with previous CS Spontaneous onset Induced onset 40 Per 100 births Year Data from Obstetrics

36 Cesarean section i twin deliveries, Rikshospitalet Twins per 100 deliveries CS in Twins per 100 deliveries Twins % CS in Twins % Year 0 Data from Obstetrics

37 Conclusions CS rates are increasing above advised rates in richer parts of the world, a resource drain that could be used to improve other areas of perinatal care A complex interplay of demographic, economic and medical aspects seem to play a role in the increasing rates The evidence of adverse effects of the procedure when perfomed without medical indication is growing

38 Source: Michelangelo Victor Hugo Ideas whose time has arrived are stronger than all armies in the world.

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