Epidemiology, trends in use of Cesarean section

February, 2010

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

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

The global situation, CS % Population based CS rates in ~1995 and most recent available figures 12-17 20-32 17-25 5-11 4-9 2.7-2.9 11-16 18-29 Health Statisitics in respective regions Cyntia K et al. Stud Fam Plann 2006.

Cesarean section in the USA

Primary Cesarean delivery in the US

Change in indication subtype 10 9 8 7 6 5 4 3 2 1 0 1991-1992 2007-2008 Dystocia Fetal distress Breech Other* No indication *Medical or obstetric indications other than breech, dystocia and fetal distress

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

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 2006. Villar J et al. BMJ, 2007;335:1025.

Cesarean section in Brazil Freitas PF et al. Inequalities in cesarean delivery rates by ethnicity and hospital accessibility in Brazil. Int J Gynaecol Obstet. 2009 Dec;107(3):198-201. Epub 2009 Sep 26.

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: 490-499.

Maternal morbidity and mortality index * % Adj. OR (95% CI) Spontaneous 1.6 1 Operative vaginal 4.2 2.1 ( 1.7-2.6) Antepartum CS without indication Antepartum CS with indication Intrapartum CS without indication Intrapartum CS with indication 0.6 2.7 ( 1.4-5.5) 6.9 10.6 ( 9.3-12.0) 7.2 14.2 ( 9.8-20.7) 11.8 14.5 (13.2-16.0) *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: 490-499.

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CS at KCMC, Moshi, Tanzania Previous caesarean section Total Caesarean section 35 Percent of total deliveries 30 25 20 15 27 % 13 % 32 % 21 % 10 0 2000 2001 2002 2003 2004 2005 2006 Year of birth Sørby I et al. Submitted

Cesarean section in Europe, 1995 and 2006 13-17 15-16 50 40 1995 2006 per 100 children born 14-23 17-28 10-22 24-35 26-39 29 30 20 10 0 Finland Sweden Norway Denmark Latvia Romania England Bulgaria Austria Germany Turkey Portugal Italy Country http://data.euro.who.int/hfadb/tables/tablea.php?w=1280&h=1024

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

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

Cesarean section in Norway 1967 2008 18 17.1 % 16 14 12 10 8 6 4 2 Percent of children born Keisersnitt i % 0 1967 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 Medical Birth Registry

Cesarean section rates, 2008 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 11,6 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

Emergency and elective CS and elective Caesarian section 70 60 In % of children born 50 40 30 20 28 % Elective CS 40 % 10 Emergency CS 0 1988 1993 1998 2003 2008 Period

Before and after labour start 100 90 80 Before After Percent of children born 70 60 50 40 30 20 10 0 1970 1975 1980 1985 1990 1995 2000 2005 Year

Indications for Cesarean Section 25 20.7 21.9 20 15 10 5 6.2 4.0 8.4 8.9 7.6 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; 864-870.

CS in breech delivery 70 70 Breech, % 60 60 CS in Breech, % 50 10 50 10 5 5 0 0 1998 2000 2002 2004 2006 2008 Year Breech CS in Breech Medical Birth Registry of Norway

CS in Breech delivery, 2008 54.2% 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 90 85 80 75 70 65 60 55 50 45 40 5 35 0 85,3 38,8 Country 67,4 Per 1000 breech deliveries

Complications (%) after CS Maternal 30weeks 29 weeks Intraoperative 8.1 9.1 Blood loss 1000ml 8.5 10.4 Hematoma 3.4 10.4 Newborn Plannedvaginal Planned CS Tranfer to NICU 5.2 9.8 Tachypnea or RDS 0.8 1.6 Häger R et al Am J Obstet Gynecol 2004 Kolås T et al Am J Obstet Gynecol 2006

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

Cesarean section among immigrants in Norway 12 24 ** (45) ** 12 20 ** (24) ** 13 21 ** 10 ** 26 ** (46) ** **p<0,001 Vangen s et al. Acta Obstyet Gynecol, 2001

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 18 16 14 Emergency Elective 12 10 8 6 4 2 0 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

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

Cesarean section at Rikshospitalet 28 27 Per 100 births 26 25 24 23 22 23,8 24,8 21 20 5 0 2003 2004 2005 2006 2007 2008 2009 Year Data from Obstetrics

Previous Cesarean section, % 13 Per 100 births 12 11 11,5 10 4 2 0 2003 2004 2005 2006 2007 2008 2009 Year Data from Obstetrics, Anne Hedvig Mellbye Pfeffer

Vaginal Birth After Cesarean section 50 43% 40 Per 100 births 30 20 0 2003 2004 2005 2006 2007 2008 2009 Year Data from Obstetrics, Anne Hedvig Mellbye Pfeffer

CS in women with previous CS 70 60 Per 100 births 50 40 30 10 0 2003 2004 2005 2006 2007 2008 2009 Year CS total Elective repeat CS Data from Obstetrics, Anne Hedvig Mellbye Pfeffer

CS in women with previous CS 50 45 Spontaneous onset Induced onset 40 Per 100 births 35 30 25 20 15 10 0 2003 2004 2005 2006 2007 2008 2009 Year Data from Obstetrics

Cesarean section i twin deliveries, Rikshospitalet 70 70 Twins per 100 deliveries 60 50 40 5 60 50 40 5 CS in Twins per 100 deliveries 0 2003 2004 2005 2006 2007 2008 2009 Twins % CS in Twins % Year 0 Data from Obstetrics

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

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