Cesarean section rate differences by migration indicators

Purpose

To answer the question: are there differences in cesarean section rates among childbearing women in Canada according to selected migration indicators?

Methods

Secondary analyses of 3,500 low-risk women who had given birth between January 2003 and April 2004 in one of ten hospitals in the major Canadian migrant-receiving cities (Montreal, Toronto, Vancouver) were conducted. Women were categorized as non-refugee immigrant, asylum seeker, refugee, or Canadian-born and by source country world region. Stratified analyses were performed.

Results

Cesarean section rates differed by migration status for women from two source regions: South East and Central Asia (non-refugee immigrants 26.0 %, asylum seekers 28.6 %, refugees 56.7 %, p = 0.001) and Latin America (non-refugee immigrants 37.7 %, asylum seekers 25.6 %, refugees 10.5 %, p = 0.05). Of these, low-risk refugee women who had migrated to Canada from South East and Central Asia experienced excess cesarean sections, while refugees from Latin America experienced fewer, compared to Canadian-born (25.4 %, 95 % CI 23.8–27.3). Cesarean section rates of African women were consistently high (31–33 %) irrespective of their migration status but were not statistically different from Canadian-born women. Although it did not reach statistical significance, risk for cesarean sections also differed by time since migration (≤2 years 29.8 %, >2 years 47.2 %).

Conclusion

Migration status, source region, and time since migration are informative migration indicators for cesarean section risk.     

Cesarean section on demand or elective. Cesarean section: request for rethinking

Nowadays, the mortality and morbidity of caesarean section, particularly elective caesarean section, are hardly different from those of vaginal delivery. 'Section on request' is so extremely rare that it is of no importance and that these terms should not be used at all. A change in thinking is necessary because only real misgivings make the pregnant woman wish for this procedure. In this context, the increasing importance of autonomy and the right to self-determination of the woman lead to a fundamental shift in the relationship between doctor and patient. Long-term sequelae after vaginal delivery, e.g. injury to the pelvic floor with functional impairment and disturbances of sexual function, but also considerations about the safety of the child become more and more important for the pregnant woman and have to be taken seriously by the physician. Although there are no precise bases for assessment, a global comparison of costs between vaginal delivery and elective caesarean section with regard to the long-term sequelae will hardly show any true differences, and therefore the health insurances are not entitled to refuse the reimbursement of costs.     

Cesarean section for fetal distress

The avoidance of neonatal medical and neurologic sequelae resulting from a compromised pregnancy, labor, or delivery is the goal of all members of the health care team. Correct identification of those patients at risk for fetal distress prior to as well as during labor is most important as a major step in achieving this goal. Correct utilization of various modalities, including ultrasound, continuous heart rate monitoring, and timely fetal scalp pH assessment will greatly improve one's ability to correctly identify the distressed fetus. Management options include immediate delivery and attempts at in-utero resuscitation. It is not possible to give a clear, generally accepted definition of fetal distress. But as a result of the experience and experimental efforts of many investigators, we now have many tools which can be used in identifying the fetus who is stressed, and ideally we can avoid the irreversible damage which results in death or life-long disability.     

Cesarean section mortality

Recent reports of large series of cesarean sections performed at various maternity centers throughout the country have, almost without exception, presented maternal mortality rates reduced to almost the ideal minimum. While these reports are admirable and the results are enviable, unfortunately, they tend to create a false impression, especially among the less experienced members of the profession—that cesarean section has become a procedure with minimal risk to the patient which does not need the same serious consideration accorded to other major surgical procedures.The reduction of maternal mortality has been brought about by many advances in obstetrie care. Among the most important are: (1) more thorough training of obstetricians; (2) the increased percentage of deliveries performed by obstetricians; (3) requirements for competent consultation for all obstetric complications; (4) blood banks; (5) antibiotic and chemotherapeutic drugs; and (6) improved obstetric anesthesia.As a result of these improvements in obstetric care, deaths associated with cesarean section have become so rare that no one individual nor even any one hospital staff has enough experience to realize that preventable cesarean section deaths still occur frequently enough to constitute an important problem at the present time. This fact can be appreciated only by a critical review of the deaths which occur among a large section of the population, such as a metropolitan area. This presentation, therefore, is an analysis of the maternal deaths associated with the cesarean sections which were performed in the City of Philadelphia from Jan. 1, 1938, to Dec. 31. 1953. The information was obtained from reports submitted to the Committee on Maternal Welfare of the Philadelphia County Medical Society.For comparative purposes, this study will be divided into two eight-year periods, 1938–1945 and 1945–1953. This division occurred at a natural point because during the second eight-year period an easily obtained and adequate supply of blood from banks was available even in the smaller hospitals. Also during this later period the obstetrician had available chemotherapeutic and antibiotic drugs covering a wide range of pathogenic organisms. A comparison of the number of deaths in each period makes it obvious that both of these advances in therapy had a great effect upon the number of fatalities.     

Cesarean section for the second twin

Twin pregnancies delivered after 26 weeks gestation were reviewed. Of 167 twin pregnancies 101 (60.5%) were delivered by cesarean section. There were 8 combined vaginal-abdominal deliveries, including 4.8% of all twins delivered and 7.3% of all twins delivered by cesarean section. The commonest indication for the cesarean birth of the second twin was transverse lie. The data suggest that cesarean section of the second twin is not possible to predict by obstetrics variables including antepartum ultrasound. In order to decrease the rate of combined vaginal-abdominal deliveries the need to reassess the currently protocol of management for twin delivery is indicated.     

Cesarean section odds ratios

Cesarean section (CS) rates for primiparas, multiparas with and without previous CS were investigated in seven obstetrical settings. Despite the great diversity of global CS rates (5.3 to 17.4%), common CS odds ratios of 3.0 and 37 have been found for primiparas and multiparas with previous CS, respectively. Internal links between CS odds ratios have also been investigated for some anomalies associated with CS (fetal distress, non-vertex presentation, hypertension, dystocia, small for dates new born and prematurity), suggesting that perinatal services may be evaluated on CS aspects according to a single general interventionist/conservative clinical attitude. Data from two additional obstetrical settings were used to verify the findings in terms of perinatal evaluation.     

Cesarean section: changing incidence and indications

There were 19,419 deliveries at Wilford Hall USAF Medical Center from 1970 through 1981. Of these, 1847 (9.5%) were by primary cesarean section and 800 (4%) by repeat operations. The most common indications for cesarean section (dystocia, breech presentation, repeat operation, and fetal distress) remained the same during this period. However, within these four indications and also between the three time periods of 1970 to 1973, 1974 to 1977, and 1978 to 1981, significant trends were apparent. From the periods of 1970 to 1973 through 1974 to 1977, the primary rate increased from 5.6% to 12.8% (P less than .0001). Dystocia (P less than .0001), breech presentation (P less than .0001), and fetal distress (P less than .0001) were responsible for this increase. However, from 1974 to 1977 through 1978 to 1981, the primary rate decreased to 9.6% (P less than .0001). This was related to significantly decreased rates for dystocia (P less than .0001) and fetal distress (P less than .0001). This decrease was temporally related to an initiation of various means to decrease the authors' overall cesarean section rate that approached 20% in 1976.     

Cesarean section on demand

The safety of cesarean section has improved dramatically over the past 50 years. During the past 20 years a greater awareness of and discussion about the symptomatic morbidity that can result for women following vaginal delivery has occurred and women's expectations for the outcome of pregnancy for them and their babies has increased. A culture of choice has been promoted in recent years, but contrary to the anticipated demand for less obstetric intervention by those promoting choice, there has been an increase in demand for delivery by cesarean section rather than the reverse. With the balance in favor of benefit for the baby from delivery by cesarean section, it is now difficult to sustain the argument favoring vaginal delivery rather than planned cesarean section, using maternal morbidity and mortality statistics. A critical evaluation of the costs indicates that there are probably few grounds for denying women their request for cesarean section for economic reasons. It seems likely, therefore, that in the near future those advising women on the options for delivery will need to ensure that the risks of vaginal delivery are explained as well as those for planned cesarean section.