strategies to address global cesarean section rates: a review of the evidence

Strategies to Address Global Cesarean SectionRates: A Review of the Evidence

Ruth Walker, BA(Hons), Deborah Turnbull, BA (Hons), MPsych, PhD,and Chris Wilkinson, MRCOG, FRACOG, MPH

ABSTRACT: Background: The steadily increasing global rates of cesarean section hasbecome one of the most debated topics in maternity care. This paper reviews and reports onthe success of strategies that have been developed in response to this continuing challenge.Methods: A literature search identi®ed studies conducted between 1985 and 2001 from theCochrane Database of Systematic Reviews, Medline, Socio®le, Current Contents, Psyclit,Cinahl, and EconLit databases. An additional search of electronic databases for Level 1evidence (systematic reviews), Level 2 (randomized controlled trials), Level 3 (quasi-experimental studies), or Level 4 (observational studies) was performed. Selection criteriaused to identify studies for review included types of study participant, intervention, outcomemeasure, and study. Results: Interventions that have been used in an attempt to reducecesarean section rates were identi®ed; they are categorized as psychosocial, clinical, andstructural strategies. Two clinical interventions, (external cephalic version, vaginal birthafter a previous cesarean) and one psychosocial intervention (one-to-one trained supportduring labor) demonstrated Level 1 evidence for reducing cesarean section rates.Conclusions: Although the evidence for one-to-one care and external cephalic version camefrom both developed and developing settings, the systematic review for vaginal birth after acesarean was restricted to studies conducted in the United States. The e�ective implemen-tation of the preceding strategies to reduce cesarean rates may depend on the social andcultural milieu and on associated beliefs and practices. (BIRTH 29:1 March 2002)

Professional opinion concurs that although cesareansection is safer today than in the past, it is associatedwith psychosocial (1,2) and physiological morbidityand mortality (3±5) for both mother and baby. Thisrecognition (6) provided the primary impetus for ourreview of strategies that have been initiated to reducecesarean birth rates.

Over the past two decades the goal of achieving areduction in rates has been evident in developed

countries. More recently, concerns have been raisedin Latin America (7), India (8,9), and Turkey (10).Accurate determination of global cesarean sectionrates suggests the need to apply international statis-tics for this intervention, but it is di�cult to collectreliable national estimates of these rates in developingcountries. In some settings, such as India, littlepopulation-based data exist (9). Although data aremore readily available for developed countries,international comparisons are limited by factors suchas time frames of data collection. Figure 1 providesinternational comparisons of cesarean section ratesfor selected countries (11±17).

The United States and Australia currently have thehighest cesarean section rates in the developed world,22 percent (16) and 21 percent (17). It is alarming thatsome developing countries, such as India, and regionsof South America, have rates between 25 and 45percent. In striking contrast, the Netherlands andSweden have cesarean section rates that have

Ruth Walker is a Doctoral candidate in the Departments of PublicHealth & General Practice and Deborah Turnbull is in theDepartments of General Practice & Psychology at Adelaide Univer-sity, Adelaide; Chris Wilkinson is in the Department of Obstetricsand Gynaecology, Women's and Children's Hospital, NorthAdelaide, South Australia, Australia.

Address correspondence to Ms. Ruth Walker, BA (Hons), Depart-ment of General Practice, Adelaide University, Adelaide 5005, SA,Australia.

Ó 2002 Blackwell Science, Inc.

28 BIRTH 29:1 March 2002

remained at approximately 10 percent since the 1980s(18). Although this review does not address the issueof whether there is a ``correct'' cesarean section rate,it is pertinent to note that of 16 countries listed inFig. 1, only 3 have rates below the World HealthOrganization's suggested optimum rate of 15 percent(19).

Methods

Criteria for Study Selection

In selecting studies for review, criteria included typesof study participant, intervention, outcome measure,and study. Types of study participants includedpregnant women in the antenatal or intrapartumperiod in hospital delivery wards. In situations whereinterventions primarily addressed physicians or hos-pitals, study participants comprised the physicians orhospitals themselves.

Types of intervention included any interventiondirected at cesarean section rates, whether ``primary''(in which the primary aim of the study was to addresscesarean section rates) or ``secondary'' (in whichcesarean section rates were a�ected during the courseof a study).

Types of outcome measures included many di�er-ent childbirth outcomes, but delivery mode was theprimary outcome measure.

Types of studies selected included those categor-ized by Level 1±4 classi®cation recognized by theCochrane Collaboration (20). These are levels ofevidence, based on the research design used. Level 1studies are systematic reviews; Level 2 are random-ized controlled trials; Level 3 are quasi-experimentalstudies; and Level 4 are observational evidence. Level1 evidence is the ``gold standard,'' or highest level ofevidence. The review identi®ed studies published indeveloped and developing settings, including Northand South America, Europe, Australasia, Asia, andSouth and Central Africa.

Search Strategy for Study Identi®cation

Our search included a review of the 1985±2001Cochrane Database of Systematic Reviews, Medline,Socio®le, Current Contents, Psyclit, Cinahl, andEconLit databases. Search terms included cesareansection, cesarean section and reduction, cesareansection and rates, cesarean section and preference,cesarean section and psychology, cesarean section andknowledge, cesarean section and psychosocial support,and cesarean section and education. The Britishspelling ``caesarean'' was also entered for each search.No language limits were applied. Interventions weresubsequently grouped into psychosocial interven-tions, clinical interventions, and structural strategies.

To ensure that the review included studies that metour criteria, the ®rst author con®rmed each study'srelevance by assessing the abstract, or if needed, theentire study before inclusion. If any uncertaintyoccurred over the relevance of a speci®c study, thesecond author con®rmed its relevance.

Results

Psychosocial Interventions

Details of the two studies (21,22) categorized aspsychosocial interventions are presented in Table 1.Interventions in this group were characterized byaddressing the cesarean section rate while focusing onthe psychological well-being of the woman in theantenatal, intrapartum, or postnatal periods. Suchpsychosocial interventions attempt to in¯uence the

Fig. 1. Comparison of cesarean birth rates fromselected countries.

BIRTH 29:1 March 2002 29

cesarean section rate by addressing the psychologicalaspects of pregnancy and birth through socialsupport and education.

Level 1 evidence has determined that the continu-ous presence of a specially trained support personduring labor can reduce likelihood of cesareansection (21). Such assistance decreases the need forpain medication, operative vaginal delivery (forcepsor vacuum), and 5-minute Apgar score below 7.Several trials included in this systematic reviewreported that continuous support reduced the likeli-hood of negative ratings of the childbirth experienceby study participants. Despite di�erences in hospitalregulations, ``risk'' status of participants, and thepresence of signi®cant others, the trial results showedconsiderable uniformity. This research highlightedthe importance of women receiving intrapartumsupport from both signi®cant others and from thosewho were specially trained.

No bene®ts were found in a second psychosocialintervention. This randomized controlled trialassessed whether a specialized vaginal birth after acesarean (VBAC) education and support programcould increase likelihood of vaginal delivery inwomen who had a previous cesarean section (22). Itfound no di�erence in vaginal delivery rates betweenwomen who received the program and those who

received a VBAC pamphlet, even when results tookinto account motivation for vaginal delivery. Theresearchers reported that women who indicated lowmotivation for a VBAC (372 women, or 29%) weremore than three times as likely to experience electivecesarean delivery, compared with those who indica-ted high motivation.

Clinical Interventions

Details of the 9 studies categorized as clinicalinterventions (23±31) are shown in Table 2. Theseinterventions primarily considered health status ofthe pregnant woman and conditions associated withthe pregnancy, such as fetal position and whether ornot the woman had a previous cesarean section.Studies included in this category examined VBAC,active management of labor, management of breechpresentation, and use of a partogram.

The oft-quoted ``once a cesarean, always a cesar-ean,'' by Edwin Cragin in 1916 (32), now recognizedto be invalid, has nonetheless permeated the beliefs ofsome physicians and pregnant women. There iscompelling Level 1 evidence from meta-analysis ofmorbidity and mortality associated with VBAC thatVBAC is a safe alternative to repeat cesarean section(26). Actively encouraging women to attempt VBAC

Table 1. Two Psychosocial Interventions Aimed at Decreasing Cesarean Section Rates, as a Primary or Secondary Outcome

Study and CountryIntervention Assessedand Number Studied Entry Criteria

OutcomeMeasures Results

Hodnett, 2001 (21)Belgium, Canada,Finland, France,Greece, Guatemala,South Africa, USA

Systematic review ofRCTs to assesscontinuous supportduring labor vs usualcare; support could beprofessional or nonprofessional

Total n� 5000

Pregnant women,in labor, inhospital deliverywards

Mode ofdelivery

Reduced likelihood of CS(OR 0.77, 95% CI 0.64±0.91)

Fraser et al, 1997(22) Canada

RCT comparingcommunity-based VBACeducation and supportprogram with pamphlet;after baseline question-naire measuring women'sself-reported motivationfor VBAC, women weredivided into Group 1:``Verbal,'' individualizedVBAC educationprogram, n� 641, withGroup 2: ``Document,''pamphlet, n� 634

Total n� 1275

Single previousCS before28 wkgestation

VBAC rate No di�erences found betweentwo groups in VBAC ratesIrrespective of interventiongroup, women with lowmotivation for VBAC weremore than three times as likelyto undergo elective repeat CSthan were women with highmotivation (47% vs 13%)

RCT� randomized controlled trial; CS� cesarean section; VBAC� vaginal birth after cesarean.OR� odds ratio; CI� con®dence interval.


is not always the practice of midwives and physicians,however, and this may be one reason why VBAC isnot chosen routinely by women (23). A recentretrospective cohort analysis (25), which reportedthat women who had a VBAC had three times therisk of uterine rupture compared with those who hada second cesarean, may further reduce women'swillingness to attempt a VBAC. Most signi®cantwas that the risk of uterine rupture was highestamong those whose labor was induced with prosta-glandin.

Active management of labor is characterized by a``protocol for the supervision of the intrapartum careof nulliparous women'' (27, p 183), including earlyadmission in and diagnosis of labor, relativelyprompt use of oxytocin, and continuous intrapartumemotional support. The practice was originally inten-ded as an attempt to shorten prolonged labor, whichit has succeeded in doing in some settings. The notion

that it potentially could reduce the cesarean sectionrate came later. Evidence that active management oflabor reduces cesarean section rates is weak, withmixed results (27) or no di�erence (28).

Since 80 percent of breech-presenting fetuses aredelivered by elective or emergency cesarean section insome settings (17), attempts to address rising cesareansection rates have included assessment of manage-ment of breech presentation. Vaginal delivery of theterm breech fetus occurs in approximately 0.8 percentof deliveries (17). One trial suggested that cesareanbirth is preferable for the baby (29). Level 1 evidence(30) con®rms the role of external cephalic version, aprocedure that aims to rotate the fetus externally tocephalic presentation, in reducing the cesarean sec-tion rate for term breech presentation.

Use of a partogram, a graph used by obstetricalsta� to record labor progress with ``alert'' and``action'' lines for intervention, has been assessed

Table 2. Nine Clinical Interventions Aimed at Decreasing Cesarean Section Rates, as a Primary or Secondary Outcome

Study and CountryIntervention Assessedand Number Studied

EntryCriteria


Vaginal birth after cesarean (VBAC)

Appleton et al,2000b (23)Australia

Retrospective analysisof over 200,000deliveries at 11 majorobstetric hospitals over5 yr, 20,000 of whichwere associated with 1or more previous CS

Total n� 234,015(of which 21,452 wereassociated with 1 ormore previous CS)

Women presentingwith previousscar

VBAC rate 25.3%, or 5149, women with1 or more previous CS hada vaginal delivery

Signi®cantuterine rupture

62 cases

In women attempting VBACafter previous lower segmentCS, uterine rupture rate wasestimated at 0.3%

Flamm et al, 1990(24) USA

Observational studyover 5 yr to assesssuccess of multicentercollaborative e�ort toencourage policy ofincreasing VBAC ratesat 9 hospitals (®rst 2 yr)and 11 hospitals(®nal 3 yr)

Total n� over 5000 VBACcases

Women with 1or moreprevious CS

VBAC 163,814 births during 5-yrperiod; of these 15,098 towomen with previous CS; ofthese 5733 (38.0%)underwent TOL, 4,291(74.8%) of whom hadsuccessful VBAC

Maternal/perinatalmortality

No maternal deaths in TOLgroup, 1 perinatal death,although debatable whetherplanned CS could haveprevented this outcome

Uterine rupture Overall incidence was1.7 per 1000 (10/5733)


Table 2. Continued



Lydon-Rochelleet al, 2001 (25)Washington,USA

Retrospective cohortanalysis of over20,000 deliveriesfrom 1987±1996 inone US state

Total n� 20,095

Women whodelivered by CSand had sub-sequent delivery,CS or vaginal,during studyperiod

Uterine rupture For repeat CS, withoutlabor, 1.6/1000 casesuterine rupture

For vaginal delivery withspontaneous onset labor,5.2/1000 cases uterinerupture

For vaginal delivery with laborinduced withoutprostaglandins, 7.7/1000cases uterine rupture

For vaginal delivery with laborinduced with prostaglandins,24.5/1000 cases uterinerupture

Rosen et al, 1991(26) USA

Meta-analysis of 31studies to evaluateassociation betweenbirth route afterprevious CS andmaternal/infantmortality and morbidity

Total n� 11,417 TOLand 6147 elective CS

Women with 1or moreprevious CS

Maternal/perinatalmorbidity

Maternal febrile morbiditysigni®cantly lower after TOLcompared with electiverepeat CS (p < 0.001)Excluding antepartumdeaths, fetuses weighing< 750 g, and congenitalabnormalities, no di�erencein perinatal death rates(OR 0.8, p� 0.9)

Uterine rupture Birth route made no di�erencein rates of uterine rupture

Active management of labor (AML)

Impey & Boylan,1999 (27)Various Westernand non-Western settings

Review of observationalstudies, meta-analysis,and RCTsevaluating AML

Total n� not speci®ed

Nulliparouswomen

CS rateDurationof labor

Maternal febrilemorbidity

EquivocalMeta-analysis of all trialsshowed signi®cant reductionin incidence of labor lasting> 12 hr (OR 0.3, CI 0.2±0.4)

Reduced by AML(OR 0.4, CI 0.3±0.7)

Perinatalmorbidity

Meta-analysis showed thatApgar scores, neonatal unitadmission, and neonatalneurological abnormalitieswere una�ected by AML

Sadler et al,2000 (28)New Zealand

RCT of womenrandomized to eitherAML or routine care

Total n� 651 (320 AML,331 routine)

Nulliparous womenwith singletonpregnancies

CS rate

Length of ®rststage labor

No evidence that AML reducedrates of CS (AML group9.4% and routine care group9.7%)

Median duration 290 min(routine care) vs 240 min(AML) (p� 0.02)

Breech delivery

Hannah et al,2000 (29)Argentina,Australia, Brazil,Canada, Chile,Denmark, Egypt,Finland,Germany, India,Israel, Jordan,Mexico,Netherlands,New Zealand,

RCT to compare policyof planned CS withpolicy of plannedvaginal birth forselected breech-presentation pregnanciesGroup 1 (assignedplanned CS), n� 1041women, 1039 infantsGroup 2 (assignedplanned vaginal delivery),n� 1042 women, 1039infants

Singleton fetus ina frank orcomplete breechpresentation

Perinatalmortality,neonatalmortality,or seriousneonatalmorbidity

All signi®cantly lower forplanned CS group comparedwith planned vaginal birthgroup (17 of 1039 [1.6%]vs 52 of 1039 [5.0%];RR 0.33 [95% CI 0.19±0.56];p < 0.0001)


for in¯uence on cesarean section rates. A randomizedcontrolled trial, comparing three di�erent partogramswith action lines at di�erent time intervals, wasinconclusive (31). On the basis of this research, it hasbeen argued that partograms may have the potentialto in¯uence the cesarean section rate, but the strengthof this relationship and the assertion itself remainequivocal.

Structural Strategies

Details of the 9 studies categorized as structuralstrategies (33±41) are presented in Table 3. Thisgroup of interventions stem from hospital organiza-tion and policy and involve interventions that exam-ined the e�ects of local opinion leaders, clinicalpractice guidelines, quality improvement strategies,midwifery care, and ®nancial incentives.

Local opinion leaders are ``health professionalsnominated by their colleagues as `educationally in¯u-ential''' (42). Studies have investigated if such initia-tives may change health care professional practice, butonly one randomized controlled trial demonstratedsigni®cant impact of local opinion leaders on cesareansection rates (33). This trial reported that physiciansrandomized to opinion leader education had higherVBAC rates compared with those randomized tocesarean section audit and feedback.

Implementation of clinical practice guidelines isanother strategy that has been directed at reducingcesarean section rates. Such directives aim to dissem-inate explicit decision-making principles for cliniciansdeveloped by the medical profession, sometimes incollaboration with government (33). A retrospectiveobservational study of the impact of legislativelyimposed practice guidelines reported no evidence of

Table 2. Continued



Pakistan,Palestine, Poland,Portugal,Romania,South Africa,Switzerland,UK, USA,Yugoslavia,Zimbabwe

Total n� 2083 maternaloutcomes, 2078infant outcomes

Singleton fetus ina frank orcomplete breechpresentation

Maternalmortality orseriousmaternalmorbidity

No di�erences betweengroups (41 of 1041 [3.9%]vs 33 of 1042 [3.2%]; 1.24[0.79±1.95]; p� 0.35)

External cephalic version (ECV)

Hofmeyr & Kulier,2001 (30)Denmark,South Africa,Zimbabwe,Netherlands,USA

Systematic review ofRCTs consideringe�cacy of ECV atterm for infants inbreech position

Total n� not speci®ed

Women withbreechpresentation atterm and nocontraindicationsto ECV

CS rate

Noncephalicbirths

Perinatalmortality

Signi®cant reduction (RR 0.52,95% CI 0.39±0.71)

Signi®cant reduction (RR 0.42,95% CI 0.35±0.50)

No signi®cant e�ect (RR 0.44,95% CI 0.07±2.92)

Partogram

Lavender et al,1998 (31) UK

RCT to compare e�ectsof three di�erent typesof partogram: 2 hr,n� 315 women; 3 hr,n� 302 women; 4 hr,n� 311 womenTotal n� 928

Primigravidwomen withuncomplicatedpregnanciespresenting inspontaneouslabor at term

CS rate Was lowest when labor wasmanaged using a 4-hr actionline partogram

Di�erence between 3- and 4-hrpartograms was statisticallysigni®cant (OR 1.8 95% CI1.1±3.2), but di�erencebetween 2- and 4-hrpartogram was not (OR 1.4,95% CI 0.8±2.4)

Maternalsatisfaction

Women in 2-hr arm moresatis®ed with labor comparedwith women in 3-hr(p < 0.0001) and 4-hr(p < 0.0001) arms

VBAC� vaginal birth after cesarean; CS� cesarean section; RCT� randomized controlled trial;AML� active management of labor; TOL� trial of labor; ECV� external cephalic version.OR� odds ratio; CI� con®dence interval; RR� relative risk.


Table 3. Nine Structural Strategies Aimed at Decreasing Cesarean Section Rates, as a Primary or Secondary Outcome



Local opinion leaders

Lomas et al, 1991(33) Canada

RCT comparingphysicians in 16community hospitalsrandomized to eitheraudit and feedback(A/F) or local opinionleader education(OLE) as methods ofencouraging compliancewith guideline formanagement of womenwith previous CS

Group 1 (control), n� 38Group 2 (A/F), n� 19Group 3 (OLE), n� 19Total n� 76 physicians,3552 cases of previous CS

Physicians:employed atcommunityhospital includedas study site

Women: hadprevious CS

Trial of laborand vaginalbirth rates

After 24 mo, TOL and vaginalbirth rates in audit group nodi�erent from those incontrol group, but rates 46%and 85% higher, respectively,among physicians educatedby opinion leader (p� 0.007,p� 0.003)

Clinical practice guidelines

Studnicki et al, 1997(34) Florida,USA

Observationalretrospective analysisof impact oflegislatively imposedguidelines about CSdisseminated tophysicians; peer reviewboards also established

Total n� 366,246 births

All deliveries beforeand afterimplementationof the guidelines

CS rates Guideline certi®cation programdid not accelerate downwardtrend in CS rates, which hadbeen evident in 3 previous yr

Quality improvement strategies

Flamm et al, 1998(35) USA

Observational study oforganizations involvedin collaborative qualityimprovement strategyincorporating workshops,conference calls, anddedicated Internet site

Total n� 28 organizations

All deliveries atparticipatinghospitals

CS rates Of 28 organizations, 15%achieved reduction of 30%or more; 50% achievedreduction between 10%and 30%

Myers & Gleicher,1993 (36) USA

Observational review athospital with initiativeto decrease CS rates;sixfold agenda consistingof second opinion VBAC,strict diagnosis ofdystocia, monitoring offetal distress, vaginaldelivery for breechpresentation (wherepossible), peer review,and detailed datacollection

Total nP17,000deliveries

All deliveriesduring studyperiod

CS rates CS rates of 10%±12%consistently achieved andmaintained with noassociated adverse outcomes


Table 3. Continued



Poma, 1998 (37)USA

Quasi-experimental studyof women deliveringover 6-yr period atone hospital, before andafter quality improvementstrategy implementedInvolved labormanagement and CSdelivery guidelines withreviews of every CSnot meeting guidelines

Group 1 (womendelivering in ®rst3 yr beforeimplementation)


Total, primary,and repeatCS

Perinatalmorbidityand mortality

Total CS rates decreased from22.5% (Group 1) to 18.6%(Group 2) (p� 0.001);primary CS rates decreasedfrom 13.5%±10.6%;(p� 0.001); repeat CS ratesdecreased from 9.0%±7.9%(p� 0.03)

Did not change

n� 6862Group 2 (women delivering insecond 3 yr afterimplementation) n� 6050

Total n� 12,912Robson et al,

1996 (38) UKObservational study, at onehospital, focusing onimplementation of qualityimprovement strategiesfor labor management;this followed results ofmedical audit that foundwomen contributing mostto overall CS rate werespontaneously laboringnulliparous women withsingleton, cephalic, termpregnancy (19.7% of all CS)Therefore, strategy involvingprinciples of early diagnosisand treatment of dystociawere implemented

Total n� 21,125 deliveries

All deliveriesduring studyperiod withparticularemphasis onnulliparouswomen withsingleton,cephalic fetusat term

CS rates Overall CS rate decreasedfrom 12%± 9.5%(p < 0.0001)

Women who had contributedmost to CS ratepreinterventionhad decrease in CS ratesfrom 7.5%±2.4%(p < 0.0001)

Midwifery care

WaldenstroÈ m &Turnbull, 1998(39) UK,Australia,Canada,Sweden

Systematic review of RCTscomparing continuity ofmidwifery care withstandard maternity care

Total n� 9148 women

Considerabledi�erencebetween trials;of 7 trialsincluded, allexcept 2involved onlywomen whowere low riskat booking

Interventionrates

Maternalmortality andmorbidity

Continuity of midwifery careassociated with less obstetricintervention during labor;however, CS rates did notdi�er statistically betweentwo groups (OR 0.91, 95%CI 0.78±1.05)

No maternal death; ratesof maternal complicationsbased on unpooled estimatesdid not show any statisticallysigni®cant di�erences

Perinataloutcomes

Admission to intensive careor special care baby unit wassimilar (OR 0.86, 95%CI 0.71±1.04) Di�erence inperinatal deaths borderingon statistical signi®cance(OR 1.60, 95% CI 0.99±2.59)


e�ectiveness (34). In this assessment, guidelines hadno e�ect on primary cesarean section rates but mayhave reduced the repeat rate.

Quality improvement strategies have been intro-duced widely as a means of addressing cesareansection rates. Such strategies have been successful inreducing rates in predominantly United States set-tings (35±38).

A widely cited systematic review of midwifery-based continuity of care reported that introduction ofmidwife-managed care, although e�ective in loweringsome obstetrical intervention rates such as induction,augmentation of labor, and electronic fetal monitor-ing, was ine�ective in reducing the cesarean sectionrate (39). In contrast, a recent Australian randomizedcontrolled trial evaluating cesarean section rates in

women randomized to receive either community-based care or hospital-based care found a signi®cantdi�erence in cesarean section rates, with lower ratesin the groups with community-based team midwiferycare (40).

The relationship between ®nancial incentives andcesarean section rates is complex and varied, accord-ing to institution, reimbursement model, and country.An Australian population-based descriptive studyfound that higher cesarean section rates amongprivate patients compared with public patients werenot due to the former being at higher risk ofcomplications (41). In Australia, a twofold strategyinvolving both private patients and the privatepractice setting may be needed to reduce cesareansection rates in this context.

Table 3. Continued



Homer et al, 2001(40) Australia

RCT to test whethercommunity-based modelof continuity of careimproved maternalclinical outcomes,particularly reducedCS rates

Group 1 (community-basedmodel) n� 550;

Group 2 (standardhospital-based care) n� 539

Total n� 1089

< 24 wkgestation, livedin designatedcatchment areaand planned todeliver at studyhospital

CS rate

Neonataladmission tospecial carenursery

Signi®cant di�erence betweengroups, 13.3% (Group1) vs17.8% (Group 2)

This di�erence maintained aftercontrolling for factorsknown to contribute to CS(OR� 0.6, 95% CI 0.4±0.9,p� 0.02)

80 babies (14.5%) fromGroup 1 and 102 (18.9%)from Group 2 admitted butdi�erence not signi®cant

Overallperinatalmortality rate

8 infants (4 from each group)died during perinatal periodfor overall rate of 7.3/1000 births

Onset oflabor, majorcomplications,perinealtrauma

No signi®cant di�erences

Financial incentives

Roberts et al,1999 (41)Australia

Descriptive population-basedstudy comparingobstetric management oftwo groups: privately andpublicly insured low-riskwomen

Total n� 171,157


Risk pro®leof privateand publicpatients

Obstetricintervention

Frequency of women classi®edas low risk was similar (48%)

CS rates higher in privatepatients (16.4% vs 10.0%) aswere rates of forceps andvacuum extraction (34% vs17%); private patients morelikely to have labor inducedor augmented with oxytocin(49% vs 29%) and to haveepidural anesthesia (51% vs25%)

RCT� randomized controlled trial; CS� cesarean section; VBAC� vaginal birth after cesarean; TOL� trial of labor.OR� odds ratio; CI� con®dence interval.


Discussion and Conclusions

Debates about the appropriate use, rates, and relativesafety of cesarean section will continue. This reviewhas identi®ed and summarized Level 1 evidence forthree strategies that can lower the cesarean sectionrate. One-to-one specially trained support for womenduring childbirth can reduce the likelihood for acesarean section (21). A systematic review of thee�cacy of external cephalic version at term foundcompelling evidence for this technique as a safe ande�ective method for reducing cesarean section rates,albeit to a limited degree (30). Meta-analysis of thesafety of VBAC con®rmed that this delivery methodshould be encouraged and used, given appropriatespecialist backup (26).

Although the evidence for e�ectiveness of one-to-one support for women during childbirth and ofexternal cephalic version came from both developedand developing settings, the systematic review ofVBAC was restricted to studies conducted in theUnited States. This limitation needs to be recog-nized amid concerns over high cesarean deliveryrates in settings as diverse as Latin America (7),India (8,9), and Turkey (10). Assessment should beconducted to determine whether such interventionstrategies could be implemented and e�ective inreducing cesarean delivery rates in countries withdiverse social and cultural settings and associatedobstetrical beliefs and practices. Even in developedcountries with di�erent health systems, such asAustralia and the United States, strategies that aree�ective in one setting may achieve less success inanother.

The aforementioned evidence for planned cesareansection for breech-presenting babies at term (29) hasstimulated international debate. Recurring themes inthe criticisms concerned the extent to which resear-chers were able to exclude noneligible women fromthe study (43±46). A related concern was the notionof generalizability of the ®ndings to other settingswhere di�erent vaginal breech delivery protocols exist(47) or, as one author from Gambia pointed out,where lack of resources means that safe surgery is notalways possible (48).

It has been postulated that one reason whycesarean section rates are rising worldwide may bedue to management of women who have had aprevious cesarean section (49). The evidence forVBAC (26) has been widely accepted and recom-mended for addressing rates of repeat cesareansection (50). Findings of a recent VBAC trial (25),which reported a threefold risk of uterine rupturewith VBAC compared with repeat cesarean section,have renewed debate over the relative safety of

VBAC. These ®ndings have also received criticism,particularly over the method of extracting retrospec-tively, data measuring uterine rupture, withoutreview of each original case (51,52). Furthermore,reliance on the International Classi®cation ofDiseases coding, a practice that some have arguedis susceptible to misclassi®cation and coding error,has been deemed problematic (52). Consumerrepresentatives argued that the data do not presentinformation of new risk per se, and maintained thatconcern about VBAC has been raised unnecessarily,with concomitant implications for women's decision-making (53,54).

With respect to ®nancial aspects associated withcesarean delivery, changing the payment structure forobstetricians is a strategy that has been proposed ashaving the potential to decrease rates of cesareansection and other intervention. It is far too simplisticto argue that physician greed is responsible for risingcesarean delivery rates. In Australia a global obstet-rical fee was introduced in 1988 to deter an acceler-ation of cesarean rates (55). This global fee, whichwas withdrawn in 1995, had no apparent e�ect oncesarean delivery rates, which have continued toclimb (17,56). It is apparent, at the level of the healthservice at least, further research is needed to establishboth the short- and long-term health service costsrelated to di�erent modes of delivery (57).

The factors that in¯uence cesarean section rates inany setting are complex. When antiquated ideaspersist (10), or where practice patterns ignore evi-dence, the rates are likely to remain high or risefurther. New cesarean reduction strategies and evi-dence to support them need to be brought to theattention of maternity health professionals (35,58,59)and more e�ective ways have to be found to persuadepractitioners to adopt them.

References

1. Mutryn CS. Psychosocial impact of cesarean section on the

family: A literature review. Soc Sci Med 1993;37:1271±1281.

2. DiMatteo MR, Morton SC, Lepper HS, et al. Cesarean

childbirth and psychosocial outcomes: A meta-analysis.

Health Psychol 1996;15:303±314.

3. Lilford RJ, Van Coeverden, De Groot HA, et al. The

relative risks of caesarean section (intrapartum and elective)

and vaginal delivery: A detailed analysis to exclude the

e�ects of medical disorders and other acute pre-existing

physiological disturbances. Br J Obstet Gynaecol

1990;97:883±892.

4. Shearer E. Cesarean section: Medical bene®ts and costs. Soc

Sci Med 1993;37:1223±1231.

5. Cohen M, Carson B. Respiratory morbidity bene®t of

awaiting onset of labor after elective cesarean section. Obstet

Gynecol 1985;65:818±824.

6. Young D. Whither cesareans in the new millennium? Birth

1999;26:67±70.


7. Belizan JM, Althabe F, Barros FC, Alexander S. Rates and

implications of caesarean sections in Latin America: An

ecological study. BMJ 1999;319:1397±1402.

8. Padmadas S, Kumar S, Nair SB, Kumari A. Cesarean section

delivery in Kerala, India: Evidence from a National Family

Health Survey. Soc Sci Med 2000;51:511±521.

9. Pai M. A debate is needed on caesarean section rates in India.

BMJ 2000;320:1072.

10. Tatar M, Gunalp S, Somunoglu S, Demirol A. Women's

perceptions of cesarean section: Re¯ections from a Turkish

teaching hospital. Soc Sci Med 2000;50:1227±1233.

11. National Health Service. Maternity Statistics, England,

1997±1998. Available from: http://www.doh.gov.uk/public/

sb0114.htm. Accessed: 25 June 2001.

12. Institute for Clinical Evaluative Sciences. Ontario rates of

cesarean section are climbing. Available from: http://www.

ices.on.ca/index.asp?head=4&main=mediadeskmain.asp

&param=. Accessed: 26 January 1999.

13. Ministry of Health. Obstetrics report gives New Zealand

picture of birth interventions. (Press release.) Available from:

www.moh.govt.nz/moh.nsf/wpg Index/News+and+Issues-

Index. Accessed: 12 April 2001.

14. Leung GM, Lam T-H, Thach TQ, et al. Rates of cesarean

births in Hong Kong. Birth 2001;28:166±172.

15. Tokyo Metropolitan Maternal and Child Health Service

Center. Statistics of Maternal and Neonatal Care in Tokyo:

Annual Report. Tokyo: Author, 1997.

16. Ventura SJ, Martin JA, Curtin SC, et al. Births: Final data

for 1999. Natl Vital Stat Rep 2001;49(1):14±15.

17. Nassar N, Sullivan E, Lancaster P, Day P. Australia's

Mothers and Babies 1998 (Perinatal Statistics Series 10).

Sydney: Australian Institute of Health and Welfare National

Perinatal Statistics Unit, 2001.

18. Notzon FC. International di�erences in the use of obstetrical

interventions. JAMA 1990;263:3286±3291.

19. World Health Organisation. Appropriate technology for

birth. Lancet 1985;ii:436±437.

20. Muir Gray J. Evidence-Based Healthcare: How to Make

Health Policy and Management Decisions. Edinburgh: Chur-

chill Livingstone, 1997.

21. Hodnett ED. Support from caregivers during childbirth.

(Cochrane Review). In: The Cochrane Library. Issue 2.

Oxford: Update Software, 2001.

22. Fraser W, Maunsell E, Hodnett E, Moutquin J-M. Random-

ized controlled trial of a prenatal vaginal birth after cesarean

section education and support program. Am J Obstet Gynecol

1997;176:419±425.

23. Appleton B, Targett C, Rasmussen M, and the VBAC

Study Group. Vaginal birth after caesarean section: An

Australian multicentre trial. Aust NZ J Obstet Gynaecol

2000;40:87±91.

24. Flamm BL, Newman LA, Thomas SJ, et al. Vaginal birth

after cesarean delivery: Results of a 5±year multicenter

collaborative study. Obstet Gynecol 1990;76:750±754.

25. Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP.

Risk of uterine rupture during labor among women with a

prior cesarean delivery. N Engl J Med 2001;345:3±8.

26. Rosen MG, Dickinson JC, Westho� CL. Vaginal birth after

cesarean: A meta-analysis of morbidity and mortality. Obstet

Gynecol 1991;77:465±470.

27. Impey L, Boylan P. Active management of labour revisited.

Br J Obstet Gynaecol 1999;106:183±187.

28. Sadler L, Davison T, McCowan LM. A randomised con-

trolled trial and meta-analysis of active management of

labour. Br J Obstet Gynaecol 2000;107:909±915.

29. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, et al,

for the Term Breech Trial Collaborative Group. Planned

caesarean section versus planned vaginal birth for breech

presentation at term: A randomised multicentre trial. Lancet

2000;356:1375±1383.

30. Hofmeyr GJ and Kulier R. External cephalic version at term.

(Cochrane Review). In: The Cochrane Library. Issue 2.

Oxford: Update Software, 2001.

31. Lavender T, Al®revic Z, Walkinshaw S. Partogram action

line study: A randomised trial. Br J Obstet Gynaecol

1998;105:976±980.

32. CraginEB.Conservatism in obstetrics.NYMedJ 1916;104:1±3.

33. Lomas J, Enkin M, Anderson GM, et al. Opinion leaders vs

audit and feedback to implement practice guidelines±delivery

after previous cesarean section. JAMA 1991;265:2202±2207.

34. Studnicki J, Remmel R, Campbell R, Werner DC. The impact

of legislatively imposed practice guidelines on cesarean section

rates: The Florida experience. Am J Med Qual 1997;12:62±68.

35. Flamm BL, Berwick DM, Kabcenell A. Reducing cesarean

section rates safely: Lessons from a Breakthrough Series

Collaborative. Birth 1998;25:117±124.

36. Myers SA, Gleicher N. The Mount Sinai cesarean section

reduction program: An update after 6 years. Soc Sci Med

1993;37:1219±1222.

37. Poma PA. E�ect of departmental policies in cesarean delivery

rates: A community hospital experience. Obstet Gynecol

1998;91:1013±1018.

38. Robson MS, Scudamore IW, Walsh SM. Using the medical

audit cycle to reduce cesarean section rates. Am J Obstet

Gynecol 1996;174:199±205.

39. WaldenstroÈ m U, Turnbull D. A systematic review comparing

continuity of midwifery care with standard maternity service.


40. Homer CSE, Davis GK, Brodie PM, et al. Collaboration in

maternity care: A randomised controlled trial comparing

community-based continuity of care with standard hospital

care. Br J Obstet Gynaecol 2001;108:16±22.

41. Roberts CL, Tracy S, Peat B. Rates for obstetric intervention

among private and public patients in Australia: A population

based descriptive study. BMJ 2000;321:137±141.

42. Thomson MA, Oxman AD, Haynes RB, et al. Local opinion

leaders to improve health professional practice and health

care outcomes. (Cochrane Review). In: The Cochrane Library.

Issue 2. Oxford: Update Software, 2001.

43. Uchide K, Murakumi K. Term breech trial [letter]. Lancet

2001;357:226.

44. Biswas A. Term breech trial [letter]. Lancet 2001;357:225.

45. Cunha-Filho JS, Passos EP. Term breech trial [letter]. Lancet

2001;357:227.

46. Keirse, MJNC. Evidence-based childbirth only for breech

babies? Birth 2001;28:72±76.

47. Somerset D. The term breech trial does not provide unequi-

vocal evidence (letter). BMJ 2001;323:244±245.

48. Erskine J. Term breech trial [letter]. Lancet 2001;357:228.

49. Churchill H. Caesarean Birth±Experience, Practice and His-

tory. Cheshire, England: Books for Midwives Press, 1997.

50. Public Health Service, US Department of Health and Human

Services.Healthy People 2000: National Health Promotion and

Disease Prevention Objectives. DHHS Publication no. (PHS)

91±50212. Washington, DC: US Government Printing O�ce,

1991.

51. Johnson K. Study may have ``chilling e�ect'' on VBAC rate.

ObGyn News 2001;36(15):1±2.

52. Ullman JB. NEJM study is invalid and biased: What

professionals in the ®eld are saying! Electronic response to:


Vaginal delivery after caesarean section triples risk of uterine

rupture. BMJ 2001;323:68.

53. Powell W. Surgical birth still twice as fatal. Electronic

response to: Vaginal delivery after caesarean section triples

risk of uterine rupture. BMJ 2001;323:68.

54. Lemay G. VBAC ups and downs. Electronic response to:

Vaginal delivery after caesarean section triples risk of uterine

rupture. BMJ 2001;323:68.

55. Commonwealth Department of Health and Family Services.

Medicare Bene®ts Schedule±Item Fee Bene®ts List for Parts 1±

11, 1 August 1987. Canberra: Australian Government Pub-

lishing Service, 1987.

56. King JF. Obstetric intervention and the economic imperative.


57. Henderson J, McCandlish R, Kumiega L, Petrou S. System-

atic review of economic aspects in alternative modes of

delivery. Br J Obstet Gynaecol 2001;108:149±157.

58. Medical Leadership Council. Coming to Term: Innovations in

Safely Reducing Cesarean Rates. Washington, DC: Advisory

Board Company, 1996.

59. Flamm B, Kabcenell A, Berwick DM, Roessner J. Reducing

Cesarean Rates While Maintaining Maternal and Infant

Outcomes. Boston: Institute for Healthcare Improvement,

1997.


strategies to address global cesarean section rates: a review of the evidence

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