(August 2008) Caesarean delivery rates are rising among mothers in many developing countries, and likely exceed the 15 percent limit recommended by the World Health Organization in 2005. Caesarean deliveries are especially common in some Asian and Latin American countries, accounting for many as 40 percent of babies delivered—but not in Africa, where they account for just 2 percent of deliveries in some countries. Within countries, Caesarean deliveries tend to increase sharply with wealth.

During a PRB Discuss Online, Cindy Stanton, assistant professor at the Johns Hopkins Bloomberg School of Public Health, answered participants’ questions about issues surrounding Caesarean deliveries in developing countries.

August 7, 2008 1 PM EST

Transcript of Questions and Answers

Diego Iturralde: I hope you are suggesting that women in developing countries should go for caesarians only because it provides a meternal health solution in the case of complications and not so that it is abused as it is in developed countries as well as by wealthy women by making use of an emergency procedure in a non-emergency situation. I think the literature is clear that in these cases caesarians carry with them their own set of complications and repercussions for maternal health.
Cindy Stanton: Absolutely. Clearly, there are situations where non-medically indicated caesareans are being provided in developing countries. For example, this has been a well documented issue of concern in Latin America for years. The trend is not, however, limited to Latin America. Iran, South Korea, China now have national rates between about 25 and 40% too. And, yes, there may well be maternal and fetal health issues resulting from over-use of caesarean. However, my concern is much more focused on extremely low caesarean rates, particularly in countries where these low rates are concentrated among the poor, when other segments of the population seemingly have adequate or excessive use. In these cases, it means that the services do exist, they just are not accessible to some in the population.

Stevenson: Do you see a role for HIV programs in developing countries to support local health systems in providing safe c-sections? There is good evidence that elective c-sections can lower MTCT around two-fold and funding in many countries for HIV related programs are often far greater than for maternal health programs.
Cindy Stanton: I do not know of anyone in the maternal health community who is a proponent of routine caesarean for HIV positive women. My vote would be to try and achieve safe and appropriate caesarean via the traditional routes of pre and in-service training, clinical audit, insurance schemes to address financial barriers and an increased role for NGOs to address transport for emergency referral.

Deki: when you say that 80 % of the women from high income group goes for caesarean, it implies that they do it even without any complication? wnereas less than 1% of women of low income group goes for caesarean, it means the services are not available or un affordable by this group? can you suggestsome ways to cope this problem?
Cindy Stanton: When one sees rates above about 20%, I think most would agree that this must include some non-medically indicated caesareans (and many would make that statement with rates lower than 20%). So yes, very high caesarean rates indicate either caesarean on maternal request and/or caesareans done for health care provider/facility reasons (convenience, concern over litigation, financial reward, etc.). The issue of caesarean on maternal request is controversial; some consider it a woman’s right, some argue caesarean delivery can be safer than vaginal delivery, some argue it is less safe and some argue it is not a good use of health care resources. And, some argue that we really don’t know what maternal “request” even means. Yes, when rates are extremely low, there are probably multiple issues of low access – low physical access to a surgical facility, low financial access, etc. A fair amount of experimentation is on-going regarding the free provision of caesarean (or all obstetric care) for all women and/or for poor women. The results are inconclusive at this point. Governments have found it difficult to assure on-going, timely and adequate reimbursement of funds to hospitals to cover these costs. Much more work is required: a) regarding the planning of the implementation of such policy interventions and b) research into how and why these interventions succeed or fail.

Rahat Bari Tooheen: Caesarian deliveries are a quick but efficient solution to a complex maternal health issue. How do nations, especially developing nations, implement national and local level policies to ensure that caesarean deliveries are available to all those who need it?
Cindy Stanton: Another excellent question. We made 3 extensive efforts to document why caesareans are being done across many developing countries. We didn’t come up with much of an answer. We know that anywhere a caesarean is being done, it is documented in the surgical register. However, our survey of 26 high and low caesarean countries only found one country (Mexico) that included indication for caesarean among the indicators that they collect in their routine health information system. So, the data exist everywhere, but almost no one is compiling them at the facility-level and passing them along for review. The following article might be of interest to you – it will be published this month or next in the Journal Birth: Recommendations for Routine Reporting on Indication for Caesarean in Developing Countries (Stanton, Ronsmans and the Baltimore group on Caesarean). We would like in the future to do a survey of developing country policies on caesarean. I strongly suspect that in the vast majority of countries, there really are not any specific policies, as we see in developed countries. Pre-service educational materials in developing countries seem to focus more on technique than on clinical judgment regarding when to do or not do a caesarean. I would summarize our experience over the past 3-4 years working on caesarean in Africa and Asia this way: No one wants to talk about it. Latin America is a very different story given the attention this issue has received for many years.

Vijay Aryal: Maternal Mortality in most of the developing countries has been found to be too high. Do Caesarean deliveries have something to do with the existing problems or they happen to increase the situation severely? What could be the probable solutions to the maternal health complications in those countries?
Cindy Stanton: When lack of access to caesarean is extreme either across an entire population or across a segment of the population, then it is clear that this lack of access is likely responsible for some proportion of maternal deaths. Check out: Ronsmans C, De Brouwere V, Dubourg D, Dieltiens G. Measuring the need for life-saving obstetric surgery in developing countries.BJOG. 2004 Oct;111(10):1027-30 for a good description of an indicator to assess met need for caesarean. It is also clear that when access to surgical care is so low, it is likely that access to all or many forms of emergency obstetric care are probably also lacking. To date, no one has developed a replacement for health facility-based emergency obstetric care in response to an obstetric emergency.

Agnes: What has the caeserean deliveries got to do with health systems status? How can these deliveries be addressed in regards to the practioners and then public especially the wealthy part of the population?
Cindy Stanton: The provision of caesarean has a great deal to do with the organization and functioning of the health system of a country. For example, the caesarean rate is likely to be affected by the proportion of deliveries which occur in the private sector, it may be affected by the restrictions on who is authorized to perform a caesarean (in some countries this is restricted to specialists such as obstetrician/gynecologists, in some countries general practictioners are permitted, in some countries midwives are permitted and in a smaller number of countries and often under special circumstances, lower level cadres are permitted to perform caesarean). The caesarean rate will be affected by the distribution of comprehensive versus basic emergency obstetric care facilities. And, some countries require families to purchase a caesarean kit before the caesarean can be performed.

Irene Maweu: Dont you think that the Ceasarean delivery cases are on the rise as Doctors have discovered a new way of making more money?
Cindy Stanton: I think it is more complicated than that, and that it varies greatly by location, by caesarean rate and by use of public vs private services. I’m sure that in some places there are financial incentives for providers to perform caesarean, but it would be unfair to pin all the blame on that. In some countries, the cost of a caesarean is the same as the cost of a vaginal birth to discourage performing caesarean for financial benefit. What is most surprising to me is that we may be starting to see caesarean on maternal request in South Asia and other countries because women seem to view it as a higher quality of care. This is an issue that must be addressed objectively. It should also be noted that caesarean on “maternal request” is a term that is frequently used, though we actually do not understand well at all what it really means.

sbyadawad@sify.com: Caesarian for life saving purpose should be widely welcomed. Making money out vulnerable situations of expectant mothers is highly objectionable. Mothers and their relatives should know whether caesarian is necessary or not. What measures should be taken to provide them all the required information and avoid unnecessary caesarian operations and enable them to get the service whenever it is necessary?
Cindy Stanton: First of all, I am not a clinician, so I cannot address when a caesarean should and should not be done. My job is to look for patterns in the data. However, what I understand from my medically trained colleagues is that identifying a situation in which a caesarean is a life or death matter for the woman is easier to determine than is the same for the fetus and certainly easier than determining whether there may be less morbidity for the woman or fetus if a caesarean is done. So, it is important to be fair to health care providers. These decisions are not always black and white. As a non-clinician my interest is getting people to talk about the issue locally, nationally and internationally. There will never be an international consensus on an ideal caesarean rate, but discussion and research can result in context-specific policy formulation. This would be a huge improvement over the current situation in many countries where the caesarean rate climbs unnoticed and for reasons that are not understood.

Irene Maweu: Considering the implications after a ceasarean delivery, are governments willing to support these mothers [from] the developing countries as most of them are the breadwinners of their families and cannot work after a ceasarean delivery?
Cindy Stanton: I have never heard of a setting in a developing country in which a woman was supported with funds or other forms of assistance following a caesarean delivery (or any other kind of medical care for that matter).

Yilma Melkamu: Dear Dr Cindy, In addition to wealth I think the flourishing of the for-profit health sector has contributed a lot in the rate of increase. In our setup you women can not ask for CS at the public sector but can do so at the for-profit facilities. There is no mechanism in place to regulate whether the physicians are using the right indications for CS or not.
Cindy Stanton: I agree completely. The issue would need to be addressed in a different manner for private/for-profit health care. However, all of these issues are interwined: a public surgeon in the morning may well be a private surgeon in the afternoon. Hi Yilma!

Sibel Kalaça: Medical students are taught that normal delivery is the best under the normal circumtances; however caesarean delivery rate is above 30% at the hospital of the same University, where most of the clients are from middle or upper socieoeconomicalstatus (SES). On the other hand caesarean delivery rate is much lower at the state hospitals, where their clients are from low SES. I know that it is an issue of inequity where poor people can not reach caesarean delivery when it is necessary. But I would like to discuss this situation from the other perspective and I would like to ask if, can it be considered an issue of inequity that the high SES women are exposed an “unnecessary, or potentially harmful” procedure?
Cindy Stanton: Yes, it certainly can. Please check out the following letter: Althabe and Belizan, 2006. The Lancet, Volume 368, p 1472-3. These authors argue that in Latin America, it is only for the caesarean rate that poorer women actually receive better quality health care than wealthier women because of their lower caesarean rates.

Soma Dey: I have recently had a caesarean. In Bangladesh, most of the doctors have preference for selected caesarean delivery. My question is – is it always a preferable option than normal delivery?
Cindy Stanton: I am not a clinician, but I don’t think that any obstetrician/gynecologist would make the blanket statement that a caesarean is always preferable to a normal delivery.

marleen temmerman: we should not forget that also in developed countries C-Sections are the most important cause of maternal morbidity and mortality, particularly in subsequent pregnancies. Let us reflect on mechanisms to lower C-Sections rates in wealthy populations and assure access to those who need them worldwide!
Cindy Stanton: I believe your first statement is incorrect re: cause of maternal death in more developed countries, but I agree that we have much to learn regarding the lowering of caesarean in all settings. Thus said, despite a large literature covering research on means to lower the caesarean rate, we haven’t been very successful. Given our track record, it is critical that we act now to prevent/discourage developing country caesarean rates from climbing well beyond medical necessity because once high rates are achieved, we have no sure answers regarding lowering them.

Chayan: The WHO guideline for C-Section was fixed at 5 to 15 percent. But we have come a long way since this upper and lower limits were prescribed. Do you think that these limits need some revision?
Cindy Stanton: Actually, I don’t think they need revision. There will never be a consensus on an ideal rate. Some authors have argued that the 15% upper limit is too low for the US and that such a rate could have detrimental effects on perinatal outcome; other authors have argued that 5% is too high in the developing world because it might encourage countries to do more just to meet the lower cut-off, but not assure that women in greatest need receive them. There will be no agreement on this issues. However, perhaps it is even a good thing if recommended ranges vary across different contexts. To me what is needed is not a new recommended range, but additional data on why caesareans are being done. Several classification systems exist (Robson classification, unmet obstetric need classification and an expert group recently met and has published recommendations regarding routine reporting of indications for caesarean in developing countries (forthcoming in the Journal Birth in September 2008). But even data on indications will not always clarify the issue. What data on rates and indications can do very effectively though is to initiate discussion and debate. And, in many countries this is needed. Rates are climbing or are unacceptably low(at least in some segments of the population) and few are noticing in many parts of the world. This issue should be discussed within communities, among facility staff, at the national and international levels.

P.Ravi Shankar: Dear Dr.Cindy, In the developing world there is a misconception in the people that the doctors perform caesarean section to ‘get’ more money from the family, but this could be reality due to the baby’s condition and greater birth weight or other complications of the mother which arises through the pregnancy.How would you answer this problem? As this kind of operation would cost any thing between Rs.30000 to Rs.60,000 in India. Also how to convince the preganant mother’s family and relatives who play a major role in the entire process. Also What are the financial implications of the low income group in India.
Cindy Stanton: You have asked many questions at once. I’ll try to cover a few of them. Yes, of course you are right, caesarean can be life-saving for mother and baby and medical professionals (should) have the training to determine this. As I’ve mentioned in a previous question, it is unfair and simply incorrect to identify health care providers and financial incentives as the only problem in assuring appropriate access to caesarean. Your question points also to the need for basic community education regarding the danger signs of pregnancy and the fact that clearly there are times when caesarean is the best thing that can happen to a woman. For example, I learned recently of a 2 week campaign in northern Nigeria to provide free surgical repair for women with obstetric fistula. Messages were announced on radio 24 hours before the beginning of the campaign and approximately 500 women showed up. What strikes me is that these are the same 500 women who could not access a cesarean in a timely manner. Yet, once they had this dire condition they were able to overcome the barriers and seek care. To me this suggests that much needs to be done with community education to discuss with women and families what is at stake (life, death, severe impairment) and to recognize when medical care is the required solution.

Lia Tavadze: Dr Stanton, What would be (if any) your analysis of Cesarean Sections’ statistics and/or the issue in Afghanistan, in a light of an external aid and its outcomes there? There was so much debate on it…
Cindy Stanton: I can’t address this. I have only seen one article from 2004 which included cesarean results from a very small sample of women, and the cesarean birth rate was under 2%. I have heard from colleagues that there may be a cesarean working group in Afghanistan, but I do not know if this came to fruition. In any case, ample debate is a good sign. Policies, funding, authorized personnel all need to be openly discussed. As I’ve responded in other questions, too often our experience has been that no one wants to talk about cesarean (outside of Latin America).

Nnenna Ike: Women who undergo a Caesarean Section (CS) are regarded as failures in Nigeria. This makes even the wealthy ones who can afford this very expensive procedure not to willingly accept it, except as a last resort to save the mother’s life. This procedure is very expensive and it seems many doctors do not want to prescribe it to their patients because of these beliefs (some woemn are known to have run from the hospital after being told they will undergo the procedure!) and probably becaue they are not experts at it. How can CS be made more attractive to both experts and women in Nigeria where the mortality rate is as high as 1000 deaths per 100,000 life births?
Cindy Stanton: As mentioned in other responses, community education is needed so that women and families recognize that cesarean can truly be a life-saving procedure. Qualitative research from West Africa has shown that women needing cesareans sometimes face severe reactions when they return home from the hospital for having “failed” at childbirth, for subjecting their families to the expense required for the procedure, and for not returning with an infant on their backs (when the child does not survive). You also mention something very important that has not come up yet in our discussions, and that is that many providers may lack confidence at performing cesareans. This may be for the very good reason that they were never trained to do so, though clearly any physician who is likely to be posted in a rural area should receive such training and experience in pre-service education. Over the last decade some countries have trained and authorized non-physicians (including midwives and medical officers) to perform cesarean. Published results thus far are promising though few in number. However, the need and acceptability of this policy absolutely requires local debate. Additional data on this issue is needed to inform those debates

DR. Ahmed Legale: is n’t more appropriate to discuss more on improving the basic skill and quality services of health staff for proper diagnosis who is eligible for Caesarean Deliveries? whereby sometimes is unimaginable to reach appropriate facilities for the operation?? I hope different scenarios will be considered and explored to answer the question…
Cindy Stanton: I agree that more work is needed to address clinical judgment regarding caesarean. When caesarean is addressed during in-service trainings on emergency obstetric care, too often the focus is restricted to technique. Again, this issue requires open discussion and debate among those responsible for medical curricula, professional associations, Ministry of Health planners and international agencies. It is promising that surgery in general is gaining in acceptance as a public health issue. For example, surgical services were included among cost-effective interventions in the most recent edition of the Disease Control Priorities in Developing Countries.

Dr. Yamini Sarwal: Dear Cindy, It is not uncommon to find women from underserved sectors reporting to health care centres late in pregnancy / labor with complications that necessitate caesarean. It does improve maternal and infant prognosis. But, once discharged from hospital, they often do not turn up for checkups and delivery in subsequent pregnany, often resulting in disastrous consequences (in spite of prior advice by health professionals). Caesarean section acts as a double edged sword in such circumstances. Please may I have your comments?
Cindy Stanton: I agree, but certainly don’t think that fewer caesareans would be the appropriate response in these circumstances. If the procedure is required for health/survival, it is required. However, lately in the literature, several have noted the near disappearance of other forms of assisted delivery (forceps, vacuum extraction) which seem to be passed over for caesarean. Where these modes of delivery would suffice for a given clinical situation, I would think that potential postpartum complications and the need for follow up would be less of a risk.

Alberto Rizo, MD: C Sections are seen convenient by patients and doctors themselves in LDCs. Insurance companies look the other way round when reimbursing doctors for these procedures. Governments are very slow in regulating the practice in LDCs. Poor patients are discriminated and put to the test of long, painful labors with serious consequences for the fetus. A comprehensive set of policies to stop the increasing C section rates, is required sooner than later. Agree?
Cindy Stanton: Yes, I agree, and as I have mentioned in other responses, I suspect that there really are not many specific “policies” regarding caesarean in many countries outside of Latin America. I say “suspect” because we have never found anything in the literature on this, but are interested in undertaking a survey of cs policies in high and low use countries. It is encouraging that several countries (particularly in West Africa) have been experimenting with fee exemption plans for obstetric care or emergency obstetric care. I think we over- simplify the issue if we only talk about excessive use of caesarean. There are serious problems with lack of access in some countries and among some segments of the population.

Glyn Chapman: Dear Cindy, Do you think it would be possible in developing countries for doctors to be required to tell women whoes caesarians are unneccessary that this is the case and if they insist on having a C/S for convenience they will have to pay for a second C/S for a poor woman who needs it in the same country? This dual deterent and fund-raising scheme could reduce the inequities in C/S and reduce matreral mortality from both excessive and under-supplied C/S. Best regards Glyn Chapman, Aberdeen
Cindy Stanton: Hi Glyn. I love the idea, but don’t know how practical/feasible it would be. Where the issue of caesarean is controversial, the data on indication for caesarean becomes highly suspect. “Fetal distress” tends to become the kitchen sink indication and is used to obscure non-medically indicated caesareans. Would anyone admit that the procedure was unnecessary? Also, there have been trials in Latin America where physicians were required to seek a 2nd opinion re: the need for caesarean before performing one. However, in a setting where caesarean is so prevalent, the 2nd opinions tended to agree and so the intervention was not successful at lowering the cs rate. But, I think your idea is worth discussing in a broader circle. I’ve thought about donor programs to sponsor a life-saving caesarean in places where the rate is below 2%. I even thought of writing a letter to Angelina Jolie after the birth of her first child (by CS in Namibia with a gynecologist flown in from Los Angeles) to encourage her to contribute financially and to increase advocacy re:life-saving caesarean. But, I never put pen to paper.

Ruth Madison: I had to read the title of the discussion several times as I was becoming angry thinking this was going to be a discussion promoting c sections as the standard or preferred method of delivery in all countries, including the US, which already conducts too many unnecessary c sections as it is. Not enough information is shared with women on the benefits of vaginal delivery and many people forget that c sections are major surgeries, with all the inherent risks surgery bring. While access to c sections is needed for the estimated 15% of women who will experience an obstetric emergency worldwide, what we also need is access to basic and comprehensive obstetric care. What one thing can policy makers do to increase access to basic and comprehensive emergency obstetric care, especially in rural and underserved settings?
Cindy Stanton: Your response is very interesting to me. I cannot tell you how many times we have presented the data on socio-economic disparities in access to caesarean and have been politely asked, if not accused, of promoting caesarean birth. Our biggest concern is where caesarean is so low (below 2% or worse, below 1%) that women are dying due to lack of caesarean – particularly in settings where some women have adequate access. Over 3-4 years now we have consistently found that a) people either don’t want to talk about access to caesarean at all or b) are immediately concerned about abuse/over-use, regardless of the context. Our point, and my interest in participating in this discussion today is two-fold: 1) to get people to recognize the vast range of settings and service access issues that exist between and particularly within countries and 2) to get people to talk about it openly. Yes, we certainly have concerns about over-use as well. Birth is changing so fast in the developing world. CS rates are increasing among the wealthy in places that we would not have expected AND given that there are very few interventions that have been found to be effective at lowering use once it is high,now is the time to act – policy wise. In 5-10 years if nothing is done, I really fear the problem will become intractable. Here’s a question for you: How can we talk about this without provoking anger? We feel we have not learned to communicate effectively about this issue based on our repeated experience.

Edwin van Teijlingen: In countries where maternal mortality is high, most deaths seem to occur around the actual birth or shorlty after. What can we do to help those attending women in childbirth in the community to recognise that there is a problem needing emergency obstetric care (and perhaps a C-Section)?
Cindy Stanton: This is an age-old problem, and not just for obstructed labor. I think educating the community about danger signs of pregnancy has been difficult, but particularly for prolonged labor and hemorrhage, because everybody has to be in labor for some length of time and everybody bleeds. The issue is getting people to realize when length of labor or blood loss is too much. So, yes, recognition is a problem (the 1st delay) but the 2nd delay (getting to care) is critical too. I’ve always wished that the NGO community (as a coalition, or organized force) would take on the issue of emergency transport in a big, concerted way. Certainly, there have been some creative programs (arrangements with taxis, bicycle ambulances), but they have been widespread. Too often, I just hear people say – referral – it’s too hard. Seems to me the NGO community is well posed to take on this issue.

Penny Haora: To say that ‘Caesarean Deliveries Are ‘Key’ for Maternal Health in Developing Countries’, I think is simplistic and reductionist, and subsequently idealises Caesarean section as the ‘silver bullet’ solution. Historically, maternal deaths have reduced considerably, before Caesarean rates reached ‘recommended’ levels, indicating the impact of many other factors including, notably, fertility decline. Additionally, maternal HEALTH, as a concept, embraces far more than simply ‘survival’. In my view, to ask a question such as “What can we do to ensure that all women and babies have access to Caesareans for life-saving purposes…” further implies that ALL women and babies are in extreme danger during birthing… and such a belief promotes a pathological view of birthing, and exacerbates the idealisation which contributes to unnecessary Caesareans. The ‘key’ question in my mind, in all settings, is ‘how can we ensure “healthy birthing”?’, encompassing healthy girls, healthy women, healthy families, healthy communities, and ‘healthy health systems’! Wouldn’t this type of approach address many, if not all of the issues, and enable us to do so in a much more holistic and contextualised way? Thank you.
Cindy Stanton: Yes, I agree with you and agree that the title that was chosen for this exchange could be better. We set out to talk about the broad range of contexts found in the developing world today and how they affect access