Interview with Cindy Stanton on Caesarean Deliveries: Why Are They Key for Maternal Health in Developing Countries?

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.

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.

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.

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.

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.

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.

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.

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.

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).

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!

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.

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.

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.

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.

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.

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).

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

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.

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.

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.

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.

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.

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.

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 to caesarean. The point was really to drive home the idea that there are serious issues of under-use and over-use co-existing in many places in the world, and often they do imply questions of survival. The point was not to just focus on "emergency obstetric care" because quite different levels of facility can manage different types of complications, whereas surgical care really is different. I think that it is great that surgical care is now beginning to be recognized as a global public health issue. Good article on progress re: this in this month's Bulletin of the World Health Organization. ... Thanks for your comment re: the title. I can see where this would provoke a reaction.

See my response for similar questions.

Thank you so much for writing in. Your situation is the perfect example of why this issue needs public debate, particularly within Ministries and professional societies. Furthermore, Ghana has made impressive attempts to address access to obstetric care via its fee exemption scheme. I cannot tell you exactly what to do, but I do believe that the fact that you are carefully documenting use of caesarean, indication and outcomes in your facility is extremely important. Do continue. These type of data are absolutely required to inform local and national discussions.

I doubt that trying to "force" Ministries and professional societies to adapt to a certain policy stance would be very effective in the short or long term. Engaging them in open discussion is much more promising. All sides have their opinions, their knowledge base and their specific mandates to take into consideration. I think a key issue here is figuring out how to start such a dialogue. My experience over the past few years, and my experience in this electronic exchange today, suggests that the issue of caesarean tends to provoke strong reactions in people. We need to find the right approach to bring people to the table with an open mind and readiness to discuss. Seems to me that only trial and error will identify the components of such an approach. It would be worth exploring how this has been accomplished for other sensitive issues.

As mentioned in other responses, a number of interventions to lower CS have been tried, but not with a great deal of success (rates keep rising). For example, some countries have made the cost of a caesarean birth the same as the cost of a vaginal birth; some have insisted on seeking 2nd opinion before conducting a caesarean, etc. Most of this work has been done in Latin America where the rate has been climbing for years.

I suspect the motivational factors may be different in Asia and Africa. I think this is a subject that is wide open for research, particularly qualitative research into women's perceptions of a good birth, quality of care, issues regarding pain, the importance of birth as a reflection of womanhood, etc. etc. There is so much we do not know about how and why rates are changing in Asia and Africa, I really feel that research is required to inform this process.

I am not a clinician, so take my response accordingly. Mozambique is not the only country that is trying the use of non-physicians for caesarean with success (at least according to published literature. Is there publication bias here? Have there been no negative results?). Given the extreme shortage of healthcare manpower, particularly, in Africa, there is a great deal of discussion of many different kinds of health care which may be able to be provided by lower level personnel. Again, I cannot prescribe this type of approach, but discussion of the various options and a careful look at the available data on outcomes is a very positive sign.

Your question makes me realize that we really do have a serious problem in how we talk about this issue. A previous participant to the discussion pointed out how misleading the title to this discussion has been (see question from Ruth Madison). We are not promoting caesarean birth. We are only interested in appropriate use of caesarean for increased survival and health of women and infants. And, we'd really like to draw attention to the under and over-use of caesarean within many countrie. This includes some very poor countries where you'd think over-use would not be a problem and some countries with very reasonable national rates (say, 7-10%), but with segments of the population that have dangerously low rates.

I am not sure how to answer your question. The issue of vaginal birth after caesarean (vbac) has gone in and out of acceptance in the United States (I have my own opinion but anything I say here would simply be debated by one side or the other). But, given the reality of poverty and self-financed health care in settings such as you describe, the issue of un-necessary caesareans is critical. First of all because of the dire need to use all health care resources effectively in such settings and second of all, because regardless of vbac, a woman with a previous cesarean should at least go to a health facility for her subsequent delivery in case of problems. If she lives very far from care, it is less likely that that will happen. Thus, appropriate use of caesarean for first births is critical in these settings.

Thanks for your comment. Yes, I've heard or read all of these reasons stated as factors before too. And, I suspect that there is some truth in all of them. However, maybe there is a great deal more to it? We probably know more about issues affecting the provision of caesarean from the supply-side perspective than we do the demand-side. I really think both sides of the issue (supply and demand) need research. How do women perceive a good birth? What are their expectations? If this has changed recently, what has prompted the change? (We hear so much about the role of mothers-in-law, particularly in South Asia. What do they have to say about this trend?). I don't see how we can begin to design effect interventions or policies if we don't understand how or why change is occurring. And, I suspect, that the issues in Africa and Asia might be very different than what the large body of literature re: caesarean in Latin America tells us. For one thing, the change in caesarean in Asia and Latin America is happening in contexts where maternal mortality is still high (or at least higher than LAC). How does that affect this change that is underway? Lots of questions. Not so many answers. Fertile ground for students looking for thesis ideas!

I do not know the answer to this question. There's also a difference between the number of countries where this is authorized and the number of countries where this occurs. In general, there is an openness these days to exploring which types of health care could be offered by non-physicians due to the extreme shortage of health care personnel. Mozambique and Malawi have published results on successful use of lower level cadre for caesarean. As long as I see data showing safe/effective performance by these lower level cadre, I would tend to support such policy decisions. I do think it is important, however, that data be monitored following such a change. Does safe performance continue? Are these caesareans being offered for appropriate indications? Are there financial incentives for the lower level cadres to perform caesarean and if so, is that causing potential problems?

A growing number of countries are experimenting with ways of removing the financial barriers to emergency obstetric care, including surgery. Check out the fact sheet on the www.immpact.org website. However, there are few findings out there to suggest that many countries are dealing with costs outside of facility care (transport, companion costs, etc.) which are very real costs. These are very real costs to families. In the gray literature you can sometimes read about community-based NGO's that have offered programs to help in this regard (community-based emergency funds, etc.)

As mentioned in other responses, a number of interventions have been tried, but none have been hugely successful (or even if they were successful during the trial period, they lose effectiveness in day to day practice following the trial). I do think that professional societies play a huge role in influencing practice, and thus said, they haven't always been helpful on this issue. And, yet, look at the Netherlands, which has one of the lowest CS rates among developed countries and highly values home-based/midwife assisted births. Why is it so different there? Is it a question regarding basic values toward birth? I don't claim to have the answer. But, although financial incentives are no doubt important, I do not think they are the only issue here. I think we do our self a dis-service by focusing solely on that.

I am very glad you brought that up. Several West African countries are trying innovative approaches to improving access to emergency obstetric care, and I really hope these efforts are being documented in a rigorous manner because we have so much to learn from them. You might be interested to see results/fact sheet about the fee exemption program in Ghana - go to immpact.org website. I've also read other studies of fee exemption or other various insurance-based approaches which have found increases in skilled attendance at birth and treatment of emergencies, though the rich tended to benefit somewhat more than the poor. Clearly, more work is to be done. The case of Ghana I find very interesting. The policy was put into place, but was very difficult to sustain (ie, facilities were not reimbursed in a timely manner, putting facility staff in a very difficult position, which ultimately leads to unofficial charges to the family since care is not cost-free anywhere).

Yes, fistula is one of the rare conditions where surgery is both the prevention (caesarean) and the cure (surgical repair). Although one rarely sees data compiled on this issue, I've recently come across individual hospital data showing women who've ended up with fistula following a caesarean (ie, the caesarean was received too late to prevent the fistula). All comes back to the need for good access to good quality obstetric care.

OK

Please see other related responses. There is so much we do not know, particularly for countries outside of Latin America.

I wish I knew. The issue seems to make people very uncomfortable. I had the same experience (talking about free access to caesarean for women in need) with a group of surgeons dedicated to the repair of fistula. You would think that of any group, this group would jump on board. But, actually, there was hesitation. This just tells me there is a great deal we don't understand. I think this whole area is very fertile ground for qualitative research - again, on both the supply and the demand side.