The Health Section

Striking the right balance: Global caesarean delivery rates

In some circumstances delivering a baby through surgery, also known as a Caesarean section, or C-section, can save the lives of a mother and baby, but performing the procedure unnecessarily can pose dangers to both the mother and newborn and increase health care costs.

C-section rates are on the rise worldwide. While there is ongoing debate in the medical community about the acceptable rate of C-sections in a given region or country, Aetna International believes there is no definitive optimal rate. Instead, efforts should focus on medical education, malpractice reform, shifting to a value-based care payment model and increasing access to evidence-backed information so women can make informed decisions.

The World Health Organization (WHO) states the optimal rate for C-sections should not exceed 10 to 15 percent across a population – a position the organization has held since 1985. Researchers of a 2015 study published in the Journal of the American Medical Association (JAMA) found that this rate was too low and better outcomes could be achieved if the C-section rate was around 19 percent.

In a white paper published in April 2017, Aetna International notes there are numerous factors that can contribute to a population’s C-section rate. In the white paper, “Striking the right balance: Global caesarean delivery rates in an era of controversy,” Aetna International examines the C-section rate among its membership in Dubai and compare it to the JAMA study and WHO’s estimate. The rate in Dubai was 44 percent in 2015.

Experts believe that more effort should focus on increasing access to medical and prenatal support, and providing women with evidence-backed information.

“How do we ensure that countries and health care partners, providers and facilities can achieve high quality care in all settings with the right proportion of intervention, resulting in healthy mothers and babies? By working at a local level with the needs of individual patients in mind,” said Lori Stetz, M.D., M.P.H., senior medical director for Aetna International and author of the white paper.

Financial and medical impacts of caesarean delivery

In some instances, a C-section may be the best choice for a safe delivery , and vaginal deliveries are not without risk. If the mother has excessive high blood pressure or if the baby has low body weight or poor growth, for example, surgery may be preferred.

In the last decade, C-section rates have been on an upward trend. The global rate increased 12.4 percent from 1990 to 2014, with medical advances in developing countries a contributing factor, according to Stetz.While there are medical reasons that make a C-section appropriate, a surgical birth also poses risks. Mothers can experience increased blood loss, uterine rupture with future pregnancies, damage to organs and an increased recovery time. If the timing of the procedure is not calculated correctly, a baby can be born prematurely and experience breathing problems.

In the U.S., one in three women, or 33 percent, opt for a C-Section. In the United Kingdom, one in four women, or 25 percent, opt for a surgical delivery.

As the number of C-sections increases, the cost of health care also rises. The average cost in the U.S. for a vaginal delivery was $30,000, according to Truven Health Analytics. For a C-section, the average cost was $50,000.

Making an informed decision

Stetz believes there is no universal optimal C-section rate and that attempting to enforce one “would be ignoring the real and significant differences in health care access across the globe, the diversity of social and cultural beliefs and even the impact of the medical malpractice environment.”

Instead, a fundamental shift in medical education, malpractice reform and payment and performance responsibility models is needed. Having good information is critical when making a decision about surgical delivery, Stetz said. She also emphasized pregnant women who plan to travel or relocate internationally should research and understand medical options in the region they intend to visit.

“While many women do have medically necessary reasons for undergoing caesarean surgery, this study shows the importance of empowering women through support and education so they can understand the consequences of surgery,” Stetz said. “If they understand the risks, they can challenge the notion that caesareans are safer by default. Ultimately, they will make the right decision for their body, their baby and their family, but they will also understand how their choice fits into the wider health care system and the population in which they live.”