Rise of Medically Unnecessary Cesarean Sections: Why are they happening?

Why concern? Global and regional trends in caesarean section, 1990–2014 Betrán AP, Ye J, et al 2014

Geographical distribution of C-section rates 2014 Why concern? Geographical distribution of C-section rates 2014 Betrán AP, Ye J, et al 2014

Where are we now? National trends in caesarean section, 2004–2014 1.9 percentage point increase per year! Bangladesh Demographic and Health Surveys

Three broad domains of factors Health Systems Provider-Level Patient level C-section Even though your study is focusing upon the provider level factors, all three of these areas are interconnected. So we began our literature review by looking at all three areas.

Patient/Mother Level factors

Perceptions Surrounding C-section C-sections are less painful Less painful, epidurals are available, not covered in NVD cost Women “fearful” about childbirth prefer CS “Too posh to push”- high income groups C-sections are safer than normal deliveries The best quality of care Reduce foetal distress, mortality, excessive pain, and trauma to the vagina, no episiotomy required Baby’s well being More modern and appropriate forms of care Previous negative birthing experience how women share their experiences with birth and C-section highly influence other women’s birthing choices Previous C-sections require subsequent C-section Mothers can not have NVD if they had previous C-section

Perceptions Surrounding C-section C-sections act as a form of contraception C-Sections will prevent future pregnancies Assisted birth techniques are dangerous to the baby parents prefer C-Section over assisted vaginal delivery to avoid baby’s injury Status symbol “wealthy” women get this procedure done and they want to be like these women indicator of “high social class” Privacy (?) C-Section is considered as a “new normal” “other women, including obstetricians themselves preferred C-section” Perceive everyone is getting a C-Section Limited involvement in decision making process Women were uninformed/poorly informed , Family takes decision often based on doctors advice (mutual agreement)

Women's characteristics with higher C-section Advanced maternal age >35, low maternal age <19 No consensus on what a healthy maternal age bracket Urban location More private facility delivery more CS Relatively high socioeconomic status mother would change facilities if C-section services are not provided costs of C-section are not often affordable for them in lower socioeconomic situations, drives catastrophic expenditure Higher education Higher ANC attendance ANC visits correlates with more institutional deliveries and consequently more C-sections doctors played upon patients and their anxieties and scheduled C-sections during antenatal care visits Decreasing parity- “precious child” Being overweight/obese Hopkins, K. (2000). Are Brazilian women really choosing to deliver by cesarean? Social science & medicine, 51(5), 725-740. doi:https://doi.org/10.1016/S0277-9536(99)00480-3

Health System Factors

Health systems weakness Human resource Limited staff makes scheduling a C-section during working hours Absence of full time specialists during after hours leads 1st and 2nd year residents feel comfortable to conduct C-section Gaps in awareness of ideal practice among providers Public policy and guidelines Absence /poor compliance monitoring of national protocol /guideline Greater financial incentive for C-sections over NVD in programmes Privatization/growing private sector Competition between the public and private sector Perceived better quality of care in private sector “Agents” from private facilities at public facilities Limited public sector monitoring and accountability for private sector C-section is sold as packaged service Absence/limited functioning referral system Physical infrastructure: “Natural deliveries are not in good condition…have to share basins in front of one another” Hopkins, K. (2000). Are Brazilian women really choosing to deliver by cesarean? Social science & medicine, 51(5), 725-740. doi:https://doi.org/10.1016/S0277-9536(99)00480-3

Provider Level Factors

Provider Characteristics Gender Male physicians are more likely to delivery through CS Training and experience Young obstetricians feels uncomfortable doing NVD in specific obstetrical indications (such as twin pregnancies or breech presentations) Residents felt more comfortable doing C-sections and often afraid of seeking advice because they would appear incompetent Physicians with higher numbers of deliveries have lower rates of CS Physicians own birthing experiences may influence Obstetricians showed interventionist attitudes in relation to their own preferred mode of delivery

Skills and competence of providers Meet requirements for medical school Higher rate of CS in teaching hospitals because trainees want chances to practice Learn C-section before becoming second year residents Receives inadequate training on delivery protocols Misconception that C-section is required for every women with previous C- sections Some health care providers credit C-sections with the reduction of maternal mortality Limited/no availability of established guideline for deciding upon necessity of C-section (partograph is for after the labour onset) Use of more subjectively defined indications Uncomfortable with assisted delivery techniques (non-reassuring fetal heart tracings, labor arrest disorders, and suspected macrosomia- large sized baby)

Financial incentives Dual practice Doctors practice in both the private facilities and public facilities C-sections are more financially lucrative Doctors, particularly those in the private sector, have financial incentive for encouraging C-sections Financial schemes often compensate more for C-section than NVD Hospital owners/ business man/ clinics own a high interest in doing C-Section (sometimes set business deal)

Providers’ perspective Convenience C-sections allow the convenience of setting the date and time NVD takes much longer time than C-section Fear/sense of insecurity/pressured by patients Patient will go to another health facility Fear of litigation in case of any neonatal adverse event CS as a cautious alternative: not having enough resource in after hour to handle emergency Attitude to compliance to protocol Provider are aware of evidence based practice, however, they believe they do not need to use partograph Specialists are more interested in C-sections; Normal delivery is not expert’s job Rising competition among junior and senior doctors

C-section- mutual agreement between provider & client Charu et al 2016

Strategies to prevent unnecessary C-sections Mandatory second opinion (Argentina, Brazil, Cuba, Guatemala) small but significant reduction in rates of caesarean section (relative rate of reduction 7·3%) Hospital policy was modified to provide co-management for cesarean (second opinion from a supervising obstetrician) (Ecuador) number of caesareans reduced while the number of monthly deliveries increased Audits of indications for Caesarean delivery, provision of feedback to health professionals, and implementation of best practices (Canada, Taiwan) significant but small reduction

Strategies to prevent unnecessary C-sections Crisis- oriented counselling of mothers in fear of birth by team consisted of two experienced midwives with additional training in mental health, a senior obstetric consultant and social worker (Norway) 86% changed their original request for caesarean section Labor and birth care by nurse with midwifery skills (Brazil) Rate of C-section was lower in maternities that had nurses/nurse-midwives in birth care Implementation of Obstetric Care Consensus Guideline (USA) C-section rate reduced both overall and target group defining 6 cm dilatation as the threshold for active labor and advocating for longer durations of expectant management before cesarean delivery for labor arrest Used on Nulliparous women attempting vaginal delivery with viable, singleton, vertex fetuses

Acknowledgements Sathya Doraiswamy Aniqa Hasan Farhana Karim Charu Chhetri Mohiuddin Ahsanul Kabir Chowdhury