1. Do we have a definition of an unnecessary cesarean section? Asociación Argentina de Ginecología y Obstetricia Psicosomática Servicio de Obstetricia. Hospital Italiano de Buenos Aires. Argentina -Dr. Mario Sebastiani-

2. Unnecesary C- section ? Published rates W.H.O.: 1 W.H.O.: 1 15 % 15 % Maximum desirable rate of cesarean section Maximum desirable rate of cesarean section No benefit for mother and the fetus for medical reasons No benefit for mother and the fetus for medical reasons 1 World Health Organisation. Appropriate technology for birth. Lancet 1985;436­7.

3. Unnecesary C- section ? Sweden: 1 59 hospitals 59 hospitals 1988 - 1992 1988 - 1992 Perinatal mortality Perinatal mortality Rate of asphixia Rate of asphixia Eckerlund I, et al.,Int J Technol Asses Health Care 1999;15:123 - 35 1 Eckerlund I, et al., Int J Technol Asses Health Care 1999;15:123 - 35 Minimum cesarean section rate is optimal No benefit Outcome based study

4. Unnecesary C- section ? 1 England 1 17 maternity units (one health region) 17 maternity units (one health region) 1988 1988 36.727 singleton pregnancies 36.727 singleton pregnancies CS rates should be 10 - 12 % More intervensionist approach in low birth weight infants 1 Joffe M, et al., J Epidemiol Community Health 1994;48:406 - 11 Outcome based study

5. Unnecesary C- section ? 1 Healthy People 2000 1 Department of Health and Human Services Department of Health and Human Services 15 % by the year 2000 15 % by the year 2000 “....the advantages of a safe vaginal delivery over a cesarean delivery are clear: a vaginal delivery is associated with lower maternal and neonatal morbilidity and it costs less...” 1 Healthy People 2000; DHHS publication Nº. (PHS) 91-50212.

6. Latin America

7. Unnecesary C- section ? Grafic I: Incidence of ceasarean secton in Latin American W.H.O. Belizán JM, et al, BMJ 1999;319:1397 -402

8. Unnecesary C- section ? Grafic I: Incidence of ceasarean secton in Latin American Belizán JM, et al, BMJ 1999;319:1397 -402 W.H.O.

9. Unnecesary C- section ? “Rates and implications of caesarean sections in Latin America: ecological study” 12 of 19 Latin American countries 12 of 19 Latin American countries 81% of the deliveries 81% of the deliveries C-S rates above 15% (16,8% - 40%) C-S rates above 15% (16,8% - 40%) Better socioeconomic conditions = higher C-S rates Better socioeconomic conditions = higher C-S rates Over 850.000 unnecesary c-sections are performed each year in LA Over 850.000 unnecesary c-sections are performed each year in LA Belizán JM, et al, BMJ 1999;319:1397 -402

10. Unnecesary C- section ? Why has the rate of cesarean delivery climbed so dramatically in the past 25 years? 1. Lower tolerance for taking risks 2. Fear of malpractice litigation 3. Increased use of epidural anesthesia ? 4. Increased use of electronic fetal monitoring 5. The convenience of physicians Sachs BP et al., NEJM 1999;340:54 – 57

11. Unnecesary C- section ? Difficulties for the analysis Which is the optimun cesarean rate? Which is the optimun cesarean rate? Many stategies to reduce the rates Many stategies to reduce the rates

12. Unnecesary C- section ? Difficulties for the analysis Which is the optimun cesarean rate? Which is the optimun cesarean rate? Many stategies to reduce the rates Many stategies to reduce the rates Vaginal Birth = Quality Caserean Section = Clasical indicaton or failure Medical and non medical reason

13. Unnecesary C- section ? Difficulties for the analysis Which is the optimun cesarean rate? Which is the optimun cesarean rate? Many stategies to reduce the rates Many stategies to reduce the rates Is there a different view ? Vaginal Birth = Quality Caserean Section = Clasical indicaton or failure

14. Unnecesary C- section ? Who are involved ? FETUS MOTHER Childbirth

15. Unnecesary C- section ? Who are involved ? Obstetricians FETUS MOTHER Health system Obstetrical Uni-Hospital Midwives Society Childbirth

16. Unnecesary C- section ? Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC 4. Cost 5. Pelvic floor damage 6. Maternal mortality 7. Cultural factors 8. Autonomy - C-section on demand?

17. Unnecesary C- section ? Cotzias C, Paterson-Brown S, Fisk N. BMJ, 319,31 july 1999 “Unexplained fetal deaths”

18. Unnecesary C- section ? Could C-S reduce fetal death rate? 5 times more frequent than SIDS 5 times more frequent than SIDS Termination of pregnancy when fetal risks in útero are larger than the risks of the newborn: 1/500 Termination of pregnancy when fetal risks in útero are larger than the risks of the newborn: 1/500 Most of fetal deaths occur in non-malformed fetuses Most of fetal deaths occur in non-malformed fetuses Cotzias C, et al., BMJ, 319,31 july 1999

19. Unnecesary C- section ? Could C-S reduce fetal death rate? 5 times more frequent than SIDS 5 times more frequent than SIDS Termination of pregnancy when fetal risks in útero are larger than the risks of the newborn: 1/500 Termination of pregnancy when fetal risks in útero are larger than the risks of the newborn: 1/500 Most of fetal deaths occur in non-malformed fetuses Most of fetal deaths occur in non-malformed fetuses Women’s preference: C-section of the risk is Women’s preference: C-section of the risk is > 1:4000 1 > 1:4000 1 Cotzias C, et al., BMJ, 319,31 july 1999 1 Thornton E, et al., J Obstet Gynecol 1989;9:283-8

20. Unnecesary C- section ? Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC 4. Cost 5. Pelvic floor damage 6. Maternal mortality 7. Cultural factors 8. Autonomy - C-section on demand?

21. Unnecesary C- section ? “Effect of Mode of Delivery in Nulliparous Women on Neonatal Intracranial Injury” 1: 664 forceps 1: 664 forceps 1: 860 vacuum extraction 1: 860 vacuum extraction 1: 907 c-section during labor 1: 907 c-section during labor 1: 1900 delivered spontaneously 1: 1900 delivered spontaneously 1: 2750 c-section with no labor 1: 2750 c-section with no labor Towner D et al., NEJM 1999;341:23 Conclusion: The common risk factor for hemorrhage is abnormal labor

22. Unnecesary C- section ? Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC 4. Cost 5. Pelvic floor damage 6. Maternal mortality 7. Cultural factors 8. Autonomy - C-section on demand?

23. Unnecesary C- section ? All c-sections Primary c-section VBAC Frequency of cesarean section, primary cesarean and vaginal birth post-c-section between 1989 - 2001 Martin JA, et al., National Center for Health Statistics. 2002

24. Unnecesary C- section ? Recomendations The most conservative recomendations. The most conservative recomendations. ACOG Technical Bulletin. Vaginal delivery after a previous cesarean birth. ACOG Technical Bulletin. Vaginal delivery after a previous cesarean birth. Int J Gynecol Obstet 48:127 – 129; 1995. Int J Gynecol Obstet 48:127 – 129; 1995. ACOG Vaginal birth after a previous cesarean. ACOG Vaginal birth after a previous cesarean. ACOG Practice Bulletin N° 5:1 – 8; 1999. ACOG Practice Bulletin N° 5:1 – 8; 1999.

25. Unnecesary C- section ? VBAC Over 1000 reports: not one RCT Over 1000 reports: not one RCT

26. Unnecesary C- section ? VBAC Over 1000 reports: not one RCT Over 1000 reports: not one RCT Economic forces rather than patient well- being, are driving the goal of fewer cesarean sections ? 1 Economic forces rather than patient well- being, are driving the goal of fewer cesarean sections ? 1 1 Clark S., et al., Am J Obstet Gynecol 2000;182:599-602

27. Unnecesary C- section ? Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC 4. Cost 5. Pelvic floor damage 6. Maternal mortality 7. Cultural factors 8. Autonomy - C-section on demand?

28. Unnecesary C- section ? Costs of deliveries Cesarean delivery: Cesarean delivery: Costs more than a vaginal delivery Costs more than a vaginal delivery Longer hospital stay Longer hospital stay Use of an operating room. Use of an operating room. Labor unit: a prolonged and difficult labor, even when it results in a vaginal delivery, is more costly to an institution than a cesarean delivery. Labor unit: a prolonged and difficult labor, even when it results in a vaginal delivery, is more costly to an institution than a cesarean delivery.

29. Unnecesary C- section ? Beth Israel Deaconess Medical Center, Boston, USA Elective repeated cesarean delivery $ 7.700 Elective repeated cesarean delivery $ 7.700 Normal vaginal delivery $ 6.800 Normal vaginal delivery $ 6.800 Intrapartum Cesarean: $ 10.000 Intrapartum Cesarean: $ 10.000 Costs of deliveries

30. Unnecesary C- section ? Beth Israel Deaconess Medical Center, Boston, USA Elective repeated cesarean delivery $ 7.700 Elective repeated cesarean delivery $ 7.700 Normal vaginal delivery $ 6.800 Normal vaginal delivery $ 6.800 Intrapartum Cesarean: $ 10.000 Intrapartum Cesarean: $ 10.000 Complication Complication Mother: + $ 4.000 Mother: + $ 4.000 Child: + $ 2.000 Child: + $ 2.000 Costs of deliveries

31. Unnecesary C- section ? Difficulties in the estimation of costs Poor quality: what resources were included in their cost estimate Poor quality: what resources were included in their cost estimate Lack of progress of labor > more hospital lenght > medical costs > nursing costs Lack of progress of labor > more hospital lenght > medical costs > nursing costs Charges are not the same as costs Charges are not the same as costs Long term sequelae: Pelvic floor - Fetal mortality - Newborn trauma Long term sequelae: Pelvic floor - Fetal mortality - Newborn trauma Malkin J, et al., Birth 2001;28:208-9

32. Unnecesary C- section ? Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC 4. Cost 5. Pelvic floor damage 6. Maternal mortality 7. Cultural factors 8. Autonomy - C-section on demand?

33. Unnecesary C- section ? Pelvic floor Urinary incontinence Urinary incontinence Fecal incontinence Fecal incontinence Sexual dysfunction Sexual dysfunction Organ prolapse Organ prolapse

34. Unnecesary C- section ? Pudendal nerve damage Pudendal nerve damage Soft tissue trauma Soft tissue trauma The levator musculature trauma The levator musculature trauma Anal sphincter trauma Anal sphincter trauma Pelvic floor

35. Unnecesary C- section ? Pudendal nerve damage Pudendal nerve damage Soft tissue trauma Soft tissue trauma The levator musculature trauma The levator musculature trauma Anal sphincter trauma Anal sphincter trauma 1 Davila GW, et al., Int Urogyneocl J 2001;12:289-291 “...neurophysiologic studies have demonstrated the etiologic role of parturition-related nerve damage in development of pelvic floor disfunction...” 1 Pelvic floor

36. Unnecesary C- section ? Reduction of pelvic floor damage Minimizing forceps deliveries Minimizing forceps deliveries Minimizing episiotomies Minimizing episiotomies Allowing passive descent in the second stage Allowing passive descent in the second stage Selectively recomending elective cesarean delivery Selectively recomending elective cesarean delivery Davila GW, et al., Int Urogyneocl J 2001;12:289-291

37. Unnecesary C- section ? Avoid labor Avoid labor Avoid passage of the fetus through the pelvis Avoid passage of the fetus through the pelvis Shorten second stage Shorten second stage Avoid routine episiotomy Avoid routine episiotomy Forget the forceps specially in macrosomia Forget the forceps specially in macrosomia Repair perineal damage Repair perineal damage Devine II, Contemporary Ob/Gyn 1999:119 Prevention of pelvic floor damage

38. Unnecesary C- section ? Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC 4. Cost 5. Pelvic floor damage 6. Maternal mortality 7. Cultural factors 8. Autonomy - C-section on demand?

39. Unnecesary C- section ? Risk of maternal death “...the presumed increased risk of maternal death with elective cesarean delivery traditionally has been the most compelling reason to reject a policy of universal cesarean delivery or "cesarean on demand." However, good evidence is accumulating that this is no longer true; the maternal morbidity and mortality from elective cesarean delivery at term before the onset of labor appear to be similar to those associated with vaginal birth....” Hannah ME, Lancet 2000;356:1375-83 Hannah ME, Lancet 2000;356:1375-83.

40. Unnecesary C- section ? Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC 4. Cost 5. Pelvic floor damage 6. Maternal mortality 7. Cultural factors 8. Autonomy - C-section on demand?

41. Unnecesary C- section ? Cultural phenomena - Brazil All birth are attended by obstetricians All birth are attended by obstetricians Training Training Doctors work in the public and private health system Doctors work in the public and private health system Status of c-section: modern and technical Status of c-section: modern and technical Women’s body are perceived as sexual than maternal Women’s body are perceived as sexual than maternal Genitals are perceived for sexual activity than for childbearing Genitals are perceived for sexual activity than for childbearing Nuttall C., et al., BMJ 2000;320:1072

42. Unnecesary C- section ? Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC 4. Cost 5. Pelvic floor damage 6. Maternal mortality 7. Cultural factors 8. Autonomy - C-section on demand?

43. Unnecesary C- section ? Cesarean section on demand 31% of female obstetricians would prefer a cesarean delivery for themselves 1 31% of female obstetricians would prefer a cesarean delivery for themselves 1 1 Al-Muffti et al. Eur J Obstet Gynecol Reprod Biol 1997:73:1-4

44. Unnecesary C- section ? Cesarean section on demand 31% of female obstetricians would prefer a cesarean delivery for themselves 1 31% of female obstetricians would prefer a cesarean delivery for themselves 1 Italian law mandates that women be given the option of an elective cesarean, and about 4% of pregnant women choose it. 2 Italian law mandates that women be given the option of an elective cesarean, and about 4% of pregnant women choose it. 2 1 Al-Muffti et al. Eur J Obstet Gynecol Reprod Biol 1997:73:1-4 2 Tranquilli AL, et al., Am J Obstet Gynecol 1997;177:245-246

45. Unnecesary C- section ? Autonomy Is the governing principle in medicine Is the governing principle in medicine We respect with better eyes a woman’s right to refuse a cesarean delivery We respect with better eyes a woman’s right to refuse a cesarean delivery Nobody is interested in respecting woman’s desire to refuse vaginal delivery Nobody is interested in respecting woman’s desire to refuse vaginal delivery Wagner M et al., Lancet 2000;356:1677-80

46. Unnecesary C- section ? Autonomy and informed consent Full and umbiased information (better=efficacy and worse=risks) Full and umbiased information (better=efficacy and worse=risks) Do we have the time to inform ? Do we have the time to inform ? Male dominated obstetric model Male dominated obstetric model Does a woman have an inalienable “right” to choose a C-S ? Does a woman have an inalienable “right” to choose a C-S ? Wagner M et al., Lancet 2000;356:1677-80

47. Unnecesary C- section ? Autonomy and informed consent “...performing cesarean section for non medical reasons is ethically not justified....” Committee for the Ethical Aspects of Human Reproduction and Women’s Health of FIGO (1999) and Women’s Health of FIGO (1999)

48. Unnecesary C- section ? Ambiguity of terms Natural as desirable Natural as desirable Natural as hazardous Natural as hazardous C-section as safe C-section as safe C-section as beneficial for doctors C-section as beneficial for doctors

49. Unnecesary C- section ? Natural (phylosophy of terms) To approve or excuse a behavior. Unnatural To approve or excuse a behavior. Unnatural Ecologist’s feeling against the danger of the nature Ecologist’s feeling against the danger of the nature Natural is everything that belong to the Universe (animate or liveless, rational o irrational) (Stuart Mill) Natural is everything that belong to the Universe (animate or liveless, rational o irrational) (Stuart Mill) Dynamic and historical concept Dynamic and historical concept

50. Unnecesary C- section ? Artificial (phylosophy of terms) What is produced by the arts and human technics What is produced by the arts and human technics Learned, modified. Natural is biologic. Learned, modified. Natural is biologic. Natural in humans is not to be as much. (Savater) Natural in humans is not to be as much. (Savater) Artificial is better than natural. Which is the meaning of arts? (Savater) Artificial is better than natural. Which is the meaning of arts? (Savater) Human Life is precisely to be different from nature Human Life is precisely to be different from nature

51. Unnecesary C- section ? What do we need 1. RCT: intention of labor vs elective c-section 2. To accept that is a cultural phenomena 3. Need of a medical and non medical approach 4. Informed Consent

52. Unnecesary C- section ? To think A change in the birth of human specie has been produced in the last years The same happened in terms of fertilization. It is not mediated by a natural evolution, Darwinian, but by an artificial evolution of human being. This controversy must not be solved replacing vaginal birth with c-section, but stimulating women’s informed consent regarding the aspects of birth.

53. Unnecesary C- section ? To think The nature of birth is related with the female’s function as a reproductive agent. Is the same for the women’s condition? The nature of birth is related with the female’s function as a reproductive agent. Is the same for the women’s condition? 9 month not natural and then a natural birth 9 month not natural and then a natural birth Have we done a damage? Have we done a damage? You can do....but, should you do it? You can do....but, should you do it? Women’s selection for vaginal birth Women’s selection for vaginal birth

54. Unnecesary C- section ? Conclusion “...perhaps the time has come when the risks, benefits and costs are so balanced between cesarean section and vaginal delivery that the deciding factor should simply be the mother’s preference for how her baby is to be delivered...” William Benson Harer

55. Unnecesary C- section ? The cesarean section should not be used as an indicator of quality of obstetrical care We do not have a good definition of unnecesary c-section Conclusion

56. Thank you. Asociación Argentina de Ginecología y Obstetricia Psicosomática Servicio de Obstetricia. Hospital Italiano de Buenos Aires. Argentina -Dr. Mario Sebastiani-