1. Why Is The Incidence of Caeserean Section Rising In This Region?
Ateş KARATEKE, MD, Prof.
Istanbul Medeniyet University
Faculty of Medicine
Dept. of Obstetrics and Gynecology, Chair

2. Caesarean section is a life saving procedure
Caesarean section is a life saving procedure both for the mother and the baby

3. WHO
In 1985, the World Health Organization considered a rate as low as 15% as an acceptable rate for performing C-section

4. CS rates above a certain limit have not additional benefit
Based on the evidence available at this time, ‘there is no justification for any region to have a caesarean section rate higher than 15%.
CS rates above a certain limit have not shown additional benefit for the mother or the baby, some studies have even shown that high CS rates could be linked to negative consequences in maternal and child health

5. Caesarean section rates are progressively rising in many parts of the world
Lavender T, Hofmeyr GJ, Neilson JP, Kingdon C, Gyte GM. Caesarean section for non-medical reasons at term. Cochrane Database Syst Rev 14: 3.

6. Average annual rate of increase was 4.4%.
Betrán AP, Ye J, Moller AB, Zhang J, Gülmezoglu AM, et al. (2016) The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: PLOS ONE 11(2): e doi: /journal.pone
Based on the data from 121 countries, the trend analysis showed that between 1990 and 2014, the global average CS rate increased 12.4% (from 6.7% to 19.1%) .
Average annual rate of increase was 4.4%.

7. Global Trend
The largest absolute increase occurred in Latin America and was followed by Asia, Oceania,Europe, Northern America and Africa
İncrease AT Caeserean section rate is not isolated to one region it is a global trend. But in some regions this increase is much higher than in others.
In every region we can see an upward (upwıd) trend
Betrán AP, Ye J, Moller AB, Zhang J, Gülmezoglu AM, et al. (2016) The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: PLOS ONE 11(2): e doi: /journal.pone

8. Global Trend BORDO COLOR SHOW THAT THE HIGHEST CS RATEs
CHİNA ,IRAN, EGYPT , TURKEY AND BALKAN COUNTRİES HAVE above 30% the CS rates

9. Our Region
At country level, Egypt, Tunisia and Morocco witnessed the largest rise in the African region .
CS rates in Egypt rose from 4.6% to 51.8% over the 24-year period.
In Asia, Turkey, Georgia and China had absolute increases of approximately 32 points and all three country had an average annual rate of increase of about 10%.
Betrán AP, Ye J, Moller AB, Zhang J, Gülmezoglu AM, et al. (2016) The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: PLOS ONE 11(2): e doi: /journal.pone

10. The latest available data shows that almost 1 in 5 women in the world now give birth by CS
The absolute and yearly increases are more remarkable in less developed countries.
The countries in Northern Africa presented a steeper increase particularly since 2000.
Egypt, Turkey and Georgia had over 30 percent points increase in their CS rates over the last 24 years
İn Egypt ,Turkey and Iran according to the latest data, more than half of all women give birth by CS without much difference between urban and rural areas
Let me summarize
Betrán AP, Ye J, Moller AB, Zhang J, Gülmezoglu AM, et al. (2016) The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: PLOS ONE 11(2): e doi: /journal.pone

11. Caesarean Rates of OECD Countries 2013
Id like to look at the turkish data more closely.
When we look at for all OECD countryies. The average CS rate was 27.4%. Turkey s was double this

12. Hospital Birth Ratio (TNSA)
LAST 24 YEARS Turkey has succeeded in increasing the hospital birth ratio to 98 %

13. Hospital Birth Ratio
As hospital birth ratio increases also C-section rate increases in all developing countries

14. Hospital Birth, Caesarean and Primary Caesarean Rates (%)
EVLİLİĞE SAĞLIKLI BAŞLANGIÇ
Between 2010 and 2016
The Hospital birth rate increased by approximately 7%, the total caesarean birth rate also increased at the same rate .
Sağlık Bakanlığı Verisi

15. Primary Caesarean Rates (%) (Based on Institutions )
EVLİLİĞE SAĞLIKLI BAŞLANGIÇ
When we look at the primary CS rate according to where the births take place
The private hospital primary CS rate has reached almost 40%
The Public hospital primary CS rate is only 16%
There is big difference between the two institutions
Sağlık Bakanlığı Verisi

16. Total Caesarean Rates (%) (Based on Institutions)
EVLİLİĞE SAĞLIKLI BAŞLANGIÇ
Total CS rate has reached 71% in private hospitals
There is a huge difference in the total CS rate according to the place of birth.
Database of Ministry of Health

17. Distribution of Hospital Births to Institutions (%)
EVLİLİĞE SAĞLIKLI BAŞLANGIÇ
Over this period
When we look at the distribution of birth according to institution
İts important to note that public hospital ratio is decreasing and private hospital ratio is increasing
Database of Ministry of Health

18. Primary Caesarean Rates in 2015
based on 12 regions(%)
EVLİLİĞE SAĞLIKLI BAŞLANGIÇ
This graph shows the primary CS rates in the different regions of turkey in 2015
Average primary CS rate in turkey was 27.2%
The primary CS rates differ from region to region.
Database of Ministry of Health

19. BIRTH RATES IN PUBLIC HOSPITALS IN ISTANBUL
This Pie chart shows birth rates in public hospitals in istanbul
Primary CS rate was 18%

20. BIRTH RATES IN PRIVATE HOSPITALS IN ISTANBUL
BUT WHEN WE LOOK AT PRIVATE HOSPITALS prımary CS RATIO WAS 35%

21. BIRTH RATES OF ISTANBUL in 2016
In 2016 in istanbul there were births ,
of those took place in private hospitals APPROXİMATLY TWO THIRDS
Most of the primary CS took place in private hospital in istanbul

22. Why is C/S rate very High in Private Hospitals
Fear of litigation
Maternal demand for caesarean section
Hard working conditions of obstetricians
Lack of on-duty obstetricians and motivated midwives
Lack of acceptable facilities of the labor Room
Physician’s declining skills of managing vaginal delivery
Vaginal delivery
Time consuming
High stress levels
Unpredictable
WE dıd a survey with in private hospital obstetricians to investigate WHY THE CS RATE İS VERY HIGH IN PRIVATE HOSPITALS
THERE IS A NUMBER OF FACTORS
İmportant factors are…

23. Lack of infrastructure in labor rooms
“In Istanbul where the C-section rate is low, there is a single-bed labor room and a particular midwife who stays with the patient until the end of the delivery process.”

24. The poor quality of education?
The capacity of the Ob-Gyn specialists and residents in conducting a NVD has reduced in recent years, as a result leading to the reduced use of operative vaginal delivery in breech presentation, twins and preterm delivery

25. Islamic Republic of Iran
The past 2 decades have witnessed a sharp increase in the number of CS operations
S. Ahmad-Nia, B. Delavar, H. Eini-Zinab, S. Kazemipour, A.H. Mehryar and M. Naghavi Caesarean section in the Islamic Republic of Iran: prevalence and some sociodemographic correlates Eastern Mediterranean Health Journal, Vol. 15, No. 6, 2009
Id like to take a brief look at the situation in ıran

26. Modernization Factors
Iranian women having CS differed from those who delivered normally in terms of sociodemographic variables.
They were older, better educated, married at a relatively later age and with lower parity.
These may be considered as modernization factors
S. Ahmad-Nia, B. Delavar, H. Eini-Zinab, S. Kazemipour, A.H. Mehryar and M. Naghavi Caesarean section in the Islamic Republic of Iran: prevalence and some sociodemographic correlates Eastern Mediterranean Health Journal, Vol. 15, No. 6, 2009
These confirm the evidence on the positive relationship between CS rates and level of socioeconomic development in the area of residence

27. Conclusion
Caesarean section rates are progressively rising in many parts of the world
The latest available data shows that almost 1 in 5 women in the world now give birth by CS
As hospital birth rate increases also C-section rate increases in developing countries
The private hospital CS rate is very high and private hospital share increase every years in Turkey
Fear of litigation is a major and common reason in our region
Privatisation and modernization are important regional factors affecting CS rates

28. THANK YOU