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A Caesarean Section could be too much, too soon

Cesarean sections have become more common in recent years. Also known as a “C-section,” the procedure involves the surgical removal of a baby as an alternative means of delivery.

About a third of all births are through C-Section. Researchers continue to investigate why C-sections have gained popularity.

During the procedure, a doctor makes incisions in the abdomen and the uterus to retrieve the baby. Sometimes a C-section is necessary based on the health of the mother or the baby. In other cases, it’s not necessary.

The increase in elective C-sections has caused concern among medical professionals because the procedure can pose unintended—and even unnecessary—complications.

About a week ago, The Lancet released the latest of its Maternal Health Series entitled: Unequal access and low quality of maternal health care hampering progress towards Sustainable Development Goals, SDGs.

Released ahead of the UN General Assembly, the series consists of six papers that cover the epidemiology of maternal health, the current landscape of maternal health care and services in both high and low income countries, and future challenges and strategies to improve maternal wellbeing.

Two broad scenarios identified the landscape of poor maternal health care—the absence of timely access to quality care (defined as ‘too little, too late’) and the over-medicalisation of normal antenatal, intrapartum, and postnatal care (defined as ‘too much, too soon’).

One of the findings from the series is that too many women are having Caesarean Sections.

In a chat with one of the series authors, Professor Wendy Graham, a professor of Obstetric Epidemiology at the London School of Hygiene and Tropical Medicine. Our discussion centered on this issue of too many unnecessary CS procedures going on in the world currently.


Graham who is also Emeritus Professor at the University of Aberdeen said the big take home message from the new Series is that although in many parts of the world, the number and the frequency of women dying because of pregnancy has gone down, there is still unfinished business. Excerpts of Graham’s contribution follow:

“There are still too many parts of the world where too many women are dying and when women are seeking care, they are often getting poor quality care and not at the right time, that is, too little, too late; and getting poor quality when they get things too much too soon.

The big discovery of this series is this problem of quality. Poor quality exists everywhere in the world the UK, US, South Africa, Nigeria. In most countries there will be women that fall in these four categories.

Some lucky women will get good quality care, some no care at all and so each year about 53 million women are still giving birth on their own without any assistance.

The two extremes are good quality care and no care at all while in the middle, there is poor quality care. Sometimes this means women are being given treatment or interventions too early, like Caesarean Sections, when the woman could have been left a little longer to try and let normal labour take place.

Intervention is too much where treatment is not evidence based, for instance, routine episiotomy. There is no evidence that every woman needs this procedure. The other extreme that is closer to women that get no care at all, are those that get treatment too late. Hence we talk about too late too little. 

So what we are trying to point out is that everywhere in the world, we need to assure quality that the time of childbirth and in pregnancy and afterwards. It is a universal goal.

One of the findings of 2016 The Lancet Series is that in the Latin America and the Caribbean, overall, there are about 41 per cent of deliveries by CS. In Brazil it is more like 57 per cent, but there is no way that proportion of women need a CS, in other words a lot of women are having unnecessary sections.

No doubt, a CS is a lifesaving intervention that can save the lives of mothers and babies. For instance, when you have an emergency that needs a CS or it is clear that there is going to be problem in labour, so you need to do bring out the baby earlier through.

We are saving many babies by CS, but once it gets above about 15 percent of deliveries being born through CS, it will suggest that we are having too many.

The impact of this development is several. One, CS can be a very safe procedure but it does carry risks. There are anesthetic risks, complications, etc. A Caesarean Section is not the sort of thing that you should undertake lightly, it is not like having your hair cut, it’s a serious surgical procedure,so women and their partners need to be properly counseled before they have a CS.

While CS can be very safe in skilled hands it carries risks. As it is, 57 per cent of surgeries in Brazil would suggest a very large proportion of them are not medically indicated as a result of the issue of risk to mother and baby.

No one can be sure that the risks will not happen if you do a CS, It is expensive to the health system because it requires and operating theatre, back up of surgical procedure and sometimes that cost is passed on to families. And it uses the operating theater and may keep the theatre busy when there is a really emergency. So there are series of reasons why an unnecessary CS should not be encouraged.

In the parts of the world where women prefer to deliver by CS, the talk is about maternal preference. Some people take the view that it is a woman’s right to deliver by whatever mode she chooses.

The difficulty with this right is in making sure that women are properly counseled and that they do understand the risks they are undertaking and the cost that it would be to them.

Some risks are not medical and may cause anxiety. For example if a mother has an early traumatic birth she might think she wants to have a CS, so we have to listen to women but ensure that they properly understand the risks, and go where the services are available able to provide safe CS, and that it is not found to take the resources away from other needed emergencies.

This is what is happening in parts of Latin America. There are some health facilities that are focused on carrying out CS. The whole thing is quite complicated.

In Northern Nigeria there is poor availability of access to CS for emergencies and this is where we need to focus attention because in the absence of a section where you really do need one it carries a very high risk of the mother and baby dying if they do not get a section.

So we have a strange world today, one where unnecessary sections are being carried out and sections that are really desperately needed are not being carried out.

We need to close that gap. We need to reduce the unnecessary CS and make sure those women who really need a CS are receiving a safe quality surgeries to save their lives and the lives of their babies.



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