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C-section is the delivery of a baby through a surgical incision in the mothers abdomen wall laparotomy and uterus wall hysterectomy. In some circumstances, a C-section is scheduled in advance. In others it's done in response to an unforeseen complication. Initially, cesarean delivery was performed to save the fetus from a moribund patient. But over and over years, this operation subsequently was developed into a surgical procedure to save both maternal and fetal from eminent complications.
2.2 Concept of C-section
The C-section rate is increasing over a period of time in developed countries, as well as in developing countries. It is also increasing for all women of all ages, race/ethnic group, gestational age, SES group. For instance in China the cesarean rate rose dramatically from 3.4 % in 1988 to 39.3 % in 2008 with the most dramatic increase among urban women (Xu, Yan, & Carine, 2012, p. 3/12). In USA, this rate climbed from 5% in 1960 to 31.8% in 2007 (Campbell, 2011). In Mali, the rate increase from 1.6 % in 2005 to 2.9 in 2009. Moreover in developed country the proportion of cesarean birth is 21.1 % on average whereas in developing countries is only 2 % (Betran et al, 2007). This rate is quite under the international norm fixed (5 % - 15 %) by WHO since 1985.
2.3 Types of C-section
C-section is made based on two types of incision on the uterus: low transversal incision and vertical uterine incision. However the direction of incision on the uterus does not necessarily match with the incision on the skin (up, down or side to side).
The low transverse incision is a horizontal cut across the lower part of the uterus. It is the one which is safer and more successful to go through labor for having a vaginal delivery in later pregnancies.
The vertical incision on the uterus is used for delivering preterm babies, abnormally positioned placentas, pregnancies with more than one fetus and in extreme emergencies.
2.4 Medical factors (indication of cesarean)
Cesarean indication can be classified into 3 groups: Maternal; fetal or maternal-fetal.
Tableau 2. Medical indication for cesarean decision
Medical condition: specific cardiac disease (Maran's Syndrome, unstable coronary artery disease); specific respiratory disease (GuillanBarre syndrome); thrombocytopenia
Conditions associated with increased intracranial pressure
Mechanical obstruction of the lower uterine segment (tumors, fibroids)
Mechanical vulvar obstruction (condylomata)
Contracted pelvis (either congenital or acquired)
No reassuring fetal status
Malpresentation: breech, transverse lie, brow or face/mentumposterior
Maternal herpes or HIV
Congenital anomalies/Vasa previa
Failure to progress in labor: either arrest to descent or arrest to dilate
Placenta previa/ placenta abruption
Elective cesarean delivery
The most common indication for cesarean delivery in America is repeated cesarean (30 %), followed by dystocia or failure to progress (30 %), malpresentation (11 %) and non-reassuring fetal status (10 %) (Murphy, Sarah K. , et Jeffrey D. , 2012, p. 2). In England, the most common indication is also repeated cesarean (29%) followed by presumed fetal distress (22 %), failure to progress (20 %) and breech birth (16 %) (caesaran sections, october 2002, p. 2). In Mali, the most common indication is prolonged/obstructed labor or suspected cephalopelvic disproportion 40.4 %, followed by previous cesarean section 16.6 %, fetal distress (16.1 %) (Valerie Brand et al, 2012).
Based on the timing of C-section (CS) at the time of decision making, the cesarean indications are grouped under one of those four categories.
Tableau 2. Different categories of C-section
- There is an immediate threat to the mother or the fetus. Therefore the CS should be done within the next 30 min in order to save on time both mother and baby
Abruption, cord prolapsed, scar rupture, scalp blood PH<7.20, fetal distress:prolonged FHR deceleration <80
There is maternal or fetal complication but was not immediately life threatening. In that case the delivery should be completed within 60-75 min
Case with FHR abnormalities are those of concern
The mother needs early delivery but there is no maternal or fetal compromise. A concern of the continuation of pregnancy is likely to affect the mother or fetus in the coming hours or days.
Iatrogenic preterm delivery where there is need to give a course of steroid for lung maturity
The delivery is timed to suit the mother and staff. There are cases where there is an indication for CS but there is no urgency.
Placenta previa with no active bleeding, malpresentation, history of previous cesareanâ€¦
2.5 Non medical factors influencing C-section rate
Beside medical factors, non-medical reasons can have an impact on the likelihood of having a C-section as well. Among those factors, maternal characteristics such as age, education, occupation, birth order, financial status (salary/affordability to pay medical fees and health insurance), residence, number of antenatal visits, health status can greatly influence the C-section rate. Some demographic factors, especially the change in the characteristics of the childbearing population can affect cesarean delivery. Ethical and economic reasons may also have some influence on the rate of surgical delivery.
2.5.1 Maternal age
Several studies show that old women (over 35 ages) are more likely to have a high risk of pregnancy complication and cesarean delivery. Other studies found the same result in lower risk women population. A significant association was also found between the risk of having C-section and advanced maternal age at the first pregnancy (Herstad & al, 2012). In addition, increasing age and parity are reported to be associated with a high risk of adverse pregnancy outcomes and C-section rate. Dystocia, non-reassuring fetal condition, pre-eclampsia, placenta previa, abruptio-placenta, malpresentation, prolonged labor and macrosomia were significantly higher in older mothers with high parity. Another high association was found among advanced maternal age of women with previous C-section and increasing C-section rate (Hiasat, 2002).
2.5.2 Education of the mother
The role of education level plays in the C-section rate is controversial. (Gilbert, Alice, & Haim A., 2010) found in a study that planned C-section was carried out more often among educated women than uneducated ones. High education level influences also positively the C-section rate of women with previous C-section (Khawaja, Tamar, & Rozzet, 2000).This significant rate of C-section rate among the more educated women are mainly due to either maternal choice for C-section (posh to push factor) or physicians behavior factors or the delay of motherhood until older age for educated women. On the other hand, when all those factors are taken into consideration, some studies show that the c-section rate is likely to be less among higher educated women because educated women are more aware about pregnancy complications and risks. Therefore they are more preventive and care better about their health during the pregnancy. For instance among women in the same age, the less educated ones are actually more likely to get a C-section (Harrison, 2012). Furthermore the education of the father doesn't have too much effect as the mother education on the C-section rate.
2.5.3 Occupation of the parents
Occupation of the mother is greatly associated with the cesarean delivery. A Nigerian study found that women with no occupation are more likely to have a vaginal delivery than those with a high occupation (Olusanya & Olumuyiwa, 2009). This might due to some reasons such as maternal choice to deliver by C-section, delaying motherhood (due to the lack of time because of her work) at an advanced age or inequitable access to maternal health care.
A study in Puerto Rico found that a direct association with the father's occupation and the rate of surgical delivery. Fathers with no occupation are associated with a lower rate of C-section rate (Jose & Vazquez-Calzada, 1997). It is probably due to the same socio-economic reasons I will quote in this subtitle.
2.5.4 Birth order
Whereas a raising of C-section rate for the maternal age is apparent for almost all the live-birth order, live-birth order affects the rate of cesarean delivery independently of the maternal age. The risk of cesarean delivery is greater among mothers having their first child no matters the age, except for teenage mothers. Then this risk falls down promptly with succeeding births. For instance, a USA study (Taffel, 1994) found the cesarean rate declined as live-birth order rose to an agegreater or equal to 20 years old mothers for both black and white women. In addition the highest cesarean rate for any age-birth order combination were found among women between 35-39 years of age having their first birth, followed by women 40-49 years. The lowest rate was for 20 year old women having a fourth or higher order birth and for teenagers having their second or third child. Marwan Khawaja et al found the same result: a higher likelihood of C-section delivery among low order birth compared to high one is expected since the delivery complications are more common among primiparious women leading to a higher rate of C-section.
2.5.5 Financial situation
Income and SES group
The cesarean rate is important among people with a better financial situation even thoughthelow income group has a higher obstetrical risk. One Brazilian study (Hopkins & Ernesto , 1998) found a higher C-section rate among the high income group than the low one.
Cesarean delivery is more common among people with high SES. This might due to the fact that low SES faces often to financial and geographic barriers to health care access.
Ability and affordability to pay
Several studies found that Women or household with less financial ability and affordability to pay for health care will have high risk pregnancy and higher C-section rate (Hopkins et al , 1998).
Cesarean rate is more common for insured women than uninsured ones.A study in Brazil (Cecatti, Helaine n, Aníbal, & Maria José, 2005.) showed that the C-section rate varies enormously according to the type of insurance. And he lowest rate is with insurance companies which contract with public facilities. Another study (KASSAK, A. MOHAMMAD, & ABDALLAH, 2000) found that universal coverage by national health insurance had a greatest impact on the likelihood to increase C-section rate.
2.5.6 Rural / Urban areas
Many articles highlight the importance of residence place on the C-section rate.Mothers living in urban areas have a higher probability to deliver by C-section, This might due to either a better access to health care in urban areas or the lack of appropriate equipments and skilled staff in rural areas. However it might also reflect the overused of cesarean delivery in urban areas (Yassin & Ghanim A, 2012).
2.5.7 Number of antenatal visits
The prenatal care is another key factor influencing the C-section rate. The greater is its number (six or over), the higher is the likelihood to get C-section. This is due to the fact that higher pregnancy risk is more likely to have more antenatal visits. On the other hand, some studies found a strong association between medical knowledge of mother and number of antenatal visits (Habib, Maysaloun , & Selwa , 2011).
2.5.8 Health status
An increase in C-section rate appears in parallel with increasing obesity rate due to the rising likelihood of pregnancy complication (diabetes and hypertension). Further, both maternal and fetus weight influence the cesarean rate (Hendrickson, 2012).
Pregnancy and delivery complication
Pregnancy complication, when it is not treated seriously can lead to serious issues. So it is an important factor affecting C-section decision. Some studies show a significant likelihood of getting cesarean birth for complicated pregnancies seeking health care(Choudhury). Chronic hypertension and uterine bleeding in Jose and all studies were reported as the most common pregnancy medical risk associated with surgical delivery. Others are diabetes and anemia.
However delivery complications leading to C-section are more considered as medical factors. They are more important than pregnancy complication because they affect directly the normal delivery and increases highly the C-section likelihood. And the chance of having a cesarean is even more for those women with two or more delivery complication.
Low/ high risk factor
C-section rate is lower among women with uncomplicated pregnancies than complicated ones. In addition a healthy woman is less likely to have pregnancy complication and C-section than the opposite (Best practices in the use of cesaean section in Nova Scotia, 2008).
2.5.9 Summary of non medical factors
On the next page, there is a summary of all non medical factors with the references and the expected sign.
Herstad et al.
Log binomial reg
â‰¥ 35: +
Gilbert et al
Harrison et al
Olusanya et al
Jose et al
Taffel et al
Marwan et al
BO ï€£ : -
Income and SES ability to pay
Hopkins et al
High SES: +
Cecatti et al
Rural / Urban area
Yassin et al
Habib et al
Nberï€£ : +
Risk ï€£: +
Tableau 2.3 Expected sign of non medical factors
2.6 Human behavior factors increasing C-section
Medical human behavior factors
Some medical explanations can explain the rising of cesarean rate. First of all, there are large variations among clinicians, hospitals in the management of the woman labor which influence the cesarean rate. Secondly, even though the proportion of assisted breech babies delivery does not increase, some clinicians prefer to avoidthe risk due to the complication of normal delivery and practice an elective cesarean for breech babies because they think it is safer. In addition, the increasing use of in vitro fertilization (IVF) has led to the rising in the number of multiple births and those babies are often delivered by CS. Finally, the development of new surgical technics, technologies and medical care has made C-section an increasingly safe operation.
Non-medical human behavior factors
126.96.36.199 Cultural and Organizational factors
In some cases, the C-section decision is very needed to save the mother and/or the baby. However this decision, in another situation is minutely a balanced judgment taken between clinical teams and the mother. So, the environment within the hospital unit and his staff is managed has greatly an impact on C-section decision, leading to a broad variation in the rate between hospitals. Further, some studies found that teaching hospitals tend to have lower cesarean rate than non teaching health facilities and private clinics (K.M Kassak et al., 2000) . On the other side, some ethical issues such as doctors' obligation not to cause harm to patients and to obtain their consent prior any treatment, instead of only to protect a patient's welfare can influence the physician choice.
188.8.131.52 Maternal choice
Some mothers, mainly the educated and famous ones prefer to give birth by C-section because they are scared of suffering for the vaginal birth. So this rise of C-section rate can be attributed to women's lifestyle choice. Because of this reason, C-sectionrate in private hospitals is often higher than public hospitals. Further, according to some studies about "cesarean culture of Brazil", other reasons are found (Giguere, 2007):
Due to modern and advanced, technological interventions, women perceived C-section as safer and more comfortable labor with better quality of health care
They want to avoid the risk of perineal damage due to normal delivery that can affect women sexual function after childbirth.
On the other side, the prevalence of maternal preference vary widely according to the country context. A study in Hong Kong (Selina & al, 2007) found a low prevalence of 16.7 % for the maternal choice and the main reason was their perceived it safer for the baby.In another study, Iran the rate was 22 % (Alimohanmadian, Manak, Mahmoodi, & Faterneh, 2007).
184.108.40.206 Profile of doctors preferring C-section
The increasing cesarean rate can also be attributed to an unjustified physician's choice due to his fear to bear the risk or financial incentive (want to make more money). It can also be due the patients demand.
Furthermore, there are worldwide various clinicians opinions about the request of elective or emergency cesarean. (Mufti, MC Carthy A, & Fisk N. M, 24 1996, p. 544) in a survey, found out that 17% of Obstetricians in London ( 31% of female and 8 % of male ) prefer ekective cesarean. Their choice wer mainly based on the avoidance of perineal damage from vaginal birth and the ris of injury to the baby. Then 68 % choose cesarean delivery for cepalic presentation with an estimated weight greater than 4.5 Kg. Another similar study (Wagner, 2000, p. 1677) in USA, showed that 46,6 % obstetricians prefer the C-section with more males (56.5 %) than females (32.6 %). And then 70 % delivered by C-sectio with an estimated weight greater than 4.6 Kg. However in (McGurgan, Coulter-Smith, S., & O'Donovan, P.J., 2001) study, there are more females than males who chose eletcive cesarean. Regarding the marital status, married clinicians do less emergency cesarean than the non married ones (Turner, Young, Solomon, Ludlow, Benness, & Phipps, 2008). In addition, clnicians request (21 %) more cesrean delivery than midwives (10 %) and coloreectal surgeons urogynecologists are more lkely to request C-section.
In Mali, the health personnel in public facilities are under salary based payment. The salary rate are based on the level of training and the number of years in service (MCI, Octobre 2010). Therefore physicians have no incentive to increase the C-section rate. In addition when patients arrive at maternal health facilities, they first contact are made with the midwives and the medical students on duty. And then when it is a omplicated or special case which need the doctor advice, they call him. Therefore the mother request for cesarea delivery to doctors are not observed in those public facilities. The cesarean decision is only taken by physicians based on medical reasons.