29. Marginal effect of second opinion on elective caesarean section (c/s) rates:

A recent multicentre study from Latin America involved 36 hospitals, was carried out by respected obstetricians and perinatologists and was statistically sound. The objective was to improve on two previous studies and measure the impact of manadatory second opinion prior to performing elective c/s, mainly because Latin America has one of the highest c/s rates in the world. The study covered almost 150 000 deliveries and the end result was a 7% reduction in c/s rate (still statistically significant but way below the expected 25%). Expressed differently, implementation would have avoided 22 caesareans per 1000 deliveries. As per comments in an accompanying editorial, the study was carried out in public hospitals (that had an average baseline rate of only ~25%) while it is well known that the highest c/s rates are in the private sector. This obviously leads to questions about the generalisability of the results: if rates exceed 50% in the private sector will such a programme have a greater or lesser effect? Interestingly, doctors who were interviewed generally favoured introduction of the programme in the public sector but were less enthusiastic about its role in the private sector. The study is certainly relevant to South Africa where private sector c/s rates are in the region of 55-60% while public sector rates probably vary from <15% to >25% depending on the type of hospital, and in a sense it is a pity that a study that could have added value in terms of moving c/s rates towards recommended WHO levels focused on hospitals probably practicing close to irreducible minimum levels rather than on those in which rates are unquestionably high.

Read more:
Lancet 2004;363:1921-2 and 2004;1934-40
N Engl J Med 1998;319:1511-6
Int J Gynaecol Obstet 2000;69:229-36