1007 Safer childbirth: elective caesarean section (C/S) and pregnancy outcomes

It is noteworthy that editorial comment in the case of the recent large-scale study into prevention of neonatal sepsis discounted results because the South African setting is not third-world enough (summary 0947), whereas a strong case is made for widely applying results of a recent Asian observational study of adverse outcomes following elective C/S. The point here is certainly not to promote and support elective C/S in a country in which the privately-insured have a C/S rate of around 60%, but to question whether one can in fact extrapolate and apply the results of this Asian phase of the WHO survey to South Africa’s well-resourced and highly-skilled private sector. The study included data for almost 110 000 deliveries in nine Asian countries, however the majority of the elective cases (82%) occurred in one country (China), 85% of the facilities were in the public sector, and 68% had “low facility complexity resources,” reflective of lower levels of care, fewer support services etc. The results almost certainly apply to the nine countries and the type of facilities in those countries, and can probably be applied reliably to similar situations elsewhere, but are they generally applicable? It is not clear what thresholds were used for adverse outcomes e.g. for admission to an intensive care unit, and reporting on results in terms of combined “mortality and morbidity” gives a little too much weight to the single death that occurred among the 2069 infants delivered electively. Yes, we need hard data if we wish to persuade both healthcare providers and pregnant women that it is illogical to assume that the natural process of pregnancy will depend in the majority of cases on an artificial process such as C/S to complete it, but that evidence should ideally come from the environment under consideration or one that matches it. The Asian report is limited to the fairly-immediate postnatal period, so on the one hand excludes follow-up of the women who delivered vaginally and suffered from 3rd or 4th degree tears, and on the other excludes possible long term childhood consequences of operative delivery (see summary 0920).

Read more:
Lancet 2010; 375: 440-2 and 490-9
BJOG 2009; 116: 886-95
Birth 2002; 29: 28-39