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Informed decisions and maternal health literacy could reduce caesarean section numbers

Following the “Conference on WHO recommendations on non-clinical interventions to reduce unnecessary caesarean section”, held on 13–14 December 2018 in Tbilisi, Georgia, 2 experts give their perspectives on the alarming increase in caesarean sections (C-sections) in the WHO European Region. Professor Giuseppe Benagiano from the Sapienza University of Rome and Dr Nino Berdzuli, Programme Manager for Sexual and Reproductive, Maternal and Newborn Health at WHO/Europe have followed the rise of the use of C-sections over the years.

Over the past 150 years, C-sections have evolved from being a surgical procedure of last resort to save the life of the baby, to an operation that is now being performed on as many as 50% of all pregnant women, even when it is not medically necessary.

However, as health literacy among expectant mothers increases, many women have begun to reconsider the negative health risks associated with C-sections, such as spontaneous preterm birth, uterine rupture, excessive maternal bleeding for mothers, and a higher risk of asthma and obesity for children.

Overreliance on C-sections

Doctors have traditionally opted for C-section deliveries because they are easier to plan and control, making them more convenient for doctors, particularly when compared to unscheduled and often lengthy natural deliveries. Doctors and hospitals also have financial motivations for preferring C-sections.

“In Europe, sometimes a hospital gets reimbursed at a higher rate for a caesarean-section delivery, and as such, it’s difficult to discourage the procedure and potentially reduce the hospital’s revenue by promoting natural birth,” said Professor Giuseppe Benagiano.

“Over-reliance on caesarean sections presents issues for medical education that can lead to a lack of training in the clinical skills necessary to manage complications during instrumental delivery,” said Dr Nino Berdzuli.

The situation has created what is now being described as something of a medical perfect storm: “You’re going to pay the doctor and hospital more, the doctors will worry less in the controlled clinical setting of such a common surgical procedure, and they will complete the surgery in an hour,” said Benagiano.

Research shows that while national rates for C-sections in 2000–2015 remained below 20% of all deliveries in parts of northern Europe, they increased to nearly 50% in several countries in south-eastern Europe.

At the same time, a recent study of Italian women shows that despite caesarean rates in Italy being relatively high, up to 80% of Italian women would choose to give birth naturally. Many women in Italy said they chose C-sections, instead of natural birth, because they were influenced by their obstetricians.

Health literacy for more informed decisions

“I believe that it’s our duty to educate our fellow obstetricians and gynaecologists because so many of them are using the procedure because it’s convenient and can be conducted in a controlled setting. If women are allowed to make their own informed decision after receiving the full information, we may be able to turn the tide,” said Benagiano.

Health literacy among women is also increasing, which means they are learning more about birth and that can be empowering for them, he said. They are asking for educational tools such as childbirth training workshops, booklets and decision-aids, and this will ultimately help them to make informed decisions, according to Benagiano.

“Supporting a woman’s right to make health-care decisions for herself is very important. But it is imperative that health-care professionals disclose the risks and benefits of the mode of delivery, explaining options. These should be discussed with the woman tirelessly throughout the antenatal period to allow the woman to absorb all of the information and be able to make an informed decision,” said Dr Berdzuli.

The operation remains vital when complications occur during birth, but once C-section rates climb higher than 10%, there is no evidence to suggest that the procedure helps to reduce maternal and newborn mortality, according to WHO.

On the contrary, the surgery can lead to complications and should be conducted only when medically necessary, especially since it can lead to excessive bleeding and the need for hysterectomy for women, and the increased risk of admission to neonatal intensive care units for children.

“Many women have been conditioned into believing that they will experience less pain and have a fast recovery from the procedure. They also believe that it might be best for the baby, so unless we show that this is untrue, we cannot win this debate,” said Benagiano.

 About health literacy

People need to acquire the knowledge, skills and information to make healthy choices, such as about the food they eat and the health-care services they need. In order to make these choices, they need access to opportunities, and assurance of an environment where people can demand further policy actions to further improve their health.

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