1. Prof.Dr.S.Cansun DEMİR Turkish Society of Obstetrics and Gynecology Çukurova University Faculty of Medicine What should we do to decrease high Cesarean Section rates ?

2. Labor Natural and Normal Physiological Process Natural and Normal Physiological Process Dystocia : % 23.6 Dystocia : % 23.6 Functional Dystocia: % 11.1 Failure in Dilatation and Descensus Arrest Dilatation and Descensus Ineffective Expulsion Mechanical Dystocia: %12.5 Cephalo-pelvic Disproportion Fetal Macrosomia Pelvic Anatomic Problems Fetal Malpresentation American Journal of Obstetrics & Gynecology. 195(1):121-128, July 2006.

3. W.H.O.: 1 W.H.O.: 1 15 % 15 % Maximum desirable rate of cesarean section Maximum desirable rate of cesarean section No benefit for mother and the fetus for medical reasons No benefit for mother and the fetus for medical reasons 1 World Health Organisation. Appropriate technology for birth. Lancet 1985;436­7. Published rates

4. Some authors have proposed an “ideal rate” of all cesarean deliveries (such as 15 percent) for a population. Some authors have proposed an “ideal rate” of all cesarean deliveries (such as 15 percent) for a population. There is no consistency in this ideal rate, and artificial declarations of an ideal rate should be discouraged. There is no consistency in this ideal rate, and artificial declarations of an ideal rate should be discouraged. Goals for achieving an optimal cesarean delivery rate should be based on maximizing the best possible maternal and neonatal outcomes,taking into account available medical and health resources and maternal preferences. Goals for achieving an optimal cesarean delivery rate should be based on maximizing the best possible maternal and neonatal outcomes,taking into account available medical and health resources and maternal preferences. Thus, optimal cesarean delivery rates will vary over time and across different populations according to individual and societal circumstances. Thus, optimal cesarean delivery rates will vary over time and across different populations according to individual and societal circumstances. Optimum C/S Rate ?

5. Department of Health and Human Services Department of Health and Human Services 15 % by the year 2000 15 % by the year 2000 “....the advantages of a safe vaginal delivery over a cesarean delivery are clear: a vaginal delivery is associated with lower maternal and neonatal morbilidity and it costs less...” 1 Healthy People 2000; DHHS publication Nº. (PHS) 91-50212. Healthy People 2000 1

6. C/S Rates Rises all over the World.

7. The Total cesarean, Primary cesarean and vaginal birth after cesarean rates in the United States from 1989 to 2006. Source: U.S. National Center for Health Statistics

8. CountryRate “LOW” RATE OF CESAREAN Cambodia1.0% Haiti1.7% Nigeria1.7% Uganda2.6% Eritrea2.7% Uzbekistan3.0% Indonesia4.1% “MODERATE” RATE United Kingdom 21.4% Canada22.5% Ireland23.3% Germany23.7% Switzerland24.3% United States 24.4% Cuba28.5% Portugal30.2% Chile30.2% “HIGH” RATE Italy36.0% Brazil36.7% Mexico39.1% China40.5% Turkey46.0% Betran AP, Merialdi M, Lauer JA, et al. Rates of cesarean section: analysis of global, regional and national estimates. Paediatr Perinat Epidemiol. 2007;21:98–113.

9. 1. Lower tolerance for taking risks 2. Fear of malpractice - litigation 3. Increased use of epidural anesthesia ? 4. Increased use of electronic fetal monitoring 5. The convenience of physicians Sachs BP et al., NEJM 1999;340:54 – 57 Why has the rate of cesarean delivery climbed so dramatically in the past 25 years?

10. Factors of taking C/S Absolute Dystocia Fetal Distress Breech Presentation ??? Previous Section ??? Relative Maternal Age Demand of Sterilization Fear of litigation from Complications Intraparturial EFM Additional Factors Time of day at delivery Lack of Experience about operative delivery among seniors C-section on Mother’s Request Stress Incontinance, Ano-genital sphincter insufficiency Disturbance in sexual function Literate High social level in status Urban or Metropolitian localization

11. C/S RATES IN TURKEY,2009

16. Indications of C/S in Turkey KAYNAK:2005 Ulusal Anne Ölümleri Çalışması Source: National Maternal Mortality Survey,2005

17. In 2005; In 2005; The C/S rate in USA is 30.3% among all deliveries. The C/S rate in USA is 30.3% among all deliveries. 62% of these cases were Primary Elective C/S. 62% of these cases were Primary Elective C/S. C/S Rates varies by mother’s request or demand was 4-18%. C/S Rates varies by mother’s request or demand was 4-18%. Cesarean on Demand

18. The incidence of cesarean delivery without medical or obstetric indications is increasing in the World, and a component of this increase is cesarean delivery on maternal request. The incidence of cesarean delivery without medical or obstetric indications is increasing in the World, and a component of this increase is cesarean delivery on maternal request. Given the tools available,the magnitude of this component is difficult to quantify. Given the tools available,the magnitude of this component is difficult to quantify. What is C/S on Demand? Definition:

19. Cesarean section on demand Until quality evidence becomes available, any decision to perform a cesarean delivery on maternal request should be carefully individualized and consistent with ethical principles. Until quality evidence becomes available, any decision to perform a cesarean delivery on maternal request should be carefully individualized and consistent with ethical principles.

20. Cesarean section on demand Given that the risks of placenta previa and accreta rise with each cesarean delivery, cesarean delivery on maternal request is not recommended for women desiring several children. Given that the risks of placenta previa and accreta rise with each cesarean delivery, cesarean delivery on maternal request is not recommended for women desiring several children.

21. Cesarean section on demand 31% of female obstetricians would prefer a cesarean delivery for themselves 1 31% of female obstetricians would prefer a cesarean delivery for themselves 1 1 Al-Muffti et al. Eur J Obstet Gynecol Reprod Biol 1997:73:1-4

22. Rising C/S rate in Turkey. The reasons: 1 Physician’s attidutes; C/S easy access and lower risk Time saving procedure ( 12-16 hours-vs 35-45 minutes); To avoid from intrapartum long-term follow-up of parturient in labor ward;and not to take any responsibility of labor complications. Malpractice and fear of litigation pushes them to take more Sections.Elective Caserean Section as an indication recorded into the statistical data. Not to able to control the unset of labor during very heavy clinical work in the day time,and also the extra and out of time.

23. To believe that C/S is minimizing perinatal neurologic injury and also prevents maternal adverse outcomes as pelvic relaxation syndrom with urinary incontinance. The reflexion of physicians preference on the gravidas as to direct them for Section seems to be another important factor. Normal delivery needs more labour-intensive work but not satisfactory rate of return. Rising C/S rate in Turkey. The reasons..2

24. The Social Background and Communal Factors; IVF-ET cycles and pregnancies.Multiple gestation. Higher prevalence of maternal obesity and related obstetric problems as hypertansion, diabetes,systemic diseases and dystocia. Extensive use of Electro-fetal Monitorization and prenatal ultrasonography (Fetal Macrosomia-15% false positive) Cesarean rates are higher among the gravidas cared by obstetricians,when compared by midwifery during antenatal period. Rising C/S rate in Turkey. The reasons..3

25. Maternal attidutes; Inadequate antenatal booking and lack of antenatal clinics results misunderstanding at choosing the mode of delivery; Not to show enough respect to the parturient’s confidence during labour in the ward,frequency of painful vaginal exams,Lack of private seperations and rooms for labour; Negative approach and the quality of correspondance during admission to the labor ward The patients and also the obstetricians adversely affected againts normal delivery because of bad consequences of obstetric complications which recognized by community. Rising C/S rate in Turkey. The reasons..4

26. The cesarean section should not be used as an indicator of quality of obstetrical care The cesarean section should not be used as an indicator of quality of obstetrical care We do not have a good definition of unnecesary c-section We do not have a good definition of unnecesary c-section Conclusion Conclusion

27. Comments – 1 High quality of Maternal Schooling.Prenatal Courses on training how to manage spontanous delivery and experienced trainers must be on this field. Encouragement and Education. Normal labor should be cared and followed by Obstetricians or Midwifes whose only is focused on this subject.Certification and Responsibility. Physical Conditions of Labor wards and hospital must be modernized and Patient Friendly Structure could be built.

28. Gravida must be treated honestly as she feels herself in confidence at labor. During the delivery the criterias which declared by WHO should be applied. ( No Routine enema,limited number of vaginal exams for low risk pregnants,unnecessary Kristeller Manoeuvre,No restriction to take fluids during labor). Midwifery System should be progressed and rebuilt as they will be responsible of normal spontanous deliveries.The Education of Midwifes must be in the responsibility of University and Teaching Hospitals which updated and upgraded. Comments – 2

29. Continuous Professional and Postgraduate Education for midwifes and labor staff. Obligatory Intrapartum Fetal Monitorization. Physicians and Midwifes must be educated on IFM. The responsibility of labor Ward must belongs to Academic Staff (Obstetricians and Midwifes ). Full Physicological Support and Obstetric follow-up. Comments - 3…

30. Comments – 4 Facility of Rapid consultation of parturient with obstetrician if necessary because of dystocia and other complications appeared at delivery. Guidelines about Normal Vaginal Delivery and Labor Care must be setup in the labor Wards. Induction of Labor

31. Thank you very much for your attention Thank you very much for your attention