Appropriate Use of Caesarean Section

Background

Despite reliable evidence to the contrary, caesarean section rates rise steadily in many countries. Birth by Caesarean section has implications beyond the prevention of maternal and perinatal morbidity and mortality, both for the present and future health of mothers and babies. It appears that the rate of increase of Caesarean section births in some countries is related more to the threat of litigation, to service and social needs, misinformation of women, than to the existence of new and reliable evidence for the need to intervene in the normal birthing process.

Caesarean section can be a lifesaving intervention for mother and baby when vaginal birth is contraindicated. Caesarean section is also associated with increased morbidity and mortality for women and their newborn infants and may impact negatively on a woman’s future reproductive health (1). Unnecessary birth by caesarean section also places extra demands on maternity services and the use of finite health resources.

Position

ICM regards the inappropriate use of Caesarean section, when evidence-based clinical criteria are not met, as a violation of women’s reproductive health rights and an avoidable burden on health and social systems.

Therefore ICM:

• Supports the use of evidence based clinical criteria as the basis for performing a caesarean section.
• Promotes the collection and dissemination of data on the allocation and use of financial and human resources for maternity services.
• Advocates that midwives and other maternity service providers be proactive as advocates for individual women and normal birth and demonstrate accountability for clinical decisions.
• Urges midwives to develop their educational and health promotional role amongst women.
• Works with obstetric colleagues to promote and support normal birth and the appropriate use of caesarean section.
• Encourages the collection and dissemination of data to monitor the ongoing global situation.

Source: Association between rates of caesarean section and maternal and neonatal mortality in the 21st century: a worldwide population-based ecological study with longitudinal data.

Recommendations

Member associations are urged to:

• Support midwives to be accountable for their role in promoting vaginal birth and the use of evidence-based criteria for the performance of caesarean section within their countries.
• Encourage the national adoption of evidence-based criteria and standards for the performance of caesarean sections that will result in maximum health gain for women and babies.
• Support midwives in their health education and advocacy roles.
• Monitor and report the outcomes, in terms of intervention and vaginal birth rates, in their countries.

Other Relevant Documents

• Baron YM (2016) Does the 10-15% caesarean section rate threshold endorsed by the world health organization in 1985 still apply to modern obstetrics in developed countries? the “ideal” caesarean section rate and the stillbirth and neonatal death perspective. . Critical Care Obstetrics and Gynecology; Vol. 2 No. 1:13.
• Betrán AP, Ye J, Moller A-B, Zhang J, Gülmezoglu AM, Torloni MR (2016) The increasing trend in caesarean section rates: global, regional and national estimates: 1990-2014. PLoS ONE 11(2): e0148343. https://doi.org/10.1371/journal.pone.0148343.
• Deneux-Tharaux C., Carmona E.,Bouvier-Colle MH., Breart,G. 2008. Post partum maternal mortality and cesarean delivery. Obstetrics and Gynaecology 108:541-548.
• Office of the United Nations High Commissioner for Human Rights. 2010. Office of the United. Nations High Commissioner for Human Rights Report on Preventable Maternal Mortality And Morbidity and Human Rights. Geneva
• Shilang L,.Liston,RM., Joseph KS.,Heaman M.,Sauive R., Kramer M.S. 2007. Maternal mortality and severe morbidity associated with low risk planned cesarean delivery versus planned vaginal delivery at term. Canadian Medical Association Journal 176 (4) o UNESCO. 2005. Universal Declaration on Bioethics and Human Rights. Paris. o Warwick C. (1999) Rising caesarean section rate: a public health issue. British Journal of Midwifery. Vol.7, no.12. 731.
• White Ribbon Alliance. 2011 Respectful Maternity Care: The Universal Rights of Childbearing Women. Washington.
• WHO. 2010. Policy Brief Caesarean Section Without Medical Indication Increases Risk Of Short-Term Adverse Outcomes For Mothers. Geneva. Retrieved from : http://whqlibdoc.who.int/hq/2010/WHO_RHR_HRP_10.20_eng.pdf
• WHO. 2015. WHO Statement on Caesarean Section Rates. WHO/RHR/15.02. o Ye J, et.al. (2016) Association between rates of caesarean section and maternal and neonatal mortality in the 21st century: a worldwide population-based ecological study with longitudinal data. British Journal of Obstetrics and Gynaecology Apr;123(5):745-53. doi: 10.1111/1471-0528.13592. Epub 2015 Aug 24.

Adopted at Brisbane International Council meeting, 2005

Reviewed at Toronto International Council meeting, 2017

Due for next review 2023

PS2011_002 V2017