Too Much of a Good Thing: Combatting Globalization of Overused Cesarean Sections

Last week in class we discussed globalization and how ideas and practices are so easily passed around the world.  One global health issue that has been able to do so is the growing rate of birth by Cesarean section.  Bringing this procedure to parts of the world that did not have it before has helped to reduce infant and maternal mortality from medically complicated births.  However, this is only up to a point. The procedure is often viewed casually here, as it occurs in about 1 of 3 births, but in less industrialized settings it can be very dangerous to do such a major surgery in an already critical moment.  Even in the developed world, the procedure has likely become overused for various reasons.  Due to stress on hospitals to see many women, a C-section may be seen as a method to quickly and efficiently move through patients.  Some women also see it as an easier or more ideal method of giving birth.   In countries, increased access to hospitals has caused the C-section rate to skyrocket, in Mexico up to about 50%.  These women face a burden of a long recovery and the need to have C-sections for their subsequent births.  The consequences go beyond this to the biological level; their child may face trouble with their immune system due to the lack of microbiome exposure that occurs during the normal labor and birth process, leading to higher risk of asthma, allergies, celiac disease, obesity, and more.

What can be done to reverse this trend?  The WHO has identified two points to address. First, population data needs to be continuously studied to determine an appropriate C-section rate.  Currently, they have set a global number at 10% of births, because once the rate goes higher than this no decrease in maternal or infant mortality is seen.  While this may be a good place to start, I think more population-specific study is necessary as well; for example, in a country with higher weights of overweight and obesity, such as the US, the optimum number of women to receive C-sections to yield the most benefit may actually be higher than 10%.  Still, I think this is a great place to start to understand the state of the problem.  Secondly, they have developed a classification system called the Robson scale that is simple enough to be implemented in all health care systems to determine what groups of women should have/are getting C-sections (see link below for more detail).  Getting data specific to birth history and complications is important to identify where we could target to reduce the C-section rate, as opposed to women who actually would benefit from the procedure.

As globalized as this life-saving surgery has become, we must now begin to globalize a more nuanced view of both its power to help and its potential to harm.  Rather than striving for a specific rate of Cesarean sections, our number one global health goal should be to make sure that this procedure is getting to the women who need it and not being forced upon women who don’t.  The rate targets are simply a crude tool to help us get there.  Gaining a better understanding of when and why this procedure is necessary will temper its use to the healthiest level possible in a given population.

Reference:

Human Reproduction Program. 2015. WHO Statement on Cesarean Section Rates. Available from: http://apps.who.int/iris/bitstream/10665/161442/1/WHO_RHR_15.02_eng.pdf?ua=1