The rising caesarean section rate: A loss of obstetric skill?

In the last 35 years, the caesarean section rate (CSR) has risen all over the Western world and also in some lessdeveloped countries (Churchill et al. 2006). The quotations above come from public health physicians. They (not obstetricians as a group) were the first in the USA to raise the alarm about the rising rate of caesarean section almost 30 years ago when the US rate had almost tripled from 5.5% in 1970 to 15.2% in 1978 (US Task Force 1981). Joffe et al. (1994) looked at a large data set from the North West Thames Region to reach their conclusion, but despite this paper; despite the WHO consensus conference (WHO 1985) suggesting that no WHO region should have a rate above 10 – 15%; despite the National Sentinel Caesarean Audit (Thomas and Paranjothy 2001); and despite the NICE Guidelines published in 2004, the rate continues to rise in the UK as it does in the USA (MacDorman et al. 2006), South America (Villar et al. 2006) and most of Europe. Italy, at 33% in 2000, leads with the Netherlands and Nordic countries as lowest at under 15%. China had a rate of 40% in 1999 as did Chile, and Brazil followed with 36%. Canada, New Zealand and Australia were 22 – 23% (Churchill et al. 2006). The USA rose to 29% in 2004 (MacDorman et al. 2006) after a fall in the early 1990s as the vaginal birth after caesarean section (VBAC) policy recommended in Healthy People 2000 took effect (DHHS 1991) and halted the rise. Since 1970, Medline lists almost 8,000 articles with the keywords ‘Caesarean section’ and over 27,000 with ‘Cesarean section’ but few of these address the issue of how to reduce the rate. Although there have been difficulties in obtaining accurate national figures about the use of caesarean section in England and Wales (Macfarlane 1998; HoC 2003), there have been three perinatal surveys of all births in 1 week in the spring, which gave a CSR of 1.1% in 1946, 2.7% in 1958 and 4.5% in 1970 (RCOG 1948; Butler and Bonham 1963; Chamberlain et al. 1975). The perinatal mortality rate fell from 44 in 1946 to 33.2 in 1958 and to 23/1,000 births in 1970. Deaths from intracranial birth trauma, many of which followed difficult high forceps or breech births, had virtually been eliminated, falling from 3.0/1,000 in 1958 to 0.4/1,000 in 1970 (Chamberlain et al. 1975). This survey and that in 1958 (Butler and Bonham 1963) are important in that accurate post-mortem data on babies were obtained and analysed and a wealth of information about labour and delivery collected. Sadly, in my experience, few trainees have even heard of these surveys, let alone read them, and yet they are important sources of data, which should be read and understood by all those entering our specialty. In 2005, the CSR had risen to 22.9% of births in England, 24.5% in Wales, 24.9% in Scotland and in 2004 to 26% in Northern Ireland (Birthchoice 2006). The NHS Institute for Innovation and Improvement (2006) give a figure of 24.1% in England for 2005 – 2006. In 1989 – 1990 it was 11.3% in England (DoH 1997) but in our survey of births in 1989, we found a rate of 12.1% (Savage and Francome 1993), although for Wales and Scotland we obtained the similar rates of 13.5 compared with 13.8 and 14.2 compared with 14.0. The Scottish data have always been more reliable than those collected originally in England and Wales. Can it be right that almost one-quarter of women in the UK are being delivered surgically? What has caused this extraordinary and seemingly relentless rise in the CSR? From the mid-30 s, when the maternal mortality had remained much the same for a century, obstetricians were focussed on reducing the unacceptable loss of young women’s lives and the confidential enquiries which took place from 1952, were an early and useful audit tool for achieving this aim (Turnbull et al. 1989). The rise in caesarean section from 1% in 1946 to 2.7% in 1958 and 4.5% in 1970 was an appropriate response to the recognition that with antibiotics, new anaesthetic agents and blood transfusion available, women were less at risk from surgery, so caesareans were performed more readily.