[Increasing use of cesarean section, even in developing countries]

Abstract

At Kaziba hospital in rural Zaire, the frequency of deliveries by Caesarean section rose from 6.2% in 1971 to 12% in 1992, and the fraction of repeated sections rose from 17% to 49%. During the same period, the overall maternal mortality decreased from 0.3% to 0.12%, and deaths connected with Caesarean section from 3.2% to 0.7%, but still the risk of dying remained 13 times higher for births by Caesarean section compared with vaginal deliveries. The frequency of vacuum deliveries was halved during the period, and mean birth weight decreased by about 100 g. Perinatal mortality remained at about 2%. Among 760 Caesarean sections performed in the years 1991 and 1992, 93% were emergency cases. Spinal anesthesia was used in 97%, and blood transfusion was given to 4% of the women. The main indications were mechanical (30%), previous Caesarean section (20%), foetal asphyxia (19%), and suspected uterine rupture (10%). Uterine rupture was verified in 37 cases (4.9%), of which 27 were Caesarean scar ruptures. 259 of the operations were performed by a nurse or a dentist. Operations carried out by persons other than physicians were complicated by wound infections at a higher rate (20.8%) than those carried out by experienced doctors (11.2%). In areas with a poorly developed health system, a high rate of Caesarean section represents a hazard to maternal health. The need for knowledge about alternative methods like vaginal extraction, symphyseotomy and active management of labour is underlined.

PIP: Available hospital statistics were used comparing the period of 1971-72 with 1991-92 with regard to births, Cesarean section, rupture of the uterus, vacuum delivery, birth weight, maternal mortality, and perinatal mortality at Kaziba Hospital in rural Zaire. In addition, a retrospective analysis was conducted of 760 Cesarean section cases performed in 1991 (386) and in 1992 (374) using data from operation protocols and patient journals. Furthermore, the partograms of 1423 women who gave birth vaginally in 1992 were analyzed as to height, weight, and parity of women as well as the birth weight of the child. The number of annual births trebled in the course of 20 years. During this time the incidence of Cesarean section increased from 6.2% to 12.0%; however, the incidence of vacuum delivery had been halved. The total maternal mortality decreased from .3% to .12%, while the mortality associated with Cesarean section dropped from 3.2% to .7%. In the first period the risk of death from Cesarean section was 31 times higher than from vaginal delivery, while in the second period the risk was 13 times higher. The perinatal mortality had stayed around 2% in these 20 years. The average birth weight was 2915 g in the first period vs. 2819 g in the last period. Repeated Cesarean sections escalated from 17.4% to 49%. Only 52 (6.9%) of 760 Cesarean sections done during the 1991-92 period were elective. 97.4% of these operations were performed under spinal anesthesia. Blood transfusions were given to 31 women (4.1%). The main indications were mechanical (30%), previous Cesarean section (20%), fetal asphyxia (19%), and suspected uterine rupture (10%). Uterine rupture was verified in 37 cases (4.9%), of which 27 were Cesarean scar ruptures. 249 operations were performed by a nurse or a dentist. In 20.8% of operations there were wound infections when the operation was carried out by a person other than a doctor vs. the 11.2% rate encountered with experienced doctors. The average operation time was 46 minutes for experienced surgeons vs. 53 minutes for less experienced surgeons, and 83 minutes for nondoctors (p .001).