New WHO guidance on non-clinical interventions specifically designed to reduce unnecessary caesarean sections
First of its kind – new WHO guideline aims to help reduce worldwide increase in caesarean section rates
A caesarean section is a surgical procedure that, when undertaken for medical reasons, can save the life of a woman and her baby. Many caesarean sections are undertaken unnecessarily however, which can put the lives and well-being of women and their babies at risk – both in the short and the long-term.
Worldwide, caesarean section rates have been steadily increasing, without significant benefit to the health of women or their babies. In recognition of the urgent need to address the sustained and unprecedented rise in these rates, WHO has today published new guidance on non-clinical interventions specifically designed to reduce unnecessary caesarean sections.
First of its kind
The new guideline, WHO recommendations on non-clinical interventions to reduce unnecessary caesarean sections, incorporates the views, fears and beliefs of both women and health professionals about caesarean sections. It also considers the complex dynamics and limitations of health systems and organizations and relationships between women, health professionals and organization of health care services. The key recommendations include:
Midwife and couples at a chirldbirth class in a swimming pool
- Educational interventions for women and families to support meaningful dialogue with providers and informed decision-making on mode of delivery (i.e. providing childbirth training workshops for mothers and couples, relaxation training programmes led by nurses, psychosocial couple-based prevention programmes, psychoeducation for women with fear of pain or anxiety).
- Use of clinical guidelines, audits of caesarean sections, and timely feedback to health professionals about caesarean section practices.
- Requirement for second opinion for caesarean section indication at point of care in settings with adequate resources.
- Some interventions aimed at health organizations are recommended only under rigorous research such as collaborative midwifery-obstetrician model of care (i.e. a model of staffing based on care provided primarily by midwives, with 24-hour back-up from an obstetrician who provides in-house labour and delivery coverage without other competing clinical duties) or financial strategies (i.e. insurance reforms equalizing physician fees for vaginal births and caesarean sections).
“These guidelines are timely and needed. When we reduce unnecessary caesarean sections, we also reduce unnecessary risks to women and their babies. We also reduce unnecessary costs for hospitals and health systems.”Dr Ana Pilar Betran, medical officer at WHO Department of Reproductive Health and Research
Inequality and risks
While many women in need of caesarean sections still do not have access to caesarean section particularly in low resource settings, many others undergo the procedure unnecessarily, for reasons which cannot be medically justified.
Caesarean birth is associated with short- and long-term risks that can extend many years beyond the current delivery and affect the health of the woman, the child and future pregnancies. These risks are higher in women with limited access to comprehensive obstetric care. Caesarean sections are also costly, and high rates of unnecessary caesarean sections can therefore pull resources away from other essential health services, particularly in overloaded and weak health systems.
Dr Betran comments, “It is crucial that women who need caesarean sections are able to access this potentially life-saving procedure, but equally unnecessary procedures should be avoided, so that the lives and well-being of women and their babies are not put at risk.”
Understanding context
There are many complex reasons for the increase of caesarean section rates, and these vary widely between and within countries. Before implementing any intervention to reduce rates, research should be done which identifies and defines why rates are increasing in the particular setting, as well as what the locally relevant determinants of caesarean births are, as well as women and providers’ views and cultural norms.
In addition, interventions to reduce rates that do not address the complex, multi-faceted reasons for the increase of rates, will be likely to have limited impact. Interventions that have multiple components are likely to be more successful and are therefore more desirable.
New series
A special series of papers entitled Optimising caesarean section use, which discusses many of the issues addressed by the new WHO guideline, has been published today in The Lancet. This series of 3 papers outlines the trends and epidemiology of caesarean section rates across and within countries, the risks and benefits of caesarean section for women, and what non-medical interventions can work to reduce unnecessary caesarean sections.
In the third of these papers, the authors underline how women’s educational interventions implemented to prevent an unnecessary procedure should “provide a sense of empowerment” and “need to be implemented in conjunction with meaningful dialogue with health professionals and with those who set maternity care norms in local communities”. They argue that “these interventions should include recognition of previous experience of birth, consider short-term and long-term effects of CS on women and children, and provide effective emotional support”. In addition, the authors discuss some of the complex motivations of women and health-care providers to undertake unnecessary caesarean sections, and highlight how this complexity must be taken into account when implementing any reduction strategies. This is important so that the beliefs and attitudes of health-care providers, women, and societies can be both respected and influenced.
The series also highlights the dire disparities between and within countries in ensuring that women in need are able to access caesarean sections.
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