Flat trend of high caesarean section rates in Peru: A pooled analysis of 3,376,062 births from the national birth registry, 2012 to 2020.

Background: National and subnational C-section rates are seldom available in low- and middle-income countries to guide policies and interventions. We aimed to describe the C-section rates at the national and subnational levels in Peru (2012-2020). Methods: Based on the Peruvian national birth registry, we quantified C-section rates at the national, regional and province levels; also, by natural regions (Coast, Highlands, and Amazon). Using individual-level data from the mother, we stratified the C-section rates by educational level, healthcare insurance and provider. Ecologically, we studied the correlations between C-section rates and human development index (HDI), altitude above sea level, proportion of the population living in poverty and proportion of rural population. Findings: C-section rate in Peru decreased slightly from 2012 (39·7%) to 2020 (38·0%). A widening gap of C-section rates was observed through the study years among the Coast that showed higher rates and the other natural regions that showed lower rates. The rates in most of the 25 regions showed a flat trend, particularly in the last four years and some provinces showed a very low rate. The rates were highest in mothers with higher education and in users of private health insurance. Higher HDI, health facility located at lower altitude, lower poverty and urbanization were positively correlated with higher C-section rates. Interpretation: C-section rates in Peru are above the international recommendations. Large differences by natural region, provinces and women socioeconomic status were found. Further efforts are needed to achieve the recommended C-section rates. Funding: Academy Ter Meulen grant of the Academy Medical Sciences Fund of the Royal Netherlands Academy of Arts & Sciences (KNAWWF/1327/TMB202116), Wellcome Trust (214185/Z/18/Z), Fogarty (D43TW011502).

Operación cesárea. Una revisión histórica / Caesarean section. A historical review

La operación cesárea que hoy en día realizamos de forma casi rutinaria en la mayoría de centros hospitalarios del mundo es consecuencia de una apasionante búsqueda de mejoras por las generaciones precedentes de obstetras. A lo largo de los años, la cesárea ha experimentado importantes cambios en la técnica quirúrgica, en la frecuencia de su práctica y en sus indicaciones, tanto maternas como fetales. En los siglos XVII, XVIII y XIX implicaba una elevadísima mortalidad materna, por lo que únicamente se realizaba en casos desesperados, con la esperanza del salvar al nasciturus. La introducción de los principios de asepsia-antisepsia por Semmelweis, Koch, Lister y Halsted, la sutura de la herida uterina, la incisión en el segmento uterino inferior y la incisión transversa en el segmento inferior del útero supusieron una importante disminución de la mortalidad materna. En la segunda mitad del siglo XX, el empleo de la antibio-ticoterapia, la transfusión sanguínea, el perfeccionamiento de la anestesia y de los cuidados perioperatorios, así como la modificación ulterior de algunas técnicas quirúrgicas, ha conseguido reducir ampliamente la morbimortalidad asociada a esta intervención. Todos estos cambios han conseguido que la cesárea haya pasado de ser una operación in extremis que condenaba con gran probabilidad a la paciente, a una técnica que en la actualidad es demandada por algunas mujeres como sustitución del parto vaginal.

The cesarean section is an operation routinely performed in the majority of hospitals around the world. The cesarean section came to be as an early generation of obstetricians passionately searched for a way to improve their field. Throughout the years, it has experien-ced numerous changes: the surgical technique, it's frequency, and it's medical indications (both fetal and maternal). During the 17th, 18th, and 19th centuries it implied a very high maternal mortality rate, which left it as a last resort option with the only hope to save the nasciturus. The introduction of asepsis and antisepsis (Semmelweis, Koch, Lister, and Halsted at the end of the 19th century), the suture of the uterine wall, and the transverse incision in the lower uterine segment drastically reduced maternal mortality. During the second half of the 20th century, the use of antibiotics and blood transfusions, improvements in anesthesia and perioperative care, and the further modifications to the surgical technique considerably reduced the morbidity and mortality associated with the operation. All these changes transformed the cesarean section from a surgical intervention done in extremis, where the mother would probably die, to a technique currently demanded by some women as a substitute to the vaginal delivery.

Evaluating the 'Focus on Normal Birth and Reducing Caesarean section Rates Rapid Improvement Programme': A mixed method study in England.

BACKGROUND: caesarean section plays an important role in ensuring safety of mother and infant but rising rates are not accompanied by measurable improvements in maternal or neonatal mortality or morbidity. The 'Focus on Normal Birth and Reducing Caesarean section Rates Rapid Improvement Programme' was a facilitative initiative developed to promote opportunities for normal birth and reduce caesarean section rates in England. OBJECTIVE: to evaluate the 'Focus on Normal Birth and Reducing Caesarean section Rates' programme, by assessment of: impact on caesarean section rates, use of service improvements tools and participants׳ perceptions of factors that sustain or hinder work within participating maternity units. DESIGN: a mixed methods approach included analysis of mode of birth data, web-based questionnaires and in-depth semi-structured telephone interviews. PARTICIPANTS: twenty Hospital Trusts in England (selected from 68 who applied) took part in the 'Focus on Normal Birth and Reducing Caesarean section Rates Rapid Improvement Programme' initiative. In each hospital Trust, the head of midwifery, an obstetrician, the relevant lead for organisational development, a supervisor of midwives, or a clinical midwife and a service user representative were invited to participate in the independent evaluation. METHODS: collection and analysis of mode of birth data from 20 participating hospital Trusts, web-based questionnaires administered to key individuals in all 20 Trusts and in-depth semi-structured telephone interviews conducted with key individuals in a sample of six Trusts. FINDINGS: there was a marginal decline of 0.5% (25.9% from 26.4%) in mean total caesarean section rate in the period 1 January 2009 to 31 January 2010 compared to the baseline period (1 July-31 December 2008). Reduced total caesarean section rates were achieved in eight trusts, all with higher rates at the beginning of the initiative. Features associated with lower caesarean section rates included a shared philosophy prioritising normal birth, clear communication across disciplines and strong leadership at a range of levels, including executive support and clinical leaders within each discipline. CONCLUSIONS: it is important that the philosophy and organisational context of care are examined to identify potential barriers and facilitative factors.

Twin Birth Considering the Current Results of the "Twin Birth Study"

The rate of caesarean sections in multiple births has grown sharply worldwide. The reason for this may be the results of large retrospective cohort studies from the 1990s, which displayed an increased risk of mortality and morbidity, especially for the second twin, in the case of vaginal births. Multiple monocentric analyses have not been able to confirm this. As a prospective, multi-centre randomised study, the Twin Birth Study published in 2013, in which 105 clinics in 25 countries took part, showed that, under optimum conditions, there was no difference in neonatal and maternal mortality and morbidity if the birth was planned to be vaginal or via caesarean. Detailed analyses, which would be helpful in choosing the type of birth method and obstetric management in the event of vaginal birth, have not previously been published. Retrospective studies must be referred to for this.