News | Sunday, 14 December 2008

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High Caesarean rates put doctors under the spotlight

With over a third of births delivered as Caesarean sections, our hospital practices raise questions on how lightly this major surgery is being taken

Matthew Vella
Malta has officially one of Europe’s highest rates of Caesarean sections – over a third of nationwide deliveries – a statistic that is raising questions over the country’s approach towards childbirth, especially within private hospitals.
The European Perinatal Health Report, an EU-financed statistical project, this week ranked Malta the fourth-highest EU country for Caesarean sections at 28.3% of total deliveries.
The ranking is only based on 2004 data for all countries, and ignores Malta’s actual rate of Caesarean sections, which last year stood at 32.3% – only a slight decrease from 2006 (34.8%).
But the EPHR also found Malta with the highest rates of planned Caesareans and induced labour, raising the spectre of more doctors choosing to induce mothers’ labour, for their personal or the hospital’s convenience.
It would mean a doctor can schedule a date for the delivery, come in at the morning, induce the mother’s labour by administering a drug, and by late afternoon deliver the baby and go back home in the evening – rather than having to wait for the labour to take its course naturally, which could take hours, and end up with ungodly 3am deliveries.
The high Caesaean rate has also promted Health Minister John Dalli to promise an investigation into the matter.
A frank admission comes from Dr Frank Portelli, the chief executive of St Philip’s Hospital, who told MaltaToday the sheer majority of deliveries are planned, Caesarean sections.
“It is true that some 90% of Caesareans are planned in the private sector,” Portelli said.
The practice is especially true of private hospital consultants, who cannot pass on their patients to other professionals. Short of waiting for mothers to endure their labour naturally, which could involve an unexpected day or time for delivery, they can induce it on a particular date that will suit their timetable, or the hospital’s particular arrangements for daytime surgery.
“They usually opt for a date, always in line with clinical guidelines, to induce the birth. On the other hand, in the public sector doctors don’t need to be present at the moment of birth, which is actually done by juniors or the midwife,” Portelli said.
Portelli also revealed that at St Philip’s, around 50% of total deliveries were by Caesarean section. “Caesarean rates tend to be higher in private hospitals because a patient there can be assured of a consultant to perform the operation. In some private hospitals abroad, the rate is 80% but at St Philip’s the rate is likely to be around 50% of total deliveries.”
Portelli said more Caesareans were being performed at Mater Dei now, since doctors were opting for the services there. “We had 46 deliveries at St Philip’s this year when previously we would have a couple of hundred,” Portelli said.
Portelli said it’s the criteria for performing c-sections that had to be examined. “If the criteria are clinically sound then there is no issue.”
But the high rate of Caesareans in developed countries is slowly becoming an accepted practice, one which the EPHR’s authors describe as a “long standing cause of concern” because the World Health Organisation mantains that there is “no justification” for any region to have Caesarean section rates higher than 10-15%.
Central to the EPHR’s worries are the high rates of induced labour, and that about half of all c-sections are planned or undertaken before the onset of labour.
This certainly rings true for Malta’s rate of Caesarean deliveries.
Of the 1,243 Caesarean deliveries last year, 652 (52%) were planned. Reasons may include previous c-section, medical conditions of mother or child, or multiple pregnancy.
In contrast, a Caesarean done during labour by necessity is termed an emergency Caesarean section. In 2007, these totalled 591 (48%), of which 267 were performed after labour was induced by drugs or artificial rupture of membranes. The rest of c-sections, 324, followed spontaneous onset.
“The importance of children today is such that mothers will instantly go for a c-section upon the first sign of trouble, if doctors recommend it,” Frank Portelli said.
“And at the end of the day, it involves keeping infant mortality down,” Portelli added, who said children were more ‘precious’ today as the birth rate falls and families becoming smaller.
“We should be looking at neonatal, infant and maternal mortality. Infant mortality is a good measure of the state of health of the nation, and UNICEF figures appear to do us justice, putting us ahead of Greece, Poland and Hungary, but behind northern Europe,” Portelli said.
But it also true that between 1995 and 2007, Caesarean sections in Malta increased by 16%, a figure that mirrors similar rates in other countries.
And in 2003, it was revealed in parliament that 114 out of the 348 deliveries (32%) in private hospitals in 2002 were Caesareans; compared with the 23% rate in St Luke’s Hospital that year.
Neither Portelli nor Dr Josie Muscat, chief executive of St James hospital group, revealed the number of deliveries for 2007 by the time of going to print. None of them said they had a problem with revealing the number of Caesarean deliveries.

Private ways
Veterean gynaecologist Donald Felice does not rule out the fact that convenience plays a part in private hospitals’ propensity for planned Caesareans, although he lists a host of other factors.
“In private hospitals it’s the consultant who delivers the baby, and that means you must stand by the mother, from weeks in advance. It means you can’t go abroad, not even go to Gozo, or to a party if you’re going to drink. If you’re not keen about that kind of waiting around, then it’s more likely that younger doctors wanting to make good money will be ready to take on a number of deliveries.”
Felice points out other factors for the high rate of Caesareans.
“One of them is big baby weight, a consequence of diabetes and obesity in the country, where over a third of our babies weigh more than 3.5kg, when the average weight is 3.2kg.
“The fact that abortion is illegal means that, in the case of abnormal births, Caesarean delivery is more common of such babies – abroad, women might choose to abort the baby.”
Felice also points that the “select population” that makes use of private hospitals, might be more inclined to demand Caesarean delivery.
“Some mothers demand it, fearing damage to their vaginal muscles. Whether this may be misguided or not, there is always a medico-legal problem if something goes wrong. I do my best to explain the natural process, and that c-sections carry certain risks. But we are finding it difficult to resist this attitude because the chances of something going wrong are always there: and litigation is becoming more common nowadays.”

Midwives’ concerns
Midwives are among the health workers who are mostly concerned at the high Caesarean rates. They question whether Caesareans – which involves major abdominal surgery – gets done as a matter of course rather than for medical necessity.
“A delegation of midwives from the European Midwives Association has already questioned Malta’s high rates,” Maria Cutajar, the vice-president of the Malta Union of Nurses and Midwives said.
“The fact is that Malta’s rate of induced pregnancies is growing, which means it is more likely that a Caesarean section will follow induction. I don’t know why we don’t have an audit by the health department on obstetrics. I would think that the alarm bells should be ringing by now.”
Cutajar said more mothers don’t want to pass through a normal delivery so it was normal to accede to such requests.
“Normal deliveries in private hospitals also don’t pay out insurance money, unlike Caesarean deliveries,” Cutajar said, referring to the financial interest in opting for expensive, medical surgery.
Cutajar said that when five Caesarean deliveries are planned on a particular day, midwifery and nursing resources get stretched to the full, while on the next day it is likely that no deliveries will be scheduled.
“There aren’t enough midwives or nurses, especially when you consider the midwifery course had been closed for six years, and then opened only intermittently. We are short of staff and we don’t actually foresee the number of Caesareans in a day: we are faced with a fait accompli because it is doctors who decide.”

Going for a C-section
Malta is not alone in the landscape of rising Caesarean deliveries.
In the UK, 24% of deliveries were Caesareans in 2007, as they were the year before. Similarly to Malta, about half were emergencies, and the rest pre-planned.
The Royal College of Midwives said the rate was “worryingly high”, linking it to a shortage of midwives. “There is clear evidence that some Caesarean sections are unnecessary and put women and babies at risk,” Cathy Warwick, general secretary of the RCM said earlier in September. Even in the US, Caesarean sections have been breaching the WHO threshold every year since 1996. There, hospitals fear that they will be sued, and instead of using methods such as allowing a woman to walk – in order to encourage a breech baby to turn – or waiting for labour to progress, obstetricians jump straight to Caesareans.
The Royal College of Midwives points out that society’s tolerance for pain has become “significantly reduced” and that women have lost their confidence in their ability to give birth, which is why they are scared of pain. Some mothers fear the effects of loosened vaginal muscles. Other reasons include a lack of information on vaginal birth, or a low awareness on the risks of Caesareans. A more suspect reason is the payout from insurance companies. Private hospitals may be paid more by insurance companies to perform a Caesarean than they are for a vaginal birth, although it might not necessarily be the case in Malta. Doctors are also urged to speed up deliveries so that a hospital can tend to as many patients as possible in the shortest amount of time.

mvella@mediatoday.com.mt

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