A Caesarean Section is Marching Around the World. What is the Danger?

The  tariff of medical reform for perinatal centers (8136 hryvnias) does not cover all their expenses and does not take into account the cost of deliveries with complications. This was announced at a briefing on May 15 by Minister of Health Maxim Stepanov. He noted that any tariff should have adjustment factors depending on the complexity of the medical intervention or the location of the hospital. Let’s try to understand the situation, considering the world experience of such differentiation of tariffs for obstetric care.

One of the most expensive diseases in obstetrics is sepsis and bleeding associated with childbirth. Such conditions really need treatment with expensive drugs. But in Ukraine in 2019, among 291,584 births, there were 15 cases of sepsis (0.0051% of the total number), bleeding – 5,416 or 1.9% of the total number of births. Of concern is the growing global trend towards caesarean section, even without clinical indications – among other things, due to the differentiation of tariffs for obstetric care.

The share of cesarean sections without clinical indications is growing  in Ukraine and the world in general.

The share of cesarean sections in Ukraine increased from 16% in 2009 to 24% in 2019. If we really want to have a positive impact on the health of expectant mothers and children, we need to invest in the prevention of complications that occur during pregnancy and childbirth, rather than stimulating unnecessary surgery intervention in the natural event of women’s lives.

In the world, the number of births by cesarean section (CR) in the absence of clinical indications since the 90’s has more than tripled – from 6% to 21%. This was reported by the International Federation of Obstetricians and Gynecologists. According to the WHO, the number of cesarean deliveries in northern Europe in 2010-2015 was 20%, while in several countries in south-eastern Europe it increased to 50% or more. WHO’s reasons for the increase include fear of pain, the convenience of such an approach for health professionals (because caesarean section can be planned and completed quickly, receiving more money for it), as well as ignorance of mothers about the health consequences after “cesarean”.

And they are as follows:

• hospitalization in neonatal intensive care units;
• the emergence of neonatal depression due to the action of general anesthesia;
• the occurrence of respiratory failure, even in full-term infants;
• problems with breastfeeding;
• the emergence of asthma, obesity and other cardiometabolic diseases in older ages;
• impaired maturation of the immune system, which contributes to an increased risk of autoimmune diseases.

The impact of CS on maternal and child health: research data

Several population-based studies have shown an inverse relationship between caesarean section (CS) and maternal and infant mortality in low-income countries [1]. In 2015, the WHO issued a statement stating that a national CS rate of up to 19% was associated with lower maternal and neonatal mortality [2]. At the same time, the proportion of CS above a certain level did not show additional benefits for mother or child, and some studies have shown that a significant proportion of CS in the total number of births may be associated with adverse effects on maternal and child health. [3, 4].

A nationwide prospective study (Netherlands) showed that routine or urgent caesarean section is associated with a fivefold (RR 5.2, 95% CI 4.8-5.6) increase in the risk of severe maternal disease [5]. Similar links have been found in population studies in other countries.

Now about the quality of medical care that has been talked about so much in recent weeks. The frequency of CS is a generally accepted indicator that indicates the quality of perinatal care. In the context of maternal health, there are two extreme situations in providing medical care: too little, too late and too much, too soon. The latter situation includes excessive medicalization and excessive instrumentalization of perinatal care [6].

Frequency of cesarean section is a global indicator of maternal health in different countries. It is quite different – too small in countries with low gross domestic product and too high in countries with moderate and high GDP.

However, according to scientists, the value of the national indicator does not reflect the real situation with the frequency of application of the CS. Even within one country after stratification by type of insurance [7, 8], financing (public or private) [8-10], by socio-financial status of the patient [11-13], these indicators can differ significantly, indicating the presence of a financial motivational component in increasing the frequency of CS.

Health care organizers, health care quality and safety professionals are concerned about the number of CS performed in the absence of medical indications for women. In 2008, 3.5-5.7 million unnecessary caesareans were performed in high- and moderate-income countries [14].

An Italian study by P. Di Giovanni (2018) found that in 66.1% of medical episodes at discharge, the main diagnosis was recorded: CS without indications [15].

Causes of “causeless” caesarean section

Scientists note that there are clear non-medical reasons for the increase in CS: organizational (lack of standardized protocols or non-compliance), economic (high cost of service), logistics and cultural.

Accordingly, the consequences after unjustified CS can be financial and medical. Cesarean section without medical indications increases the financial burden on both the individual family and the health care system, thus creating certain obstacles to universal medical coverage of all citizens [14].

According to the WHO, based on numerous studies conducted around the world, excessive use of cesarean section in the absence of medical indications (the situation is “too much and too early”) is associated with increased adverse effects on mothers and newborns [3].

Due to all the above factors, during the pilot project on the transformation of the health care system in Poltava region, any childbirth (simple, complicated and cesarean section) was paid at a single rate. This tariff was UAH 5,114. for city and district hospitals, UAH 6,648. for regional. The tariff of the NHSU for childbirth in 2020 is UAH 8,136. And this  is average tariff. It is higher than normal births (i.e. cheap) and lower than difficult births (i.e.  expensive).

By the way, the tariff for neonatal care in Ukraine (ie baby care) is the highest in the program of medical guarantees for 2020 and ranges from UAH 26,088 to UAH 98,534. Of the 121 institutions that aid in complex neonatal cases, 103 under contracts with the NHSU in 2020 received almost 3 billion UAH more than in 2019 from the subvention. In one institution it is from 1 to 121 million more. Childbirth and infant treatment are two budget-generating services for perinatal centers.

Conclusion

Thus, considering the study of the perinatal situation in other countries, we did not find any case where the differentiation of childbirth tariffs would have a positive impact on the health of mother and child. The state gets what it pays for. We will pay for cesarean sections – we will get an increase in the number of cesarean sections and risks for mother and child.