Rising caesarean section rates: a cause for concern?

Over the past 25 years, there has been a sustained increase in caesarean section rates in the developed world, with massive public interest, and debate, on both the causes and appropriateness of increasingly employing a surgical procedure to short circuit, or entirely bypass, labour and delivery. This debate has largely centred on the operative risks to the mother, the increased respiratory morbidity in the infant, the increased use of expensive hospital resources balanced against the reality of defensive obstetrics, maternal request, operator convenience and remuneration. A frequently quoted World Health Organisation consensus statement examined caesarean section rates and maternal and perinatal mortality rates in a number of countries and concluded that there were no additional health benefits associated with a caesarean section rate above 10% to 15%. This concept has formed the impetus for a recent national audit of caesarean section rates in the UK. However, the use of crude perinatal mortality rates may mask any benefit from caesarean section, as the main contributors to crude perinatal mortality rates, lethal anomalies and low birthweight, are not readily amenable to obstetric intervention and unlikely to be affected by caesarean section. This study re-examines the relationship between caesarean section rates and birthweight-specific perinatal mortality rates in three large maternity hospitals in Dublin over a 22 year period.