Caesarean section surgical techniques: all equally safe

8 www.thelancet.com Vol 388 July 2, 2016 Since 1985, a caesarean section rate of 10–15% has been deemed optimum by the international health-care community. When caesarean section rates rise towards 10% across a population, maternal and newborn deaths decrease; when they are higher than 15%, there is no evidence of reduced mortality. Complications of caesarean sections can be substantial and sometimes permanent for both mothers and babies, and can result in disability or death, especially in settings with inadequate facilities or capacity to undertake safe surgery and treat surgical complications. Despite this evidence, fi ndings from 150 countries show that the number of caesarean sections being done worldwide has increased to unprecedented levels, currently at 19% of all births worldwide ranging from 6% to 27% in low-income and high-income regions, respectively. In some countries, caesarean section rates are up to 50%, mainly in the private sector, including in Brazil, Iran, and Mexico, resulting in millions of women undergoing unnecessary surgery. In 2008, 3·18 million additional caesarean sections were needed and 6·20 million unnecessary caesarean sections were done. The cost of the global excess caesarean sections was estimated to be US$2·32 billion, with the cost of the global needed caesarean sections about $432 million. The need to reverse these trends notwithstanding, the primary need is to ensure safe and high quality standards for this very common surgical intervention. Astonishingly, no standard evidence-based guidelines exist for caesarean sections and much variation is apparent between what is considered best practice; diff erences include blunt versus sharp abdominal entry, single versus double layer closure, closure versus non-closure of the peritoneum, and polyglactin sutures over chromic catgut. For that reason, the results of the CORONIS trial reported by the CORONIS collaborative group in The Lancet are important for healthcare providers. The CORONIS trial is a pragmatic international 2 × 2 × 2 × 2 × 2 non-regular fractional, factorial, unmasked, randomised controlled trial done at 19 sites in Argentina, Chile, Ghana, India, Kenya, Pakistan, and Sudan. Women were enrolled if they were to undergo their fi rst or second caesarean section through a planned abdominal incision. In 2013, the researchers reported the short-term outcomes associated with diff erent surgical techniques at caesarean section in 15 935 women in low-income and middle-income countries. Blunt versus sharp abdominal entry was compared, as well as exteriorisation of the uterus for repair versus intra-abdominal repair, single versus double layer closure of the uterus, closure versus nonclosure of the peritoneum, and chromic catgut versus polyglactin-910 for uterine repair. On a range of these short-term outcomes, up to 6 weeks after delivery, no clear benefi ts of any of the comparisons were reported. Primary outcomes of the CORONIS follow-up study in The Lancet include pelvic pain, deep dyspareunia, hysterectomy, and outcomes of subsequent pregnancies. 13 153 (84%) of 15 633 women were followed up for an average of 3·8 years, and no signifi cant diff erences were recorded in long-term outcomes, including pelvic pain, deep dyspareunia, incisional hernia, intra-abdominal adhesions, outcomes of subsequent pregnancies, hysterectomy, and the morbidity and mortality of children. Overall, severe adverse outcomes were uncommon in these settings. The CORONIS collaborative group’s follow-up study has some limitations, such as a lower than anticipated subsequent pregnancy rate (44% vs 80%), and a high incidence of caesarean section before the onset of labour in subsequent pregnancies, which lowers the power of the study to look at uncommon events. Nevertheless, it is the largest trial on caesarean section surgical techniques so far, with a signifi cant follow-up. The researchers noted Caesarean section surgical techniques: all equally safe