Caesarean section, a practice not always justified

Publié le : 3 April 2013

 In its supplement devoted to science and ethics, the daily La Croix examines Caesarean births.     

The newspaper looks first of all at China, which holds the world record for the rate of Caesareans: between October 2007 and May 2008, 46.2% of deliveries were by Caesarean section, according to a report published in 2010 by the World Health Organisation (WHO). Various explanations are put forward.   
First of all, "many observers say that doctors are mainly responsible, in a health system that is widely corrupt." Many witnesses "talk about the insistence of the personnel to persuade patients to choose the surgical option which is much more expensive and hence more profitable…"         
Moreover, "the Chinese one-child policy is also responsible for this high rate of Caesarean births." Thomas Lloret, deputy director of a large public hospital in Shanghai, says that this is even the principal reason: "it derives from the thinking that ‘the child is king’: there is an overprotection of the child compared to the mother, for whom the operation is more risky than normal delivery. Furthermore, we know that one of the principal risks of Caesarean section is the rupture of the uterus in the case of a second birth. But that is ruled out in China." According to Ngai Fen Cheung, midwife and director of a research unit on the midwife profession in Hangzhou university, in the majority of hospitals, "the tasks normally reserved to midwives are usually allocated to doctors or nurses. So the ill-prepared future mothers are more inclined to opt for the surgical solution."    
As a result, "lowering the rate of recourse to Caesarean section requires a deeper change in people’s mentalities and practices, of which some signs are emerging." For example, "a number of training courses for midwives have opened around the country" and "more and more maternity hospitals are actively promoting natural delivery.

The newspaper then looks at the situation in France. The French Hospital Federation (FHF) says that "the growth in the number of Caesarean sections is a problem because this growth is not medically justified." The rate of Caesarean births rose from 14% in 1991 to 18% in 2001 and then to 20.2% in 2009, a rate that has remained stable since then. In Italy and Portugal, the rate is over 30%. Professor Paul Sagot, head of the Gynaecology-Obstetrics department of the university hospital of Dijon, says that "the fact remains that we are still carrying out too many unjustified Caesareans." As with any surgical intervention, a Caesarean section is not risk-free. He points out that it "is associated with a higher risk of maternal mortality. It is still a very low one, but real nonetheless."    
As regards Caesareans for reasons of "convenience", Dr Thierry Harvey, head of the Gynaecology-Obstetrics department of the Diaconesses hospital in Paris, explains that "these requests generally involve the irrational fears of certain women about natural delivery. So we need to take the time to discuss with them and know how to resist a request that is not justified." Similarly, the gynaecologist Jacques Lansac, president of the National Commission for Obstetric and Foetal Ultrasound Scanning (CNEOF), says that "as always in medicine, there are advantages as well as inconveniences that we would like to eliminate so as to keep only the advantages! But that is not possible: so it is not ethical to carry out so-called ‘comfort’ Caesareans because they create a risk for the future mother and her child, without being justified by urgent medical reasons." Moreover, while he admits that "this practice can save lives, it must continue to be done for medical and not social reasons" and he points out that "if the social facet is allowed to determine the outcome, I fear that we are forgetting two crucial aspects: the balance of benefits and risks […] but also the universalist dimension of medicine." On this last point, the gynaecologist Jacques Lansac adds that "wealthy people demand excessive medical services for reasons of convenience" while "poor women are deprived of the minimal safety conditions for their delivery.

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