Background: Caesarean deliveries are one of the most commonly performed surgeries in this world. However, the past decades have witnessed a gradual rise in the caesarean section rate in India as well as worldwide. The objective of this present study is to analyse the rate and indications of caesarean delivery over a five year period in 7 Air Force Hospital, Kanpur, Uttar Pradesh. Methods: This is a retrospective study that analysed the rate and indications of caesarean delivery that took place over five years from 01 Jan 2019 to 31 dec 2023. Data of the patients was obtained from the hospital records and statistical analysis was done. Results: There was an overall rise in the rate of caesarean delivery from 21.3% in 2019 to 32.2% in 2023. Previous caesarean status was the most common indication. There was an increase in primary caesarean section as well from 10% in 2019 to 24% in 2023. At the same time, there was a reduction in the incidence of neonatal birth asphyxia from 1.28% in 2019 to 0.5% in 2023. Conclusion: Efforts should be made to ensure that every caesarean delivery is medically justified and that every patient who needs a caesarean delivery receives it on time, instead of trying to achieve a specific rate of caesarean delivery. At the same time, patient education, better intrapartum care, improved monitoring of labour and regular audits can help us minimize the rate of caesarean delivery over time.
Caesarean deliveries are one of the most commonly performed surgical procedures in the world. It is a surgery to deliver the fetus by giving incision over the abdomen and over the uterus. In recent years, there has been an increasing trend towards caesarean deliveries in most of the countries. As per WHO, the rate has nearly doubled from 12.1% in 2000 to 21.1% in 2015 (1). In India, we have witnessed a gradual increase in the rate of caesarean deliveries as well,from 17.2% during National Family Health Survey-4 (NFHS-4 (2015-16)) to as high as 21.5% during NFHS-5 (2019-21)(2). The reason behind this rise is multifactorial. The most common indication is fetal distress, followed by previous caesarean delivery and antepartum haemorrhage. Maternal request is the most common non-medical indication(3).
Caesarean deliveries are lifesaving surgeries for both the mother and the baby when medically indicated. However, in the recent years there has been a growing public concern regarding the increasing rate of caesarean section (3)(4). WHO in the past had suggestedthat if the rate of caesarean section exceeds10-15%, it may not lead to better maternal and neonatal outcomes. This statement has been criticized for several reasons and so WHO released a statement in 2015 mentioning that every effort should be made to provide caesarean sections to a woman in need rather than to achieve a specific rate (1)(5).
The present study was conducted in a zonal hospital in Kanpur, Uttar Pradesh. The objective of this study was to analyse the rate and indications of caesarean delivery performed over a period of five years.
This is a retrospective study of all deliveries that had taken place from 01 Jan 2019 to 31 Dec 2023 in 7 Air Force Hospital, Kanpur, Uttar Pradesh. This hospital is a zonal hospital that caters to the need of serving soldiers, ex-servicemen and their dependents. This hospital cares for over 1000 deliveries every year.
The objective of this study is to analyse the trend and indication of caesarean deliveries in our institute. The data was obtained from the hospital records after necessary permission was obtained from the institutional ethical committee.
Year |
Total delivery
|
Caesarean delivery |
CS rate |
2019 |
1094 |
233 |
21.3% |
2020 |
1027 |
307 |
29.9% |
2021 |
896 |
238 |
26.6% |
2022 |
1069 |
282 |
26.4% |
2023 |
1176 |
379 |
32.2% |
Table 1: Year wise deliveries, LSCS and LSCS rates
Year |
Primary LSCS |
Primary LSCS rate |
2019 |
96 |
10% |
2020 |
159 |
18% |
2021 |
140 |
17.5% |
2022 |
168 |
17.5% |
2023 |
251 |
24% |
Table 2: Year wise Primary LSCS and primary LSCS rate
|
2019 |
2020 |
2021 |
2022 |
2023
|
Previous LSCS status
|
137 (58.8%) |
148 (48.2%) |
98 (41.17%) |
114 (40.43%) |
128 (33.77%) |
Abnormal lie/presentation (breech/transverse lie)
|
31 (13.3%) |
34 (11.07%) |
36 (15.13%) |
22 (7.8%) |
31 (8.18%) |
Fetal distress |
24 (10.3%) |
45 (14.66%) |
33 (13.87%) |
50 (17.73%) |
65 (17.15%) |
Non-Progress of Labour
|
06 (2.58%) |
29 (9.45%) |
25 (10.5%) |
28 (9.93%) |
72 (19%) |
Failed Induction |
07 (3%) |
21 (6.84%) |
18 (7.56%) |
22 (7.8%) |
40 (10.55%) |
Second stage arrest |
08 (3.43%) |
10 (3.28%) |
11 (4.62%) |
20 (7.09%) |
20 (5.28%) |
Antepartum Hemorrhage (Placenta previa/ Abruptio placenta) |
10 (4.29%) |
8 (2.6%) |
6 (2.52%) |
10 (3.55%) |
7 (1.85%) |
Multifetal Gestation |
10 (4.29%)
|
12 (3.91%) |
11 (4.62%) |
9 (3.19%) |
7 (1.58%) |
Total |
233 |
307 |
238 |
282 |
379 |
Table 3: Year wise indications of LSCS, frequency and rate
|
Frequency of birth asphyxia
|
Rate |
2019 |
14 |
1.28% |
2020 |
10 |
0.97% |
2021 |
10 |
1.11% |
2022 |
9 |
0.84% |
2023 |
6 |
0.5% |
Table 4: Year wise frequency and rate of birth asphyxia
The analysis shows an overall rising trend in the incidence of cesarean deliveries in our hospital from 21.3% in 2019 to 32.2% in 2023 (Table 1). There rate of primary caesarean sections has more than doubled from 10% in 2019 to 24% in 2023 (Table 2).
In all these five years the commonest indication for caesarean deliveries has been previous caesarean status. Abnormal lie/presentation was the second most common indication in 2019 and 2021 respectively, whereas fetal distress was the second most common indication in 2020 and 2022. Caesarean delivery due to non-progress of labour was second most frequent indication in 2023 after previous caesarean status (Table 3).
Along with rising caesarean rate, there was also a more than double reduction in the frequency of birth asphyxia from 1.28% in 2019 to 0.5% in 2023 (Table 4).
The increasing frequency of caesarean deliveries has been a growing public health concern. In South Asia the frequency has increased from 7.2% to 18.1% between the year 2000 to 2015 (1). The frequency has also been increasing in India from 17.2 % (2015-16) to 21.2% (2019-21) as per the data from National Family Health Survey (NHFS) (2). Several studies have tried to explain the causes behind this. Studies have suggested that increase in maternal age at childbirth, rising maternal obesity and increase in multifetal gestation in the recent times have been important contributing factors(6)(7)(8). Changes in obstetric management for breech presentation, multifetal gestation, suspected growth retardation and reduction in the willingness of instrumental delivery are some of the other important factors (6) (9). Caesarean delivery on maternal request has been found to be the most common non-medical factor. The main reason behind this is fear of labour pain and perineal trauma, as well as convenience and certainty. Cervical laceration, vaginal tear, and the stress of healing and recovery plays in the back of the mind of most individuals. Apart from this, a good “Mahurat” or an auspicious time for childbirth as per religious beliefs plays an important role in the decision making even in the educated and elite class of women in the Indian society(10)(11).
Fear of litigation among obstetricians is another important non-medical factor. Obstetrics is one of the leading specialties in terms of litigation risks and cost. The care provider has to ensure a good outcome for both the mother and the fetus, and the prevailing norms in the present scenarios such as a growing intolerance towards complications compels the obstetrician to keep a lower threshold towards caesarean deliveries (12)(13).
Our study has shown a rising trend of caesarean section rate in our hospital from 21.3% in 2019 to 32.2 % in 2023. The most common indication in all these five years has been previous caesarean status. Trial of labour in post caesarean patients is usually not practiced in our hospital as a routine. This is mostly because of doubtful scar strength, unavailability of details regarding previous caesarean delivery and unwillingness of the patients for a trial of labour.
Fetal distress, abnormal presentation/lie and non-progress of labour have been fairly common indications as well. These indications are also responsible for the increase in the primary caesarean section rates, from 10% in 2019 to 24% in 2023. Efforts are being made to reduce the primary caesarean rate by implementing suitable protocols for labour induction, judicious use of various methods for labour augmentation and the use of partogram/ WHO Labour Care Guide in every cases. It is also worth noting that along with the rising rate of caesarean delivery, the incidence of birth asphyxia has also reduced from 1.28% 2019 to 0.5% in 2023. This is mainly because of better methods of monitoring during labour and early intervention measures that are being practiced in this hospital.
A growing rate of caesarean section has been seen as a matter of concern in public health(14)(15). However, instead of aiming to achieve a specific rate, efforts should be made to ensure that every caesarean delivery is medically justified and that every patient who needs a caesarean delivery receives it on time. The WHO statement released in 2015 has also emphasized the same (1)(16).
Improving intrapartum care and better monitoring facilities will not only help to identify complications on timebut will alsohelp in deciding whether a patient requires caesarean delivery or not. The WHO Labour Care Guide published in 2020 is a great manual for this purpose(17). It is based on current evidence, and is different from previous partograms regarding labour duration, timingfor clinical intervention and emphasis on respectful maternity care.
Regular audits at the institutional level will also help in identifying the cohort of patients where the rate of caesarean deliveries can be reduced through appropriate measures. The use of Robson’s classification is an essential tool in this regard (18)(19). This simple-to-use classification system is easily reproducible and allows to easily identify target groups of patients where interventions can be made to reduce the overall rate of caesarean deliveries.
At the same time, patient education regarding labour and how to handle it is of great importance. It will help in allaying the fear and concerns about childbirth and perineal trauma, and therefore, will help in better decision making as per as caesarean delivery on maternal request is concerned. Awareness about vaginal birth after caesarean (VBAC) and its advantages can also help patients make an informed decision, and this may lead to a reduction in the overall rate of cesarean deliveries.
Conflict of interest: None
Funding Received: None