Beyond numbers: the multiple cultural meanings of rising cesarean rates worldwide

Birth and breastfeeding dynamics in a modernizing indigenous community

BACKGROUND

Changes in health care access and birthing practices may pose barriers to optimal breastfeeding in modernizing rural populations.

OBJECTIVES

We evaluated temporal and maternal age-related trends in birth and breastfeeding in a modernizing Maya agriculturalist community. We tested 2 hypotheses: (1) home births would be associated with better breastfeeding outcomes than hospital births, and (2) vaginal births would be associated with better breastfeeding outcomes than cesarean births.

METHODS

We interviewed 58 Maya mothers (ages 21-85) regarding their births and breastfeeding practices. General linear models were used to evaluate trends in birthing practices and breastfeeding outcomes (timing of breastfeeding initiation, use of infant formula, age of introduction of complementary feeding, and breastfeeding duration). We then compared breastfeeding outcomes by location (home or hospital) and mode of birth (vaginal or cesarean).

RESULTS

Timing of breastfeeding initiation and the rate of formula feeding both increased significantly over time. Younger mothers introduced complementary foods earlier, breastfed for shorter durations, and formula fed more than older mothers. Vaginal hospital births were associated with earlier breastfeeding initiation and longer breastfeeding durations than home births. Cesarean births were associated with later breastfeeding initiation, shorter breastfeeding durations, and more formula feeding than vaginal hospital births.

CONCLUSION

We have observed temporal and maternal age-related trends toward suboptimal breastfeeding patterns in the Maya community. Contrary to our first hypothesis, hospital births per se were not associated with negative breastfeeding outcomes. In support of our second hypothesis, cesarean versus vaginal births were associated with negative breastfeeding outcomes.

Demand and supply factors affecting the rising overmedicalization of birth in India

OBJECTIVE

To understand the interaction between health systems and individual factors in determining the probability of a cesarean delivery in India.

METHODS

In a retrospective study, data from the 2007-2008 District Level Household and Facility Survey was used to determine the risk of cesarean delivery in six states (Punjab, Delhi, Maharashtra, Andhra Pradesh, Kerala, and Tamil Nadu). Multilevel modeling was used to account for district and community effects.

RESULTS

After controlling for key risk factors, the analysis showed that cesareans were more likely at private than public institutions (P<0.001). In terms of demand, higher education levels rather than wealth seemed to increase the likelihood of a cesarean delivery. District-level effects were significant in almost all states (P<0.001), demonstrating the need to control for health system factors.

CONCLUSION

Supply factors might contribute more to the rise in cesarean delivery than does demand. Further research is needed to understand whether the quest for increased institutional deliveries in a country with high maternal mortality might be compromised by pressures for overmedicalization.

Caesarean delivery and subsequent pregnancy interval: a systematic review and meta-analysis

Background

Caesarean delivery has increased worldwide, however, the effects on fertility are largely unknown. This systematic review aims to compare subsequent sub-fertility (time to next pregnancy or birth) among women with a Caesarean delivery to women with a vaginal delivery.

Methods

Systematic review of the literature including seven databases: CINAHL; the Cochrane Library; Embase; Medline; PubMed; SCOPUS and Web of Knowledge (1945 - October 2012), using detailed search-strategies and reference list cross-checking. Cohort, case–control and cross-sectional studies were included. Two assessors reviewed titles, abstracts, and full articles using standardised data abstraction forms and assessed study quality.

Results

11 articles were eligible for inclusion in the systematic review, of these five articles which adjusted for confounders were combined in a meta-analysis, totalling 750,407 women using fixed-effect models. Previous Caesarean delivery was associated with an increased risk of sub-fertility [pooled odds ratio (OR) 0.90; 95% CI 0.86, 0.93]. Subgroup analyses by parity [primiparous women: OR 0.91; 95% CI 0.87, 0.96; not limited to primiparous women: OR 0.81; 95% CI 0.73, 0.90]; by publication date (pre-2000: OR 0.80, 95% CI 0.68, 0.94; post-2000: OR 0.90, 95% CI 0.86, 0.94); by length of follow-up (<10 years: OR 0.81, 95% CI 0.73, 0.90; >10 years: OR 0.91, 95% CI 0.87, 0.96); by indication for mode of delivery (specified: 0.92, 95% CI 0.88, 0.97; not specified: OR 0.81, 95% CI 0.73, 0.90); by cohort size (<35,000: OR 0.79, 95% CI 0.67, 0.92; >35,000: OR 0.90, 95% CI 0.87, 0.95), by definition of sub-fertility used divided into (birth interval [BI]: OR 0.89, 95% CI 0.84, 0.94; inter-pregnancy interval [IPI]: OR 0.91, 95% CI 0.85, 0.97; and categorical measures: OR 0.81, 95% CI 0.73, 0.90); continuous measures: OR 0.91, 95% CI 0.87, 0.96) were performed. Results of the six studies not included in the meta-analysis (which did not adjust for confounders) are presented individually.

Conclusions

The meta-analysis shows an increased waiting time to next pregnancy and risk of sub-fertility among women with a previous Caesarean delivery. However, included studies are limited by poor epidemiological methods such as variations in the definition of time to next pregnancy, lack of confounding adjustment, or details of the indication for Caesarean delivery. Further research of a more robust methodological quality to better explore any underlying causes of sub-fertility and maternal intent to delay childbearing is warranted.