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Too Much, Too Soon

In this video, Marleen Temmerman describes the concept of 'too much too soon' in maternal health care.
MARLEEN TEMMERMAN: A very warm welcome to this session on Caesarean sections. My name is Marleen Temmerman. I am a professor in obstetrics and gynaecology and in public health at the Aga Khan University in Nairobi, Kenya. The topic is Caesarean section, and more specifically optimising the rates of Caesarean sections because what we have seen in the last years is almost a doubling of the number of babies born via Caesarean section in about 15 years. In 2000, we counted 16 million babies born via Caesarean. And now, 15 years later, we are at almost 30 million, which is one baby in five, in the whole world, who is born via Caesarean section, and this is very high. There are also huge discrepancies.
There are about 44% of the babies born via CS in Latin America versus 4% in Africa. So this huge difference, also differences between the rich and the poor women in any geography. Now, what is the problem? We know– and there is no ideal rate– but we know that if there is no access to Caesarean section, or only very limited, that babies and women can die or have very serious complications of pregnancy because they cannot access the health care facilities they need where they can have access to Caesarean section and to high-level obstetrical care. On the other hand, because the surgery is quite safe, we have, in many parts of the world, too many Caesarean section, mainly for non-medical reasons.
The drivers of these increased rates are number one, C-section is relatively safe. It is very often reimbursed. The fee for the health care provider is higher with a Caesarean section than a normal delivery. And number three, now increasingly also women and families, they are asking for Caesarean section. And women are saying, I have the right to decide how I will deliver my baby. And it’s very hard to discuss women’s rights, but we think that women should be well-informed about the pros and the cons, the advantages and the disadvantages. Because with this increase of Caesarean sections, we have not seen better outcomes for the mum, not for the babies.
So we have to be very careful because Caesarean section remains a major surgery, the most common major surgery in the world, actually. So what are the dangers of too many Caesarean section? It is a surgery with potential complications, but also with a higher risk for the next pregnancy. Because once you have a scar, there is always a risk for placental infiltration and abnormalities. So your next pregnancy is at a higher risk, and you have a higher risk to have a new Caesarean section, which is not really a good health benefit.
Also for the baby, there is more and more evidence now that babies who are born mainly through elective Caesarean section that they have a higher risk and immunological disorders– asthma, diabetes, obesity. So more and more evidence is there that also for the sake of the baby, we have to make sure that we don’t use this loosely. Many babies are also born preterm because we don’t know exactly the gestational age. The gynaecologist is not sure. So then they have an additional problem of prematurity. So what can we do about it? We know the drivers of the epidemic. And what we need, there are interventions with proven benefit to reduce the high Caesarean section rate.
And some countries like Scandinavian countries, even Portugal, China have proved with good policies that you can reduce your Caesarean section rates. For example, if there is a breech delivery, you can allow, in many cases, to have a trial of labour. There is also proof that a companion during childbirth can reduce anxiety, and fear, and so on, and can produce a better outcome. So there are a number of interventions, and mainly also educational interventions. Women have to be aware of the pros and cons, and they have to be aware that there are alternatives. Many women fear pain, so you could advise epidural anaesthesia or painkilling during labour.
So what we are doing now, we have published a number of papers in The Lancet showing what is happening in that area, showing what can be done to reduce Caesarean section and using this as a call, launching it together with the obstetricians, gynaecologists, with the midwives, with the women agencies to call upon everyone to try to optimise Caesarean section rates. And every woman who needs it who is in danger, every baby who is in danger should have access. On the other hand, we should not use it too often. I’m going to stop here, but this is actually my key messages. And those who want to know more about it can read The Lancet series that we published last year.
And it is actually supported by a new publication in The Lancet showing that women in Africa are 50 times at higher risk of dying from Caesarean section than, for example, in the Western world. So a lot needs to be done– investing in health care, investing in normal delivery with midwifery and gynaecologists share care companions in labour, a lot of information, a lot of education trying to offer Caesarean section where needed where only Caesarean section will help us to do better than normal delivery.

In this video, Prof Marleen Temmerman will discuss the concept of “too much, too soon” (TMTS), with an example of overuse of caesarean section births. TMTS refers to care provided before, during and after childbirth which can be too much, inappropriate and over-medicalised. TMTS describes overuse of non-evidence-based interventions, as well as overuse of interventions that are lifesaving if practiced appropriately but can cause harm if they are overused or applied routinely.

What are the issues?

  • Unnecessary medical interventions (i.e., overuse of episiotomies, medically unnecessary caesarean section)

  • Lack of evidence: conflicting recommendations within guidelines on harms and benefits of interventions.

  • Unnecessary interventions can be a financial burden to the health system. The cost is exacerbated if the interventions results in unnecessary harm that would require treatment.

What can be done?

  • High quality guidelines combined with consistent and proper use within clinical practice worldwide

In the next step we will discuss care which is ‘too little, too late’ which is describing provision of care below evidence-based standards, lacking adequate resources, or care which is unavailable or withheld until it is too late.

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