Australian and New Zealand Journal of Obstetrics and Gynaecology 2004; 44: 103 –106 103 Blackwell Publishing, Ltd. Opinion Caesarean section rate debate Will there ever be an end to the Caesarean section rate debate? Hans Peter DIETZ 1 and Michael J. PEEK 2 1 Royal Prince Alfred Hospital, Camperdown and 2 Department of Obstetrics and Gynaecology, Nepean Hospital, Penrith, New South Wales, Australia Abstract Caesarean section rates continue to rise. To date, no serious attempt has been made to address this issue. There are no scientific grounds for identifying an ‘appropriate’ level for Caesarean section rates. A ‘Term Cephalic Trial’ may provide such information, but poses major logistic and ethical challenges. The authors propose that a combination of known and newly developed predictors of emergency operative delivery may allow an antenatal risk assessment that could make intervention trials both ethically sound and logistically feasible. Key words: Caesarean section rate, operative delivery, pelvic floor trauma, risk assessment, Term Cephalic Trial. The increasing Caesarean section rate has become a major public health issue. This is mainly due to the fact that more and more women are being delivered abdominally for poorly defined medical reasons. So far, no serious attempts have been made to address the issue, although a large proportion of the population and the medical profession perceive this, rightly or wrongly, to be a problem. Over the last 30 years, there has been a seemingly inexorable rise in the rate of babies delivered by Caesarean section, and the trend shows no sign of reversing. The latest figures for Australia indicate that, in the higher age groups, Caesarean section rates in primiparous women have reached 44.2% in the private sector and 38% in public patients for women aged 35–39 years. Even higher rates are found in older women with 59.1% of women aged 40 and above in private hospitals and 46.2% in public hospitals delivered by Caesarean in 2000. 1 A significant proportion of this rise is a result of elective surgery, with approximately half of all Caesarean deliveries currently attributable to elective procedures. 1 Although the appropriate Caesarean section rate is not known, the rise in Caesarean section rates have been deplored almost universally. Alarm is expressed at high Caesarean section rates, whether in India, 2 Chile, 3 the UK, 4,5 or Australia. 1 The most common justification for such a negative assessment of current practice is a World Health Organization statement published in 1985, citing 15% as an appropriate level for Caesarean section rates 6 and an International Federation of Gynaecology and Obstetrics committee report stating that Caesarean section should not be performed for ‘non-medical’ reasons. 7 While many obstetricians in Australia and overseas would choose a Caesarean for themselves or their partners 8–10 and are prepared to perform an elective Caesarean on request, 11 negative voices prevail in the scientific literature. It is common for authors to state that ‘unnecessary Caesareans’ do more harm than good. Consequently, a rise in elective Caesarean section rates is assumed to have negative con- sequences on mother and child, as well as on the country’s public health system. The debate has become so emotional that some authors see a need to provide politically correct disclaimers in abstracts of scientific papers. 12 Increasingly however, other voices are being heard. In an editorial in the New England Journal of Medicine in 2003, 13 it is stated that ‘elective Caesarean delivery is no longer a marginal idea’. This shift in attitudes is largely the result of two developments, and neither of the two is likely to lose strength in the near future. First, the incidence of morbidity and mortality associated with elective Caesarean section continues to fall. The best data in this regard originates from the UK, with the relative risk of death associated with Caesarean delivery in the 1997–1999 triennium being two. 14 This figure includes emergency deliveries, and as the mortality of emergency Caesarean section is likely to be a multiple of elective Caesarean section, 13,15 it may be assumed that the true difference in mortality between an ‘intention to perform elective Caesarean section’ and ‘intention to deliver vaginally’ would be lower, possibly non-significant. Recent data from Israel support this contention. 16 After all, one has to consider that elective Caesarean section is not an alternative to normal vaginal delivery, but rather an alternative to attempting a normal vaginal delivery which, in a nulliparous Australian, currently implies a 60–75% likelihood of normal vaginal delivery, a 10–20% Correspondence: H.P. Dietz MD PhD FRANZCOG DDU CU, 1/68 Brook St, Coogee 2034 New South Wales, Australia. Email: hpdietz@bigpond.com Received 18 November 2003; accepted 26 November 2003.