Eugene Declercq professor, maternal and child health, Fay Menacker statistician, Marian MacDorman statistician
Declercq E, Menacker F, MacDorman M.
Rise in “no indicated risk” primary caesareans in the United States, 1991-2001: cross sectional analysis
BMJ 2005; 330 :71
doi:10.1136/bmj.38279.705336.0B
Is there a role of prevention in the rise in "no indicated risk" primary cesarean section?
To the Editor:
Declercq, Menacker and MacDorman bring to light "no indicated risk" as an interesting new classification of cesarean delivery. Like other classes of cesarean delivery, annual rates of "no indicated risk" cesareans have been increasing in the United States. What surprises me about the entire situation of rising cesarean delivery in the United States, and in the world, is that preventive approaches have not often been considered.
The article by Dedlercq et al contains the statement that "the likelihood of cesarean is strongly related to age of mother and parity." There is evidence that cesarean delivery is also strongly correlated with increasing gestational age within the term period of pregnancy in low risk parturients (2). If increasing maternal age, increasing gestational age and nulliparity are all risk factors; if cesarean delivery is an outcome worthy of prevention; and if a latent period between the identification of these risks and the outcome can be identified (e.g. the term period of labor), then perhaps a preventive approach can be developed that would encourage patients with advanced maternal age and/or nulliparity to enter labor earlier in the term period of pregnancy.
An article from a group that I work with was recently published in the American Journal of Obstetrics and Gynecology that outlines this type of preventive approach (3). This method of care utilizes a relatively simple risk scoring system to estimate the upper limit of the optimal time of delivery, offers preventive induction of labor to patients that have not entered labor on or before this gestational age, and involves the use of pre-induction cervical ripening in patients scheduled for preventive induction that have an unfavorable uterine cervix (modified Bishop's score < 6).
Perhaps it is only through the use of preventive strategies that cesarean delivery rates will safely fall. As with all preventive strategies, this will require that we identify the disease, define risks for the disease, recognize a latent period between the identification of risks and disease, and develop a safe and effective intervention to prevent or reduce the incidence of the disease. While Declercq et al suggest that research be done to elucidate "whether the risks of a no indicated risk primary cesarean delivery will be offset by associated benefits," I hope that an equal amount of time and effort will be spent on developing and testing method that might prevent, or lower, rates of cesarean delivery performed for a variety of indications.
References: 1) Declercq E, Menacker F, MacDorman, M. Rise in "no indicated risk" primary caesareans in the United States, 1991-2001: cross sectional analysis. BMJ 2005;330:71-72. 2) Caughey AB, Musci TJ. Complications of Term Pregnancies Beyond 37 Weeks Gestation. Obstetrics and Gynecology 2004;103(1):57-62. 3) Nicholson JM, Kellar LC, Cronholm PF, Macones GA. Active management of risk in pregnancy at term in an urban population: An association between a higher induction of labor rate and a lower cesarean delivery rate. AJOG 2004;191:1516-28
Competing interests: None declared
Competing interests: No competing interests