Cesarean Section Deliveries In Paraguay: A comparison of trends between 1995 and 2008
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University of Washington Abstract Cesarean Section Deliveries In Paraguay: A comparison of trends between 1995 and 2008 Jiasong Yuen Chair of the Supervisory Committee: Donna M. Denno Associate Professor, Pediatrics, Joint Global Health, Adjunct Health Services Background: Cesarean section (CS) can be a life saving intervention and is an important component of Emergency Obstetric and Newborn Care. However, unnecessary CS represents a resource drain on health care systems and is associated with increased maternal and neonatal morbidity and mortality. Objective: To identify maternal factors associated with an increase in cesarean section (CS) rates from 16.7% in 1995 to 35.6% in 2008 in Paraguay. Study Design: Retrospective analysis of 1995 and 2008 Paraguay Demographic and Sexual and Reproductive Health Survey data. Main outcome measures: The change in CS rates between 1995 and 2008. Results: The proportion of CS births is higher in 2008 (35.6%, 95% CI 32.9-38.4%) than in 1995 (16.7%, 95%CI 14.9-18.6%). The home birth rate in 2008 decreased by 72.9%. This decrease accounted for approximately 33.3% of the change in CS rate. Despite an only slight increase in the proportion of women delivering in private facilities in 1995 (16.7%, 95%CI 14.7-18.9%) compared to 2008 (20.6%, 95%CI 18.0-23.3%), there was a 53.8% increase in delivery by CS in public facilities, and a 71% increase in private institutions from 1995 to 2008. This higher rate of increase in private institution CS delivery accounted for approximately 32.8% of the change in CS rate between 1995 and 2008. Of the women who had a live birth in the 5 years preceding the survey, 72.6% and 86.3% of those who had a previous CS delivery ended up having a repeat CS delivery in 1995 and 2008, respectively. Other important factors that were associated with CS delivery included living in Asuncion and in urban areas more generally, higher socioeconomic and education levels, increasing frequency of prenatal care visits, pre-term delivery and having health insurance. Conclusion: A change in where births occurred was a contributor to the increase in CS rates, but did not account for all of the change, as CS rates increased regardless of institution of birth. The combination of overall increasing CS rates regardless of institution, a shift away from home births and from public to private institutions (which in general have higher CS rates) means that the observed overall rates increased more than the within institution rates. Efforts to increase skilled birth attendance at deliveries must be balanced by informed, patient-centered delivery decision-making. Expectant mothers and health care providers in Paraguay need to be better informed about the risks and benefits of both vaginal and CS delivery. This could help dispel misconceptions that CS delivery is a superior standard of care, especially among the wealthy. Community-based education approaches that allow women to exchange reproductive health information with family and friends have been shown to be particularly effective. Nurse-led relaxation classes, birth preparation classes, and implementing guidelines with mandatory second opinion can lead to a small reduction in CS rates. Seeking local opinion leaders' endorsement of VBAC guidelines may increase the proportion of women with previous CS being offered TOL in appropriate settings. Policy makers must attempt to regulate and prevent unnecessary procedures in the short term, but also look to address any underlying issues in the healthcare system that encourage institutions and professionals to misuse and overuse CS procedures for institutional and personal financial gains, especially in private institutions.
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