New intervention package could be key to reducing C-sections

Once upon a time, Caesarean sections (C-sections) were considered a last resort when giving birth, reserved for high-risk pregnancies or complications during labour. Now, there is an alarming upstream trend of C-sections, with recent studies suggesting one in five women globally will have a Caesarean birth.

The most critical period of a normal birthing process is second stage labour (SSL). Photo: GMB Akash / icddr,b

In Bangladesh, approximately one million C-sections are performed each year, rising from 12 per cent in 2010 to 31 per cent in 2016. According to the World Health Organization (WHO), countries should maintain their rate of C-sections to 10-15 per cent and every effort should be utilised to ensure it is carried out of medical necessity given the risk it poses to the mother and the baby.

Reducing the rate of caesarean births requires a shift in normalising vaginal deliveries among healthcare practitioners and providing and availability of quality care. Misconceptions and complications surrounding vaginal births was another reason for women opting for C-sections, including fear of labour pain, post-partum haemorrhage, episiotomy, cervical and perineal tears, and birth asphyxia among others.

The most critical period of a normal birthing process is second stage labour (SSL), when the cervix is fully dilated and the baby is delivered. WHO has developed a guideline for labour but international health policy and programming has primarily focused on the first and third stages of labour, with little attention given to the second stage. Researchers at icddr,b developed and tested an intervention package for this particular stage of the birthing process and examined the effects in easing maternal and neonatal complications. 

The intervention package comprised of regular monitoring of the vital signs that need to be performed, maintaining the woman’s preferred birthing position, providing support for using the spontaneous pushing technique, the presence of a trained healthcare provider, and a support person for the woman throughout the whole process. All the components combined greatly increases the likelihood of a successful delivery with minimal complications.

All physicians, nurses and midwives at icddr,b’s Matlab hospital were trained on the various labour positions, pushing techniques and the need for support persons during delivery. Implementing the package saw a sharp increase - 76 per cent from just 1 per cent - in adopting the lateral or upright positions, which has more advantages than the dorsal position in reducing complications.

The spontaneous pushing technique, which is considered to be more comfortable for the woman and results in fewer complications, rose in favour from 77 per cent to 97 per cent. Additionally, engaging a support person for the woman significantly increased from 2.5 per cent to 91.4 per cent. The combination of all these factors is poignant, with maternal and neonatal complications decreasing by 46 per cent between the pre-intervention and post-intervention periods.

Commenting on the future of this intervention, principal author Dr Jesmin Pervin notes “ours is the first study to assess the effects of using this package of interventions and we were greatly heartened by the positive results. Episiotomies, perineal and cervical tears were considerably reduced, as well as median blood loss during birth. This signifies that this intervention package can immensely benefit women during the second stage of labour, providing both physical and emotional comfort”.

For an intervention such as this to be successful on a larger scale, healthcare facilities need to ensure that the adequate services are available to those who are seeking it while simultaneously monitoring the quality of care so that patients are not neglected. If more healthcare professionals were trained and encouraged to promote initiatives to better facilitate SSL, it could assist in curbing the number of unnecessary Caesarean sections.