Zdenek Hájek, Lucia Haaková, Dušan Kolarík

E-mail:hajekz@vfn.cz

At the end of the seventies and beginning of the eighties, in countries with the most modern perinatal care, we have seen rapid growth in the indications for operative delivery with the aim of lowering perinatal mortality [2,3]. The international study of the WHO, ”Having a Baby in Europe,” [4] found increasing differences in the frequency of both caesarian sections and vaginal operative deliveries (forceps, vacuum extraction). This has been one of the most significant differences in obstetric care between the individual European countries [6]. However, with the increase in operative deliveries, there has not been a proportional decrease in perinatal mortality. The increase in expenses (longer hospital stay, maternal and neonatal complications) has also not been proportional to the benefits (decreased perinatal mortality and morbidity) [8,9,11]. Thus we have started to evaluate the cost effectiveness of the increase in obstetric operations [7,11]. And that is why, in some countries with a high frequency of obstetric operations, there has been an attempt to decrease their frequency. In the Czech Republic, the increasing trend has been delayed relative to western countries, due to the concept of perinatal care as well as the differences in the conditions under which this care was possible until the year 1989 [2]. Currently, the Czech Republic has reached a low perinatal mortality, comparable on the international level, with a low frequency of caesarian sections [2,3].

CS : Caesarean section, PM : Perinatal mortality

The aim of the study was to determine the professional and economic aspects of the increase in obstetric operations in a large Perinatology Center in Prague, in the Czech Republic. Between 1955 and 1999, we evaluated the increase in the number of caesarian sections and forceps deliveries in relation to the number of total deliveries and in relation to the trend in perinatal mortality (Tab.1). In the perioperative period, we noted the incidence of complications in comparison to the length of hospital stay and the increase in expenses. The complications were classified as severe (coagulopathy, sepsis, hysterectomy), moderate (hypotonia, subfascial and uterine hematomas, urinary tract injuries), and mild complications (blood loss greater than 700 ml associated with anemia). In the Czech Republic, the average length of hospital stay after caesarian section or forceps delivery was compared with the extended hospital stay related to the mentioned complications and the increase in expenses in CZK. The average hospital stay after an uncomplicated vaginal delivery is 3 days, after a caesarian section the stay is 6 days. Nationally, we evaluated maternal mortality in relation to the type of operative delivery. On the basis of statistical results in the Czech Republic, in recent years, the overall mortality after caesarian section is stated in comparison to the total number of caesarian sections performed and in comparison to the overall maternal mortality (Fig.1).

Since 1955, in our department, there has been almost an 8-fold increase in the number of caesarian sections, and the perinatal mortality has decreased 5.5 times. The number of vaginal obstetric operations (forceps deliveries) has remained constant between 2-3%. We noted the greatest increase in the frequency of caesarian sections in the last 5-6 years. In an analysis of the perioperative complications in 1998, we found that of the 687 caesarian sections performed there were 116 complications that prolonged the hospital stay and thus significantly increased medical care expenses. The frequency of complications, 16.8%, extended the hospital stay by an average of 13.6 days, and the expenses increased by approximately 713,000 CZK (Tab.2 and 3). This sum includes only one day at the postoperative intensive care unit. Not all expenses are included in the mentioned sum (administration of transfusions, whole blood, fresh frozen plasma, special antibiotics). In 9 cases of severe complications (coagulopathy), the expenses for one patient hospitalized at the Dept. of Anesthesiology and Resuscitation were tens to hundreds of thousands CZK.

The total lethality of caesarian sections in the Czech Republic decreased from 0.88 per 1000 in the period 1988-90 to 0.49 per 1000 in the period 1991-97. The direct relation to CS in the evaluating periods from 0.44 to 0.24 per 1000. Despite of this, the risk of deaths due to caesarian sections was 4.4 times higher compare to total maternal mortality. The proportion of lethal complications related to caesarian section was 44% in the period 1978-1990. This proportion increased to 61% during the period 1991-1997 (Fig.1)

The decrease in perinatal mortality has not only been a result of the increase in obstetric operations but also and primarily due to the improvement in neonatal care, which has led to a decrease in early neonatal mortality, and also due to the overall improvement in prenatal care [2]. The benefit of the increase in caesarian sections grows until reaching 10%, while further increase has no influence on lowering the perinatal mortality [2,3]. The increase in low- and high-risk states in pregnancy (vaginal delivery after a prior caesarian section, breech presentation delivery) plays a role in the gradual increase in caesarian sections [6,10]. Another factor influencing the frequency of caesarian sections is the obstetrician’s anxiety of a lawsuit in the case of neonatal death or disorders in the child. In the complicated cases, the constantly rising medical expenses negatively influence the hospital’s budget. In the Czech Republic, the frequency of complications after caesarian section is between 15-20% [1,2]. This is alarming since 60% of maternal deaths are directly or indirectly related to caesarian section [1]. The stated expenses for the hospital stay of 713,000 CZK, are not the complete expenses. In the cases with severe complications such as coagulopathy or cases where hysterectomy was performed, with the possibility of additional complications, the expenses increase several-fold. These expenses are in hundreds of thousands CZK. Often, even mild complications such as wound infection, unnecessarily prolong the hospital stay [5,11]. It would be advantageous to solve these situations in the frame of ”home care.” However, in the Czech Republic, home care is not at an adequate level. Thus several complications, including the mild ones, are treated in the hospital setting, which is more expensive than home care. Most of the complications after caesarian section occur in acute cases- emergent caesarian sections. The complications after elective caesarian section are comparable to those after spontaneous vaginal delivery [6,12]. However, this last statement is misleading, since it could lead to a further increase in the number of obstetric operations, for example by the patient’s decision. In the Czech Republic, this indication has been discussed, but as yet it has been rejected. On a national level, the maternal mortality is alarming, although it is low at 0.11 per 1000,but in 61% of the cases is a association to caesarian section and in 29% is a direct relation to this operation.

1. In the year 2000, in our Perinatology Center, the frequency of caesarian sections has reached 18.9%.
2. The decreased perinatal mortality (5.1 per 1000) is not due to the increase in caesarian sections, but to improved neonatal care (decreased early neonatal mortality) and improved prenatal care.
3. The frequency of complications at our department is between 15-20%. In 1998, we noted 116 complications associated with caesarian section and the expenses for the basic medical care reached 713,000 CZK. With the inclusion of intensive care (for example in the case of coagulopathy) the expenses reach hundreds of thousands CZK.

4. On a national level, in more than 50% of caesarian sections is a direct or indirect association to maternal mortality.