PubMed1998
For more than twenty-five years, the cesarean rate in France, as in other developed countries, has continued to increase, and in 1995 was 15.9%. Cesareans are now taken for granted by the general public, who are usually unaware of their consequences for maternal mortality and morbidity and continue to consider this form of delivery as the safest for the new born child. Yet it has been clearly demonstrated that cesarean deliveries are associated with higher rates of maternal and perinatal morbidity than vaginal deliveries and that they increase maternal mortality by a factor of from 5 to 7. From an economic standpoint, cesareans are between two and three times more expensive than vaginal deliveries. The two main indicators which account for the increase in cesareans are cicatricial uterus and dystocia. These are indicators in which individual practitioners' normal practice and the fear of medical malpractice suits play a clear role. There appears to be a particular correlation between the proportion of cesareans and obstetricians' insurance premiums, obstetricians' own assessment of the risk of malpractice suits and the number of complaints lodged against hospitals or individual doctors. Cesareans performed on grounds of fetal suffering or breech deliveries represent a diminishing proportion of the total. The use of scalp pH and radiopelvimetry have made it possible to restrict the number of cesareans based on these indicators. Other factors play a role in this increase, such as parity, education level, type of maternity insurance, whether the hospital is private or public, whether or not there is a neonatal resuscitation unit, the size of the city and the obstetrician's experience and type of training. The time and day or delivery have also been shown to be relevant factors. For obstetricians themselves, the higher fees earned from cesareans do not appear to be important. Of more relevance is the opportunity they offer doctors to organise their schedule and save time. Among the various methods proposed for reducing the cesarean rate, a strict definition of and respect for the indications for a cesarean, involving comparisons between establishments and between practitioners, have been shown to be effective. To allow such figures to be compiled, France should therefore produce for each confinement a standard record containing the different perinatal data, as is already the case in numerous other countries.