At 37% of births a year, the rate of caesarean sections in the Cayman Islands is more than double the rate recommended by the World Health Organization.
Since 1985, the WHO has considered the ideal rate of C-sections to be 10-15% of overall births a year.
Cayman’s rate is considerably higher than the European average of 25%, and also higher than the US average of 31.7%.
According to a response to a Freedom of Information request, the Health Services Authority said 10% of C-sections are requested by the mother, and most mothers who have previously had a caesarean opt for one in later pregnancies.
The HSA stated that similar rates of C-sections exist in both the private and public sector.
Last year, Cayman recorded 832 births, meaning 308 of those babies were delivered via caesarean section.
There are a variety of reasons why Cayman has a higher-than-average number of caesareans, ranging from multiples births, diabetes complications and easy access to medical care, local obstetricians told the Cayman Compass.
Between 10% and 15% ‘ideal’ rate
According to a 2015 WHO report, since 1985, the international healthcare community has considered the ideal rate for caesarean sections to be between 10% and 15%.
The WHO report noted, “Since then, caesarean sections have become increasingly common in both developed and developing countries. When medically justified, a caesarean section can effectively prevent maternal and perinatal mortality and morbidity. However, there is no evidence showing the benefits of caesarean delivery for women or infants who do not require the procedure.”
“As with any surgery, caesarean sections are associated with short- and long-term risk which can extend many years beyond the current delivery and affect the health of the woman, her child, and future pregnancies.”
The WHO report pointed out that these risks are higher for women with limited access to comprehensive obstetric care.
Easy access to medical care
However, Cayman has extensive obstetric care available for pregnant women, with 22 OB-GYNs registered to practice on the islands. In fact, studies show that such access to medical care and continuous monitoring of expectant mothers and their unborn babies in hospital account in many developed countries for higher C-section rates than those seen in less developed countries.
Dr. Kendra Chisholm, an OB-GYN at the Health Services Authority, said many mothers request a caesarean if they have had one previously, though they are offered a ‘trial of labour after caesarean’, which is a plan to deliver vaginally, at least until something occurs that changes the plan.
“The fact is that once you’ve had a previous caesarean,” Chisholm said, “you can do a trial of labour within 18 month to two years. The highest risk is uterine rupture… However, with that choice, some moms are saying no, because they saw the convenience, even though they had to go through the recovery part of the procedure.”
Generally though, she said, the hospital does not offer C-sections to first-time pregnant women as an elective procedure.
However, C-sections are done for high-risk pregnancies or emergencies. In the event of an induction of labour, for example, if there has been no progress within 48 hours, a C-section would be done, Chisholm said.
For mothers who have had two previous C-sections, the hospital would not offer them the option of a vaginal birth, Chisholm said, as “at that stage the risk is too high”.
Another factor that often leads to a caesarean is Cayman’s high prevalence of diabetes.
Chisholm said she believes there needs to be more education about nutrition among pregnant women, as some are developing diabetes or high blood pressure during pregnancy.
“It all has to do with diet,” she said. “They’re consuming more, eating things like Wendy’s, Popeye’s, saturated in fat and high in salt. It makes the situation so much worse. They go into pre-term labour because of complications, and we have to offer emergency solutions, because the baby is showing non-reassuring CTG (cardiotocography) or there is foetal distress, and we have to offer something more invasive.”
After closely monitoring these patients, if it’s found that the baby is failing to grow or is undernourished due to blood flow issues, an early delivery is planned and the woman is induced at 36-37 weeks in some cases, Chisholm said.
“That doesn’t always mean the mom can delivery vaginally,” she said. “Some of the ones we have given emergency C-sections to are the ones we’ve put on inductions, that are already considered high risk.”
One practising obstetrician and gynaecologist on island said she had been surprised to learn that the C-section rate at the HSA was the same as that among private practitioners.
She said that in Cayman, generally, the delivery of twins or triplets, and breech births or other high-risk deliveries, are done via C-sections, though that is not the case in all countries.
The doctor stated that in her home country, caesareans would usually only be done if there was a serious problem with the pregnancy or delivery, like a uterine rupture, for example.
Inductions and C-sections usually mean a faster delivery than vaginal births, she said, which can appeal to some private practitioners so they can fit in more patients and schedule their time, but she said, “I don’t understand why the government hospital [numbers are] so high.”
She said she has observed that labour induction rates in Cayman also appear to be high.
C-section audit proposed
Doctors from the private and public sectors meet once a month to discuss cases where babies have had to be placed in the Neonatal Intensive Care Unit or have neonatal issues.
The OB-GYN said she would like to see those meetings discuss in depth cases where C-sections have been done and the reasons why. “I’d like a proper audit of one year of cases,” she said. “I’m sure if you had an audit over five years of caesareans, I think you would find only 10% is necessary.”
According to a 2015 report, the WHO found that as countries increase their caesarean section rates up to 10%, maternal and neonatal mortality decrease. However, caesarean section rates higher than 10% were not associated with reductions in maternal and newborn mortality rates.
The WHO does not recommend a specific caesarean section rate in hospitals, acknowledging that “the need for caesarean section at each hospital can vary dramatically depending of the type of population served by the hospital”. It pointed out that, for example, some hospitals tend to receive referrals of most complicated pregnancies or deliveries which, in turn, may need more caesarean sections.
In an analysis of why more women worldwide are getting caesareans, the WHO report said this was “a multifactorial phenomenon and in many cases country- and culture-specific”.
It stated, “Caesarean section has become a very safe procedure in many parts of the world to the point of considering it almost infallible. Some of the most omnipresent reasons behind this rise are the fear of pain during birth including the pain of uterine contractions, the convenience to schedule the birth when it is most suitable for families or health care professionals, or because it is perceived as being less traumatic for the baby. In some cultures, caesarean section allows choosing and setting the day of the birth according to certain believes of luck or better auspicious for the newborn’s future.
“In many countries, societal consensus has imposed a demand for the perfect outcome and doctors are sued when the results are not as expected fuelling the fear of litigation. In addition, in some societies, delivery by caesarean section is perceived to preserve better the pelvic floor resulting in less urinary incontinence in the future or sooner and more satisfactory return to sexual life.”