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RESEARCH ARTICLE
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Abstract
Background: Rates of caesarean section are progressively increasing in many parts of the world. As a result of
psychosocial factors there has been an increasing tendency for pregnant women without justifiable medical
indications for caesarean section to ask for this procedure in China. A critical examination of this issue in relation to
maternal outcomes is important. At present there are no clinical trials to help assess the risks and benefits of
caesarean section in low risk women. To fill the gap left by trials, this indication-matched cohort study was carried
out to examine prospectively the outcomes of caesarean section on women with no absolute obstetric indication
compared with similar women who had vaginal delivery.
Methods: An indication-matched cohort study was undertaken to compare maternal outcomes following
caesarean section with those undergoing vaginal delivery, in which the two groups were matched for nonabsolute indications. 301 nulliparous women with caesarean section were matched successfully with 301 women
who delivered vaginally in the Maternal and Childrens Hospitals (MCHs) in Shanghai, China. Logistic regression
model or binomial regression model was used to estimate the relative risk (RR) directly. Adjusted RRs were
calculated adjusting for propensity score and medical indications.
Results: The incidence of total complications was 2.2 times higher in the caesarean section group during
hospitalization post-partum, compared with the vaginal delivery group (RR = 2.2; 95% CI: 1.1-4.4). The risk of
haemorrhage from the start of labour until 2 hours post-partum was significantly higher in the caesarean group
(RR = 5.6; 95% CI: 1.2-26.9). The risk of chronic abdominal pain was significantly higher for the caesarean section
group (RR = 3.6; 95% CI: 1.2-10.9) than for the vaginal delivery group within 12 months post-partum. The two
groups had similar incidences of anaemia and complicating infections such as wound complications or urinary
tract infection.
Conclusions: In nulliparous women who were at low risk, caesarean section was associated with a higher rate of
post-partum morbidity. Those requesting the surgical procedure with no conventional medical indication, should
be advised of the potential risks.
Background
Rates of caesarean section are progressively increasing in
many parts of the world, particularly among developing
* Correspondence: wangbingshun@sjtu.edu.cn; lifeng.zhou@waitematadhb.
govt.nz
1
Department of Biostatistics, Shanghai Jiao Tong University School of
Medicine, 227 South Chongqing Road, Shanghai 200025, PR China
2
Planning and Funding, Waitemata District Health Board, Private Bag 93-503,
Takapuna, North Shore 0740, New Zealand
Full list of author information is available at the end of the article
countries such as China [1-4]. In many Chinese hospitals, the caesarean section rate was more than 40%,
while in some cases, it was up to 80% [2-4], which was
much higher than the acceptable caesarean rate (5-15%)
in WHOs guidelines [5]. Although the rate of caesarean
section resulting in the best outcome for mothers and
children continues to be a matter of debate, it is evident
that a better outcome (including lower morbidity and
2010 Wang et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Methods
This study was an indication-matched cohort study, comparing women who had caesarean section with a comparable low risk group of women who had vaginal delivery
(Figure 1). It involved pregnant women without obstetric
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indications (subgroup C and F in Figure 1) or with relative medical indications (subgroup B and E in Figure 1)
for caesarean section, in other words low risk pregnant
women. Women with absolute medical indications for
caesarean section were excluded (subgroup A and D in
Figure 1). There are different classification systems
recommended for use in high or low caesarean delivery
rate settings [20]. The absolute and relative indications
for caesarean section in this study, which are shown in
Table 1, were classified according to the Practice Guidelines for Gynaecology and Obstetrics in Shanghai [21] and
the opinions of the expert team on this project.
Patient selection
This study was undertaken in three district level Maternal and Childrens Hospitals (MCHs) in Shanghai. The
inclusion criteria were: 1) older than 20 and younger
than 35 years; 2) more than 37 weeks gestation at delivery; 3) nulliparous; 4) no history of induced abortion
(including medical abortion and surgical abortion);
5) no history of heart, liver, lung, kidney, endocrine or
psychiatric diseases resulting in hospitalization; 6) planning to have the delivery at the present MCH and planning to live in Shanghai after delivery. The exclusion
criteria were: 1) unmarried, divorced or widowed; 2) a
history of spontaneous abortion; 3) multiple foetus;
4) more than 42 weeks gestation at delivery; 5) low
birth weight (less than 2500 g); 6) the presence of absolute indications for caesarean section.
Nulliparous women were selected because of the
One-Child family planning policy in China. Moreover,
this restriction should avoid possible confounding by
parity in the analysis.
Women meeting these inclusion and exclusion criteria
were enrolled in this study, and women with relative
indications or without any obstetric indication for caesarean section were finally accepted following preliminary screening in the antenatal clinics and re-screening in
the maternity wards after birth. The exposure group of
eligible women included those with no identified risk
and some with relative indications for caesarean section.
The control group included some who had relative indications, but did not proceed to caesarean section.
The research team took no part in the clinical care of
the women and did not participate in the decision to
have a caesarean section.
The women in the caesarean section group were
matched with those who delivered vaginally (Figure 1).
The matching criteria were:
1. The absence of any indication for caesarean section (subgroup C and F in Figure 1).
2. The presence of a relative indication (subgroup B
and E in Figure 1). Where possible the women were
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Figure 1 Group classification and matching. a Women with absolute medical indications for caesarean section were excluded in the study;
Women with relative indications in the caesarean section group were matched with those who delivered vaginally; c Women with no indications in
the caesarean section group were matched with those who delivered vaginally.
Data collection
the study (Figure 2). Details recorded were demographic characteristics, smoking habits, alcohol use and
medical history. In addition, the weight and height
before pregnancy and health events and medicine use
during pregnancy were recorded. A post-partum questionnaire was completed by interview in conjunction
with the obstetrical record. The data recorded were
method of delivery, gestational weeks at delivery, medical events during delivery, and the occurrence of complications post-partum. The volume of blood loss was
recorded from the start of labour until two hours postpartum by a measurement cup (when losing a large
amount of blood) and weighing gauzes. Post-partum
haemorrhage (PPH) was defined as the total loss of
blood of more than 400 ml from the start of labour
Relative indications
* The categories of indications were set down according to the Practice Guidelines for Gynaecology and Obstetrics in Shanghai [21] and the opinions of the expert
team on this project. Accordingly, foetal distress refers to the presence of meconium in the amniotic fluid concomitant with increased or decreased foetal heart
rate. Lactic acidosis assessment is not generally available.
Page 4 of 10
Figure 2 Flow diagram of screening, matching and follow-up indicating losses from the original cohort of the study. a The preliminary
screening was conducted in the antenatal clinics and re-screening in the maternity wards after birth; b Eligible women in the caesarean section group
were matched with those who delivered vaginally (Figure 1) according to the matching criteria; c Post-partum investigations were made in the
maternity wards, and follow-up of 1 month, 6 months and 12 months post-partum in the Maternity and Child Health Institutes affiliated to MCHs.
Page 5 of 10
Results
A total of 1460 pregnant women were screened for eligibility at the antenatal clinics between 2001 and 2003.
There were 933 women who met the inclusion criteria
and had no exclusion criteria. Of these, 301 had caesarean section and were matched successfully with 301
women who delivered vaginally.
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Women in both groups had a similar duration of gestation when delivered (c2 = 0.46, P = 0.64), with most at
25.4 2.7
24.9 2.6
20.4 2.7
20.0 2.5
18 (6.0)
24 (8.0)
23 (7.6)
25 (8.3)
16 (5.3)
11 (3.7)
127 (42.2)
127 (42.2)
Foetal distress
Cephalopelvic disproportion
104 (59.8)
49 (28.2)
117 (67.2)
46 (26.4)
Other indications
21 (12.1)
11 (6.3)
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RR
95%CI
aRR*
Total complications
29 (9.4)
15 (5.0)
1.9
1.1-3.5
2.2
95%CI
1.1-4.4
Haemorrhage#
12 (4.0)
2 (0.6)
6.0
1.4-26.6
5.6
1.2-26.9
Infection$
7 (2.3)
3 (1.0)
2.3
0.6-9.0
2.3
0.5-9.8
Puerperal fever
13 (4.3)
10 (3.3)
1.3
0.6-2.9
1.8
0.7-4.5
Some patients had more than one. When fever and infection co-existed in a woman, it was counted only once in the total morbidity statistics.
#
Post-partum haemorrhage was defined as the total loss of blood more than 400 ml from the start of the labour until 2 hours post-partum [22].
$
Including endometritis, wound infection, urinary infection.
episiotomies due to infection or abscess. The most frequent problems within one year after discharge included
anaemia, reproductive tract infection, wound complications
and waist/back pain. No statistically significant differences
were found for these events in the two groups (Table 4).
The incidence of chronic abdominal pain was 4.4% and
1.7% respectively in the caesarean section group and vaginal delivery group (adjusted RR = 3.6, 95%CI 1.2-10.9)
(Table 4). There were 5 women (6 times) rehospitalized
for medical reasons within one year post-partum respectively in both groups (c2 = 1.17, P = 0.28). Four women
were rehospitalized within one month post-partum: one
due to fever and one due to mastitis in the caesarean section group, and two women due to mastitis in the vaginal
delivery group. There were four women rehospitalized
between one and 6 months post-partum: three women
due to fever, mastitis and gallstone respectively in the caesarean section group, and one woman due to adenoma of
the parathyroid in the vaginal delivery group. Three
women were rehospitalized between 6 and 12 months
post-partum: all three women were in the vaginal delivery
group, two women due to ruptured corpus luteum cyst
and one woman due to ectopic pregnancy.
Discussion
Caesarean section is now the most frequently performed
major obstetric operation in China. In some areas,
Table 4 Clinical events within one year after discharge by mode of delivery
Factor
RR
95%CI
aRR*
95%CI
Anaemia
40 (13.6)
40 (13.5)
1.0
0.7-1.5
1.2
0.7-1.8
RTI
20 (6.8)
26 (8.87)
0.8
0.4-1.3
1.0
0.5-1.8
Wound complications
31 (10.5)
32(10.9)
1.0
0.6-1.5
1.2
0.7-1.9
Waist/back pain
60(20.3)
50 (17.0)
1.2
0.9-1.7
1.2
0.8-1.7
13 (4.4)
5 (1.7)
2.6
0.9-7.2
3.6
1.2-11.0
Rehospitalization
5 (1.7)
5$ (1.7)
1.0
0.3-3.4
0.7
0.2-3.6
# The clinical event was counted only once when women had the same outcome twice or more after discharge from hospital at 1, 6 and 12 months postpartum.
* Adjusted for propensity score and medical indications.
Wound complications refers to incisional pain without infection and delayed healing of abdominal incisions and episiotomies due to infection or abscess not
manifested while in hospital, all reported at follow-up interviews.
$ There were 5 women (6 times) rehospitalized due to medical reasons within one year post-partum in the vaginal delivery group.
Page 8 of 10
Incidence of infection
Conclusion
Caesarean section in low risk nulliparous Chinese women
carries increased risks over vaginal delivery. Those
requesting caesarean section without conventional obstetric indications or medical indications for mother or foetus, should be advised of these potential risks.
Additional material
Additional file 1: The first additional file is compressed by open
source software 7-Zip (http://www.7-zip.org/). The additional file 1
includes 11 separate questionnaires, which were originally written in
Chinese for the study. They were converted from the original WORD
version to Adobe PDF format.
Additional file 2: The additional file 2 is in Microsoft WORD format.
It includes two supplementary tables to make the context of the study
clearer.
Acknowledgements
This study was supported by Grant Number 30070667 from the National
Natural Science Foundation of China. The authors work was independent of
the funder. We thank all the medical doctors and nurses in Putuo MCH,
Jiading MCH and Yangpu MCH in Shanghai for their great work in enrolling
the participants and follow-up. We also thank Ms Zheng Biyu and Ms Tang
Guici for coordinating aspects in the study fields.
Author details
1
Department of Biostatistics, Shanghai Jiao Tong University School of
Medicine, 227 South Chongqing Road, Shanghai 200025, PR China. 2Planning
and Funding, Waitemata District Health Board, Private Bag 93-503, Takapuna,
North Shore 0740, New Zealand. 3264 Highgate, Roslyn, Dunedin 9010, New
Zealand. 4Department of Epidemiology and Social Sciences, Shanghai
Institute of Planned Parenthood Research, 2140 Xie Tu Road, Shanghai
200032, PR China. 5Center for Clinical Epidemiology and Biostatistics,
University of Pennsylvania, 507 Blockley Hall, 423 Guardian Drive,
Philadelphia, PA 19104-6021, USA. 6International Peace Maternity and Child
Health Hospital, Shanghai Jiao Tong University School of Medicine, 910
Heng Shan Road, Shanghai 200030, PR China. 7Shanghai Womens Health
Institute, 122 South Shan Xi Road, Shanghai 200040, PR China.
Authors contributions
BW undertook the field work, completed the data analyses and draft. LZ
designed and supervised the study and was the study guarantor. DC
critically reviewed the draft and modified the text significantly. HL drafted
the paper under supervision of LZ. YZ, LPZ and XG helped to design the
study. YG assisted with managing the project. WY and EG provided expert
knowledge during the design and made comments on the draft. All authors
read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 17 December 2009 Accepted: 2 December 2010
Published: 2 December 2010
Page 9 of 10
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