Copyright 2001 R. Klimek

"Operative deliveries, professional and economic aspects."

ZDENEK HÁJEK, LUCIA HAAKOVÁ, DUŠAN KOLARÍK

Introduction
Materials and Methods
Results
Discussion
Conclusions
References


Abstract Since 1995, at our Perinatology Center (the Department of Obstetrics and Gynecology of the 1^st Faculty of Medicine and Charles University, Prague), there has been a rapid increase in the frequency of caesarean sections. In the year 2000, the frequency reached 18.9% (with a national frequency of 13%). The low perinatal mortality of 5.1 per 1000 is not only related to the increased frequency of operations but mainly with the improvement in neonatal and prenatal care. In 1998, the number of complications after caesarean section was 16.8%. The expenses for basic medical care have reached 713,000 CZK, when including intensive care in the cases with severe complications (coagulopathy, hysterectomy) the expenses are in the hundreds of thousands CZK. On a national level, the maternal mortality is alarming, although it is low at 0.11 per 1000, but in 60% of the cases there is a direct or indirect association to caesarean section.
Key words: caesarean sections, complications, economic aspects

Introduction

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 caesarean 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 caesarean sections [2,3].

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Materials and Methods

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 caesarean sections and forceps deliveries in relation to the number of total deliveries and in relation to the trend in perinatal mortality (Tab.1).

Table 1. Operative deliveries and perinatal mortality in the period (1955 - 2000). Gynaec.Obstet.Dept. 1st Faculty of Medicine,Charles Univ., General Hosp. Prague.

Year	deliveries	CS	%	forceps	%	PM ‰
1955	3650	80	2,2	106	2,9	23,6
1965	4680	104	2,2	178	3,8	22,3
1975	6031	306	5,1	109	1,8	16,3
1985	3625	360	9,9	80	2,2	11,7
1995	3580	589	16,5	82	2,3	10,1
1996	3665	562	15,3	132	3,6	10,8
1997	3558	576	16,2	107	3,0	9,1
1998	3586	687	19,2	100	2,8	8,0
1999	3335	619	18,6	37	1,1	5,8
2000	3407	644	18,9	75	2,2	5,1

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 caesarean 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 caesarean 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 caesarean section is stated in comparison to the total number of caesarean sections performed and in comparison to the overall maternal mortality (Fig.1).


Figure 1. The proportion of lethal complications related to caesarean sections.

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Results

Since 1955, in our department, there has been almost an 8-fold increase in the number of caesarean 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 caesarean sections in the last 5-6 years. In an analysis of the perioperative complications in 1998, we found that of the 687 caesarean 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.2,3).

Table 2. Peroperative and postoperative complications of caesarean sections in 1998 (n= 687) Gynaec.Obstet.Deptm, l^st Medical School, Charles Univ.,General Hospit.,Prague

Type of complication	No	%
Serious complications*	9	1,3
Moderate complications **	23	3,3
Mild complications ***	83	12,0
TOTAL	116	16,8

*	serious complications: coagulopathy, sepsis, hysterectomy
**	moderate complications: hypotonia, subfascial and uterine haematomas, urinary tract injuries,endometritis
***	mild complications: anaemia, blood loss >700cc, wound infection

Table 3. The duration of hospital stay of the patients with perioperative complications after CS and the additional expenses (CZK) in 1998 (CS=687)

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 caesarean 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 caesarean sections was 4.4 times higher compare to total maternal mortality. The proportion of lethal complications related to caesarean section was 44% in the period 1978-1990. This proportion increased to 61% during the period 1991-1997 (Fig.1).

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Discussion

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 caesarean 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 caesarean section, breech presentation delivery) plays a role in the gradual increase in caesarean sections [6,10]. Another factor influencing the frequency of caesarean 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 caesarean section is between 15-20% [1,2]. This is alarming since 60% of maternal deaths are directly or indirectly related to caesarean 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 caesarean section occur in acute cases- emergent caesarean sections. The complications after elective caesarean 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 caesarean section and in 29% is a direct relation to this operation.

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Conclusions

1. In the year 2000, in our Perinatology Center, the frequency of caesarean sections has reached 18.9%.
2. The decreased perinatal mortality (5.1 per 1000) is not due to the increase in caesarean 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 caesarean 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 caesarean sections is a direct or indirect association to maternal mortality.

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References

1. Srp B.,Velebil P.(1999) Proportion of caesarean section and main causes of maternal mortality during 1978-1997 in the Czech Republic. Ces.Gynek.64:219-223
2. Štembera Z. (1995) Development of the frequency of Obstetric operations and perinatal mortality in the Czech Republic, as Compared with other countries. Ces.Gynek.60:131-138
3. Notzon F.C. (1990) International differencies on the use of obstetrical nterventionas. J.Amer.med.Ass.263:3286-3291
4. Having Baby in Europe. WHO Regional Office for Europe ICP/MCHA Copenhagen: 1-181
5. Kirkinen P.(1988)Multiple caesarean sections: outcome and complications. Brit.J.Obstet.Gynaec.95:778-782
6. Joffe M.,Chapple J., Paterson C. et al.(1994) What is the optimal caesarean section rate? An outcome based study of existing variation. J.Epid.Comm.Health 48:406-411
7. Stafford R.S.(1990) Caesarean section use and source of payment:an analysis of California Hospital discharge abstracts. Amer.J.Publ.Health.80:313-315
8. Sachs B.P.,Yeh J.,Archers D.et al.(1987) Caesarean section related maternal mortality in Massachusetts 1954-1985. Obstet.Gynec.69:696-700
9. Pettiti D.B.(1985) Maternal mortality and morbidity in caesarean section. Clin.Obstet.Gynec.28:763-768
10. Nielson T.F.,Hokegard K.H.(1984) Caesarean section and intraoperative surgical complications. Acta Obstet.Gynec.scand.63:103-108
11. Štembera Z.,Holub,J (1996) Hospitalisation during pregnancy-Professional vs. economic aspects. Ces.Gynek.61:332-337
12. Beck C.K.,Klingemann H.,Dallacker W. et al.(1992) Emergency caesarean section analysis of 143 emergency sections. Geburtsh.Frauenhk.52:96-102

Department of Obstetrics and Gynecology, 1^st Faculty of Medicine, Charles University and General Hospital,Prague Czech Republic

Zdenek Hájek
Department of Obstetrics and Gynecology, 1^st Faculty of Medicine and General Hospital Apolináoská 18, 128 51,Prague 2,Czech Republik, E-mail:hajekz@vfn.cz

This work was financially supported by the grant of the Internal Grant Agency of the Ministry of Health,No.4837-3

Table 1. Operative deliveries and perinatal mortality in the period (1955 - 2000). Gynaec.Obstet.Dept. 1st Faculty of Medicine,Charles Univ., General Hosp. Prague.

Year	deliveries	CS	%	forceps	%	PM ‰
1955	3650	80	2,2	106	2,9	23,6
1965	4680	104	2,2	178	3,8	22,3
1975	6031	306	5,1	109	1,8	16,3
1985	3625	360	9,9	80	2,2	11,7
1995	3580	589	16,5	82	2,3	10,1
1996	3665	562	15,3	132	3,6	10,8
1997	3558	576	16,2	107	3,0	9,1
1998	3586	687	19,2	100	2,8	8,0
1999	3335	619	18,6	37	1,1	5,8
2000	3407	644	18,9	75	2,2	5,1

Table 2. Peroperative and postoperative complications of caesarean sections in 1998 (n= 687) Gynaec.Obstet.Deptm, l^st Medical School, Charles Univ.,General Hospit.,Prague

Table 3. The duration of hospital stay of the patients with perioperative complications after CS and the additional expenses (CZK) in 1998 (CS=687)

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