Caesarean sections in Mexico: are there too many?

GUILLERMO J GONZALEZ-PEREZ 0 MARIA G VEGA-LOPEZ 0 CARLOS CABRERA-PIVARAL 0 ARMANDO MUOZ 0 ANA VALLE 0 0 Centre for Health, Population and Human Development Studies, University of Guadalajara , Mexico This paper seeks to quantify the magnitude of caesarean sections in Mexican public health-care institutions in recent years, to characterize the evolution of caesarean section rates (CSR) during the last decade, and to estimate the possible economic cost caused by the excess of caesareans performed in these institutions. The study is based on data obtained from the health sector, both for Mexico in the 5-year period 1993-97 and for the Mexican State of Jalisco between 1983 and 1998. Linear regression analysis was used to evaluate time series, and 'excess of caesareans' was considered the number of caesarean deliveries performed above the admissible 15% CSR. The results reflect that on the national level, more than one-quarter of the deliveries handled by public institutions ended in caesarean section for each analyzed year, and if the deliveries performed in private institutions are included, the national rate is around 30%. A marked increase in CSR can be observed in Jalisco between 1983 and 1998 (almost 50%); and the cost for the nation of this CSR excess in financial terms is highly significant: several millions of dollars - obtained from public funds - are spent annually and unnecessarily by health services. The findings suggest that the increase in CSR is a public health problem that has not been satisfactorily faced by the health sector authorities. Many unnecessary caesareans would undoubtedly be avoided if the policies of these public health-care institutions were to consider, as a priority, both the known higher risk implicit in a caesarean for the health of the mother and child, and the economic impact on the country and its health institutions of the excessive number of caesareans performed yearly. Introduction The caesarean section is an operation conceived originally as a last resort to alleviate maternal or foetal conditions when there are risks posed to the mother, the foetus or both in the delivery stage. In recent decades, however, caesarean section practice has spread notably on the world level, thanks to the availability of powerful antibiotics and the development of modern surgical techniques.1 This increase has occurred in spite of the potential complications that such a procedure implies for the health of the mother and the neonate.1,2 Various authors agree when affirming that, along with purely clinical aspects, other reasons of a socio-cultural and economic character, or those related to medical practice, play a substantial role in explaining the high caesarean section rates (CSR) that have appeared during recent decades in many nations.3,4 In the mid-1980s, the World Health Organization (WHO) warned about the inadequate use of technology for childbirth, and it stated that a CSR higher than 1015% is unjustified, for whatever reason, in any region or country.5 During this period, many nations showed CSR well above 20%.5 Since the 1980s, while the CSR in developed countries such as Canada and the United States seems to have finally stabilized at around 2025%,68 and other countries, such as the Netherlands, England and Norway6,8,9 show much lower rates, in some Latin American countries the CSR has either stabilized at very high level (as appears to be the case in Brazil2,10) or continues to increase, reaching relatively high rates.11,12 Mexico has not been exempt from this rise1315 which seems The study is based on secondary data (births according to type of delivery per health institution) obtained from the National Institute of Statistics, Geography and Computation (INEGI, its acronym in Spanish) and of the health sector, both for Mexico in the 5-year period 199397, and for the State of Jalisco between 1983 and 1998 (see Tables 1 and 2). The CSR were calculated as the percentage of total hospital deliveries in which this surgical procedure was used. This calculation was performed for each of the three major health institutions in Mexico, which altogether handle more than 80% of the births that occur in the health sector at the national level.16 These institutions are: The Mexican Institute of Social Security (IMSS, its acronym in Spanish), an institution that offers health services and social security to people with stable employment (e.g. industrial and service workers, employees) and their families. The institutions budget is provided by the government, employers and workers. The Social Security Institute Serving State Workers (ISSSTE, its acronym in Spanish), an institution that offers health services to government officials essentially bureaucrats in different federal agencies and to their families. Among the population receiving these services, teachers stand out because of their large number. ISSSTEs budget is provided by the government and the workers. The Ministry of Health (SS, its acronym in Spanish), which offers medical services to the population that does not have access to Mexicos social security institutions, and who, by and large, lack the resources to receive private medical care. Thus, the institutions budget is wholly provided by the government. The State of Jalisco had nearly 6 million inhabitants in 1995, whose behaviour in terms of health resembles the national average. For example, in 1995 the life expectancy at birth in Jalisco was 73.4 years while in all Mexico it was 73 years; infant mortality rates were 27.3 and 27.8 per 1000 live births, respectively.17 It was included in the study in order to construct time series which would make it possible to perform a trends analysis, something that is not possible to do with national data. In the first place, the CSR was estimated for each institution. Then, a simple linear regression analysis was performed, taking the CSR for each institution as the dependent variable and time (measured in years) as the independent variable, to evaluate the increase in CSR in the period analyzed. The Durbin-Watson test statistic (d) was used to test for auto-correlation in the analyzed series. Also, the relative growth of the rates during the period studied, according to institution, was calculated through the formula: final CSR initial CSR initial CSR The 1996 costs for natural and caesarean deliveries at the studied institutions (from only IMSSi and ISSSTEii unfortunately the SS does not handle this information) were ascertained as: at IMSS, 2828 Mexican pesos (US$377 at 1996 exchange rate of 7.50 pesos per dollar, approximately) and 3220 Mexican pesos (US$429.33), respectively;18 at ISSSTE, 825 Mexican pesos (US$110) and 2750 Mexican pesos (US$366.66), respectively.19 As WHO considers caesarean rates over 15% to be excessive, the excess numbers of caesarean deliveries according to institution were identified that is, the number of caesarean sections performed above the admissible 1 (...truncated)