by Elisabetta Zocchi
In Italy caesareans are still “too many” but they are decreasing. To continue thus ensuring safety, the Italian Society of Gynecology and Obstetrics (SIGO) requests an organizational review of the birth path
31.2% of children in our country are born with a caesarean section (Cedap data, Certificates of assistance in childbirth, related to 2021). Still too many, if we consider that already in 1995 the World Health Organization indicated the limit of 10-15% to maximize the benefits while minimizing the risks of a caesarean section and, thus, protect the health and safety of mother and child. Now, the report of the National Outcome Program (PNE) 2022, which photographs the situation in 2021, confirms the improvement underway since the early 2000s, when the average number of cesareans for the first birth was around 40%, albeit “spot leopard”, due to the greater use of intervention in the South of the country (with peaks of up to 60%) and in accredited private structures. A gap which, finding no justification from an epidemiological point of view, signaled a risk of inappropriateness, if not actual abuse in the realities with the highest rates. To counter these critical issues, the WHO recommendations have been accompanied by the objectives contained in Ministerial Decree 70 of 2015 in order to correct the national trend: a maximum ceiling of caesarean sections of 25% for hospitals with over a thousand births per year and 15% for the realities under one thousand. Thus, thanks to the appeals of the scientific and public health authorities and the commitment of health professionals, the virtuous trend of decreasing caesarean sections has continued to date and birth centers continue in their “timid” march towards the goals set by the decree. But something is undeniably changing enough to highlight the flaws in the system.
The opinion of the Italian Society of Gynecology and Obstetrics
The long-standing phenomenon of falling birth rates in our country brings with it a corollary of consequences – an increase in maternal age for the first child, greater use of MAP techniques, a growing incidence of obstetric pathologies – which inevitably affect the risk factors in pregnancy and in childbirth. This is why, in determining the choice of intervention, many factors now come into play, in addition to the eminently medical ones, which involve managerial, organizational, health policy and, last but not least, cultural and psychosocial aspects. In this context, already last year the note sent to the Ministry of Health by the Italian Society of Gynecology and Obstetrics (SIGO) through the voice of its president Nicola Colacurci noted that, due to the tendential increase in medical indications for the induction of labor at 39-40 weeks (which in 30% of cases could lead to surgery) and primary cesareans, compliance with the thresholds established in the State-Regions agreement has become difficult in most birth centres. Therefore, to avoid the risk of default by numerous healthcare companies and bridge the gap between theory and practice, a revision of the parameters was requested, correcting the thresholds upwards to at least 20 and 30% respectively for the first and second level structures. This suggestion takes into account the ongoing difficulties in applying the “Hub&Spoke” model, which provides for the concentration of complex cases in reference centers with greater expertise, reserving physiology for satellite centres. An organizational criterion that should also be valid with a view to limiting caesarean sections, for example by avoiding, in the absence of contraindications, re-caesarean sections (which have a greater impact on the rate rise) thanks to the trial labor performed in contexts of excellence and evaluating the feasibility of turning maneuvers in cases of breech presentation of the fetus.
The priorities according to the SIGO President: safety and appropriateness
«Today pregnancy is increasingly perceived as a precious event, often unique in the life of future parents and often conquered at the price of great expectations and sacrifices. A state of mind that feeds an expectation of safety and appropriateness of perinatal care, which requires specialist skills, new generation technologies for monitoring maternal-fetal well-being and reinforcement of the workforce with personnel adequate in number and qualifications. Only in this way is it possible to accept the appeal of the institutions to contain the number of caesarean sections and deal with the significant increase in medico-legal disputes in the obstetric-neonatal field», explains Professor Nicola Colacurci, who continues: «The revision of the parameters for Caesarean sections in first and second level hospitals, it is necessary to support a rethinking of tariff reimbursements, which takes into account the evolution of the birth path in the years that have now passed since the signing of the State-Regions agreement at the end of 2010». In fact, the articulation of the system in first and second level hospitals does not really appear to respond to a network organization according to the Hub&Spoke scheme: «There is rarely continuity of care with a real transmission of data and a continuous flow of patients between the centers that should manage treatments and interventions of different complexity», notes the SIGO President. «Furthermore, to guarantee the safety of the mother, even a first-level birth center should equip itself with organisation, equipment and skills equal to those of a second-level centre, in order to deal with maternal emergencies and, in particular, the postpartum hemorrhage, which can occur in any birth, is the major cause of maternal death. Conversely, a second-level hospital must take charge of the management of high-risk pregnancies which, in addition to assuming responsibility, involve an increase in unrecognized costs because, in the face of long hospitalizations and intensive check-ups which allow in the neonatal intensive care, they are paid exclusively on the delivery”. Safety, therefore, is a priority that must be guaranteed according to SIGO also by arranging adequate organizational structures thanks to effective health policies.
The numbers of the cesarean: lights and shadows
In recent years, the frequency of primary caesarean section (i.e. at first birth) has decreased, going from an average of 24% in 2015 to 21% in 2021 without significant pandemic-related interference. But the use of surgical delivery remains high in structures with fewer than 500 births a year (which was scheduled to be closed in the 2010 State-Regions Agreement) and there is still a marked North-South variability and within the regions themselves. A picture which, as the PNE report points out, demonstrates a tendency to underestimate the benefits and risks associated with the different delivery methods and little attention to the verification of clinical indications. Therefore, to limit the need for a caesarean section, means, resources, multi-specialist skills and experience in the field are needed, preferably gained from a wide range of cases and supported by an effective connection with the local services. This is why compliance with current standards certainly cannot be taken for granted in all birth centers, which represent a very varied constellation internally, as noted in the note from SIGO to the Ministry of Health which set up a technical table in June for revision of the hospital care regulation (DM 70 of 2015).
And it is no coincidence that a large part (70%) of the centers with the largest volumes of activity are compliant and, therefore, prepared to express a potentially higher level of intensity of care, against the meager 14% of the realities below share a thousand. Compared to 2020, however, both second and first level hospitals in line with the parameters increased slightly (they were respectively 62.8% and 10.1%). No progress, however, in the range under 500 births which achieves the highest rates of recourse to the scalpel. The 2021 Report published by the Ministry of Health with the monitoring of the Essential Levels of Assistance according to the new guarantee system also highlights a similar picture of stalemate: if in structures under a thousand deliveries the proportion of primary caesareans remains stable compared to the previous year, there is an improvement, sometimes slight, in 11 regions exclusively in the structures above one thousand.
August 30, 2023 (change August 30, 2023 | 17:36)
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