“An unnecessary cut?” multilevel health systems analysis of drivers of caesarean sections rates in Italy: a systematic review

Abstract

Background Improvements in medical technologies have seen over-medicalization of childbirth. Caesarean section (CS) is a lifesaving procedure proven effective in reducing maternal and perinatal mortality across the globe. However, as with any medical procedure, the CS intrinsically carries some risk to its beneficiaries. In recent years, CS rates have risen alarmingly in high-income countries. Many exceeding the World Health Organisation (WHO) recommendation of a 10 to 15% annual CS rate. While this situation poses an increased risk to women and their children, it also represents an excess human and financial burden on health systems. Therefore, from a health system perspective this study systematically summarizes existing evidence relevant to the factors driving the phenomenon of increasing CS rates using Italy as a case study. Methods Employing the WHO Health System Framework (WHOHSF), this systematic review used the PRISMA guidelines to report findings. PubMed, SCOPUS, MEDLINE, Cochrane Library and Google Scholar databases were searched up until April 1, 2020. Findings were organised through the six dimensions of the WHOHSF framework: service delivery, health workforce, health system information; medical products vaccine and technologies, financing; and leadership and governance. Results CS rates in Italy are affected by complex interactions among several stakeholder groups and contextual factors such as the hyper-medicalisation of delivery, differences in policy and practice across units and the national context, issues pertaining to the legal and social environment, and women’s attitudes towards pregnancy and childbirth. Conclusion Mitigating the high rates of CS will require a synergistic multi-stakeholder intervention. Specifically, with processes able to attract the official endorsement of policy makers, encourage concensus between regional authorities and local governments and guide the systematic compliance of delivery units with its clinical guidelines.

Has the cesarean epidemic in Czechia been reversed despite fertility postponement?

“…The courts continue to maintain the misconception that CS is the best form of intervention in terms of assuring the health of the child and mother. A similar situation has been reported by Longo with respect to Italy [ 5 , 60 , 61 ].…”

“…1 ). Currently, the CS rate in Czechia is below the average of other developed countries [ 3 – 5 ] (Fig. 2 ).…”

Characteristics and outcomes of pregnant women with placenta accreta spectrum in Italy: A prospective population-based cohort study

“…A low CS rate in the population has been already proved as the most effective way to decrease CS-related adverse outcomes, including PAS [ 36 , 60 , 61 ]. Considering that Italy holds one of the highest rate of primary and elective repeat CS among European nations [ 28 , 30 ], it is urgent to promote educational efforts to support Italian obstetricians in safely reducing primary CS and admitting women with prior CS to a trial of labor [ 29 ].…”

Which classification system could empower the understanding of caesarean section rates in Greece? A review of systematic reviews

“…A 2020 systematic review by Longo et al 22 , examined the increase in the number of CSs performed in Italy from the perspective of a healthcare system. They reported that CS rates in Italy are influenced by complex interrelationships, by several involved and specific circumstances and factors such as the over-medicalization of delivery, legal and social issues, variations in practice and policies across healthcare institutions and national nations, and women’s point of view regarding pregnancy and childbirth.…”