From therapeutic to elective cesarean deliveries: factors associated with the increase in cesarean deliveries in Chiapas

We performed a retrospective, crosscut, descriptive, observational study to analyze cesarean births in Chiapas from 2011 to 2014 employing different databases and a statistical analysis.

The results of the descriptive analysis (Table 1) show that approximately 40% of the 349,058 certified births, during the 2011–2014 period, corresponded to women who had their first or second child by C-section, i.e., approximately 9% less than the national figure of 49%. A frequency analysis revealed that C-sections occurred more frequently for the first or second pregnancy, and decreased as the total number of pregnancies increased.

Over the study period, the frequency of women having C-sections varied according to the maternal age: <18-years-old (30% had C-sections), 18–24-years-old (33%), 25–34-years-old (39%), 35–44-years-old (42%), and ≥45-years-old (30%). There was also a direct relationship between cesarean births and the mother’s level of schooling: 72% of women with university or graduate degrees had C-sections, whereas 23% of women who did not attend school or did not finish primary school had C-sections.

Only 21% of women who had one or fewer prenatal checkups had C-sections, whereas 41% of those who had ≥6 checkups had C-sections. Women who began prenatal checkups during the first trimester of their pregnancy had a higher C-section frequency than did those who began later (40% and 29%, respectively); C-sections accounted for 23% of deliveries for women not receiving prenatal care.

The percentage of cesarean births reached 86% among women attending private medical facilities, whereas it was 23% in IMSS-Oportunidades (now known as Prospera) facilities.

Women residing in municipalities with an indigenous presence had a C-section frequency of 43%, compared with 32% of women in municipalities with dispersed indigenous population and 25% of women in municipalities with an indigenous population. Among women who registered their child’s birth in Chiapas municipalities having lower HDIs, 2.4% had C-sections; that number rose to 48.1% among women giving birth in municipalities with higher HDIs.

In this study, we not only confirmed the findings reported in previous publications [4, 12, 13, 16, 44], but also offered additional insights on the factors associated to the increase of C-sections. Some variables that produced categorical results are related with the type of facility where the delivery occurred. For example, a cesarean birth is more likely to occur in private medical facilities [36‐38] than in public facilities. Another variable is the direct relationship between C-sections and the mother’s level of schooling, as previous studies have shown [41, 44‐50]. Whilst it could be thought that maternal age and schooling are both associated, in Chiapas this does not occur owing to the women education lag. Of the total number of women over 15 years of age in Chiapas, 36.2% are illiterate and 77.1% have incomplete basic education [51]. Therefore, it can be said that if schooling is taken into account, regardless of age, women with professional or postgraduate studies are more likely to have a cesarean delivery.

Our results indicate that single women are 17% more likely to have C-sections than those in the reference group. Among these women, 55% were <24-years-old and 12% were <18-years-old. Similarly, 87% were primigravida or secundigravida. These results coincide with those of a study carried out among Peruvian adolescents undergoing C-sections, with a similar demographic profile. Specifically, 62% were single and 82.1% were primigravida [52]. Therefore, the possibility of having a C-section increases when a woman is single, <24-years-old, and primigravida. These factors may highlight the vulnerability of single women to cesarean delivery.

An important finding of this study is the inclusion of structural variables, such as HDIs and SIL municipalities. When women had attained higher educational levels and socioeconomic development, they were more likely to undergo C-sections than women who were more disadvantaged (as previous studies have shown [41, 44‐46]).

Contrary to previous reports [19, 53, 54], more C-sections occurred in municipalities with indigenous populations, suggesting that an indigenous woman delivering at a healthcare institution has a greater possibility of undergoing a cesarean delivery. For decades, international organizations have emphasized the lag in healthcare access among indigenous populations, and the need for countries to increase their coverage of these populations [54‐56]. Therefore, we are interested in deepening on the strategies designed to expand this coverage, and the attendant effects, to indigenous women.

The Mexican government’s goal of reducing maternal mortality (MM) has been linked to the medicalization of childbirth. One strategy involved centralizing healthcare in states with larger indigenous populations [26, 57]. A nationwide study revealed a rate of maternal mortality (RMM) of 85 in municipalities with ≥70% SIL, which is more than twice the RMM of 37 in municipalities with <40% SIL [58]. Based on these results, we surmise that hospitals may be performing cesarean deliveries to avoid turning away patients who do not arrive in active labor and who, having been rejected, do not return. Early arrival or early labor may be a C-section risk factor (in primigravida patients <3 cm dilated and multigesta 6 cm) [59].

In 2016, the Committee to Promote Safe and Voluntary Maternity in Chiapas surveyed the opinions of 1986 women (381 expectant mothers and 1605 mothers with children <3-years-old) in towns with >80% SIL in the Chiapas region of Los Altos and in the city of San Cristóbal de Las Casas. The study aimed to evaluate the perinatal care preferences of indigenous women. The results indicated that only 25% of this population preferred hospital care. The rest of these women preferred care offered by midwives, relatives, or healthcare personnel in their own communities. However, this database mainly included indigenous women who were enrolled in the public health program because they received monetary transfers. These programs force women to change their maternity care practices [60].

The conditional cash transfer program in Mexico has increased C-section rates among the rural and poor sector; women who are considered to be high-risk are sent to a second level of care and are scheduled for C-sections with the effect of increases in the disposable income of the cash transfer.

Similarly, the fact that 40% of first or second births are cesarean deliveries may reflect a new strategy to resolve overcrowding in public obstetric/gynecology facilities in Chiapas. This suggests that childbirth medicalization is linked to the increased C-section rate in this area.

We also found a positive relationship between the number of prenatal checkups and the C-section rate. The relationship between the number of prenatal checkups and the increased numbers of C-sections has also been documented by other authors [44, 45, 61]. These authors noted that insurers provided higher rates of remuneration to doctors with patients undergoing checkups; doctors justify these remunerative actions by the greater preponderance of checkups. Although SP insures 49.9% [51] of the Mexican people, and pays twice as much for a cesarean birth as it does for a vaginal birth, an additional payment for checkups is not made by this public health institution [4]. Private insurances cover only a small percentage of the Chiapas population; hence, they cannot fully explain this close relationship. Thus, the current policies aimed at reducing MM may have led to an intentional selection of high-risk women and an increased number of C-sections.

An inverse relationship was found between the possibility of a C-section and the later onset of prenatal checkups; specifically, when women had their first checkup during the third trimester of pregnancy, they were less likely to undergo cesarean delivery. However, the possibility of a C-section was higher when women did not receive any prenatal care. Women who do not attend prenatal care are likely to only go to the hospital if they feel they are experiencing complications. This is consistent with an investigation conducted in Chihuahua, Mexico, among pregnant adolescents. In that study, 34% of 19-year-old indigenous women, as opposed to 20% of similarly aged non-indigenous women, underwent C-sections following indications of preeclampsia and fetal distress. These complications were attributed to a lack of prenatal care [62]. The indigenous population in Mexico is highly impoverished and marginalized [63]. Reflecting this, indigenous women in Chiapas commonly begin bearing children early in life, and many deliver their children at home [64, 65]; thus, some of these births are likely not reflected in the available statistics.

C-section rates in Chiapas, and more generally throughout Mexico, are much higher than the expected standards. Governmental interest in reducing the MM has likely contributed to this observation. However, in 2002, a study was conducted to examine representative C-section data, obtained from surveys and administrative records, from 129 countries worldwide [66]. That study investigated the relationship between cesarean delivery and MM rates, based on a non-parametric regression method. The estimated average rate of C-sections was 15%. Comparing this rate with country-specific MM (RMM), a clear relationship is not observed, even when there may be a correlation between higher C-section rates and lower RMM [4]. In Latin America and the Caribbean, C-section rates were higher than in other developing countries, but lower than the average C-section rates in developed countries [66]. Inverse relationships between cesarean delivery rates and maternal and fetal mortality rates were observed in poor countries that provide little access to obstetric care. Furthermore, C-section rates above certain threshold values do not translate into higher maternal or neonatal benefits, and may lead to negative consequences [67].

Our results show that cesarean deliveries are also related to other factors. For example, educated women and those with a higher quality of life are more likely to have C-sections as they believe that this method is the safest, easiest, and quickest way to give birth, and that vaginal births are old-fashioned [68, 69]. Thus, for this population, the main reason for having C-sections is the ability to schedule an exact date, allowing the father and other relatives to be present. The care of older offspring can also be scheduled, and painful labor, often lasting 6–10 h, can be avoided. This has been further enabled by new technologies that, besides informing parents of their baby’s sex so they may choose an appropriate name, can establish the degree of fetal maturity and make it easier to select an optimal delivery date. These justifications are also strengthened by the practices of healthcare professionals [70‐73].

Conversely, more impoverished women and those with lower quality lives have fewer delivery possibilities and are rarely informed about the risks associated with C-sections. Thus, certain rights advocates believe that when a C-section is unnecessary and unjustified, the procedure may constitute a violation of the woman’s reproductive rights. The Mexican government has admitted partial or total failure in its duty to “respect, protect, and guarantee human rights, of which women’s rights are a part” ([74] p. 20). Chiapas and Mexico City are the only subnational entities that include reproductive rights in their Laws of Women’s Access to a Life Free of Violence. Moreover, unjustified C-section is considered violence in the women’s Life Free of Violence laws of nine Mexican states and only in Chiapas¹⁵ and Veracruz¹⁶ it forms part of the “obstetric violence” crime specified in its criminl code.

Within medical associations [75], it has been acknowledged that the performing of elective C-sections is due to their working conditions and, thus, places the responsibility for the violation of women’s rights on the Mexican state. However, a statement from the Observatory of Maternal Mortality in Mexico [76] indicated that this stance is dubious, as most cesarean births (as compared with vaginal births) occur in private medical practices (86% in Chiapas and 80% nationally, in 2014),¹⁷ where private specialists could, in fact, accompany the process of labor and birth. So, a call upon the government is made to improve infrastructure, training, and human resources for providing holistic care following childbirth.

When the need for a C-section is clearly justified, physicians can save lives; however, the procedure is more costly for institutions, owing to the required inputs and medical equipment, and to the general public, owing to the short-, medium-, and long-term complications of the procedure. Women undergoing C-sections have a 25% higher possibility of remaining hospitalized for 2–7 days, a 10% higher possibility of remaining hospitalized for 8–30 days, and an 8% higher probability of remaining hospitalized for ≥100 days. These numbers point to the higher risk of complications.

Furthermore, since the establishment of private medical insurance companies in Mexico, the number of C-sections has grown exponentially, clearly indicating a cost-benefit relationship. A similar situation exists in public facilities. Since 2004, the SP has, together with other medical insurance plans, paid operating facilities twice the amount for a C-section as for a vaginal delivery. In addition, some services covered by the SP can be subcontracted to the private sector [77]. In Chiapas, the poorest families are signing up for this policy [78], which means that low-income women are exempt from paying for obstetric care, regardless of the delivery procedure required.

Careful study should be undertaken to investigate how these new health policies impact the number of C-sections in public hospitals in Mexico. Such policies may lead many women to submit to unnecessary C-sections, even if they lack the higher-risk conditions that have historically driven the need for C-sections.

This study underscores the need for a variety of actions, as unjustifiable C-sections are a multicausal problem. Clearly, institutional organization and the regulation of medical personnel limit adherence to institutional protocols and federal and state laws. We consider that, in the case of indigenous populations, strengthening primary care by hiring professional midwifes to attend vaginal deliveries is important. This is a strategy that the Mexican government and the state of Chiapas, specifically, must strengthen. We have previously made specific recommendations for the reduction of maternal mortality [79, 80], and will not reiterate those here.

This study has some limitations, including a paucity of the detailed information necessary to address the interrelationship between the fundamental factors driving cesarean deliveries, such as the number of women who request cesarean delivery, how birth order influences C-section rates, or the fact that the absence of prenatal care increases the C-section probability. The dynamics leading to the observed increase in C-sections among indigenous women should be elucidated. Little information is available, even in the administrative records of hospital discharges from public institutions, regarding physician rationales for performing C-sections. Such a study would require an analysis of the clinical files of indigenous women, in particular, who are unlikely to be available to an outside researcher. Therefore, this analysis was not included in the study; such decisions or specificities cannot be identified or taken from the existing database, and would require more extensive fieldwork and archiving.

In the future, the SINAC database will allow us to conduct a longer-term analysis based on reliable information for estimating the tendency of C-sections, and thus, in a context of sexennial public policies, to compare Mexican government’s efforts to reduce C-sections.

We identified some of the factors associated with the increased numbers of C-sections in Chiapas, Mexico. The study considered women who reside in municipalities with indigenous populations and municipalities with higher HDIs, and among educated women and those undergoing regular prenatal checkups. Although C-sections are associated with women of middle or high socioeconomic status, the most important finding of this study is that the increase in the numbers of C-sections among indigenous women in Chiapas appears to be related to policies aimed at reducing MM. Furthermore, the analysis showed an increased C-section rate among women giving birth for the first or second time. The current results, in the context the recent legislative changes, allow us to conclude that the medicalization of childbirth and the increased C-section rate represent obstetric violence. Owing to the health risks associated with C-sections, we stress the need to implement actions to limit the number of C-sections. Better institutional organization is required to create space for women to recuperate. Medical regulations are needed to ensure that protocols and technical norms are being adequately implemented. Awareness should be increased among health personnel and the public regarding women reproductive rights. To this end, actions should be taken to limit or prevent procedures that are considered obstetric violence, including, where appropriate, exposing them to the public. In the particular case of reducing C-sections among indigenous populations, strengthening primary healthcare and promoting professional midwife attendance at normal births are necessary.