Thousands of pregnant women in Germany get their baby by Caesarean section without good reason. The operation also seems welcome to some clinics. Is something going wrong? A guideline wants to create clarity.
Berlin (dpa) - Caesarean section yes or no? In Germany, a first guideline from medical associations wants to offer doctors and expectant parents more help with this decision. Because only ten percent of births consider the operation really necessary.
According to the Federal Statistical Office, the caesarean section rate in Germany has settled at almost 30 percent: in 2018, that was around 220,500 sections in the abdominal wall and uterus of women. The quota has doubled since the early 1990s. Does this make sense?
Caesarean sections require medical reason
The co-authors of the German Society for Gynecology and Obstetrics (DGGG) emphasize that the new guideline does not want to specify a limit due to the lack of data. However, it should be considered certain that a section rate of over 15 percent would not bring any major health gain - neither for mother nor for child. Therefore caesarean sections should be medically well-founded.
The long version of the guideline with many study results is a book of more than 130 pages. It summarizes the level of knowledge and does not claim to have clear answers to every question. Because the advantages and disadvantages of vaginal birth and caesarean section are not a black and white puzzle. Some things have not been researched enough.
According to the guideline, it is considered indisputable that a lying baby, an impending tearing of the uterus, an incorrect position of the mother's cake or its premature detachment are indicators of a caesarean section. With all other childbirths - around 90 percent at least - the risks for mother and child should be weighed. The guideline also deals with alternatives to Caesarean sections, says coordinator Frank Louwen from the University Hospital in Frankfurt am Main.
Not always enough information and advice
There sometimes seems to be a lack of factual information and advice. "So far, advice and action has mainly been based on" expert opinion ", with everyone often being their own expert," explains Patricia Van de Vondel from the women's clinic in Cologne's Porz am Rhein hospital. The reasons for the high German section rate were also due to errors in the system: lack of training, questionable organization, remuneration and a lack of staff.
The attitudes, which is too much for caesarean sections, are already divided at the Leipzig University Clinic. "I find the caesarean section rate acceptable in Germany because nobody knows what the" right "caesarean section rate is," says Holger Stepan, director of the clinic for obstetrics. The rate is significantly higher than it should be, judges Ulrich Thome, head of the newborn department. A caesarean section is a serious injury for women. There are sure to be a number of adjustments to lower the high rate.
- Facts: How delivery takes place in Germany also depends on where you live. The rates differ considerably between the federal states. According to an analysis by the Science Media Center, significantly fewer children are born per Caesarean section in the east. Saxony had the lowest rate with 24 percent, the Saarland with 40 percent. A check by the center on the basis of quality reports from the hospitals for 2018 showed that at the federal level, just over one in ten of the total of 686 maternity hospitals is well above the tolerance range for Caesarean section rates. The odds fluctuated between 10.4 and 66.7 percent. Striking: The highest rates often produced smaller houses, but not a single clinic with over 1000 births a year. Van de Vondel therefore misses a call for more centralization in the guideline - for a better pooling of experience.
- Risks: There is no birth without risk. However, according to many studies, vaginal delivery has fewer complications for the mother. The risk for the child is considered to be very low in absolute numbers, although it is comparatively higher than with the planned caesarean section. According to studies, the risk of incontinence and pelvic floor problems for the mother is higher for vaginal birth than for a section. A caesarean section, on the other hand, can pose an increased risk of infertility and complications in further pregnancies. In addition, the child's lack of contact with the maternal vaginal flora seems to affect the child's later health - for example with a view to allergies and obesity. For many doctors it is uncertain how much caesarean sections are associated with long-term health risks. You see today's "cesarean epidemic" as a kind of large-scale medical experiment.
- Role models: The Caesarean section rate in Germany is in the middle of the range. However, all Scandinavian countries have significantly lower rates. In Finland, according to the Science Media Center in 2018, it was 16.7 percent - one of the lowest death rates for mothers and babies worldwide. Finnish hospitals are in municipal hands, they are not primarily profit-oriented. All clinics with fewer than 1000 births a year - except for the sparsely populated Lapland - were closed. "This centralization leads to more quality through quantity and routine," reports Georg Macharey, senior consultant at Helsinki University Hospital.
- Possible adjustments: According to estimates, ten percent of women in Germany would like to have a cesarean section without good reason - for example, out of fear of contractions and pelvic floor damage, worry about the baby and because of better predictability. Convincing for a vaginal birth takes time, which in many clinics hardly anyone has. According to critics, the health insurance billing system does not support psychologically well-trained staff enough.
Midwives are also missing in many German clinics. Caesarean sections are easier to plan for clinics, can be processed more quickly and tie up fewer staff. And they are paid much better as an operation than a vaginal birth.
In medicine, obstetrics is also considered a high-risk area. Doctors are more likely to be sued for complications from a vaginal delivery than for an unnecessary caesarean section. According to obstetricians, the fear of not being able to control the natural birth process is an important reason for a caesarean section in everyday clinical practice. That is why doctors call excellent training and experience with vaginal births as a prerequisite for fewer caesarean sections.
Federal Office of Statistics
Guideline