Editorial [Better Use of Interventions in Women Care]

In this issue of the Journal a review made some considerations about the increased use of cesarean sections (CS) in one high income country. In this report in a South-east region of Italy CS rate is about 48%, and is increasing about 4.25% in the last two years. If nothing changes it is expected that in one or two years the rate will be above 50%. If we consider “normal” as “the most frequent”, then a normal delivery in this region will be a CS. Many high-income countries and some middle-income countries are seeing a very high use of cesarean sections and many regions in these countries show figures above 50% of CS. We are facing a new obstetrician behavior. But, is this new behavior justified? Many ecological studies have shown that national figures above 10-15% are not associated with better maternal and neonatal outcomes [1, 2]. When measuring benefits and consequences of CS, the outcome could be influenced by the cause generating the CS. A systematic review of 79 studies of elective CSs versus vaginal deliveries, including observational and randomized trials, has shown that women with CS have decreased urinary incontinence at 3 months and decreased perineal pain in comparison with those having a vaginal delivery [3]. On the other hand, CS was associated with a higher risk of maternal mortality, hysterectomy, ureteral tract and vesical injury, abdominal pain, neonatal respiratory morbidity, fetal death, placenta previa, and uterine rupture in future pregnancies [4]. In summary, there are no medical justifications for the increasing trends of CS. One reason sometimes mentioned for the increase in CS is women's choice. However, at least in Latin American countries, pregnant women still favor vaginal delivery, either because recovery is faster or because it is the natural way to deliver [5, 6]. This preference is found even among women receiving a C-section and at hospitals with extremely high C-section rates. On the other hand the ecological studies already mentioned showed a low rate of CS in low income countries and an association of low rates with maternal and neonatal mortality [1, 2]. It has been estimated that the low rate of CS in low-income countries contributes to about 80, 000 maternal deaths a year [7]. This is another striking example of inequity of health provision, with some receiving more than needed and many with less than needed [8]. In this issue, Dr. R. K. Naz made a thoughtful review of contraceptive methods and how to obtain a better availability of them by every woman. Women empowerment is a needed strategy to obtain an equitable and sustainable reproductive health in every woman.