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Cyprus

Concern over high number of caesareans

Professor Sir Sabaratnam Arulkumaran

By Evie Andreou

ONE of the world’s top gynaecologists has expressed his concern at Cyprus’ high rate of caesarean sections – a whopping 60 per cent at private clinics – and said a solution should come from national health professionals.

Professor Sir Sabaratnam Arulkumaran, who has just been appointed as chair of the department of obstetrics and gynaecology at the Medical School of the University of Nicosia, is the head of the International Federation of Gynaecology and Obstetrics (FIGO) and outgoing president of the British Medical Association. He was appointed Knight Bachelor in 2009 for his services to medicine.

Caesarean sections account for 60 per cent of births in private clinics and 45 per cent of births in state-run hospitals according to the health ministry. Commenting on the high level of caesarean sections in Cyprus, the professor said that in the UK caesareans are 25 per cent. At his hospital, London St George’s which oversees the medical degree programme at the University of Nicosia, caesareans are 20-21 per cent, the lowest in the UK.

According to the World Health Organisation, caesareans should only account for 12-15 per cent of total births. In May Health Minister Philippos Patsalis expressed concern over Cyprus high caesarean rates and promised to promote natural birth in low risk-pregnant women.

The professor, whose widely published research has focused on understanding and improving the quality of life for women and new-born babies, also said that the pre-term birth-rate is very high in Cyprus, and that even though Cyprus ranks high in birth safety, morbidity rates are needed in order to have a complete picture.

“The best approach to improve anything has to be a local solution, by local people. You can’t come in and tell people what to do, because circumstances are different,” said Sir Sabaratnam, who has been in clinical practice for 37 years and was a professor at St George’s for nearly 13 years.

“The best way we can work together is actually for us to have a discussion, to present our own programme and to discuss, this is on natural labour, these are the pre-terms, these are the guidelines, these are the results on postpartum haemorrhage, sepsis and in the end can we do something here?”

The professor explained that the reasons behind high rates of caesareans varied and can range from the reluctance of obstetricians to pull all nighters or their fear of being sued in the case something goes wrong during childbirth, to women demanding the procedure themselves.

Sir Arulkumaran said that knowledge on how to monitor the foetus and how to act in different kinds of crisis is one factor that contributes to the reduction in the caesarean rate.

“We have found in the UK that if people know how to interpret the foetal heart rate, how to act in different kinds of crisis then we might be able to reduce the caesarean section rate. It is important to know how we best can reduce it without compromising the health of the mother or of the baby,” he said.

Cardiotocography or the monitoring of the foetus’ heartbeat was the subject of a workshop he presented at the end of last month in cooperation with Cypriot health professionals, during his first trip to Cyprus.
The professor explained that most maternity wards in the UK use ‘Maternity Dashboards’ to plan and improve their maternity services and to keep the national standards like, for example, the caesarean rates.

The Dashboard is a questionnaire that “serves as a clinical performance and governance score card to monitor the implementation of the principles of clinical governance on the ground”.

It measures the number of normal deliveries, the caesarean rates, blood transfusions, other complications during childbirth. It also records patients’ complaints and staff performance.

Although the professor will be travelling to Cyprus mainly to supervise and coordinate medical students during their obstetrics and gynaecology postings, he also wants to use any free time to present workshops on childbirth safety for women and new-born babies or to run programmes, specifically tailored to Cyprus.

“I will be coming every few months and will stay for one to two weeks, and I would like to meet and interact with the local obstetricians. In a few months’ time I will present a workshop on safer child birth, and then the following time

I’m here maybe on pre natal diagnosis or something similar,” Sir Sabaratnam said.

He believes that pre-term birth rates (births before week 37 of gestation) could be a research question on Cyprus since, according to research in the Lancet medical journal, it is very high in Cyprus and the reasons for this are not known.

According to the 2012 results published by the Lancet the preterm birth rate increased from 7.5 per cent in 1990 worldwide with a total preterm birth rate of two million in the 65 countries to 8.6 per cent in 2010 with a total of 2.2 million preterm births, and it is still the single biggest cause of neonatal death.

The largest average rise in preterm birth rates in Europe per year since 1990 was registered in Cyprus with a 2.8 per cent increase followed by Slovenia with 2.6 per cent and Belgium with 2.5 per cent.

“We don’t know the reason why, so we may have to do some research on Cyprus, specific for Cyprus,” Sir Sabaratnam said.

The doctor also commented on child birth safety in Cyprus which is the third safest place on earth to have a baby, according to a study published in the Lancet in May.

The study looked at several aspects of natal care and ranked 195 countries in terms of how birth safety.
“In child birth safety Cyprus is doing well, but the figures we know about safety are usually about child mortality,” he said. “When a mother dies we call it the tip of the iceberg. Everybody knows the mother has died, but below the water-level the iceberg is huge, about 20 times bigger than that part of the tip that you see.”

The professor said that the goal is actually to see how many of the mothers had blood transfusions, how many had intensive care admissions etc and that the idea would be to build a system that can measure the morbidity in some way.

“In many countries including Cyprus we don’t know what the morbidity figures are. We know the tip of the iceberg which can be seen, but we don’t know the bottom part,” Sir Sabaratnam said.

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