Over the last generation the CS rate in Ireland has increased dramatically from 10.6% in 1990 to 26.1% in 2009 according to the latest figures from the National Perinatal Reporting System (NPRS). The reasons for this are complex, but it has attracted the attention of both healthcare providers and healthcare analysts. One of the priorities of the HSE programme in obstetrics and gynaecology is to stop the CS rate in first-time mothers increasing.

As part of this initiative, Professor Richard Greene and his colleagues at the National Perinatal Epidemiology Centre (NPEC) organised a successful well-attended multidisciplinary meeting in Cork dedicated to the subject of caesarean delivery. There also needs to be an improvement in data collection and analysis, and in their 2008 national report the National Perinatal Reporting System has presented, for the first time, an analysis by CS overall (and not just singleton vs multiple pregnancies) and an analysis of CS by parity.

The NPRS have also analysed CS by emergency and elective rates nationally according to maternity unit. These show considerable variations between hospitals that cannot be explained by casemix. A national normal CS range per maternity unit has been developed, and this Spring the results for each maternity unit will be sent to the programme’s local Implementation Boards for their consideration (see Table 1).

Hospitals outside the normal range will be asked to review their obstetric practices. The publication of these ranges will also allow individual obstetricians to benchmark their own elective and emergency CS rates against the national rate. It is hoped that reviewing local clinical practices may narrow the wide variation in CS rates and lead to an improvement in the quality of practice. The audit of CS rates locally and nationally will be ongoing.

The Institute’s Clinical Advisory Group chaired by Dr Michael O’Dowd have also started the process of developing national guidelines for obstetrics and gynaecology. Individual Members of the Institute have agreed to develop these guidelines based on best clinical practices worldwide. When the new guidelines are approved by the Advisory Group and the HSE Programme, they will be submitted to the newly-established National Clinical Effectiveness Committee for endorsement.

An important part of the process will be, not only the development, but also the dissemination and implementation of the guidelines in each maternity unit. The caesarean section rate has already been identified as a Key Performance Indicator by the Department of Health and Children and by the Health Services Executive.

Caesarean section is an important obstetric intervention which has made a positive impact on the lives of many women and their children. While a caesarean delivery may be economically more expensive than a vaginal delivery, not doing a caesarean section when it should have been done may have negative human and financial consequences if there is an adverse clinical outcome. The view of the HSE Obstetrics and Gynaecology Programme is that any response to CS rates must be carefully calibrated, and the focus needs to be on the quality of clinical outcomes and not on short-term financial gains.

The work of the HSE Programme, in partnership with the Institute, has started but considerable challenges lie ahead. The Institute will continue to update you on developments on this key subject of caesarean section rates.

Table 1: National quality control rates for caesarean sections 2009