Preface

At a global level, a great effort is being made to reduce the rates of cesarean sections (CS). The World Health Organization (WHO) defines "birth as a natural and normal function of life, which should not be approached as a disease." Vaginal labor is the benchmark, and CS should not exceed 15% of all births in a country. Per the WHO website: "Rather than recommending specific target rates, WHO underscores the importance of focusing on each woman's unique needs in pregnancy and childbirth In Europe, countries such as the Netherlands (CS rate of 15%) and Slovenia (CS rate of 14%) follow these standards.

According to recent studies, the continuous increase in the mean age of pregnant persons in developed countries and the simultaneous increase in multiple pregnancies due to in vitro fertilization (IVF) may have led to an increased percentage of CS estimated at about 30%. Worldwide, the frequency of CS has increased during the last 30 years. In the United States, the percentage of CS is around 32%. Greece has one of the highest percentages of CSs in Europe at 38% although there are no clear statistics that include all births. The percentage of CS is steadily increasing In Greece, 38% of children are born even though this operation should be applied only in special cases when the health of the child or mother is in danger. CS was not a common obstetric surgery 40 years ago, at which time its frequency was about 10%.

In the last decades, there was a dramatic increase in the frequency of CS (> 1%/ year). In the United States in 1986, CS rates approached the highest levels of about 25%. Since then, it has stabilized at around 22%. At the start of the 21st century, a new increase was observed with a frequency reaching 31.1% in 2006. In most European countries the percentage also exceeds 30%. The medical effects of this phenomenon remain unclear. This phenomenon is also observed in the developing countries of Latin America. For example, in Brazil the frequency of CS increased from 15% in 1970 to 43% in 2005.

Some possible reasons for the increased rate of CS include:


Nowadays, there is a tendency for people to have fewer children, which has led to a greater proportion of firstborns who are known to be at high risk for CS. In addition, increased rates of twin (35%) and multiple (77%) pregnancies worldwide due to assisted reproduction measures have consequently increased rates of CS with sciatic projection. Other factors include the small stature of the pregnant person, which is associated with a 40% increased risk of CS, and pre-existing obesity in the pregnant person, which is associated with a 60% increased risk of CS. The above risk ( body weight in pregnancy) does not include the increased birth weight or the increased incidence of diabetes and hypertension in the pregnant population. A forecasted newborn birth weight > 4000 gm is also associated with a threefold increase in the risk for CS. Pregnant persons have 40% increased rates of CS due to more frequent problems of dystocia (because of heavier weight) and fetal distress (the cause is unclear).

Indications for CS include a threat to the life of the mother or child and preventive signs by the mother or fetus health problems. Contraindications to CS include when the risk of surgery is greater than the risk to the fetus (hydrocephalus, extreme prematurity, stillbirth).

According to meta-analyses, the use of cardiotocographic monitoring of the placental unit led to an increase of 20% in the frequency of CS. This may be due to an overestimation of the records regarding the presence or absence of perinatal asphyxia. Several blind studies in which it has been reported that comparing CS after induction or waiting in pregnancy extension without fully documented conclusions and without significant differences. The method of active childbirth is applied mainly with the aim of reducing CS. However, the application of epidural analgesia is likely to increase in frequency (13% vs. 8% in the United States).

The increased frequency of primary CS led to an increase in the pool of pregnant persons with previous CS despite the last small increase in the rate of vaginal delivery after cesarean section. Regarding maternity hospitals, there are public and private maternity centers with high CS rates. In contrast, academic hospitals have lower rates even though they treat more high-risk pregnancies. This is due to their educational nature. Of particular interest are pregnancies in adolescents. According to researchers, 50% of births in adolescence have complications, resulting in a rate of CS approaching 27% for single pregnancies with head projection. The increased risk of prematurity and delayed intrauterine growth observed at these ages also contribute to the increase in CS rates.

Despite the relative safety of CS, it is accompanied by increased maternal morbidity and treatment costs. Therefore, efforts should be made to develop frequency reduction strategies. This requires increased attention and improved timely certification

**V**

projection.

and treatment of problems that arise during childbirth. Particular attention should be paid to reducing the frequency of CS in firstborns with single pregnancy and head

**Panagiotis Tsikouras and Nikolettos Nikos**

Department of Gynecology and Obstetrics,

Gynecology and Obstetrics Department,

Democritus University of Thrace,

**Georg Friedrich Von Tempelhoff**

Alexandroupolis, Greece

St. Vinzenz Hospital Hanau,

Hanau, Germany

Faculty of Medicine, University Kiel, Kiel, Germany

**Werner Rath**

Greece Department of Obstetrics and Gynecology,

Professor,

and treatment of problems that arise during childbirth. Particular attention should be paid to reducing the frequency of CS in firstborns with single pregnancy and head projection.
