KCE REPORT 275AS

SYNTHESIS

Planned Caesarean: WHAT ARE THE HEALTH EFFECTS OF MOTHER AND CHILD?

2016 www.kce.fgov.be
KCE REPORT 275AS
HEALTH TECHNOLOGY ASSESSMENT

SYNTHESIS

Planned Caesarean: WHAT ARE THE HEALTH EFFECTS OF MOTHER AND CHILD?

SABINE STORDEUR, Pascale JONCKHEER, NICOLAS FAIRON, CHRIS DE LAET

2016 www.kce.fgov.be
KCE Report 275As Planned caesarean Synthesis 1

■ PREFACE The birth of an offspring for the human species - as for every form of life - the most essential step in its continued existence. And so you would not expect
much "play" to sit here, but that such a crucial event proceeds according to very strict patterns optimized by millions of years of evolution. Only "the human
animal" turns out to be wrong this. Throughout history and cultures, women give birth in different ways, culminating with the advent of modern midwives and
midwifery. And with the huge achievement of an unprecedented decline of infant and maternal mortality. A realization that we were not handed on a platter!
Zomag the story of Ignaz Semmelweis never make us forget that medicalization increasingly may involve potential risks. He discovered that the lack of hand
hygiene obstetricians itself contributed to the dramatic figures of puerperal fever and maternal mortality in the Vienna of the mid-19th century. But another
reason is Semmelweis important because he can safely adorn the ranks alongside John Snow and Florence Nightingale as founder of what we today evidence-based
medicine to mention.

Today as well as in 1847, it remains essential to place the key figures of the individual against the conviction of the obstetrician or the prevailing 'culture
obstetricale. This is the only way to objectify the benefits and risks. That is chosen by a transverse orientation or placenta previa for a cesarean is obvious,
and so there are still a number of indications which are under discussion today no longer. But what the outcome figures for a planned cesarean section at a
pregnancy without specific risk factors? With our 21% of births by Caesarean we are indeed still far from the very alarming figures for countries such as
Greece, Turkey or Brazil, where more than 50% of births take place via caesarean section. But at home we see the trend, and if it establishes that some
maternity hospitals are already at 33%, one may wonder. Similarly, in determining the risk a third higher among least educated women to the best educated
in an induction or elective caesarean. Where is the line? Why not every cesarean birth? A crucial question is where is the proof. This is very clear for KCE:
who chooses must present figures invasive surgery to replace a natural childbirth that evidence or at least sufficiently demonstrate the utility of the
procedure. The idea of ​an 'optimal' caesarean rate has since been abandoned by deWHO and cultural factors will continue to play today, if only in the
relative weight they give to various risks. The minimum seems that informs clearly and objectively the expectant parents so that they can judge for
themselves what is best. The best ... for mother and child, of course.

Christian LÉONARD Deputy General Raf MERTENS Managing

Manager Director
2 Planned caesarean Synthesis KCE Report 275As

■ CORE
• The number of caesareans is just about everywhere risen sharply in the world over the past thirty years. In 1985 the World Health Organization
(WHO) recommended to limit the number of caesarean sections to 10 to 15% of births, but nearly 35% in 2010, the rate in some European
countries.
GROCERIES • In Belgium, the percentage currently around 21% (20.6% in Flanders, 22.2% in Wallonia and
20.4% in the Brussels Region). However, in each region there are significant differences between the hospitals (from 11.8% to 32.9%).

• For cesarean without medical indication, there is no evidence that they offer health benefits for mother and child. More and more publications even
report negative effects in the short and long term. Some of these effects are well established, others are more hypothetical. A significant portion of
the risks after a Caesarean section refers to the course of the subsequent pregnancies.

• There exists an abundance of scientific studies that compare the immediate and long-term effects from the delivery point (cesarean vs vaginal
route). These studies are of high quality indeed, but however often give conflicting results. Therefore, it is difficult to draw clear conclusions, or in
order to establish a clear causal relationship.

• A recurring weakness in the literature is that there is no reliable information about the reason for the implementation of the studied cesarean.
Therefore it should be clearly recorded in the future. The categories 2 and 4 of the Robson classification should still get a break, so that planned
cesarean sections and induced births are distinguished.

• In 2015, the WHO has updated its advice in 1985. They acknowledged that a cesarean is effective to save the lives of mothers and children, but
only when there is a medical indication. At a population level, the execution of more than 10% of caesarean sections not associated with a
decrease in the mortality rate in mothers and newborns. The priority should not be to achieve an "optimal" rate of caesarean sections, but in limiting
the procedure to clinically justified situations.

• Caesarean section in a woman who has never given birth before, is often followed by another cesarean. A solution to prevent the progressive
increase in the number of caesarean sections in many countries, is to avoid as much as possible of that first cesarean.

• The future parents should be given clear information about the impact of various delivery modes for mother and child at the beginning of the third
quarter, as the benefits and risks can be assessed. This information must focus primarily on the impact of the delivery mode for subsequent
pregnancies.
KCE Report 275As Planned caesarean Synthesis 3

■ SYNTHESIS
■ PREFACE................................................. .................................................. ................................... 1
TABLE OF CONTENTS ■ KEY MESSAGES ................................................ .................................................. ................... 2

■ SYNTHESIS ................................................. .................................................. ........................................ 3

1. CONTEXT OF THIS STUDY .............................................. .................................................. ............ 5

2. IMPERIAL CUTS IN BELGIUM ............................................... .................................................. .............. 6

3. LITERATURE ................................................. .................................................. ....................... 9

3.1. OBJECTIVES AND METHOD ............................................... .................................................. .... 9

3.2. EFFECTS OF caesarean ON MOTHER'S HEALTH ......................... 10

3.2.1. Short term health .............................................. 10 ................................

3.2.2. Maternal mortality ................................................. .................................................. ..................... 10

3.2.3. Effects on breastfeeding .............................................. .................................................. . 10

3.2.4. long-term health .............................................. ............................... 11

3.2.5. Effects on subsequent pregnancies: results for the mother ............................. 12

3.3. EFFECTS Cesarean ON CHILD HEALTH ................................. 14

3.3.1. Short-term health problems for the child ........................................... ................. 14

3.3.2. long-term health of the child ........................................... ................ 15

3.3.3. Effects on subsequent pregnancies: results for the child ................................. 18

4. CONCLUSIONS ................................................. .................................................. .................................. 19

5. EXISTING INITIATIVES ................................................ .................................................. ............ 22

■ RECOMMENDATIONS ................................................. .................................................. .......................... 23

4 Planned caesarean Synthesis KCE Report 275As

Figure 1 - Percentage of cesarean deliveries in six European countries ......................................... ............................ 5

LIST FROM
Picture 2 - Rates of caesarean sections per Robson Category in the three Belgian regions ...................... 7
PICTURES
Figure 3 - Relative share of Robson categories in the total number of caesarean sections in Belgium, for the three regions ..............................
.................................................. .................................................. ............ 8

Table 1 - Comparison of the effects of planned caesarean sections and vaginal births for women with low risk after a full-term pregnancy
LIST OF TABLES ............................ .................................................. ................ 21
KCE Report 275As Planned caesarean Synthesis 5

A caesarean section is considered necessary if the risks to mother or child first be overestimated in a
1. CONTEXT OF THIS STUDY vaginal birth a ( elective, scheduled or planned caesarean section for medical reasons), or when an
attempt to vaginal birth is not successful (unplanned (emergency) caesarean). The absolute and relative
The number of births by caesarean section, the last thirty years to just about anywhere
indications clearly be formulated in a large number of
world robust increased. In 1985 recommended the
World Health Organization (WHO) to reduce the number of caesarean sections to 10 to 15% of births,
guidelines and is
but by 2010 that percentage had risen in some European countries to over 30%. Outside Europe the
scientifically proven that certain indications caesarean the mortality and morbidity risks for mother and
increase is striking. As done in the US and Korea, respectively 33 and 35% of births by Caesarean
section. In Belgium this percentage fluctuates currently around 21% (125,000 births per year). child reduces. Today cesarean is however often considered a routine procedure performed in an overly
medical trolled environment, and as a risk-free alternative to vaginal delivery. The medical necessity to
perform the increasingly against personal or organizational reasons. The reason why is chosen for a
cesarean, even if there is no medical necessity, are listed in the literature planning of the hospital,
availability of midwives who succeeded pregnancy, organization of the family at the time of birth (
Figure 1 - Percentage of cesarean deliveries in six European countries presence of the partner, care for the other children) or fear of pain and discomfort of a vaginal delivery.
without medical

indicator is there however no evidence

health benefits of cesarean for mother or child. More and more publications even mention negative
consequences in the short and long term. Some consequences are well documented, on another there
is still uncertainty. Much of the risk is related to the conduct of the subsequent pregnancies.

In 2015, the WHO has updated its advice in 1985. In giving up instead of an optimum rate of
caesarean sections, she says that a cesarean section should be performed only when absolutely
necessary.
Sources: Declercq et al (for the years 1987 to 2007) and Xie et al (for the year..
2010)

a
We use this report the term "child" although certain
long-term effects are not confined to childhood in the narrow sense.
6 Planned caesarean Synthesis KCE Report 275As

2. IMPERIAL CUTS IN BELGIUM

In Belgium we have a very complete annual data on births and neonatal epidemiology, thanks to two Robson Classification
institutions: the Center for Epidemiology perinatal (CEpiP) for maternity hospitals in the French-speaking
part (separate data collection for Brussels and Wallonia) and the Center for perinatal Epidemiology Robson classification divides the deliveries into 10 categories, according to their obstetric
(SPE), the maternity hospitals in Flanders. characteristics.

1. Primipara, loner in head position, ≥ 37 weeks, spontaneous labor

2. Primipara, loner in head position, ≥ 37 weeks, labor initiated or

Their annual reports (2014) indicate a fairly homogeneous situation, 20.6% cesarean rate in Flanders, elective caesarean
22.2% in Wallonia and 20.4% in the Brussels Region. A more in-depth analysis (not included in this
3. Multi Para (without antecedent of Caesarean-Section), loner in head position,
document), however, shows great variations between the hospitals, with percentages ranging from 11.8
≥ 37 weeks, spontaneous labor
to 32.9% (IMA data, 2014). The causes of these differences are not clear, but they probably reflect the
4. Multi Para (without antecedent of Caesarean-Section), loner in head position,
populations or practices of the maternity hospitals.
≥ 37 weeks, initiated labor or elective cesarean

5. Multi Para with antecedent of caesarean section, loner in head position, ≥ 37

weeks
In Flanders planned the majority of cesarean sections, while
6. All primiparous women, loner in breech
in Wallonia and Brussels about the same as planned
its emergency cesarean. 7. All multipara, singleton breech (including antecedent of caesarean section)

The Robson Classification is a simple and easy to apply the system in order to describe the type of
8. All multiple pregnancies (including with antecedent of caesarean section)
delivery (see text frame on the right). The categories are based on relevant criteria that exclude each
other and that together comprehensive. Ideally categories 2 and 4 are further subdivided into a
(induction) and b (elective caesarean) to facilitate the analysis and comparison of data. 9. All pregnancies, loner in transverse or oblique position (including the antecedent of caesarean
section)

10. All pregnancies, loner in head position, <37 weeks (including the antecedent of caesarean section).

On Figure 2 it is clear to see that with transverse orientation (category 9), breech (categories 6-7) and
multiple pregnancies (category 8) is carried out the greatest number of cesarean sections. These four These ten categories are mutually exclusive. Childbirth so each can only belong to one category.
groups, however, make only 6% of all pregnancies in.

According to the SPE and CEpiP the number of caesarean sections at the first-born and in multiple
pregnancies with a prior cesarean increased in recent years.
KCE Report 275As Planned caesarean Synthesis 7

Picture 2 - Rates of caesarean sections per Robson Category in the three Belgian regions

Source: "Study Center for Perinatal Epidemiology" and "Center d'Perinatal Epidemiology" 2014

Figure 3 shows the relative share of each Category Robson in the total number of caesarean sections in
Belgium. A caesarean section is most often carried out in the category 5, so when women who used
already underwent a Caesarean, with a full-term baby in head position. The second group in order of
frequency is that of the pregnancies with breech (category 6 and 7 together), followed by the first
full-term pregnancies with induction of labor, or with a planned cesarean section (category 2).
8 Planned caesarean Synthesis KCE Report 275As

Figure 3 - Relative share of Robson categories in the total number of caesarean sections in Belgium, for the three provinces

Total share of births by caesarean

section by region:
- Flanders: 20.6%
- Wallonia: 22.2%
- Brussels: 20.4%

Source: "Study Center for Perinatal Epidemiology" and "Center d'Perinatal Epidemiology" 2014
KCE Report 275As Planned caesarean Synthesis 9

3. LITERATURE After the selection process we held over 61 publications. Their quality was assessed using validated
tools (Amstar- scale systematic studies, assessment schedules of the Cochrane Collaboration for RCTs
and observational comparative studies).
3.1. Objectives and Methodology

This report consists of a systematic study comparing the health of mother and child after a (planned or
emergency) caesarean and after (spontaneous, induced or assisted) vaginal delivery, each
As far as possible, we give the results of planned cesarean again. However, the medical literature does
not always clearly distinguish between cesarean for medical and non-medical reasons. Studies with data
for full-term (≥ 37 weeks), with low-risk pregnancies, in high-
from regional or national registries add only recently (after 2010) the "requested by the midwife / mother"
income countries. pregnancies with low risk are mature
to the list of indications. In this way one should in future be more clearly distinguish between planned
singleton pregnancies (pregnancy of 37-41 weeks) in head position, with no known medical risk factors,
cesarean for medical and non-medical reasons. Several systematic studies include meta-analyzes each
without placenta previa or previous cesarean.
outcome. The primary studies that will be included in it, are often very heterogeneous (characteristics of
female patients, position and characteristics of the child, measurement of the outcomes, modalities of
It contains no economic analysis and no study on the organizational aspects (duration, cesarean or vaginal birth [with / without introduction or without instrumental ...]). In that case, we used
costs etc.). ethical the results of the primary studies instead of the meta-analysis. For the same reason we did not bring any
reflections on the delivery method without medical indications are not covered. No studies were also new meta-analysis on the results of primary studies.
performed to initiatives in Belgium or abroad to reverse the upward trend in the number of caesarean
sections.

Method

The Cochrane Library databases Medline, Embase and CENTRAL were searched for systematic
studies. The reference lists of selected articles was searched carefully for important publications. Then
we went in search of primary studies to update the selected literature studies. No study design was In the absence of randomized controlled clinical trials (RCTs) of full-term low-risk pregnancies we chose
excluded beforehand. We observational studies (cohort and case-control studies) based on individual or population data
(environmental studies). In many Western countries, regional and / or national birth records available.
thus included randomized controlled trials They are accurately updated with validated data maternity clinics, midwives, and contain lots of useful
(RCT), and observational studies (prospective and retrospective cohort studies and case-control studies) information to carry out large-scale epidemiological studies over long periods.
of high-income countries. In consultation with a group of clinical experts (see colophon) we decided to
enroll all outcomes in the literature, if they were compared with vaginal deliveries and the research
methodology had a sufficiently high quality.
10 Planned caesarean Synthesis
However, most available studies suffer from significant methodological biases (the disregard key
confounding factors, heterogeneity in defining and measuring the outcomes, indicating biases ...). These
biases are systematically described in the appendix to the report, after the quality of the publications. As
a result, the conclusions are based on low to very low levels of evidence. These studies show no
strong causal relations, or associations.
3.2. Effects of caesarean section on health
mother
3.2.1. Short-term health problems
Evaluation based on: a directive of NICE (2011) based on a systematic literature review (2011)
The WTO working group on maternal morbidity defines morbidity in the short term as "any problems
caused or aggravated by the pregnancy or childbirth, which has negative effects on the welfare of the
mother" (up to 42 days after the end of pregnancy ). Our literature review shows that a planned
caesarean section, compared with the vaginal delivery at term has the following effects:
• reduced incidence perineal pain and abdominal pain during childbirth and the following three
days (just four months after giving birth no difference);
• moderate risk cardiac arrest and hysterectomy;
• conflicting results infections during the postpartum, deep vein thrombosis and complications of
anesthesia;
• we find No difference in the incidence For lesions of the vagina, cervix, bladder or urethra,
lesions caused by the surgery itself, bleeding during the post partum (which requires a
transfusion), pulmonary embolism, perioperative trauma, need
KCE Report 275As
artificial respiration or intubation, acute renal failure, or
obstetric shock.
3.2.2. Maternal mortality
Evaluation based on a systematic literature review (2014)
because maternal mortality is rarely found in high-income countries, it is very difficult to evaluate this
aspect statistically. We found one systematic study on this topic. she sets no difference in risk stuck
between the delivery point.
3.2.3. Effects on breastfeeding
Evaluation based on a systematic literature review (2012) + 2 cohort studies
After analyzing the literature covered two elements that can explain a possible association between birth
by Caesarean section and a difficult start to the breastfeeding. To begin with, it is possible that the pain
or any complications after a cesarean delivery, the child later will be the mother, while the first hours after
birth are crucial for the formation of a bond between mother and child and the success of breastfeeding.
The other element is related to the separation of ocytocin and prolactin, which may vary depending on
the mode confinement. These hormones also play a role in the development of the bond between mother
and child and breastfeeding. Furthermore, the blood levels of the hormones could which regulate the
appetite of the newborn, differ slightly depending on the mode confinement. get started and the
continuation breastfeeding nevertheless give different results. Some studies show a negative
association between caesarean and the initiation of breastfeeding, other studies confirm this or not.
Once breastfeeding has been successfully launched, there is no difference between women who gave
birth by Caesarean section or vaginally.
KCE Report 275As Planned caesarean Synthesis 11

The methodology in the primary studies (the systematic study and updates) was very heterogeneous
and predominantly based on interviews with self-completed questionnaires. Many countries took part in
it (developed and developing countries). Remarkably, no study ascertained whether the figures for the
start of breastfeeding were higher in the "baby-friendly" hospitals, where staff encourages breastfeeding
very active. Indeed, one could argue that such support inside a large majority of mothers fails to start
breastfeeding, regardless of the delivery method.
3.2.4. long-term health
3.2.4.1. Urinary incontinence
3.2.4.2. fecal incontinence
Evaluation based on a Cochrane literature (2010) + a cohort study (2011)
Faecal incontinence is the involuntary loss of feces. Anal incontinence is the involuntary loss of feces or
gases. Both of these diseases are usually regarded as a possible consequence of the work, and the
vaginal delivery. They can also occur in the immediate post-partum and persist lifelong. According to a
number of obstetricians promotes a vaginal delivery urinary and fecal incontinence. They recommend a
caesarean on to protect the pelvic and anal continence. The Cochrane review of 21 studies (> 30,000
women) decide again that there is no association between delivery method and fecal incontinence.
Furthermore, no study shows that a cesarean should be preferred over a vaginal delivery, to reduce the
risk of stoelgang- or gas leakage.

Evaluation based on a systematic literature review with meta-analysis (2016)

The hormonal and mechanical changes pregnancy is a recognized risk factor for incontinence. Vaginal
delivery increases that risk still likely, especially if there happen obstetric manipulations during delivery
(suction, forceps). A planned caesarean is generally regarded as a good protection against injuries to
The subsequent longitudinal study where women were followed for 12 years, shows no long-term
the pelvic floor.
difference between women who are vaginally, exclusively via caesarean section, or both ways like.

The selected systematic study makes a distinction between two types of long-term urinary incontinence
(which may persist for more than a year after childbirth): 3.2.4.3. Postpartum depression

• stress incontinence (involuntary loss of urine during physical exertion or when sneezing or Evaluation based on a systematic literature review (2014) + four primary studies (2005 to 2015)

coughing) is three times more common after a vaginal delivery (without instruments) than after a
planned cesarean (statistically significant);
Some argue that form a complicated labor or an emergency Caesarean section stress to the mother.
The researchers investigated whether there was an association between cesarean and postpartum
• urge incontinence (involuntary loss of urine due to a sudden, and not to suppress urge to urinate) depression, but its existence could not demonstrate clearly.
is slightly more common after a vaginal birth, as compared to all kinds of cesarean sections
(statistically significant).
12 Planned caesarean Synthesis
3.2.5. Effects on subsequent pregnancies: results for the mother
If a Caesarean is considered, one must above all be wondering what the possible effects on future
pregnancies and deliveries. As is apparent from Figure 3 (page 8), a cesarean section is often
scheduled because of a previous cesarean section.
3.2.5.1. Effect on the length of time between pregnancies and
fertility
Evaluation based on: two systematic literature reviews (2013) and three cohort studies (2014 and
2015)
It was long thought that a caesarean section the number of subsequent pregnancies limited and that
they are the length of time until the next pregnancy extension (which was sometimes erroneously
confused with lower fertility). Our literature confirms neither associations. The longer duration until the
next pregnancy or even the absence of a subsequent pregnancy is rather caused by numerous social
and educational factors (preference for a small family, professional reasons, long study ...), then by a
previous birth. As the average age rises at first pregnancy in many countries and the female fertility
decreases with age, it is also possible that fewer women consider a new pregnancy.
KCE Report 275As
3.2.5.2. Risk of ectopic / ectopic pregnancy
Evaluation based on a registration study (2008) + 2 cohort studies (2001 and 2006)
When an ectopic (or ectopic) pregnancy, the embryo is outside the uterine cavity, for example. In a
fallopian tube. While rare (1 to 2% of all pregnancies), may have a negative impact on the health of
women and may reduce the chance of a future pregnancy or even cause death. The classic risk factors
for ectopic pregnancy: a history of ectopic pregnancy, surgery, inflammation in the pelvis (. Eg
endometriosis or salpingitis), sexually transmitted diseases or use of intrauterine contraceptive (IUD).
Also, previous cesarean are often considered a risk factor, although the evidence is contradictory.
Based on data on planned and emergency caesarean sections in the Danish registry study, we propose
underwent a slight but statistically significant increase of 9% of ectopic pregnancies fixed in women who
have had a caesarean section, compared to women who have previously given birth only vaginally. For
the planned cesarean is only to increase 12%, which is also significant. If we only take into account
planned cesarean sections at the request of the future mother (so theoretically without medical
indication) disappears association. Presumably plays why a Caesarean was planned role.
The conclusion is that there are few compelling reasons for an association between a planned
caesarean section and risk of subsequent ectopic pregnancy.
KCE Report 275As Planned caesarean Synthesis 13

3.2.5.3. Risk of placenta previa, placenta accreta, detachment of the placenta
and uterine rupture during subsequent pregnancies
Evaluation based on a registration study (2008) + 2 cohort studies (2001 and 2006)
In general, it is assumed that the scar on the uterus (by a previous cesarean) can cause complications in
a subsequent pregnancy and childbirth.
American studies confirm that the risk of placenta accreta and uterine rupture increases with the number
of cesarean sections. Reports a large US cohort study (> 30,000 women) that the percentage of cases
of placenta accreta 0.24% at a first caesarean. In a 2nd, 3rd, 4th, 5th and 6th caesarean the percentage
increased to respectively 0.31%, 0.57%, 2.13%, 2.33% and 6.74%. Another American cohort (> 20,000
women) examined the risk of uterine rupture during a vaginal delivery in women with a previous
cesarean (scarring of the uterus). A uterine rupture occurred in 5 in 1000 women after spontaneous
onset of labor. A rupture occurred in approximately 8 in 1,000 women, when the work was initiated
(without prostaglandins) and from 25 to 1. 000 women after the initiation of the work after administration
of prostaglandins. In a second cesarean were less than 2 to 1,000 women with a uterine rupture.

According to a registered in Norway study in which women were followed with up to 3 consecutive
pregnancies, increases the risk that one of the complications listed hereinafter arises, statistically
significant in women who have already undergone one or more of cesarean sections.

• Placenta praevia: a placenta is abnormally low in the uterus. This can cause excessive bleeding
during pregnancy.

• Placenta accreta: a placenta grows abnormally deep in the uterine wall. Placenta accreta is
probably the obstetrical complication that is most often associated with a previous cesarean. It can
cause severe bleeding and often ends with a hysterectomy.

• Of placenta during pregnancy (placental abruption)

detachment of the entire or a part of the placenta with formation of a hematoma between the
placenta and uterine wall. When a large part of the placenta detaches, it may involve risks for
mother and child.

• Uterine rupture: a rare obstetric complication (0.07%), which however is very serious for both
mother and child. There is a clear correlation between the presence of a cesarean scar on the
uterus and many cesarean sections.
14 Planned caesarean Synthesis KCE Report 275As

3.3. Effects of Cesarean on health These studies provide very different results, but there are also some differences between the situations
examined. Eventually only gives the registration research an answer to our research question. But while
child
taking account of certain factors that could affect the results (such as the duration of the pregnancy or
the age of the mother), significant biases can not be ruled out. The decision to proceed with a cesarean,
3.3.1. Health problems in the short term in children
can indeed be taken by the presence of risk factors for neonatal mortality.

3.3.1.1. neonatal mortality

Evaluation based on a systematic literature review (2012) + an ecological study in 31

high-income countries (2015) 3.3.1.2. Breathing problems at birth

Neonatal mortality is defined as a die during the first 28 days of life.

Evaluation based on a systematic literature review (2007) + a cohort study (2008)

The systematic study of NICE includeert two observational studies. The first study compares neonatal
mortality after cesarean (performed for breech) and after vaginal delivery (spontaneous labor) in full-term One suspects have long known that children who are born at higher risk for breathing problems over a
babies. This study shows no difference in mortality at planned caesarean. This is attributed to their low gestational age (gestational age) at birth. Possible
consequences of these breathing problems are a separation of mother and child (which may impair the
between the two groups but fog statistical development of a tire and early lactation), a recording of the newborn
discernment (too few registered cases). The second registration study covers 8 million births and
neonatal mortality analyzes after pregnancy risk (singleton, cephalic, without medical risk factor, placenta
previa or antecedent of caesarean). An "intent-to-treat" analysis was conducted in which all patients the neonatal intensive care, the need from

were enrolled in their original group (planned cesarean vs. vaginal delivery) with a view to the final respiratory support, painful manipulations, treatments with antibiotics and an increased risk of serious
analysis, even when a patient during labor have changed group (eg . caesarean section because the complications. The analyzed studies

work was too long and difficult). The neonatal mortality rate of 1.7 deaths per 1000 live births and 0.7 show that the risk

after cesarean deaths per 1,000 live births after vaginal delivery. The ecological study does not report difficulty breathing two to seven times as large is a planned cesarean than with a vaginal birth. The
magnitude of the relative risk appears to depend on the gestational age. The risk is high in babies with a
any positive correlation between the percentage of births through a planned cesarean section, and
gestational age of 37 weeks or even between 37 and 38 weeks. Therefore, the authors recommend after
neonatal mortality, after correction for a number of risk factors. But because mortality data mainly related
at least 39 weeks to carry out a planned caesarean.
to premature births and specific causes (malformation, intrauterine infections ...) are all possible effects
on the full-term births masked with low risk.
KCE Report 275As Planned caesarean Synthesis
3.3.1.3. cerebral Palsy
Evaluation based on a systematic study of meta-analysis (2013)
Cerebral Palsy (CP) is caused by abnormal development or damage to the part of the brains that
movement controls balance and posture. For this there are several causes that can occur during
pregnancy (eg. Hypoxia or damage to the brains of the fetus by a prenatal infection) or after birth, such
as hypoxic-ischemic encephalopathy or large prematurity.
The incidence of cerebral palsy all remain remarkably stable for decades (about 1.5-2.5 / 1,000 live
births, and 1.0-1.5 / 1000 in term infants), with little or no differences between the western countries. In
very premature babies with extremely low birth weight prevalence increased after the introduction of
neonatal intensive care giving these babies could survive.
Fears of cerebral palsy and related litigation contributed greatly to a defensive attitude of many midwives
who are convinced that a cesarean may have a protective effect.
As a general conclusion of the retained meta-analysis, we can say that this literature does not confirm
an elective caesarean section for a full-term baby in head position without risk is the risk of cerebral
palsy larger or smaller. Unfortunately, no mention of the studies included the indication for the
caesarean section.
15
3.3.2. Long-term health of the child
3.3.2.1. immune disorders
It is thought a long time that a cesarean affects the development of innate and existing immune
functions. However, the mechanisms behind it are still largely hypothetical. The premise is that the child
caesarean not come into contact with the vaginal and intestinal flora of the mother. Precisely this first
contact would initiate the formation of intestinal flora (microbiome) in the child. We know that bacterial
colonization of the gut plays an important role in the maturation of the child's immune system.
However, the immune disorders listed below were only investigated in observational studies with a large
bias risk. Most studies also make no
the distinction between planned and
emergency caesarean sections, or between planned cesarean for medical or non-medical reasons. The
observed associations may be misleading.
Asthma
Evaluation based on a systematic literature review with meta-analysis (2015) + 5 cohort studies
(2015-2016)
According to earlier publications caesarean is a higher risk of asthma in children than a vaginal delivery.
Outside a small, prospective Dutch study, which did not find any significant association, showing the
most recent meta-analysis and cohort studies, all of which are large-scale, that the risk for caesarean
about 20% higher than with a vaginal delivery. That association (although shown), however, must be
qualified because the cesarean rate is much higher among mothers with immune disorders (asthma,
juvenile arthritis, type 1 diabetes, celiac disease or other
immunodeficiencies). The result may be distorted because of asthma may have to make a child with a
history in the mother. Also premature children run greater risk of developing asthma. as
16 Planned caesarean Synthesis
Caesarean section is performed before rupture of membranes, also increases the risk of asthma in
children.
Finally, there may be an association between a (planned) Caesarean section and the development of
asthma later in the child's life. However, a causal relationship is difficult to show, and the association is
based on the weak evidence.
atopy
Evaluation based on a systematic literature review with meta-analysis (2008)
As several old publications for asthma show an association between cesarean and a moderately
increased risk of atopic syndromes such as allergic rhinitis and food allergies.
Our evaluation is based on a meta-analysis that was born a slight increase in the risk of food allergies
and atopic rhinitis in children demonstrates by Caesarean section. For eczema, atopic dermatitis or
inhalant allergies, there is no difference. The relevant observational studies do not distinguish between
planned and emergency caesarean sections. Again, the evidence level is low. could be attributed to a
C-section, only 1 to 4% of the cases.
Infections of the respiratory tract
Evaluation based on: three registration studies (2012, 2015 and 2016) + a cohort study (2015)
A recent registration Danish study (2016) showed that the risk of laryngitis and "pneumonia, or infection
of the lower respiratory tract" approximately 20% higher in children born via caesarean section than a
planned in vaginally born infants. In an emergency caesarean section is that connection is less
pronounced for laryngitis and not significant for pneumonia and other infections of the lower respiratory
tract.
Another Danish registry study looked at hospital admissions for infection with respiratory syncytial virus
(RSV); children born by a scheduled caesarean section have a higher risk (27%)
KCE Report 275As
to be taken during the first years of life for RSV than children born vaginally.
A Norwegian cohort study (2015) found no relationship between respiratory infections and (planned or
emergency) caesarean sections. An ambitious Australian registration study (2012) reported an
association between planned cesarean and the incidence of bronchiolitis during the first year, but in the
second year of life no more association exists.
The conclusion is that there can hardly be a causal link demonstrated by the conflicting results of these
observational studies
between (Planned) caesarean section and later
respiratory infections. So the association is based on a low level of evidence.
diabetes t Y pe 1
Evaluation based on a systematic literature review with meta-analysis (2008) + 4 + 1 registration
studies case-control study (2014-2016)
The authors of the systematic study of 2008 concluded that (planned and emergency) caesarean
sections provide a 20% increase in the risk of type 1 diabetes in childhood that can not be explained by
confounding factors.
Five major studies of recent date not confirm this association. As with asthma appear namely be
performed more caesarean sections in diabetic female patients. If diabetes in the mother in the analysis
is regarded as a biasing factor, there is no association between longer birth method and diabetes in the
child. A Swedish study (2014) to 2.6 million children also showed an association between planned
cesarean section and type 1 diabetes. When the researchers children from the same country who were
born vaginally or by cesarean, compared, the hypothesis of a causal connection was rejected. The
authors conclude that the association may be due to family factors such as genetic susceptibility and
environmental factors.
KCE Report 275As Planned caesarean Synthesis 17

inflammatory bowel disease planned or emergency caesarean section. The authors report no or a laboratory test confirmed the
diagnosis.
Evaluation based on: two systematic literature reviews with meta-analyzes (2014) + 3 cohort
studies (2015-2016)
celiac disease

The major chronic inflammatory bowel diseases are Crohn's disease and ulcerative rectocolitis, both
caused by undesirable immune reactions involving the intestinal flora would play a role. The influence of
the caesarean on the intestinal colonization of the newborn, some authors suggested a caesarean for
the child can be a risk factor for inflammatory bowel disease.
Evaluation based on: four cohort studies (2012-2016)
The possibility that the bacterial flora involved in the development of celiac disease, is a hypothesis
which is often reflected in the literature. However, the associations between this disease and the delivery
manner are contradictory and do not constitute a good basis for the claims.

A systematic study looking at the two diseases separately and see an association between cesarean
and Crohn's disease, but not all rectocolitis or inflammatory bowel disease together. In the other 3.3.2.2. Overweight and obesity
meta-analysis, most of the results were not statistically significant. The other studies provide conflicting
results. Evaluation based on 3 systematic studies (2013-2015) and three cohort studies (2013-2015)

Gastroenteritis
Evaluation based on: 2 registration studies (2010 and 2016)
Baby intestinal flora plays an important role in the induction of immune tolerance, the defenses of the
mucosa against pathogens and the development of innate and adaptive immune homeostasis. The
impact of caesarean section on the baby intestinal colonization increase in the number of caesarean
sections may affect susceptibility to infection by intestinal bacteria.
Because the number of caesarean sections and obesity werld wide gradually increasing (environmental
studies) a link is suspected between caesarean and obesity in the child (and later adult). This
association can be explained by several mechanisms, the most important are the aforementioned
changes to the intestinal flora. Some studies suggest a link between cesarean section and a high body
mass index (BMI) during childhood and adulthood, others do not. The best meta-analysis reports for
caesarean sections in general at risk, but that increase was not significant when the planned Caesarian
be examined separately. Cohort studies with follow-up until the age of 21 give conflicting results.

A registration study of 1.7 million Danes (2010) shows a significant (and confirmed by laboratories)
increase (5%) on the risk of gastroenteritis in children between 1 and 5 years who were born by
Obesity in children is in any case a problem with many facets and many
cesarean (compared to vaginal birth children). That association disappears after five years. The delivery
known causes (Dietary habits, lack to
method seems to be a determinant of the risk of gastroenteritis.
exercise, genetic influence, ...). Epidemiological studies into a possible link between the delivery mode
and a high BMI but not take into account these essential factors. It is therefore quite possible that the
delivery method rather than a biasing a causative factor in the development of obesity.
The other study (2016) reports a significant increase in the risk of gastroenteritis by about 20% in
children aged between 0 and 14 years after
18 Planned caesarean Synthesis
3.3.2.3. pediatric cancers
Evaluation based on 3 cohort studies (2014-2016)
It has also been suggested that cesarean sections in can increase the child's risk of cancer. There are
three potential mechanisms might be the cause:
• the above-mentioned disturbance in the intestinal flora;
• disorders of the hypothalamic-pituitary-adrenal axis, which is normally activated by the labor and
then plays a role in the maturation of the immune system;
• epigenetic changes (such a strong methylation was observed in the DNA of leukocytes in cord
blood after cesarean).
The strong increase in the number of caesarean sections in most European countries, even a slight
increase in cancer risk among children involved have a major impact on public health. The results of the
three available large studies conducted in four European countries (Scotland, Denmark, Sweden and
Finland)
But do not show
significant association between cesarean and the most common form of childhood cancer (leukemia,
cancers of the nervous system, kidney cancers and non-Hodgkin's lymphoma). There are insufficient
cases of rarer cancers in order to be able to draw conclusions on this fitting. Despite the effect of
cesarean section on the functioning of the immune system also seems unlikely that it increases an
individual's risk of cancer.
KCE Report 275As
3.3.2.4. Developmental and behavioral disorders
Evaluation based on: two cohort studies (2015-2016)
Some clinical trials (including those for animals) establish a link between birth by Caesarean section and
the development of mental or developmental disabilities
as autism, ADHD and several
behavioral disorders, but their results are contradictory. One possible explanation is that these disorders
difficult objective and reproducible manner can be measured.
The two studies, the researchers selected, leave it up to the parents to report any developmental and /
or behavioral disorders, without diagnostic confirmation by a healthcare professional. Moreover, the
"diagnosis" respectively set at the age of 3 years and 7 years. Neither of these studies show an
association between delivery method and the development of the abovementioned disorders.
3.3.2.5. Long-term mortality
Evaluation based on a retrospective literature review (2015)
Long-term mortality was studied in a Scottish study
321 287 full-term newborns who were followed until their 21 years. The mortality risk of 21 years (all
causes combined) was 0.40% in children born by Caesarean section, compared with 0.32% for vaginal
births. This difference is statistically significant. However, no account of important confounding factors
such as the educational level of the mothers, ethnic origin, especially the indication of caesarean.
KCE Report 275As Planned caesarean Synthesis
3.3.3. Effects on subsequent pregnancies: results for the child
3.3.3.1. Risk of stillbirth in subsequent pregnancies
Evaluation based on a systematic literature review with meta-analysis (2013) + registration study
(2014)
There are different classification systems for stillborn children (according to the gestational age, weight
at death, death before or after delivery). No classification is generally accepted. The killers also differs
widely: placental insufficiency with stunted growth, infections, (pre-) eclampsia, birth defects in the child,
detachment of the placenta and rupture of the umbilical cord, high maternal age, obesity, diabetes or
hypertension in the mother. In the two studies we analyzed show a statistically significant increase, 15 to
20%, the risk of in utero death in women with a history of caesarean delivery versus women who have
always given birth in previous pregnancies. Due to the highly heterogeneous nature of the studies used
in the meta-analysis,
to do with Others, not established
(Methodological and clinical) factors. Underlying medical conditions and the indication of caesarean
certainly play a major role in increasing the risk.
19
4. CONCLUSIONS
A caesarean is a surgical procedure that can save the life of the mother or the child if he is executed
clearly defined medical reasons. The intervention, however, is increasingly routinely performed over the
past thirty years, sometimes at the request of the parents for personal reasons, without medical
necessity. Even midwives often ask for a caesarean section, because it can be better planned in their
calendar.
The KCE report wants an informed and objective comparison made between the health effects of births
by Caesarean section in the short and long term and that of vaginal deliveries. However, there is one
major obstacle: there are very few studies with a high level of evidence on this issue.
Many researchers have attempted to bring the effect of cesarean for the future health of the mother,
especially for subsequent pregnancies, and the children involved objectively identified. We are dealing
here, however, with a very special subject of study in which a randomization, a prerequisite for a good
study, is not evident. A randomized controlled clinical trials (RCTs) involving pregnant women, selected
to undergo a Caesarean section from the "intervention group" without medical reason, after doing
serious methodological, but also raises ethical and moral questions. Such studies are only performed in
special situations, such as a breech or when all required a caesarean in a previous birth. But we can not
allow the conclusions of these studies apply to cases without medical necessity. Indeed, the results
would be affected by many other obstetrical and medical factors.
Because RCT's missing so we opted for retrospective and prospective observational studies. There
exists an abundance of scientific studies that compare the immediate and long-term effects from the
delivery point (cesarean vs vaginal route). Very large studies in which tens of thousands of women and
children were followed for a long time, sometimes making very strong associations between the type of
delivery and the studied health outcomes (morbidity in mother or child). The
20 Planned caesarean Synthesis KCE Report 275As

most recent and accurate investigated even siblings, and compared their health comes as the way why The future parents should indeed more generally to be informed clearly and objectively. According to the
they were born. Other studies, using the same methodological quality, contrast, show no association 2002 Law on patients' rights is even a legal requirement in our country. This report offers obstetricians
between delivery method and examined health outcomes. However, the main weakness of all these and midwives a solid reference to support that information.
studies is that they do not mention reliably why cesarean sections were performed. They confuse as the
birth process with the reason why they had to be done (health problems of mother or child, making a
vaginal birth was difficult or impossible). To therefore remains dangerous today to draw a firm
Table 1 compares the effects of planned caesarean sections and vaginal deliveries on mother, child and
conclusion, or to impose an undeniable causal relationship for most health outcomes for mother and
the subsequent pregnancies. This only goes to women with low risk and full-term babies.
child.

Some consequences of caesarean section are clear and leave no room for doubt. Which
the case for the effects on the next
pregnancies after a first-section. The risk of uterine rupture is understood, is considerably higher and
increases with the number of cesarean sections. The clinical experts who worked on this report, pointing
the way long the impact of any cesarean on later pregnancies. In 2011 presented by Physicians for the
mother and the newborn college already having a first cesarean without strict indications should be
avoided in order to prevent these births happen via caesarean section. b Belgian and international data
indeed show that the main reason for cesarean section, previous caesarean, and the risks are greater
with each operation. It is therefore important that future parents of this are notified so that they can
decide along with knowledge about a cesarean section without medical indication.

b
Absil G, Van Parijs AS, Bednarek S. et al., Determinants of high and low rates or Caesarean accessed on http://overlegorganen.gezondheid.belgie.be/sites/default / files / documents /
deliveries in Belgium. Recommendations to avoid Unnecessary Caesarean sections. A Report of college_van_geneesheren_voor_de_moeder_ en_de_pasgeborene / 19074153.pdf
the Board Mother and New Born, 2011.
KCE Report 275As Planned caesarean Synthesis 21

Table 1 - Comparison of the effects of planned caesarean sections and vaginal births for women with low risk after a full-term pregnancy
22 Planned caesarean Synthesis KCE Report 275As

In 2011, the mother and the newborn the College of Physicians published a report on the factors that
5. EXISTING INITIATIVES determine the number of caesarean sections in Belgium. At the end of this report are a series of clinical
and organizational recommendations for the number of unnecessary cesarean sections
At the birth of a child in Belgium should the caregiver who has accompanied the birth, indicating the birth
and enter a number of medical statistics for the Communities, and ultimately the FPS Economy. This
to decrease. The Link to this publication:
declaration is made on a paper form, or by electronic application e-Birth (since 2010). In the e-Birth form
( http://overlegorganen.gezondheid.belgie.be/sites/default/files/documents/c
must be encoded in a number of medical variables on the previous and current pregnancy, childbirth (eg.
ollege_van_geneesheren_voor_de_moeder_en_de_pasgeborene / 190741
Position of the baby, induction, epidural, fetal monitoring, mode of delivery, episiotomy ...) and the health
53.pdf ). According to the report, these recommendations were followed by the hospital and
status of the baby. This can be very useful for epidemiological studies. Thanks to the detailed registration
privéspecialisten who practiced obstetric activity in a university hospital in 2010. As a result, the rate
(maternal indication, without further specification, cesarean section without any medical indication on
dropped caesarean sections from 26% to 20.2%. Rates of caesarean section after recording contrast,
demand of the patient, placenta previa, multiple pregnancy, various indications are distinguished for a
remained unchanged in intensive maternity ward (MIC). This shows that the decline is almost exclusively
caesarean. The information about the hospital (Hospital NIHDI code and the hospital site) and healthcare
due to a lower number of cesarean sections among women with low risk.
(name, first name, health insurance number) who supervised the birth are also recorded.

Every year provide the Study Center for Perinatal Epidemiology (SPE) and the Center for Epidemiology
perinatal (CEpiP) to all maternity hospitals in the country a confidential report with feedback on the
indicators on birth certificates, their evolution since 2008 or 2009, and their position relative to the other
maternity hospitals for obstetric indicators. This annual report is delivered together with a report per
Region. The reports are not commented, but interested maternities can ask the research team a
presentation of the results. They can receive an electronic version of the report for a single presentation.
It is not an audit of the maternity hospitals and state specialists free to adjust their practice or not.
KCE Report 275As Planned caesarean Synthesis 23

■ RECOMMENDATIONS c The providers involved in childbirth:

• Future parents must receive clear information about the consequences of childbirth method for mother and child. The
information must be provided at the beginning of the third trimester, because in that stage of pregnancy get a good picture
of the benefits and risks. That information should certainly be given to the

impact which may have given birth on the way

subsequent pregnancies.

At the College of Physicians for the mother and the newborn:

• Gynecologists and obstetricians should be made aware of the consequences of cesarean without medical indication,

especially in a pregnancy of more than 37 weeks of a firstborn loner in head position. The perinatal epidemiology centers:

• Besides the annual reports on hospital statistics, there could be a feedback about the statistics each caregiver should be
considered, in which the Robson Classification is used.

• The data in the birth registration (e-Birth) indications for cesarean section can be identified and reported:

O Categories 2 and 4 of the Robson classification should be divided into

subcategories' induction 'and' planned caesarean;

O The category "non-medical reasons" should be added to the

data analysis and feedback.

c
The KCE is solely responsible for the recommendations.
CREDITS
Title: Planned caesarean section: what are the consequences for the health of mother and child? - Synthesis

authors: Sabine Stordeur (KCE), Pascale Jonckheer (KCE), Nicolas Fairon (KCE), Chris De Laet (KCE)

project Senior coordinator and supervisor: Sabine Stordeur (KCE)

Editors synthesis: Karin Rondia (KCE), Gudrun Briat (KCE)

reviewers: Raf Mertens (KCE), Dominique Roberfroid (KCE), Geneviève Veereman (KCE), Leen Verleye (KCE)

Acknowledgments: Julien Ligot (Fedopress)

External experts: Karel Allegaert (KU Leuven and Erasmus MC Rotterdam), Katrien Beeckman (UZ Brussel, VBOV and VUB), Filip Cools (UZ Brussel), Caroline Kirby (Hôpital
Erasme, Brussels), Benedicte the Thysebaert (Union Professionnelle des Sages-Femmes Belges [ UPSfB]), Alexandra Denys (Flemish Association of
Midwives), Wilfried GYSELAERS (Ziekenhuis Oost-Limburg, Genk and Hasselt University), Lieve Huybrechts (Midwife), Anne-Britt Johansson (Hôpital
Universitaire des Enfants Reine Fabiola [HUDERF], Bruxelles) , Chantal Lecart (Grand Hôpital de Charleroi [GHdC], Charleroi), Liesbeth Lewi (University
Hospitals Leuven), Pierre Maton (CHC Liège)

External validators: Hendrik Cammu (Center for Perinatal Epidemiology, UZ Brussel, Belgium), Malcolm Griffiths (Luton and Dunstable Hospital, UK), Virginie Van Leeuw
(Center d'perinatal epidemiology, CEpiP ASBL, Belgique)

Other reported interests: Membership of an interest group to whom the results of this study could have an impact: Chantal Lecart (Groupe Belge des Néonatologues, GBN-BVN)

A scholarship, fees or funds for staff or any other form of compensation for performing an examination Wilfried GYSELAERS (Limburg Clinical Research
Program (LCRP) Hasselt University for research into pre-eclampsia)

Presidency responsibility or function of an institution, association, department or other entity to whom the results of this study could have an impact: Katrien
Beeckman (member of the Flemish Association of Midwives); Pierre Maton (Cercle francophone des néonatologistes)

Other possible interests which could lead to a potential or actual conflict of interest: Malcolm Griffiths (had and has several funtions in the NICE (National
Institute for Health and Care Excellence): Secondary care representative (and vice-chair), NICE Quality Standards Advisory Committee ( 2013-), Assessor
Panel member, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Center (2016-), Expert Adviser, Center for Clinical
Practice, NICE (2016-), NICE CG132 Caesarean section: guideline surveillance review participant ( 2016); RCOG (Royal College of Obstetricians and
Gynecologists): Obstetric Assessor Each Baby Counts project, RCOG (2016-); and, MBRRACE-UK (Mothers and Babies: Reducing Risk through audits and
Confidential Inquiries across the UK): Obstetric Assessor,Confidential Inquiries into Maternal Deaths,
 MBBRACE-UK / RCOG (2013-); Regional Chair Confidential Inquiries into Maternal and Child Health (2008-2011), RCOG, Clinical Guidelines Committee
(2009-2014; vice-chair 2011-2014), Chair NICE Guideline Development Group for Caesarean Section (2010-2012), Chair NICE Quality Standard Topic
Expert Group for Caesarean Section (2012-2013), Chair East of England Regional Development Group for O & G (2006-2013), NHS - Shared Decision
Making - Birth after Caesarian section patient decision aid (PDA) - Advisory Group (2012- 2013), Chair NICE Evidence Update for CG132 (Caesarean
section) (2012-2013), Regional College Advisor, RCOG East of England (2009-2012 reappointed 2012-2015); he has Conducted research and published
papers on a range of obstetric topics in particular Relating to Caesarean section and vaginal birth after Caesarean section.

Layout: ine Verhulst

Disclaimer: ● The external experts were consulted about a (preliminary) version of the scientific report. Their comments were discussed at meetings. They
are not co-author of the scientific report and did not necessarily agree with its contents.

● Then, a (final) was submitted to the version validators. The validation of the report follows a consensus or a majority vote among the
validators. They are not co-author of the scientific report and did not necessarily agree with all three of its contents.

● Finally, this report approved unanimously by the Board of Directors (see,

http://kce.fgov.be/nl/content/de-raad-van-bestuur ).

● Only the KCE is responsible for any remaining errors or omissions as well as the recommendations to the government.

Publication date: November 8, 2016

Domain: Health Technology Assessment (HTA)

MeSH: Cesarean section; Delivery, Obstetric; Elective Surgical Procedures; Mortality

NLM Classification: WQ 415

Language: Dutch

format: Adobe PDF ™ (A4)

Legal deposit: D / 2016/10 273/80

ISSN: 2466-6459

Copyright: KCE reports are published under the Creative Commons License "by / nc / nd"
http://kce.fgov.be/nl/content/de-copyrights-van-de-kce-publicaties .
How to refer to this document? Stordeur S Jonckheer P, N Fairon, De Laet C Planned caesarean section: what are the consequences for the health of mother and child? - Synthesis. Health
Technology Assessment (HTA) Brussels: Belgian Health Care Knowledge Center (KCE). 2016. KCE Reports 275As. D / 2016 / 10.273 / 80. This document
is available on the Belgian Health Care Knowledge Center website.