Is a 6.7% cesarean section rate significantly different from 5% for low‐risk women in the years 2001–2003?

Sir, We would like to thank Judy Slome Cohain for her interest in our study, and the opportunity to discuss it. The points she raises are all very important in the discussion of factors leading to an increase in the incidence of cesarean sections. Our study, however, had a more pragmatic approach: will separation of low-risk births lead to a reduced cesarean section rate among the low-risk parturients? Our setting was two hospitals with maternity wards in the city of Oslo that provide uniform public health care to all citizens. The same obstetricians were rotating between the two hospitals. The guidelines for medical care and interventions during delivery were the same at both hospitals. Both hospitals provided one-on-one attention. There was little difference in fetal monitoring between hospitals; 52% of nulliparous and 26% of multiparous women had electronic fetal monitoring at Ullevål Hospital (the mixed-risk department), compared with 59% and 25%, respectively, at Aker Hospital (the low-risk department). The data base does not contain data on whether the electronic fetal monitoring was continuous, only on whether it had been used. Also there was little difference between hospitals in the use of epidural anesthesia. At Ullevål Hospital, 40% of nulliparous and 15% of multiparous women used an epidural during labor compared with 49% and 14%, respectively, at Aker Hospital. Of those receiving epidural anesthesia at Ullevål Hospital, 89% of nulliparous and 78% of multiparous women also received oxytocin for augmentation of labor; at Aker Hospital the corresponding figures were 92% and 74%. The guidelines for augmentation of labor and for cesarean section because of failure to progress in labor were not different between hospitals, and followed the recommendations of WHO. In the second stage of labor an intervention (mostly ventouse) is done after 1 hr of pushing with no progress. Our study shows that the differences in cesarean section rates between the two maternity wards were statistically significant. Finding a disfavorable difference in cesarean section rates in the department with low-risk births, it is tempting to try and look for explanations in the management protocols. There might be many factors, some of them perhaps subtle, working together. Our main point was, however, to show that an organization that divides labors into high- and low-risk units does not necessarily lead to better care for low-risk parturients.