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Cesarean section rates in the Dominican Republic

The Dominican Republic, occupying the eastern two-thirds of the island of Hispaniola, is now home to more than 10 million people. The western one-third of the island is Haiti with a similar sized population. The complex relationship between the peoples of these two countries on this one island is unfortunately tense again with concerns related to a controversial federal ruling in the Dominican Republic which has made many persons of Haitian ancestry living in the Dominican Republic stateless and at risk of deportation even though they may have been born in the Dominican Republic.1 Not making the news, however, is the rapidly expanding and extraordinarily high Cesarean section (C-section) rate in the Dominican Republic, which is now one of the highest in the world with more than one in every two new Dominicans born via C-section. In a study of 137 countries based on 2008 data, the Dominican Republic was estimated to have a C-section rate of 41.9% resulting in a tie for second with Iran and not far behind the world leader in C-section rates, Brazil, with a rate of 45.9%.2 The next Latin American country was Mexico in fifth place at 37.8%.2 For comparison purposes, Canada had a value of 26.3% at that time, while Haiti had a value of 3.0%.2 Based on a 2013 Dominican survey, the national rate was estimated at 56% (and within private hospitals, an estimated 87%!).3 A preliminary report from 2014 now pegs the national overall rate at 58.1%.4 This represents a steep rise from 1991 when an estimated one in five Dominicans was born via Csection.5 T h e W o r l d Health Organization has stated that there is no justification for a n a t i o n a l C - section rate above 15%.6 That said, access to Csections is a critical and necessary component of maternal care. There is some consensus that a 10% rate is reasonable and lower levels, particularly less than 5%, are related to higher maternal and perinatal deaths.2 There is some evidence that the rate of increase in high-income countries is slowing.7 However, many of the highest rates in the world appear in middle-income countries, particularly in Latin America, and it is not yet clear whether they will also experience the slowing seen in high-income countries. Little has been published in the peer-review A new mother in the Dominican Republic. Photo: A Latin American Research Centre publication literature on obstetrical care in the Dominican Republic to help explain this rapid rise in C-sections in that country. Previous reports on obstetrical care in the Dominican Republic have flagged a number of concerns about quality of care.8,9 Information as to whether any improvements have been realized more recently or whether previous identified gaps in care persist were not found in recent peer-reviewed literature. Recent and complex reform and restructuring of the health care system in the Dominican Republic has increased the challenge of understanding current health system function.10 In contrast to the information deficit for the Dominican Republic, there has been much more written about Brazil’s exceptionally high C-section rates. Among many factors considered, there is particular interest in the role of healthcare financial factors (e.g., private vs. public hospitals, types of health insurance) to help explain differential rates across public and private domains.11 Although clearly playing a role, the lower but still very high rates in the public sector and under public insurance also need explanation. A series of new reports based on a very large study called Nascer no Brasil (Birth in Brazil) 12 is beginning to unpack additional influential variables in that country, some or many which may be relevant to other countries, including the Dominican Republic. In an editorial on this work in Brazil, one potential explanatory variable that was highlighted was fears expectant mothers may have for what may be an over-medicalized approach to vaginal births.12 While further investigative work is needed to understand factors underpinning high C-section rates, there is also an urgent need for evaluated intervention efforts to improve obstetrical care. Several years ago, a large randomized trial across several Latin American countries (which did not include the Dominican Republic) aimed to reduce C-sections through requiring second opinions for nonemergency C-sections.13 This resulted in a statistically significant, but relatively small C-section rate reduction in the intervention hospitals.13 While a start, much more work is needed on this and related perinatal care issues in the Dominican Republic, Latin American and elsewhere.

John D. McLennan (MD, MPH, PhD) is a public health specialist, child psychiatrist, and associate professor in the Departments of Pediatrics (Developmental Pediatrics Section), Community Health Sciences and Psychiatry in the Cumming School of Medicine at the University of Calgary. He has worked with nongovernmental organizations in the Dominican Republic on child health projects for over 25 years. Currently he helps manages an early childhood health and development project called Niños Sanos in a low-income community on the outskirts of Santo Domingo. More information on this project and related work is poste d a t h t t p : / / r e s e a r c h / g l o b a l - h e a l t h / dominican-republic.