Changes in caesarean section anaesthesia between 2011 and 2015

Editor, The aim of OBAAMA-INT survey (Obstetric Anaesthesia and Analgesia Month Attributes – International) was to audit the current practices in obstetric anaesthesia in the Czech Republic (CZE) and Slovakia (SVK). We also wanted to assess the potential benefit of education of healthcare providers in obstetric anaesthesia during the last 4 years. We already published data about analgesia for labour gathered from OBAAMA-INT survey in International Journal of Obstetric Anesthesia.1 A particularly high proportion of general anaesthesia for caesarean section compared with regional techniques was described in OBAAMA-CZ study in 2011.2 Therefore, the Section of Obstetric Anaesthesia and Analgesia of the Czech Society of Anaesthesiology and Intensive Care Medicine (SPAA) prepared an educational program (lectures, workshops, national recommendations) for anaesthesia for caesarean section. After 4 years SPAA decided to review the situation and, due to good cooperation with Slovak colleagues, expanded the survey to SVK. All centres providing obstetric anaesthesia care in CZE and SVK were personally (or by phone) contacted personally (or by phone) by one of the steering committee with a request to participate in the 1-month study monitoring anaesthetic practices, delivered by anaesthesiologists, in the peripartum period. The centres participated in the project via an electronic application form on the study website (obaama.registry.cz). Records from different types of participating centres (university, regional and local) were weighted based on population data. Detailed methods are described in the article published in International Journal of Obstetric Anesthesia.1 The study response rate was 74% (70 of 95 centres) in CZE and 65% (35 of 54 centres) in SVK; participating centres represented 87.7% of all births in CZE (7256 births from 8275) and 66.4% of all births in SVK (2863 births from 4311) during the study period. We enrolled 78.6% (1689 from 2150) of all caesarean section in CZE and 64.2% (859 from 1339) of all caesarean section in SVK. Representation of participating centres were as follows in CZE: 11 university hospital (15.78%; all), six regional (8.6%; all) and 53 local centres (75.7%, 53 of 78 local obstetric centres). In SVK, four university hospitals (11.4%, all), five regional (14.3%; five of seven regional obstetric centres) and 26 local (74.3%, 26 of 43 local obstetric centres) centres participated in the study. The demographic characteristics of the parturients at the time of caesarean section are shown in Supplemental Tables, https://links.lww.com/EJA/A214. The overall caesarean section rate was 24.4% (CZE 23.3%, SVK 30%). 56.8% of these were nonelective caesarean section. Table 1 show an overview of the type of anaesthesia for caesarean section and indications for general anaesthesia. Regional anaesthesia was used in 60.8% (95% confidence interval (CI), 58.5 to 63.1) of cases in CZE which is 5.2% more than in OBAAMA-CZ study (55.6% incidence of regional anaesthesia in 2011)2 and in 67.0% of cases in SVK (95% CI, 63.8 to 70.1). The overall rate of regional anaesthesia in university hospitals increased in CZE from 55.6% (95% CI, 51.5 to 59.6) to 60.2% (95% CI, 56.4 to 63.9), in regional hospitals from 32.4% (95% CI, 26.4 to 39.0) to 41.0% (95% CI, 34.2 to 47.7) and in local hospitals from previous 60.7% (95% CI, 55.2 to 66.0) to 65.0% (95% CI, 61.8 to 68.2) in 2015. Detailed characteristics of general and regional anaesthesia for caesarean section are shown in Supplemental Tables, https://links.lww.com/EJA/A214.Table 1: Types and indications of anaesthesia for elective and nonelective caesarean section during study period in Czech Republic (2011 and 2015) and in Slovakia (2015)The main finding in our survey was the change of anaesthesiologic approach to the parturient in CZE most likely influenced by focused education with emphasis on latest trends in obstetric anaesthesia topics. We observed a decrease in the number of general anaesthetics in CZE (26 vs. 34% in elective and 50 vs. 58% in nonelective caesarean section). This change was identical for all types of centres except regional hospitals, where the proportion of general anaesthetics was still significantly higher compared with other centres (59 vs. 39%). In contrast, the lowest general anaesthesia rate in the SVK was university hospitals (28%) and even in regional centres, the highest proportion of general anaesthesia for caesarean section was 39% lower than in the CZE. Higher rate of regional anaesthesia for caesarean section in SVK compared with CZE (60 vs. 67%) is surprising if we consider the common history. Anaesthesia practice varies from country to country.3 Significantly, close to both countries, according to the survey from 2017, Austrian anaesthesiologists use spinal anaesthesia for routine caesarean section in almost 100% of cases.4 The use of epidural or spinal analgesia/anaesthesia in France increased progressively, from 53.9% in 1995 to 83.8% in 2016 and at the same time, the frequency of general anaesthesia decreased from 5.3 to 1.2%.5 On the contrary, in Greece in 2016 average use of regional anaesthesia was 69.2% of all caesarean section (Athens 77.1%, other cities 64.5%).6 The main limitation of our study is noncoverage of 100% of the population accompanied by random participation of different types of centres. On the other hand, the 2015 participation is 20% higher than in 2011 in CZE. Most of missing centres are local hospitals with the possible potential for ‘old-fashioned’ anaesthetic practice. Another limitation is missing data from SVK from year 2011 and thus is not possible to compare the improvement in both countries over the 4 years. In conclusion, regular national and international audits of obstetric anaesthesia practices in Central European countries allowed the focusing of scientific education with an emphasis on the latest trends in obstetric anaesthesia. The increase in use of regional anaesthesia for caesarean section over 4 years in CZE and the higher rate of regional anaesthesia as a starting position in SVK can be explained by the pursuit of joint education of Czech and Slovak anaesthesiologists in topics of obstetric anaesthesia by both national anaesthesiology societies. Acknowledgements relating to this article Assistance with the study: the authors thanks to all members of OBAAMA-INT Study Group and all other investigators from participating centres for their extraordinary work on this international survey. The members of OBAAMA-INT Study Group are listed in Appendix 1, https://links.lww.com/EJA/A214. Financial support and sponsorship: research grant of the Czech Society of Anaesthesiology and Intensive Care Medicine (CSARIM 201501). Conflicts of interest: none. The members of OBAAMA-INT Study Group are listed on https://links.lww.com/EJA/A214 (accessed 20th August 2019), the members of the steering committee are listed on http://obaama.registry.cz/index.php?pg=odborna-garance (accessed 20th August 2019).