I read the Michelsen et al. [1] and Eskildd and Grytten's [2] comments regarding cesarean section and fetal death rates. Cesarean section is an important topic among obstetricians worldwide. Michelsen stated that cesarean section is not related to perinatal mortality [1]. This may imply that declining fetal death rates are not caused by increases in cesarean section rates. They also claimed that cesarean section is associated with many more complications than vaginal birth, such as postpartum hemorrhage, infection, and hysterectomy [1]. I agree somewhat with the letter by Michelsen et al. [1]. However, I have also stated that different countries, such as Korea, have different health care systems and the impact of the claim made by Michelsen on other countries should be considered [1].

First, I recommend that the authors consider the legal problems associated with cesarean section and fetal mortality. Korean obstetricians have complete legal responsibility for fetal problems. We have already revealed that general physicians do not want to be obstetricians because of concerns over the risk of medicolegal problems [3]. Korea does not have a legal compensation system for obstetric injuries. Korean obstetricians may not have easily access to assistant staff members such as residents and midwives.

Secondly, for more than 12 years in Korea, the Health Insurance Review & Assessment Service (HIRAS) has evaluated the performance rate of cesarean sections based on delivery counts, allowing for hospitals to be ranked. The HIRAS has reported rankings regarding the cesarean section rate in newspapers and online. Low-ranking hospitals should be avoided by pregnant women. The HIRAS calculate all scores based on their own risk guidelines. For example, the previous section state has a score of 92.9, so if the obstetrician does a cesarean section because of a previous section, they receive the 92.9 score, which signifies a good indication for the cesarean section. However, a 1.0 score is given when cesarean section is done with an indication involving older primiparous women, macrosomia, preterm birth, hypertensive diabetes, obesity, and fetal anomalies. A zero score is given in cases of fetal distress, fetal dystocia during labor, induction failure during post-term pregnancy, and maternal requests for cesarean section. If we describe in the operation records the cesarean section indication, the HIRAS will evaluate and give the score based on their HIRAS guidelines.

The HIRAS is not responsible for legal problems associated with perinatal morbidity or vaginal birth. HIRAS does not evaluate the obstetrician's resources in the hospital; assistant staff members, including midwives; or physician assistants. In addition, the HIRAS does not evaluate the delivery time and labor duration. Nighttime delivery is stressful and difficult for obstetricians. HIRAS does not evaluate critical situations such as fetal distress, fetal dystocia, or induction failure for post-term pregnancy.

Michelsen's article suggests that cesarean section is a riskier procedure with higher morbidity for the mother than vaginal birth [1]. A claim that vaginal birth is better than cesarean section may have important impacts on public and professional opinions, national health care centers, legal problems, and obstetricians in countries such as Korea. Thus, comparisons between cesarean section and vaginal birth should take into account the different circumstances of the obstetric field among countries.


  1. Top of page
  • 1
    Michelsen TM, Vangen S, Henriksen T. Cesarean sections and fetal death rates. Acta Obstet Gynecol Scand. 2014;93:3123.
  • 2
    Eskild A, Grytten J. The reduction in fetal death rates; a result of improved identification of high-risk pregnancies? Acta Obstet Gynecol Scand. 2013;92:11234.
  • 3
    Lee HH, Kim TH. Health system composition, rather than labor ward size, should be the basis for determining obstetric legal issues. Acta Obstet Gynecol Scand. 2014;93:430.