Does It? Really? “WHO Admits: There Is No Evidence for Recommending a 10-15% Caesarean Limit”
This is the title of a Medical News Today piece, actually a re-posting of a press release from a coalition of websites that promote elective cesarean surgery. The press release claims that the 2009 edition of the WHO’s “Monitoring Emergency Obstetric Care: A Handbook” has rescinded its 1985 recommendation that cesarean rates not exceed 10-15%. Can this be true? Not so much.
In fact, not at all.
The handbook still reads, as it always has:
The press release goes on to state that the WHO “updated” its (actually unchanged) recommendation, “admitting” that, quote, “no empirical evidence for an optimum percentage” exists, an “optimum rate is unknown,” and world regions may now “set their own standards.” The material from the WHO handbook is accurately quoted so far as it goes, but it doesn’t go very far. The handbook goes on to say: “A growing body of research shows . . . a negative effect of high rates,” cites studies in support of this (see below), and continues, “It should be noted that the proposed upper limit of 15% is not a target to be achieved, but rather a threshold not to be exceeded. Nevertheless, the rates in most developed countries and in many urban areas of lesser-developed countries are above that threshold” [emphasis mine]. In other words, countries with rates under 15% should not be striving to increase their rates, and countries “setting their own standards” means determining optimal rates, which may vary, within the WHO range.
This brings us to the second flat out untruth: The press release states that rates above the 10-15% range recommended by the WHO “have not led to a concomitant rise in maternal mortality or foetal, perinatal and neonatal mortality.” The WHO supports the 15% upper limit precisely because cesarean rates above the 15% ceiling result in higher maternal and perinatal death and morbidity rates. Here are the studies they cite:
This French study determined maternal deaths directly attributable to cesarean surgery by excluding women with risk factors that could lead to the need for cesarean surgery and reviewing the confidential reports generated after each maternal death. “After adjustment for potential confounders, the risk of postpartum death was 3.6 times higher after cesarean than after vaginal delivery. . . . Knowledge of the causes of death associated with this excess risk informs contemporary discussion about cesarean delivery on request.” The analysis, moreover, undercounts cesarean-related deaths because investigators excluded deaths that might have arisen from complications that occur more often in women with prior cesarean surgery, including ectopic pregnancy and deaths from hemorrhage due to placenta previa, placental abruption, and placenta accreta.
Investigators in a U.S. study found that after isolating an ultra-low-risk population with no indication for cesarean, babies born after cesarean surgery were 1.8 times more likely to die than babies born after vaginal birth. This amounted to an excess of about 1 per 1000. They conclude: “Understanding the causes of these differentials is important, given the rapid growth in the number of primary cesareans without a reported medical indication.”
A report on Latin America derived from a WHO 2005 survey of maternal and perinatal health, it found that “Rate of caesarean delivery was positively associated with . . . severe maternal morbidity and mortality, even after adjustment for risk factors. Increase in the rate of cesarean delivery was associated with an increase in fetal mortality rates and higher numbers of babies admitted to intensive care for 7 days or longer even after adjustment for preterm delivery. Rates of preterm delivery and neonatal mortality both rose at rates of caesarean delivery of between 10% and 20%.” In other words, 15% is a liberal and probably overly generous maximum.
Shame on whoever is behind these websites for circulating such dangerous misinformation—but even more shame on Medical News Today for passing it on without spending two minutes to fact check its accuracy.
In this video from the Lamaze Video Library, Eugene Declercq, PhD, fact checks claims about the rates of perinatal mortality, maternal mortality, and cesarean surgery in the United States. Special thanks to Orgasmic Birth for sharing this DVD Extra with Lamaze International.
[flashvideo file=http://www.lamaze.org/portals/0/video/Birth_by_the_Numbers512k.flv /]