Does It? Really? “WHO Admits: There Is No Evidence for Recommending a 10-15% Caesarean Limit”

October 30th, 2009 by avatar

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 The press release claims that the 2009 edition of the WHO’s “Monitoring Emergency Obstetric Care: A Handbook”  has rescinded its 1985 recommendation that cesarean rates not exceed 10-15%.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:

WHO chart

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:

Deneux-Tharaux (2006)
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.

MacDorman (2006)
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.”

Villar (2006)
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 /]

Research for Advocacy , , ,

  1. | #1

    “…shame on Medical News Today for passing it on without spending two minutes to fact check its accuracy.”

    No kidding!

  2. | #2

    Thank you for posting this! I read the article, and noted the same things, and wondered if I were as bad at reading comprehension as the spin-doctors were trying to make me think. Glad to know my reading comp is just as good as it always was. :-)

    It is incredible to me that they can take a statement like, “The C-section rate is not to exceed the 15% threshold” and make it sound like “C-sections: the more, the merrier!” I was also upset over the lie about C-sections not harming mothers and babies.

    Again, thank you!

  3. | #3

    Thank you, Henci for sharing this info & the citations. Very helpful. Lisa H.

  4. avatar
    | #4

    Make sure to leave feedback for the Medical News Today staff! They need to know that others are fact checking them. http://www.medicalnewstoday.com/articles/169058.php

  5. | #5

    …..ohhh, I just love it when you do this, Henci. Thank you!

  6. avatar
    | #6

    So how many healthcare workers will read this article and feel validated? I’d think that MNT wider reader’s base. They should print an apology and report the facts. IMO this is fraud.

  7. avatar
    | #7

    BTW they are not approving ANY comments so far!!!! Be sure to let Christian Norqvist know what you think and that he should post a retraction! editors@medicalnewstoday.com

  8. | #8

    I just submitted a request that they correct the misinformation that included the link to this S&S blog post. Here’s hoping the website is more interested in the truth than these pro-cesarean websites.

  9. | #9

    Your welcome! This is my idea of fun.

  10. | #10

    What gets me is that this group, the CCG, says more women should have choices due to traumatic births, or other traumas surrounding birth. It seems strange to me, that they would advocate this instead of dealing with the actual problem(i.e. our birth practices that cause this problem). It seem much safer and more cost effective to advocate for labor support, therapy, educating medical personnel, etc.

    Of course, I’m an advocate of birth choices, but to sell women the line that c-sections are a completely safe alternative seems irresponsible to me.

  11. avatar
    | #11

    Did they actually remove the article? I could not find it just now.

  12. | #12

    @prairiesprite – They have in fact taken the article down, thanks no doubt to readers who let them know that they had been fact checked! :)

  13. | #13

    Praise to all of the “Get to the Truth” investigators! Confounding the public seems to work in favor of those who make their living from mis-represented information.

    The gullability of cyber culture needs vigilant leaders! It seems however, that even I did not understand the angle of this article until I delved further. Most people don’t have that attention span.

    How can we replay this information to reach the larger populus that is so quick to adopt the dangerous myths of modern culture?

  14. | #14

    Medical News Today editors have this week re-posted the Coalition for Childbirth Autonomy’s press release and apologized for its mistaken retraction.


  15. | #15

    So they have. Notice, though, the weasel wording: they state that the retraction was in error, not that the content of the press release was accurate, and they have now termed the piece a “press release,” which means they bear no responsibility for the accuracy of its contents whereas before, it was simply a news item. It makes me wonder what happened behind the scenes. It may not be coincidence that one of the pro-cesarean websites that is a member of the coalition has an endorsement from an executive VP of ACOG on its home page.

    Thanks, by the way, for writing to them and linking to my blog post.

  16. | #16

    This is a nice review.

    >> – 6.2% induction/prostaglandin vs. 7.8% expectant/prostaglandin. Difference did not achieve statistical significance, meaning it was likely to be due to chance.

    It is helpful to report actual p values, even when it is “not statistically significant.” If the p was 0.07 we might say it wasn’t statistically significant, because of our arbitrary decision to have an alpha of 0.95, but in reality this still means that the study would have the same result 93 out of 100 times (or that there is a 93% chance that the study result is _not_ based on chance, or a 93% chance that the study result is a beta error).

    “not statistically significant” does not mean “likely due to chance”. The absolute p value is important.

    “6.2% induction/prostaglandin vs. 7.8% expectant/prostaglandin” may not have achieved a p < 0.05, but may still be a very real difference that the study was underpowered to find.

    Nicholas Fogelson MD

  17. | #17

    This comment does not seem to follow on to the original blog post. Did it get posted in the wrong place somehow, or am I missing something?
    @Nicholas Fogelson

  18. avatar
    | #18

    At 3:00 he states, “thankfully, mothers really die” ????? Am I missing the context of this statement? Can someone clarify this for me, please.

  19. | #19


    I think he says “mothers *rarely* die” — I’m not sure what his accent is (perhaps he’s from Boston?), but I had to pay attention to understand what he was saying a lot of the time too.

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