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WHO Finally Admits - the 'Optimum Rate [of Caesarean Section] Is Unknown' and 'There Is No Empirical Evidence' for Its 1985 Recommendation of 10-15%

Back in 1985, the World Health Organization recommended that there was no justification for a caesarean delivery rate higher than 10-15% in any world region, and since then, this percentage range has been used to criticise rising national caesarean rates in the developed world. However, for 2009, the WHO has updated its 24-year-old recommendation, admitting that 'no empirical evidence for an optimum percentage' exists and an 'optimum rate is unknown'. It now recommends instead that world regions make a choice. They 'might want to continue to use a range of 5-15% or set their own standards.'

In what is one of the most oft-quoted figures in caesarean delivery discourse, the World Health Organization has at last reviewed its 1985 assertion that 'there is no justification for any region to have a [caesarean section] rate higher than 10-15%'.(1)
Almost a quarter of a century has passed since the WHO document 'Appropriate Technology For Birth'(1) was published, yet advocates of natural birth and members of the news media have continued to quote the figure 15% as an authoritative recommended caesarean rate threshold, and evidence of caesarean overuse.
In fact, caesarean rates in most of the developed world have long since risen above the 10-15% rate range suggested in 1985, and while many other areas of debate on the subject of caesarean delivery usage remain (e.g. repeat caesarean versus VBAC, maternal request with no medical indication, breech delivery, multiple gestation, macrosomic foetus, foetal distress during labour etc.), the removal of this arbitrary number at least leads us away from the idea that appropriate use has a generic numeric value for all worldwide maternal populations.
What the WHO now states
In its latest 2009 publication, 'Monitoring Emergency Obstetric Care: a handbook' http://www.who.int/reproductivehealth/publications/monitoring/9789241547734/en/index.html section 2.5, (2) the WHO states that, 'Both very low and very high rates of caesarean section can be dangerous, but the optimum rate is unknown. Pending further research, users of this handbook might want to continue to use a range of 5-15% or set their own standards.'
The statement continues, 'Earlier editions of this handbook set a minimum (5%) and a maximum (15%) acceptable level for caesarean section. Although WHO has recommended since 1985 that the rate not exceed 10-15%, there is no empirical evidence for an optimum percentage or range of percentages, despite a growing body of research that shows a negative effect of high rates.'
Evidently, there is now a degree of ambiguity in what the WHO recommends. It recommends that regions 'use a range of 10-15%' (even though there is no empirical evidence for such a range) or implement their own standards. Consequently, it is perhaps inevitable that different birth advocate groups will take a different view on what the new handbook statement actually means, and arguments over the credibility of an optimum caesarean rate (emergency and/or elective) will continue.
Previous challenges to the 1985 WHO recommendation
In October 2008, the Coalition for Childbirth Autonomy (CCA) called on the World Health Organization to re-examine what it described as an 'outdated and unsafe'(3) recommended 10-15% cesarean threshold, claiming that efforts to keep within it 'could lead to increased morbidity for both mothers and infants.'
The CCA cited a number of medical studies in support of its argument, and included sixteen examples of medical publications and cited opinion(4) that criticised the 1985 recommendation. The group maintained that 'the provision of truly unbiased information for women, with full disclosure of risks and benefits associated with all birth types, and crucially, respect for women's individual decisions' was more important than any 'national efforts to reduce the incidence of one particular birth type.'
Clearly, the WHO has now shifted its focus on caesarean sections towards safe birth outcomes in favour of recommending national percentage thresholds, and concludes that, 'Ultimately, what matters most is that all women who need caesarean sections actually receive them.' Of greatest concern is the devastating loss of life that occurs during childbirth in areas of the developing world with caesarean rates of only 0-5%. Meanwhile, in the 21st century maternal landscape of the developed world, where pregnant women are now larger, older, and having fewer and larger babies than at any point in history, it is likely that an 'optimum rate' of caesarean delivery will remain an 'unknown' quantity for the foreseeable future.
References
(1) Appropriate Technology For Birth. No authors listed. The Lancet - Volume 326, Issue 8452, 24. August 1985, Pages 436-437. doi:10.1016/S0140-6736(85)92750-3.
http://www.ncbi.nlm.nih.gov/pubmed/2863457
(2) Monitoring Emergency Obstetric Care: a handbook. World Health Organization 2009 ISBN 978 92 4 154773 4
http://whqlibdoc.who.int/publications/2009/9789241547734_eng.pdf
(3) Birth Group, CCA, Calls On WHO To Re-examine 'Outdated And Unsafe' 10-15% Recommended Cesarean Rate
http://www.medicalnewstoday.com/articles/128550.php
(4) Coalition for Childbirth Autonomy - PR 2008 - Challenging the WHO rate - references
http://www.electivecesarean.com/index.php?option=com_content&task=view&id=447&Itemid=1

Pauline McDonagh Hull
Editor, www.electivecesarean.com
Co-founder, www.coalitionforchildbirthautonomy.org
Blog, www.cesareandebate.blogspot.com

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HEADLINE

Birth Group, CCA, Calls on WHO to Re-examine ‘Outdated and Unsafe’ 10-15% Recommended Cesarean Rate

SUMMARY

The oft-quoted 10-15% cesarean limit, as recommended by the World Health Organization in 1985, is outdated, unsafe and in urgent need of review. The international birth group, CCA, warns that attempts to reduce national cesarean rates to these levels are leading to maternal and infant deaths, disability and trauma.

MAIN BODY

Embargoed until: October 29, 2008, 00:01 GMT – Evidence shows that strategies to reduce national cesarean rates to levels of 10-15% are fundamentally flawed and could lead to increased morbidity for both mothers and infants. The Coalition for Childbirth Autonomy is urging national government and local hospital policy makers to be wary of implementing targets that aim to reduce cesarean rates to a range recommended 23 years ago, as the evidence reviewed at that time has been superceded by more recent and relevant studies. The group consists of birth support and information groups from three countries, including www.electivecesarean.com (USA), www.birthtraumacanada.org (Canada), www.birthtraumaassociation.org.uk (England) and www.csections.org (England).

OUTDATED

In 1985, the World Health Organization document ‘Appropriate Technology For Birth’(1) stated: “There is no justification for any region to have a [cesarean] rate higher than 10-15%.” This recommendation continues to be quoted by special interest groups and media commentators as the ‘ideal’ rate that developed countries should adopt. By highlighting unfavorable cesarean outcomes following emergency surgery or medical necessity (e.g. pre-term deliveries), they present an argument for reducing national cesarean rates and refusing cesarean delivery on maternal request (CDMR). Yet Dr Monir Islam, Director of the WHO’s Making Pregnancy Safer Program, during an August 2008 interview with Pauline M Hull, said that with regard to CDMR: “Women should be given the information and they should have the right to decide.”

Dr Islam pointed out that the original document itself leaves room for countries’ own individualized interpretation: “The above recommendations acknowledge differences between various regions and countries. Implementation must be adapted to these special situations.” Since its publication, a large number of medical professionals and institutions have criticized the 1985 cesarean guidance, and questioned its authority in contemporary maternity care. In 2006 for example, the U.S. National Institutes of Health said: “There is no consistency in this ideal rate, and artificial declarations of an ideal rate should be discouraged... optimal CS rates will vary over time and across different populations according to individual and societal circumstances.” This statement, together with fifteen others, is presented in full in support of this press release.(Ref.A)

INCONSISTENT

In addition to the question about whether 23-year-old advice on a worldwide cesarean limit remains relevant today, it is also questionable whether women are being informed of the context in which this limit appears. Some of the less publicized recommendations, contained in the same 1985 WHO document, include those that are also inconsistent with contemporary maternity practice. For example:

“During delivery, the routine administration of analgesic or anaesthetic drugs (not specifically required to correct or prevent any complication) should be avoided.”
“There is no evidence that caesarean section is required after a previous caesarean section birth. Vaginal deliveries after a caesarean should normally be encouraged wherever emergency intervention is available.”
“There is no evidence that fetal monitoring has a positive effect on the outcome of pregnancy. Electronic fetal monitoring should be carried out only in carefully selected cases related to high perinatal mortality rates and where labour is induced.”

Medical evidence has questioned the appropriateness of the above recommendations in the years since 1985, and in most hospital settings today, epidurals are freely available, repeat cesarean delivery is considered safer than VBAC, and fetal monitoring is often standard. Yet attempts continue to defend an ingrained 10-15% figure that is wholly inconsistent with this reality: pregnant women are larger and older, and they are having fewer and larger babies than at any point in history. An 85% safe vaginal delivery success rate is simply unachievable.

UNSAFE

Given the growing evidence of benefits associated with planned cesarean delivery, rates of 10-15%, and attempts to reduce rates to this level, would most certainly be associated with poorer outcomes for mothers and infants. 2008 research into the UK’s incidence of maternal mortality found a lower risk with planned cesarean delivery compared to all other birth types.(2) Separate Canadian studies in 2007 reported less chance of hemorrhage with planned cesarean delivery(3) and in 2003, increased morbidity with assisted vaginal delivery and cesarean delivery in labor.(4)

A 2003 U.S. study(5) identified statistically significant higher vaginal complication rates in hospitals that did fewer than expected preplanned cesarean sections, and vice versa in those that did more than expected, “suggestive of, but not definitive of, inappropriate under-utilisation of preplanned first time c-sections [and] counterproductive to the goals of a lowered national primary cesarean rate.” Without question, damage to the pelvic floor should not be ignored at the expense of reducing rates.(6)

There is also evidence of improved benefits for the infant with planned cesarean delivery, including reduced neonatal(7) and perinatal(8) mortality and reduced severe morbidity.(9) But most notably, particularly in the context of ensuring positive psychological birth outcomes and reducing postpartum depression, are studies that report greater levels of satisfaction in women following a planned cesarean delivery when compared with a planned vaginal delivery, which is more likely to result in a traumatic outcome.(10,11,12,13,14,15)

Important note: The CCA is not suggesting that cesarean delivery is the best or first choice for all women; on the contrary. We want to ensure the provision of truly unbiased information for women, with full disclosure of risks and benefits associated with all birth types, and crucially, respect for women's individual decisions. This information should not be impeded by personally held medical opinions or national efforts to reduce the incidence of one particular birth type.

BIRTH GROUP QUOTES

Maureen Treadwell from the UK’s Birth Trauma Association, says: “What women need is accurate and genuinely balanced information about all birth types, and there needs to be more respect for the decisions women make. We see women with extreme fear of childbirth who have been forced to go through vaginal birth with appalling mental health consequences. It is completely inhumane.”

Penny Christensen, Chair of Birth Trauma Canada, says: “We support mothers traumatized by their childbirth experiences and we advocate for the basic human right of all women to reproductive choice. The individuality and autonomy of each woman must be acknowledged and respected and they have a right to unbiased, credible evidence about the risks and benefits of planned vaginal deliveries and planned cesarean delivery options. Access to competent planned cesarean deliveries must be provided if that is their choice.”

Leigh East, who founded c-sections.org, agrees: “Balanced antenatal education is crucial. Reducing the ‘expectation-experience gap’ can significantly improve a woman's interpretation of her birth experience.(16) In the NHS, only 52% of births are ‘normal’(17), and women who have unrealistic expectations and a firm insistence on a single birth route increase their likelihood of mental trauma.”

Pauline McDonagh Hull, editor of electivecesarean.com, says: “I’m concerned how rate-focused policies might affect women with tokophobia and healthy women with no medical indication who request a cesarean following careful evaluation of the risks and benefits. In the U.S., the NIH and ACOG agree that cesarean delivery is ethically justified at 39 weeks gestation and with a small family plan, but I still receive emails from women worldwide, desperate for help, whose valid choice is not being respected. For this reason, I started an online petition in July 2008.”(Ref.B)

CASE STUDIES

For quotes from correspondence we have received from women about their birth fears and experiences, please go to this page.(Ref.C)

CURRENT CESAREAN RATES

These stand at 31.1% (USA), 30.3% (Australia), 26.3% (Canada), 24.3% (England), 26.9% (Wales), 24.7% (Scotland) and 23.9% (Northern Ireland). Any attempt to reduce these rates should not be at the expense of infants’ and mothers’ health or women’s autonomy.

REFERENCES

(1-17) www.electivecesarean.com/index.php?option=com_content&task=view&id=448&Itemid=631

(A) Challenging the WHO rate

www.electivecesarean.com/index.php?option=com_content&task=view&id=447&Itemid=631

(B) Petition

www.gopetition.com/online/20660.html

www.electivecesarean.com/index.php?option=com_content&task=view&id=449&Itemid=631

CONTACT INFORMATION

The birth groups listed here are working together to help better educate women about their birth decisions, and the risks and benefits associated with these different decisions. They also provide support for women who have had traumatic experiences before, during or after the birth of their child.

Pauline McDonagh Hull, Editor, electivecesarean.com
(USA +001) 610 838 8011

Email info@electivecesarean.com
www.electivecesarean.com

Blog www.cesareandebate.blogspot.com

Penny Christensen, Executive Director, Birth Trauma Canada
www.birthtraumacanada.org

Email mail@birthtraumacanada.org

Leigh East, Founder, csections.org

www.csections.org
Email: info2006@csections.org

Maureen Treadwell, Press Officer, Birth Trauma Association

(UK +01144) 0845 1583 503

www.birthtraumaassociation.org.uk

Email: enquiries@birthtraumaassociation.org.uk