Last week, news stories from Great Britain reported that a target to reduce the number of cesarean surgeries in the United Kingdom has been quietly dropped based on “new” recommendations from the World Health Organization. My first response was, “Oh no!” In the US, the March 2010 NIH VBAC Conference focused attention on the risks of multiple cesareans. The Joint Commission in their new perinatal quality measures and some OB leaders are calling for a reduction in the primary cesarean rate as the most obvious strategy to reduce the risks associated with multiple cesareans. To dig deeper into the UK news story, I googled the reference for the “new” WHO recommendation, Monitoring emergency obstetric care: a handbook (2009). I found what I was looking for on pages 25 to 26. The “new” recommendation was taken out of context. Here is the complete paragraph from the booklet:
“Earlier editions of this handbook set a minimum (5%) and a maximum (15%) acceptable level for cesarean section. Although WHO has recommended since 1985 that the rate not exceed 10-15% (125), 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 (126-128). 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. Ultimately, what matters most is that all women who need caesarean sections actually receive them.”
Beyond a doubt, the World Health Organization is most concerned with the women in the least-developed countries of the world who are dying because cesarean surgery is not available. WHO cites an average cesarean rate of 3.5% in Africa. Efforts to increase the availability of life-saving cesarean surgery in those countries with rates under 5% will clearly improve maternal and newborn mortality rates. But WHO is also concerned about cesearan rates and maternal mortality in countries with high cesarean rates. From page 26 in the handbook,
“Many observers consider that we are experiencing a worldwide epidemic of overuse of caesarean section (131) and that the rates will continue to rise, in view of practitioners’ and administrators’ fear of litigation, local hospital culture and practitioner style as well as increasing pressure from women in highly industrialized countries to undergo cesarean sections for nonmedical reasons (132, 133). At the same time, evidence for the negative consequences of caesarean section is increasing: recent studies in countries with high rates suggest that caesarean section carries increased risks for maternal and neonatal morbidity and mortality (126-128.)”
Shame on all those who took words out of context to suggest that the World Health Organization has, in any way, backed off on their recommendation that cesarean rates in any part of the world not exceed 15%.