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TARGETS aimed at reducing the number of caesarean deliveries have been questioned as new research suggests the WHO rate of no more than 10%‒15% of live births is too low.
A cross-sectional, ecological study published in JAMA last week estimated the contemporary relationship between national levels of caesarean delivery and maternal and neonatal mortality for 172 WHO member states. (1)
Contrary to the WHO’s consensus-based target of 10%‒15% of live births set in 1985, the study concluded that caesarean delivery rates of around 19% were associated with optimal levels of maternal and neonatal mortality.
Although the study authors stressed that the association could not be considered causal with their study design, they said the WHO’s previously recommended targets “may be too low”.
The WHO target was a consensus opinion based on the observation that some countries with the lowest perinatal mortality rates had caesarean delivery rates that were less than 10 per 100 live births, the authors wrote.
With caesarean deliveries compising 32% of live births in Australia, Professor Michael Permezel, president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, said the setting of targets by the WHO and others had been “unhelpful”. (2)
“Australia’s caesarean rate is comparable to much of Northern Europe, the USA and Canada”, he told MJA InSight. “Australia is not an outlier; perhaps we are doing the right thing.”
Professor Permezel said the countries with the lowest caesarean delivery rates were generally those with poor socioeconomic conditions and limited health resources — factors that contributed to poor maternal and neonatal outcomes, in addition to the lack of access to caesareans.
However, there were also some Scandinavian countries with both low maternal and neonatal mortality and comparatively low rates of caesareans, he said.
“It’s worth looking at what Scandinavian countries are doing; however, it is unlikely to be the low caesarean rate per se that is responsible for the good neonatal outcomes”, he said.
The authors of the JAMA research said their findings highlighted “a significant correlation between caesarean delivery rate and lower mortality that merits attention in the development of policy to strengthen surgical components of health systems”.
Previous studies on caesarean delivery rates had included fewer countries and had used data from varying years, without accounting for heterogeneity, the authors wrote. Their study aimed to reduce bias by focusing estimates to a single year, 2012.
An accompanying editorial concluded that the optimal level of caesarean delivery could not be as simple as a “one-fits-all figure”. (3)
“The appropriate” caesarean delivery rate remained unknown, the editorial authors wrote, adding that the primary goal of all obstetric services should be patient safety.
Professor Permezel told MJA InSight it was “not the role of obstetricians or midwives to determine the health priorities of women”.
“The vast majority of women just want what’s safest for baby and in many cases that turns out to be caesarean, particularly if the baby is breech or there has been a previous caesarean or there is another situation of increased risk”, he said.
Professor Peter Dietz, an obstetrician and gynaecologist at Western Sydney’s Nepean Hospital, said the goal of reducing caesareans was a “misguided obsession” underlying initiatives such as NSW Health’s Towards Normal Birth policy directive. (4)
“The worst consequence is that focusing on caesarean section rates makes us focus less on morbidity and mortality”, he told MJA InSight.
Professor Dietz said he was particularly concerned that clinicians and midwives were ignoring significant damage to the pelvic floor caused by long, complicated labours in pursuit of normal vaginal delivery.
He gave the example of a resolution by the American College of Obstetricians and Gynecologists last month not to use the rate of severe perineal lacerations as a measure of obstetric quality, partly because doing so would lead to increased caesareans. (5)
“We are ignoring permanent damage to women’s bodies because to care about these things might lead to more caesareans”, he said.
There were also rarer but more serious complications potentially associated with the drive towards natural vaginal delivery, including neonatal asphyxiation, post-partum haemorrhage and uterine rupture in women attempting vaginal birth after caesarean section, Professor Dietz said.
(Photo: Martin Valigursky / shutterstock)
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Economic rationalists rule; or that’s what it sounds like when targets, optimal rates, are introduced into an argument.
I prefer the model where patients’ (mother’s and baby’s) welfare are the determining factors for caesarean delivery.
I’m flabbergasted that “rates” could even be considered as a clinical guideline.
Another childbearing woman (and Obstetrician) to add their voice! I have two children both born by a Caesarean section for maternal choice! My aims for my birth were to have a healthy baby with as little stress to either the baby or the pelvic floor! And I achieved that with Caesareans! As an obstetrician, more and more I hear patients say “I don’t care how the baby comes out of my body, as long as it is healthy”. And also more and more women who are aware of the (now evidence based) fact that Caesarean sections are protective to the pelvic floor! Do we really think that the voices of childbearing women would be asking for vaginal delivery if they were really informed of the risks to the pelvic floor? At least 1 in 3 women who delivers vaginally has long term stress incontinence and 12% will require prolapse surgery (and that this is 9 fold greater after NVD and 20 fold greater after forceps delivery when compared to elective C/Section). It is time we stopped seeing increasing the Caesarean section rate as a sin! “Towards Normal Birth” is only an appropriate policy if women are informed and this is what they want! And many seem to have forgotten that the title is Towards Normal Birth” not Towards VAGINAL birth – forceps are not included!
Anonymous asks: “where is the voice of child-bearing women in this discussion? “
Right here, my friend!
And I want my medical advice evidence based.
I want my children alive and well.
Both my caesareans offered me these things.
My ‘experience’ of the birth is *fundamentally* less important than the wellbeing of my babies and also my own long-term health
I also want the evidence-based privileges I’m so lucky to have (because I have access to private health insurance), afforded to *all* women.
I don’t want some woo-seduced bureaucrat making non-evidence-based decisions for women who don’t have the resources I have.
“Anonymous” asks “where is the voice of child-bearing women in this discussion? “. It’s right before our eyes, in the private hospitals, where women who have more agency and choice have higher rates of Caesarean delivery. Obstetrics practice, like every other area of practice, has changed with time and evidence. We now know that instrumental delivery (forceps) can cause significant maternal injury, and is a difficult skill to master. Caesarean surgery is relatively easy to master and standardise. It also leads to better neonatal outcomes, at the small cost of some morbidity for mothers (mostly minor and short-term, such as wound infection). This, combined with increasing maternal age and weight, fewer childre per family and greater expectations for birth outcomes and better-than-ever anaesthetic techniques means that an increasing Caesarean rate is just what our community wants, and needs.
A normal delivery is not a caeserian section. Reductions in maternal and fetal morbidity/mortality rates are more likey associated with socio-economic circumstances than the frequency of caeserian section. More importantly, where is the voice of child-bearing women in this discussion?
maternal mortality ratio (mmr) available data are not computed with comparable methodologies among countries. Using death certificate only is associated to underestimation of mmr. Countries with more accurate mmr data are also with lower prevalence of caesarian section.
It seems to me that we are failing to aknowlege the slow but significant increase in babies birth weights over the last 50-odd years, during which time there has not been a concomitent increase in maternal pelvic dimensions. We also have large numbers of midwives who have no understanding of the data provided by Friedman to the providers of maternity services i.e. 1 cm/hr of cervical dilatation in the active stage of labour in Primipara is NOT adequate progress yet they regard it, and often slower progress as normal. The result is often very long labours, stressed babies and mothers with permanent pelvic floor damage as illustrated repeatedly by Prof Deitz. Isn’t it time to survey the 30% of mothers who have had an abdominal delivery and seek their opinions ? In my view Deitz is absolutely correct with his “misguided obsession” comment and the end result of a pregnancy should be judged by more than simple mortality and morbidity figures and include longer term issues related to the maternal pelvic floor as he has demonstrated. In this regard Caesarean Sections trump vaginal deliveries every day of the week.
we have come a long way to reduce maternal and foetal morbidity and mortality as well as satisfying the needs of pregnant women and let us NOT turn the clock back to attempt to reduce the caesaen section rate at the peril of health and safety of our mothers and babies to satisfy the ILL INFORMED radicals. There has NEVER been a better time to be pregnant and have a baby than TODAY and will only improve as we move along. I feel at this the CAESAREAN SECTION RATE is appropriate for preset circumstances.
In its wisdom, the federal government has eliminated the medicare rebate for pelvimetry. While widely acknowledged as imperfect, here is one investigation which may have had a role in increasing vaginal delivery rates, or at least increasig a doctor’s and patient’s confidence in attempting vaginal delivery, effectively removed from service.
While not clinically involved in O&G I found the NSW “policy directive” disturbing.
This will only apply to public patients and alter the standard of services in a negative direction for the public patient.
Having had two caesareans myelf, my first was an emergency as the baby had a massive head and my pelvis was too small, making it imposble to deliver him naturally. The second was judged as being too big for a natural delivery as well, after having a pelvic x-ray. Having major surgery is no fun, but preferable to two dead babies.
I would trust a clinical decision to operate, rather than trying to push in vain at the risk of the baby.