Wednesday, 8 March 2017

Thirty years of the World Health Organization’s target caesarean section rate. It’s time to take it seriously.

Australia, like much of the western world faces burgeoning numbers of women having caesarean sections along with increasing rates of postpartum haemorrhage, postnatal depression and other morbidities. There are many who argue for surgical birth, saying childbearing women are older, fatter and sicker and therefore require the life-saving operation. Others are critical of the increase. Then there are those who examine the literature and seek the truth of the matter.

Today's blog post is by Dr Kirsten Small, an Obstetrician and Gynaecologist who teaches in the School of Nursing and Midwifery at Griffith University in Queensland, Australia. 

Kirsten has a research interest in examining the mismatch between the evidence base and what happens in clinical practice in maternity care.

In line with her research interest, Kirsten provides the following thought provoking lens on a recently published review of the World Health Organisation's target caesarean section rate. Read on, I think you'll find what she has to say fascinating.

The Medical Journal of Australia recently published a narrative review, titled “Thirty years of the World Health Organization’s target caesarean section rate: It’s time to move on.” (link:

Authors Stephen Robson and Caroline DeCosta argue that the “ideal” caesarean section (CS) rate proposed by the World Health Organization in 1985 is “too low” (Robson & DeCosta, 2017, p 184).

By selective use of published literature, they generate a narrative to support this argument, and somewhat obtusely recommend that “in Australia, we should be aiming to provide CS to all women in need” (Robson & DeCosta, 2017, p 184). It is difficult to disagree with this point, but the high Australian CS rate would suggest that we are also providing CS to women who have no need for it, and who may not desire it.

The key points of their paper are presented in a summary as Figure 1 below. 
 Figure 1: Summary Robson & DeCosta, 2017, p 181

It is possible however, to use the published literature to create a different narrative, one that supports the contention that Australia’s CS rate is not appropriate.

An alternative summary of the evidence is:

  • It has been two years since the WHO reaffirmed its longstanding position that the ideal CS rate is under 20% (Betran, et al., 2015).
  • CS rates, particularly in wealthy industrialised countries continue to rise, with no evidence of associated improvement in perinatal outcome (Betran, et al., 2015)
  • The strongest predictor of CS birth for the first infant is birth in a private hospital (Dahlen et al., 2012).
  • Women whose first baby is born by CS find it difficult to access a care provider who will support them to achieve a vaginal birth in subsequent pregnancies (Toohill, Gamble, & Creedy, 2013).
  • Outcomes that interest the patriarchal medical model typically exclude those that reflect women's experience of their care (Parry, 2008).
  • Longer term outcomes for the neonate are better following vaginal birth rather than CS (Hyde, Mostyn, Modi, & Kemp, 2011).
  • Pelvic organ prolapse and incontinence are not strongly correlated with mode of birth (Bozkurt, Yumru, & Şahin, 2014). Surgical procedures for these conditions are increasingly safe and carry low risks of complications (Ogah, Cody, & Rogerson, 2011).
  • Serious complications of CS such as placenta accreta, while rare, are of increasing concern to health care systems, given the large number of operations performed annually (Cheng, Pelecanos, & Sekar, 2016).
  • We should aim to provide all women with evidence based care that achieves high rates of vaginal birth (Caughey, Cahill, Guise, & Rouse, 2014). All women should be involved in decision making regarding their birth options, to the extent that they wish to be.
Conclusion: There are ingrained systemic reasons why the medical model presents CS as the safe, easy option for women (Bryant, Porter, Tracy, & Sullivan, 2007). The evidence is clear – there is no population benefit for a CS rate of over 15%. Clinicians should focus on applying evidence to the care of individual women in order to achieve the best outcomes for them and for their infants.

Betran, A.P., Torloni, M.R., Zhang, J., Ye, J., Mikolajczyk, R., Deneux-Tharaux, C.,Gülmezoglu, A.M. (2015). What is the optimal rate of caesarean section at population level? A systematic review of ecologic studies. Reproductive Health, 12(1), 57–57.
Bozkurt, M., Yumru, A. E., & Şahin, L. (2014). Pelvic floor dysfunction, and effects of pregnancy and mode of delivery on pelvic floor. Taiwanese Journal of Obstetrics and Gynecology, 53(4), 452–458.
Bryant, J., Porter, M., Tracy, S., & Sullivan, E. (2007). Caesarean birth: Consumption, safety, order, and good mothering. Social Science & Medicine, 65(6), 1192–1201.
Caughey, A. B., Cahill, A. G., Guise, J.-M., & Rouse, D. J. (2014). Safe prevention of the primary cesarean delivery. American Journal of Obstetrics and Gynecology, 210(3), 179–193.
Cheng, H. C., Pelecanos, A., & Sekar, R. (2016). Review of peripartum hysterectomy rates at a tertiary Australian hospital. Australian and New Zealand Journal of Obstetrics and Gynaecology, 56(6), 614–618.
Dahlen, H. G., Tracy, S., Tracy, M., Bisits, A., Brown, C., & Thornton, C. (2012). Rates of obstetric intervention among low-risk women giving birth in private and public hospitals in NSW: a population-based descriptive study. BMJ Open, 2(5), e001723–e001723.
Hyde, M. J., Mostyn, A., Modi, N., & Kemp, P. R. (2011). The health implications of birth by Caesarean section. Biological Reviews, 87(1), 229–243.
Ogah, J., Cody, D.J. & Rogerson, L. (2011). Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women: A short version Cochrane review. Neurourology and Urodynamics, 30, 284–291. doi:10.1002/nau.20980.
Parry, D. C. (2008). “We wanted a birth experience, not a medical experience”: exploring Canadian women's use of midwifery. Health Care for Women International, 29(8), 784–806.
Robson, J., & de Costa, M. (2017). Thirty years of the World Health Organization's target caesarean section rate: time to move on. The Medical Journal of Australia, 206(4), 181–185.
Toohill, J., Gamble, J., & Creedy, D. K. (2013). A critical review of vaginal birth rates after a primary Caesarean in Queensland hospitals. Australian Health Review, 37(5), 642–7.

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