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: https://www.mja.com.au/journal/2017/206/4/thirty-years-world-health-organization-s-target-caesarean-section-rate-time-move).

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.

References

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. http://doi.org/10.1186/s12978-015-0043-6

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. http://doi.org/10.1016/j.tjog.2014.08.001

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. http://doi.org/10.1016/j.ajog.2014.01.026

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. http://doi.org/10.1111/ajo.12519

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. http://doi.org/10.1136/bmjopen-2012-001723

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. http://doi.org/10.1111/j.1469-185X.2011.00195.x

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. http://doi.org/10.1080/07399330802269451

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. http://doi.org/10.5694/mja16.00832

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. http://doi.org/10.1071/AH13044

"midwives' views" etc have NO place in our literature. Bugger their views!”

The other evening I posted this article to twitter.

“Women who plan to birth at home with midwives are more likely to receive Evidence-based Care http://fb.me/1puDpq2un”

The article described research that found that first-time mothers who chose to give birth at home were not only more likely to give birth with no intervention but were also more likely to receive evidence-based care that women who gave birth in hospital despite care by the same midwives. (BIRTH 39:2 June 2012)

There was an immediate reply tweet from a female obstetrician who has the twitter name @obgynkenobi

Image from Twitter @obgynkenobi

Obygnkenobi  tweeted:  “primips should not then home birth according to recent bmj RCT. This article is level 9 evidence. Sorry.” 

I responded:  er no, that's not what that study showed at all

Obygnkenobi  tweeted: “p0s [nulliparas]: increased risk of adverse outcomes if home birth. Please don't make me get out of bed to get the ref. it's cold.”  

I responded: "the BMJ study showed a miniscule increase risk to the neonate with a primigravid woman birthing at home"

Obygnkenobi  tweeted: “let's not just pick and choose which evidence suits us”.  

I replied:  “birthing at home is still far safer than driving with your child in the car or having a swimming pool in one's back yard”

Obygnkenobi tweeted:  "I'm not debating the safety. I'm debating the article that stated that homebirth midwives were more likely to use EBM [evidence based medicine]” And further “Yes, the absolute risk is low but if EBM is the master we all serve, primips should not home"

I wrote back: “actually, the researchers said that people needed to be aware of the risks, not that they shouldn't”

Obygnkenobi tweeted: “because clearly, "some" midwives choose whichever evidence is more appropriate to their aims”  

I asked "clearly"? why clearly?"

Obygnkenobi replied:  "b/c some mws (and drs) don't practice EBM. Interpreting evidence based on proving a point"

That comment reminded me of the way people responded to a very poor study that changed practice overnight, so I replied “Hmmm, I guess the Term Breech Trial is a good example of your point. So many so quick to jump based on such flawed research” 

Obygnkenobi responded: “probably true to a degree. However I know many skilled docs who won't touch a breech” 

To that I commented: “then they're not skilled with breech; over decades I've seen many breech births & brilliant doctors & midwives; now fear rules”

Obygnkenobi  tweeted: “It's not just the medicolegal aspect but the trial confirmed what they had always thought”. 

I was confused by that statement, so replied: “sorry, you've lost me here” and when I thought more about what she said, I asked: “so you think they stopped doing breeches because the skewed trial confirmed what obstetricians thought all along?”

Obygnkenobi responded: “no but it probably was one of the factors #beforemytime"

I was confused by this comment too, because surely, understanding why we do what we do involves knowing one’s history and ensuring that what we are doing is evidence based. I am also aware of how one’s own cognitive bias leads us to perceive and interpret things from our own viewpoint, which is what happened with the Term Breech Trial. Cognitive bias was also happening in response to the BMJ article, so I tweeted in response “the biggest issue is ensuring the evidence is robust and real - we know how easy it is to find what you are looking for”

Obygnkenobi  tweeted: “So there IS a role for using our brain!! Who'd thought!”

I didn’t recognise this at the time as sarcasm, but I did feel confused so said: “and I'm not sure what this was in relation to either?? erk - I've missed something :( and I was enjoying this conversation”

Obygnkenobi replied:  “EBM raises a difficulty: either use our brains or use evidence. It's ok to use either but don't dress it up as EBM if it's not”

I fully agreed with that statement about evidence based [medicine] care being a difficulty, I was experiencing that in this conversation and replied: “very much so!”

Obygnkenobi  then tweeted: “precisely. And that's why the article with "midwives' views" etc have NO place in our literature. Bugger their views!” (my emphasis)

I was surprised and disheartened by that comment and replied: “I find that comment depressing :( “

Obygnkenobi responded:  “ok. How about: ebm and individuals views should not coexist in the same article. Better?” and then “individuals views are ok, so long as they're not gusseyed up to look like evidence. It's all good really.”

I didn’t respond to those two statements as it was 1230am and I was not wanting to say anything that could be misconstrued or appear rude.

The next day I tweeted:  @obgynkenobi I'm curious to know if you read the actual paper?

I haven’t received any response to my query. 

This morning I tweeted: @obgynkenobi “did you see this? Term Breech Trial 10 years on” 

That article is worth reading as it revisits the criticisms of the Term Breech Trial and highlights the fact that there has been an increase in maternal deaths with the rise of caesarean section surgery for breech presentations following that study. 

The abstract states:

Abstract:  In 2000, the Term Breech Trial was published, and its authors recommended cesarean section as the safest mode of delivery for breech-presenting babies. Criticisms of the trial were raised at the time, which the authors dismissed. Since then, maternal deaths have been recorded among women undergoing cesarean sections for breech presentations. Accordingly, those initial criticisms deserve to be revisited. (BIRTH 39:1 March 2012)

Not only did the BMJ article that Obgynkenobi had referred to earlier in our twitter conversation Perinatal and MaternalOutcomes Perinatal and maternal outcomes by planned place of birth for healthywomen with low risk pregnancies: the Birthplace in England national prospectivecohort study   not say women having their first baby should not give birth at home, they concluded: 

“Our results support a policy of offering healthy nulliparous and multiparous women with low risk pregnancies a choice of birth setting. Adverse perinatal outcomes are uncommon in all settings, while interventions during labour and birth are much less common for births planned in non-obstetric unit settings. For nulliparous women, there is some evidence that planning birth at home is associated with a higher risk of an adverse perinatal outcome. A substantial proportion of women having their first baby who plan to give birth in a non-obstetric unit setting are transferred to an obstetric unit.

These results will enable women and their partners to have informed discussions with health professionals in relation to clinical outcomes and planned place of birth. For policy makers, the results are important to inform decisions about service provision and commissioning. The relative cost effectiveness of the different birth settings will also be of interest to policy makers and is being compared in another component of the Birthplace Research Programme.

Further research is needed into the avoidability of adverse perinatal outcomes, the effect of staffing and service configuration on outcomes, and more detailed analyses of transfers from non-obstetric unit settings. It is unfortunate that routine maternity information systems are not currently of a sufficiently high quality to enable the analyses presented here to be repeated without carrying out another large prospective cohort study.”

I also retweeted the article that sparked the twitter conversation:

I tweeted: @obgynkenobi in terms of evidence based practice, did you actually read the article about midwives use of evidence and place of birth? 

There is still no response, but it is Sunday!   

I would like to think that we can have good, intelligent conversations about evidence and practice without denigration and dismissive behaviour.  

Interprofessional collaboration in Delivery Suite was the subject of a research project I did in 2008. Attitudes like those displayed here by this obstetrician fit the model of Negative Interprofessional Interactions and stereotypical behaviour. This model is linked to low social and emotional intelligence of the midwives and obstetricians together with adverse outcomes for women and their babies.  Obstetricians and midwives don't feel good about these negative interactions either. I certainly feel very disconcerted with the attitude of this doctor towards midwives and our practice and the misinterpretation of these three studies.