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)
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.
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)
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.
(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
(C) Experiences of women www.electivecesarean.com/index.php?option=com_content&task=view&id=449&Itemid=631
Pauline McDonagh Hull
Executive Director, Birth Trauma Canada
Press Officer, Birth Trauma Association