| PR 2008 - Challenging the WHO rate |
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Publications *NIH State-of-the-Science Conference Statement, Cesarean Delivery on Maternal Request, 27-29 March 2006 Some authors have proposed an "ideal rate" of all cesarean deliveries (such as 15%) for a population. There is no consistency in this ideal rate, and artificial declarations of an ideal rate should be discouraged. Goals for achieving an optimal cesarean delivery rate should be based on maximizing the best possible maternal and neonatal outcomes, taking into account available medical and health resources and maternal preferences. Thus, optimal cesarean delivery rates will vary over time and across different populations according to individual and societal circumstances. *Cyr RM, Myth of the ideal cesarean section rate: Commentary and historic perspective, USA 2005 Attempts to define, or enforce, an ‘ideal' cesarean section rate are futile, and should be abandoned... let everyone practice the best obstetrics they know, and let the cesarean section rate seek its own level. *Dietz & Michael, Will there ever be an end to the Caesarean section rate debate? Australia 2004 There are no scientific grounds for identifying an 'appropriate' level for cesarean rates. *Rozenberg P, valuation of cesarean rate: a necessary progress in modern obstetrics, France, 2004 ...The purpose of this review of the literature was to demonstrate how the concept of CS rate limitation has become obsolete. *Robson MS, Can we reduce the caesarean rate? UK, 2001 Maternal satisfaction has now become one of the most significant outcome factors after childbirth and must be taken into consideration when implementing any changes in childbirth... Cesarean rates should no longer be thought of as being too high or too low, but rather whether they are appropriate or not, after taking into consideration all the relevant information. Medical Opinion *Dr Bruce Flamm (quoted in 2007 by Womens'eNews), an obstetrician with Kaiser Permanente, Riverside, CA: there isn't enough data to say what the appropriate c-section rate should be. ‘Some of my colleagues think it should be higher. I have heard some doctors say that all women should have babies by c-section, that vaginal births are archaic. Some docs have a c-section rate of 50% because they believe in their hearts it's the best thing for their patients.' *Dr Andre Lalonde (quoted in 2007 by Times Colonist), executive vice-president of the Society of Obstetricians and Gynaecologists of Canada: there is no definitive guideline for what the c-section rate should be, but the society's best estimate is that 15 to 25% is an acceptable range. *Medical opinion (quoted in 2007 by The Statesmen): One thing on which people on all sides of the issue agree: The stated national goal of a 15% cesarean rate will probably never happen. *NIH opinion (quoted in 2006 by US News): dismissed the 15% public-health goal as ‘artificial', stating that ‘declarations of an ideal rate should be discouraged.' *Dr Ralph W Hale (quoted in 2005 by electivecesarean.com), executive vice-president of ACOG: There is absolutely no data to support it. *Dr W Benson Harer Jr (quoted in 2005 by electivecesarean.com), a retired obstetrician and former President of ACOG: [The WHO] clings steadfastly to a 15% maximum despite its own data indicating benefits to both mother and child from a much higher rate. In 1999, Belizan reported on data from twelve Spanish-speaking nations in South America with cesarean rates above 15% and concluded that more than 850,000 ‘unnecessary' cesarean deliveries were done annually, resulting in ‘an unnecessary increased risk for young women and their babies.' Yet when Groom and Brown charted Belizan's data in 2000 (BMJ author reply), it was obvious that maternal and neonatal and infant mortality rates progressively improved as the cesarean rate increased to 40%. *Samantha Collier, MD (quoted in 2005 by electivecesarean.com), vice-president of Medical Affairs at HealthGrades: Many organizations, including the Health and Human Services and the World Health Organization, want to decrease the rate of cesareans, even though recent studies have been saying we shouldn't... In our research, we have predicted twelve medical indicators that support primary elective cesarean and from this predicted what the rate should be. Where there were lower rates of cesareans than expected, there were higher vaginal complications... This is very worrisome and we need to get away from this 'number' or % of cesareans because it gives incentives to people to possibly do the wrong thing. *Professor James Drife (quoted in 2005 by electivecesarean.com), an obstetrician at Leeds General Infirmary: The idea of applying a blanket figure that is 20 years out of date is nonsense, particularly when it is to be applied to every country in the world. It's a figure picked by a group of people in a room in Geneva and it doesn't reflect reality. *Professor Gordon Smith (quoted in 2005 by electivecesarean.com), Head of Obstetrics and Gynaecology at Cambridge University: I would completely disregard this figure. I think it is ludicrous to attempt to define cesarean rates which would cover the demographics of many different countries. My understanding is that this analysis is made on the basis of looking at national cesarean rates and perinatal mortality rates. However, the vast bulk of perinatal mortality is unrelated to mode of delivery, being antepartum stillbirth and neonatal death due to prematurity. An intelligent analysis of the effect of cesarean rate on perinatal mortality would have to confine this to outcomes which are potentially affected by mode of delivery. In practice this requires very detailed information on the cause of perinatal death in a very large number of cases and such analyses have not been done. *Dr Harry Gee (quoted in 2005 by electivecesarean.com), a consultant obstetrician at Birmingham Women's Hospital: They are unrealistic in a modern society. I don't know any developed country with a cesarean rate that low. The cesarean rate has increased over the years for good reasons. Statistics for cesarean are averaged out to include third world countries where cesarean is more dangerous. So it makes sense to encourage vaginal delivery there. On the other hand, the perinatal or maternal mortality rates are not often quoted, nor are other vaginal complications. I suspect that if they were, these statistics would just not be acceptable to our society. *Dr Charles Lockwood (quoted in 1998 by The New York Times), obstetrician, New York University Medical Center: 'The assumption that our cesarean rate is too high is based on zero data... [Lowering the CS rate to 15%] may be dangerous.' |
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