World Health Organization’s warning on C-sections is ideology masquerading as science

Group of People Brainstorming about Ideology Concept

Once again, the World Health Organization has dressed up ideology to mimic science and is hoping no one notices the difference.

This is not the first such misleading effort on the part of the WHO. In 1985, Marsden Wagner, then head of Maternal and Child health in the European Regional Office of the WHO, convened a conference that declared that the optimal C-section rate was 10-15%. Wagner and colleagues simply made that up, thereby elevated their strongly held ideological conviction, unmoored from science of any kind, into policy.

In 2009, the WHO was forced to acknowledge that there is no optimal C-section rate and that there had never been any scientific evidence of any kind to support an optimal rate.

Although the WHO has recommended since 1985 that the rate not exceed 10-15 per cent, there is no empirical evidence for an optimum percentage … the optimum rate is unknown …

For 24 years the World Health Organization touted a C-section target that was an utter fabrication, created to suit the prejudices of its creators, without any evidence to support it.

Pretty embarrassing, no?

Apparently not, since the WHO has just done it again.

According to the Daily Science Journal:

The global health guidelines suggest that the ideal rate for Caesarean births is between 10% and 15% and unnecessary surgery could be “putting women and their babies at risk of short and long-term health problems.”

In order to make that claim, you’d need to show two things: first that in industrialized countries, C-section rates above 15% did not lower perinatal mortality; second that C-sections rates above 15% increase maternal and neonatal morbidity and mortality.

The WHO has shown NEITHER. And there are two critical caveats to what they did show:

They looked at middle income and poor countries where C-section is far more dangerous than in industrialized countries.

They did not include stillbirth rates. Since C-sections are used in large part to prevent stillbirth, it means the findings are woefully incomplete.

Consider the WHO Statement on Caesarean Section Rates itself:

1. The first sign that this is ideology, and not science, is that there are no scientific references. That’s a curious omission for a warning that purports to be based on scientific evidence.

2. The second sign is that this is ideology and not science is that it based on two studies that aren’t identified:

In 2014, WHO conducted a systematic review of the ecologic studies available in the scientific literature, with the objective of identifying, critically appraising, and synthesizing the findings of these studies, which analyse the association between caesarean section rates and maternal, perinatal and infant outcomes. At the same time, WHO undertook a worldwide ecologicstudy to assess the association between caesarean section and maternal and neonatal mortality, using the most recent data available. These results were discussed by a panel of international experts at a consultation convened by WHO in Geneva, Switzerland, on 8–9 October 2014.

What studies might those be?

The second half of the pronouncement discusses the Robson classification of C-sections. I was able to find this paper published on Friday in The Lancet, Use of the Robson classification to assess caesarean section trends in 21 countries: a secondary analysis of two WHO multicountry surveys. According to this paper, the two studies that were analyzed were:

The WHO Global Survey of Maternal and Perinatal Health (WHOGS) was undertaken in 2004–05 (in Latin America and African countries) and in 2007–08 (in Asian countries).17–19 The primary aim of WHOGS was to explore the association between the use of caesarean section and maternal and perinatal outcomes.20–22 A stratified, multistage, cluster-sampling approach was used to obtain a sample of deliveries in 24 countries from Africa, Asia, and Latin America.

Both studies looked primarily, and possibly exclusively, at middle and low income countries, which means that their conclusions are INAPPLICABLE to industrialized countries.

Why? Because the risk of performing a C-section in resource limited and resource poor countries (with decreased or no access to state of the art anesthesia, antibiotics, blood banking, etc.) is dramatically higher than in industrialized countries. Because the risks of C-section are much higher, the point at which the risk of dying of a C-section outweighs the risk of surviving because of a C-section (the “optimal” rate) is going to be MUCH LOWER than the industrialized countries where the risk of the C-section itself is relatively trivial.

The WHO statement is based on conference of a panel of international experts convened by WHO in Geneva, Switzerland, on 8–9 October 2014. Who were those experts? The World Health Organization doesn’t say.

3. Third sign that this is ideology, and deliberately misleading at that, is that the data comes from middle and low income countries, but the conclusions are inappropriately extrapolated to industrialized countries.

The conclusions:

Based on the WHO systematic review, increases in caesarean section rates up to 10-15% at the population level are associated with decreases in maternal, neonatal and infant mortality. Above this level, increasing the rate of caesarean section is no longer associated with reduced mortality…

Current data does not enable us to assess the link between maternal and newborn mortality and rates of caesarean section above 30%.

Quality of care, particularly in terms of safety, is an important consideration in the analysis of caesarean section rates and mortality. The risk of infection and complications from surgery are
potentially dangerous, particularly in settings that lack the facilities and/or capacity to properly conduct safe surgery.

The association between stillbirth or morbidity outcomes and caesarean section rates could not be determined due to the lack of data at the population level…

Since mortality is a rare outcome, especially in developed countries, future studies must assess the association of caesarean section rates with short and long-term maternal and perinatal morbidity outcomes (e.g. obstetric fistula, birth asphyxia)…

4. The fourth sign that this is ideology and not science is that the WHO publicized the study as a warning to women in industrialized countries when it knows the data has nothing to do with industrialized countries.

In the wake of exposure of 1985 optimal C-section rate as a fabrication, the WHO has done it again, albeit this time with greater sophistication. In 1985, Wagner and colleagues merely conjured the “optimal” rate out of thin air; this time they’ve disingenuously, and without any scientific justification, applied the optimal rate for low and middle income countries to high income countries.

The bottom line is that thirty years on, the WHO is still placing ideology above science, and still lying about the optimal C-sections rate.

76 Responses to “World Health Organization’s warning on C-sections is ideology masquerading as science”

  1. Nathan
    April 15, 2015 at 8:28 am #

    Again, the WHO shows they have no place making recommendations. The raw cesarean section rate cannot be used for comparisons as there are different populations (eg first-time mothers versus those who previously delivered vaginally). As one researcher said:

    raw cesarean delivery rate should not be used to compare quality of care within and among different institutions unless they are adjusted for different patient characteristics. We believe that using unadjusted cesarean delivery rates without appropriate adjustments in quality assurance and when comparing data with other institutions and the national rate is erroneous and misleading.

    Thus, this WHO statement is erroneous and misleading.

  2. Ob in OZ
    April 15, 2015 at 6:14 am #

    I used to care what the WHO had to say, with the caveat that it was written with the entire population in mind. That was when they were advocating for a minimum standard of care for all women in all countries. When they first came out with an optimal c-section rate it was over time proven to be a stupid mistake and thus dropping it was the right thing to do. I am truly shocked that they would try this again and think no one would pay attention. Actually, that is exactly what should happen. When it comes to this topic, there is no reason to pay attention to the WHO.

  3. KBCme
    April 14, 2015 at 5:19 pm #

    Can you imagine a doctor saying to a patient, “Well, your baby is breech, but it we give you a c-section, that will push the hospital over our goal of less than 15% csections. So you’ll be delivering this breech the old fashioned way. Don’t worry, we’ve got the NICU down the hall…..”. Gah.

    • Inmara
      April 15, 2015 at 6:53 am #

      Actually, that is exactly what happens in my country – breech itself is not an indication of MRCS (and the difference between MRCS and elective CS is a fee of about 2000 EUR while medium neto salary in country is ~550 EUR). That’s what you get with government funded healthcare – they will use any option to reduce costs whenever it seams feasible enough.
      I don’t have access to statistics regarding breech delivery outcomes here, personal anecdotes tell that mostly they are fine, but they definitely doesn’t show whole picture.

    • The Computer Ate My Nym
      April 15, 2015 at 9:37 am #

      So you’ll be delivering this breech the old fashioned way.

      Or not delivering it the old fashioned way if the labor gets obstructed.

    • Sarah
      April 17, 2015 at 12:40 pm #

      The very concept of an ideal percentage is nonsensical anyway. We know that the relative safety or otherwise of CS varies according to mother’s age, health, weight and number of previous births. If the WHO were to suggest that there’s an optimum number of sections, is that not also effectively requiring them to suggest there’s an optimum number of women who should get pregnant for the first time at 40? I assume we would all agree that’s overstepping the line!

  4. April 14, 2015 at 12:54 am #

    Someone ought to tell the WHO that the C/S RATE is irrelevant; the reasons for performing a C/S are not. It’s all about WHY the C/S is done, not how many.

    • Daleth
      April 14, 2015 at 8:53 am #

      The WHO should already know that, having acknowledged in 2009 that the “15%” rate was made up out of thin air and that there is no evidence that there even IS an ideal rate, much less what the rate should be.

      • rh1985
        April 14, 2015 at 1:17 pm #

        There will never be an ideal rate but of course they won’t admit it. Population differences and varied access to medical care makes an ideal rate impossible.

    • The Bofa on the Sofa
      April 14, 2015 at 1:51 pm #

      But that’s why they have to go after the MRCS. However, the challenge is that, in fact, the purely maternal choice CS rate is not all that high, at least in the US. Almost all of the “elective” c-sections are done for a medical reason. The reason the number is going up is because the line where the c-section becomes medically viable is going down. And as our monitoring capability is improving, it means were are better at identifying risks in vaginal deliveries (e.g. we can watch a strip to identify bad looking decels that we not have been able to see before).

      So you get a combination of better ability to identify risky situations and improved procedures for dealing with them, it only makes sense that the rate of intervention will increase.

      How is that not a good thing?

    • The Computer Ate My Nym
      April 14, 2015 at 2:57 pm #

      If the c-section rate is “too high” for any given definition of “too high” the first question that should be asked is “which c-sections are unnecessary or undesirable and why?” not “how do we reduce the c-section rate?”

    • Trust in WHO
      April 14, 2015 at 11:16 pm #

      I highly recommend reading the WHO report itself because that’s actually exactly what they say. The reason to use the Robson classification is to make fair comparisons among institutions, some of which may serve high or low risk populations or be in countries with different resource levels. Ideally, section rates for similar populations would be similar across institutions, even if the overall rate for the institutions was different. The report emphasizes that there is no ideal rate for an individual institution, and that there should be an emphasis on making sure all women who need cesareans have access to them.

      • fiftyfifty1
        April 16, 2015 at 8:46 am #

        I have read the WHO report itself, and no it doesn’t make me “Trust in WHO”. The report is contradictory. It says there should be no set rate, but then keeps citing 10%. It raises important issues (e.g. the possible protective effect of CS on maternal and neonate morbidity/injury) only to dismiss them. It makes unsupported claims such as that the “omnipresent reasons” behind the worldwide increase are 1. maternal fear of pain, 2. desire for convenience, and 3. perception that CS is less traumatic for baby. Really?! CS is going up in virtually every country worldwide, including those with easy access to epidural, but the main driver is maternal fear of labor pain? And how women really receive CS only out of convenience? Sure, if a CS is planned anyway, people rightly choose convenient dates and times over inconvenient ones. But that is far different than saying that Convenience is one of the “omnipresent reasons” for worldwide CS increase. And perception that CS is less traumatic on baby? Well, multiple studies show it is, and if you are planning only one child as nearly all Chinese and the many many European women are, it is not unreasonable to keep this in mind. Yet the WHO statement is very clear that it does not support MRCS.

        • The Bofa on the Sofa
          April 16, 2015 at 8:59 am #

          It makes unsupported claims such as that the “omnipresent reasons” behind the worldwide increase are 1. maternal fear of pain, 2. desire for convenience, and 3. perception that CS is less traumatic for baby


          Once again, they are beating on this (at least in the US) strawman of the rampant “maternal choice” CS. In fact, as Mrs W will attest, getting a MRCS is really, really hard, and you need some sort of medical indication.

          So while my wife was happy to be able to have a CS to avoid the pain of childbirth (she never wanted to do a VB), that’s not why she had the CS. Our baby was breech. End of story. And after that, she had no interest in a VBACS.

          But if the baby hadn’t been breech, she wouldn’t have had a c-section, despite her wishes.

          • Daleth
            April 16, 2015 at 9:00 am #

            Perception? But um… the perception is TRUE…

          • The Bofa on the Sofa
            April 16, 2015 at 9:05 am #

            I guess I am confused about their language of “less traumatic.” It sounds too much like they are talking about “emotional scars” or something.

            However, if that is actually referring to medical trauma and things like mortality and morbidity, then the “perception” is absolutely true. Personally, I think the obfuscation is intentional.

            They can’t come out and say, “the perception that a C-section is safer for the baby” because that would make them obviously idiots.

        • SporkParade
          April 16, 2015 at 9:00 am #

          What I find maddening is the assumption that not having a medical indication means “doing it for the hell of it,” when there are quite often personal reasons for choosing a C-section.

          • Sarah
            April 17, 2015 at 12:41 pm #

            I have elective abdominal surgery for the hell of it all the time. Doesn’t everyone?

        • The Computer Ate My Nym
          April 16, 2015 at 9:45 am #

          It makes unsupported claims such as that the “omnipresent reasons”
          behind the worldwide increase are 1. maternal fear of pain, 2. desire
          for convenience, and 3. perception that CS is less traumatic for baby.

          Why is “desire for convenience” a bad thing? In oncology there are often situations where there are two potential treatment options which are essentially similar in terms of outcome. In those cases, the choice is specifically made based on patient preference and convenience. Why is “convenience” only bad in OB?

          • fiftyfifty1
            April 16, 2015 at 10:31 am #

            “Why is “convenience” only bad in OB?”

            Because it challenges society’s misogynistic ideal of the all-sacrificing mother.

          • KarenJJ
            April 16, 2015 at 10:33 am #

            Uppity women.

          • Sarah
            April 17, 2015 at 12:40 pm #

            Can’t have these beehatches doing what they want with their sexual organs.

      • fiftyfifty1
        April 16, 2015 at 9:00 am #

        “The reason to use the Robson classifications is to make fair comparisons…[…]…ideally, section rates for similar populations would be similar across institutions, even if the overall rate for the institutions was different.”

        Actually no. This is where the Robson Criteria really fail. The Robson Criteria sort women into groups based on parity, previous CS status, weeks of gestation, fetal lie and number. What it fails to do, however, is sort women based on other important risk factors for needing CS. For example maternal age. In developed countries, we can see that CS rates increase greatly with maternal age. In the US, the lowest rate of CS occurs at age 16, and climbs steadily from there until if you are a 40+ nullip, your chance of needing a CS is nearly 3 times what it was when you were a teen. But by the Robson Criteria, a 15 yo nullip and a 45 yo nullip both get thrown into the same category and “ought to” have the same chance of CS. So a hospital in Kenya where it is normative to have first births as a teen, ought to have the same Group 1 CS rate as in Italy where normative first birth occurs in your 30s? Baloney!

  5. Sara M.
    April 14, 2015 at 12:54 am #

    So only 10-15% of pregnancies deal with pre-e, breech birth, cord entanglement, and a host of other issues that can have better outcomes via c-section? I don’t buy it. If it weren’t for the c-section I had a week ago, my baby wouldn’t be here. I don’t give a damn about what WHO thinks the best statistic should be. They should stick to vaccines and clean water

    • Cobalt
      April 14, 2015 at 6:07 am #

      Congrats on the new arrival! Glad you got the intervention your baby needed, and I hope all is well.

    • demodocus' spouse
      April 14, 2015 at 10:56 am #


    • Maya Markova
      April 14, 2015 at 12:33 pm #


      Your comment touches something important that I also want to comment: To my opinion, recommendations about a medical procedure such as c-section should state not percentages but indications and contraindications; if percentages are recommended, it is ideology and not science because, even if the rate looks good, there is no guarantee that it is “composed” of the correct patients.

      So WHO should state that, based on outcome of c-sections vs. vaginal birth (references should be cited here), it recommends c-section in… – list of indications – and does not recommend c-section in… – list of contraindications.

      Rates alone make no sense. They remind of other situations where norm-makers are motivated to crack down on a phenomenon, say: “We have 20 per 100,000 deaths by car accidents per year. Let’s aim at bringing them down to 15 per 100,000 in 10 years; let’s discuss what measures to take.” The authors of the WHO document consider c-section a disaster in itself, like car accidents and crime.

      • rh1985
        April 14, 2015 at 1:19 pm #

        there also needs to be different recommendations based on access to health care in developed vs undeveloped countries. Sad as it is, it may make sense to keep trying for a vaginal birth if a woman won’t have access to a hospital for her next delivery and the chance of a stillbirth with a vaginal birth is higher than normal but still relatively low, however in a developed country a CS should absolutely be done unless the mother refuses to consent.

      • Roadstergal
        April 14, 2015 at 3:19 pm #

        And if ‘list of contraindications’ includes lack of access to suitable facilities for the birth in question as well as future births, and lack of availability of contraception to control future pregnancies, they can have recommendations that can be applied to the developed and developing world.

    • April 14, 2015 at 12:49 pm #

      Welcome to your new arrival – all the best during your recovery from birth and your adaptation to motherhood!

    • Ob in OZ
      April 15, 2015 at 6:16 am #

      Yes yes yes and congrats

  6. April 13, 2015 at 12:49 pm #

    The WHO’s stance on CS is as about as sensible as telling your kid to clean their plate as there are “starving children in Africa” – it does nothing to help the starving child in Africa.

    • MLE
      April 13, 2015 at 10:06 pm #

      An apt comparison, except the point of telling kids that there are starving children in the rest of the world is to help them learn to appreciate their good fortune and to be aware that there are others who aren’t so lucky. The point of c-section shaming and second guessing is to blatantly ignore how good we in the developed world have it, and to essentially envy and encourage emulation of those who don’t have access to top notch care, a fact I know you’re all too well aware of!

      • KarenJJ
        April 13, 2015 at 11:05 pm #

        Maybe an excuse to divert attention and resources away from women’s health care? A way to blame women for “their lot” in life? It feels like something very ugly underlies this mentality and I’m not sure I’ve really got a grip on what it is.

        • Sarah
          April 17, 2015 at 12:43 pm #

          I’ve often thought that was true of some of the pro breastfeeding lobby, actually. That is, it’s very convenient that the reason for so many health problems can be blamed on women, particularly poor ones, and what they do with their bodies. So we can achieve better health outcomes by just berating women into breastfeeding and denying them sections, which is awesome because it’s cheap and doesn’t really have any downsides other than crapping on women. Which nobody cares about anyway.

      • Ob in OZ
        April 15, 2015 at 6:19 am #

        Great comment, but I see your “name” and think mediolateral episiotomy

  7. April 13, 2015 at 12:41 pm #

    This is so incredibly disheartening. The idea that misogyny runs so deep at the WHO (really that is the only explanation I can conceive for this kind of behaviour) that they are willing to violate the rights of women to informed consent and medical decision making in service of what exactly? The answer to health disparities is not to tell women in rich countries that they should behave like women in poor countries – but rather to relentlessly fight for improvements for women in those poor countries. Don’t bring the third world to the first world – find ways to lift up the circumstances of women in the third world. Improve access to education. Improve access to nutrition. Improve access to healthcare. Make the first world care about the lot of those who are not as well off, by painting an accurate picture of the disparity that exists.

    • Roadstergal
      April 13, 2015 at 1:26 pm #

      “tell women in rich countries that they should behave like women in poor countries” – yes, this is exactly it, I think you’ve nailed it. WHO BF and C/S recommendations are based on the harsh realities of the worst-off women in the world, and whatinhell is it that makes them do _that_ instead of telling women in the developing world, “Hey, C/S and FF/combo are perfectly valid options where you are, so don’t stress about it, and while you’re doing what works best for your families, can we have some money and volunteers for improving the lives of people who don’t have the options we do?”

    • Angharad
      April 13, 2015 at 1:53 pm #

      Exactly! I was reading the WHO report on infant feeding, and it really seems to assume that women in developed countries should act just like those in developing nations. For instance, it recommends against feeding bottles because they’re hard to keep clean (I realize I’m privileged, but I just rinse them out when done and throw them in the dishwasher), says not to prepare extra baby food to save (probably more relevant if you don’t have a fridge and freezer) and recommends extended breastfeeding to help space out children (while I have easy access to all sorts of safe, effective, affordable birth control).

      • rh1985
        April 13, 2015 at 10:02 pm #

        The WHO just needs to have separate recommendations for developed and undeveloped countries already. I really don’t get why they are so stubborn with their one size, fits all policies. I am not going to breastfeed while taking medications or use donor milk when I have access to clean drinking water and can safely formula feed my child. I don’t really care if my CS could have been avoided, because there were no complications and the chances of complications were quite low anyway. Their promotion of the BFHI in developed countries angers me as well.

      • demodocus' spouse
        April 13, 2015 at 11:10 pm #

        Not to mention extended breastfeeding is rather unreliable contraception. I got my period again before my boy was 2 months old.

        • Cobalt
          April 14, 2015 at 7:08 am #

          Mine was back pretty quickly, too. I wonder if this is an area where nutrition/condition is a factor. As in, women with fewer reserves are more likely to have a longer fertility delay. Your own hormone response is going to be the deciding factor, but excess strain on the body (starvation, intense exercise) can stop your period without pregnancy/lactation hormones.

          Would women in dire poverty be less able to bounce back because of nutritional concerns?

          • SporkParade
            April 14, 2015 at 10:29 am #

            Huh. Mine hasn’t come back thanks to the pill, but my doctor told me at the 6-week check-up that I was about to ovulate and needed to be sure to use secondary birth control for the next week.

          • demodocus' spouse
            April 14, 2015 at 10:54 am #

            Likely, but then, doesn’t starvation cause you to have fewer periods anyway?

          • Cobalt
            April 14, 2015 at 1:52 pm #

            If you’re normally compromised nutritionally, but not enough for amenorrhea, lactation might be the extra strain that puts you over the edge, so to speak.

            Just a thought, I have no solid scientific backup for it.

          • Mac Sherbert
            April 15, 2015 at 9:52 am #

            I think it just depends on the woman and her hormones more than anything. It was nearly a year before I got my period again. I eat plenty. Trust me. I would think if you were starving your body might just stop lactating in an attempt to keep you alive…too bad for baby. ??

          • KeeperOfTheBooks
            April 20, 2015 at 11:11 pm #

            Pretty much, yep. For background, I’m Catholic, as in use-NFP-only when it comes to kid spacing. Because of this, I’m in a few online groups associated with one or both of those factors. The general conclusion in these groups is that despite what a lot of NFP instructors would like to tell us, breastfeeding just isn’t a very effective way of spacing births. (Don’t get me started on the insane lactivist ideology present in a lot of NFP-esque groups…it’s sickening and just plain inaccurate.)
            Oh sure, it works…for SOME women. I mean, in my admittedly limited experience, I didn’t get my period back until a month or two after I stopped even very brief once- or twice-daily feeds. Another mom I knew didn’t have her period return until she stopped pumping at about 18 months PP. On the other hand, the majority of moms see a return of fertility much, MUCH sooner than that, even when cosleeping (once again, don’t get me started) and so on.

        • Michelle
          April 16, 2015 at 11:38 am #

          Me too, I didn’t know the first time around it could come back that quick at 6 weeks (just about when I’d just about stopped) and freaked out and rung up the midwife who calmly told me it was my period back. For the next two, it was about 4 weeks but I was expecting it. Also, I’ve been told one of the reasons why breastfeeding is unreliable is because regular feeding, especially the night feeds are critical. Once baby extends feeds/starts solids and sleeps through the night, while periods might not be back, it is possible to be fertile.

          I concur that this is a disheartening event, I think in a previous post Dr Amy has indicated that in countries with good outcomes they tend to have rates over 23% or so for this and I can’t find anything in that report (which is pretty slim) that really refutes that. I suppose because they’ve come to the figure, and are applying to everywhere when that doesn’t apply. The focus should indeed be on making it safer and solving problems in those countries, rather than arbitrary rates which don’t account for why babies are delivered that way and what might be happening demographically within a country.

      • SuperGDZ
        April 14, 2015 at 4:11 am #

        It is a conscious strategy on the part of WHO not to separate recommendations for developed and developing countries. The reason is that it is believed that people in developing countries will be mistrustful of advice if they see different advice being given in developed countries. At least with regard to breastfeeding, the thinking was originally that women in developing countries would have access to expert advice if the generalised recommendations were inappropriate to their circumstances. Of course the reverse happened – where a doctor’s advice differed from the WHO’s, women assumed that it was their doctor that didn’t know what they were talking about.

        • FormerPhysicist
          April 14, 2015 at 9:25 am #

          It gives me such a warm, fuzzy feeling to know that the WHO is making medically inappropriate recommendations to gloss over the fact that resources are unevenly and unfairly distributed. /sarcasm

        • rh1985
          April 14, 2015 at 1:20 pm #

          how many of those women in less developed countries have access to computers and internet and are reading the WHO website anyway? I would assume in undeveloped countries, it’s mainly medical professionals reading WHO recommendations. Someone who doesn’t own a dishwasher and a fridge probably doesn’t own a computer either.

          • SuperGDZ
            April 16, 2015 at 5:24 am #

            The women that don’t have access to the WHO website don’t have access to doctors either. Their medical information comes from NGO groups and governmental organisations, possibly travelling clinics, and auxiliary healthcare workers, all of whom follow policy informed by the WHO.

          • rh1985
            April 16, 2015 at 9:38 pm #

            Which is why I don’t understand why they continue to have one policy regardless of a country’s level of development and healthcare resources. It’s not like women are going to go to the WHO website if they said it was okay to formula feed as a first choice rather than use donor milk or breastfeed with questionable medications in first world countries, and then refuse to breastfeed because women in first world countries don’t have to. None of these women would even know if different advice was being given to women in more developed countries.

          • SuperGDZ
            April 20, 2015 at 8:28 am #

            But the policymakers would.

          • rh1985
            April 20, 2015 at 10:31 pm #

            And why would this offend the policymakers, and how does it justify having poor, unsuitable recommendations that harm the mental and/or physical health of women in developed countries who are forced to deal with things like the BFHI, mandatory rooming in when they are in no physical condition to do, etc? Just because women and babies have a lower chance of death in the first world (and there have been a small number of babies who died due to rooming in, smothering when their exhausted mothers fell asleep trying to hold or breastfeed them while not being properly monitored, sometimes after the nurses refused to take the baby to the nursery despite the mom literally begging) doesn’t mean it’s okay to have recommendations that are unhealthy and medically unjustified for women in first world countries, and that are influencing policymakers in these countries to implement things like the BFHI.

            The benefits of BF are trivial in the first world. It’s not okay to push the implementation of policies that result in poor care inappropriate to the circumstances just because other people have it even worse.

          • SuperGDZ
            April 21, 2015 at 5:03 am #

            I know it isn’t ok. I’m telling you what the issue is, not what I think it should be.

            There is historically a great deal of mistrust of anything Western (and the WHO is perceived as such) in formerly colonised countries. This has not been improved by reports of unethical medical testing, forced sterilisations, etc. Even if government policymakers don’t hold these opinions themselves, they are vulnerable to attacks from other influential people – religious and traditional leaders, for example – who do, or who have anti-Western agendas of their own, as well as traditional healers who are interested in asserting their own authority over local healthcare matters.

            Then of course there are the NGO activist types for whom it’s more about sticking it to Nestle than actual health concerns…

            The thinking was that the breastfeeding message might be diluted if it became known that different recommendations were made in Western countries, and that people (including policymakers) would assume that what was being promoted in the West was automatically best. It wasn’t thought that there was any particular harm in Western babies being breastfed for 6 months, and that the individual medical attention available to people in the West would be sufficient in those cases where breastfeeding was not the best solution. Unfortunately it seems that both practitioners and policymakers in the West have not been up to the task.

          • rh1985
            April 21, 2015 at 7:28 pm #

            Well, unfortunately harm has been done, we have moms who can’t recover or properly care for the baby because they are forced to room in and deprived of all sleep while recovering from a difficult birth. We have moms who develop serious mental health problems and babies who end up dehydrated because moms are brainwashed about how important exclusive breastfeeding is (when it isn’t important at all if safe formula feeding is accessible) and how just one bottle will *RUIN EVERYTHING!!!!!!!*. And rather than standing up and stopping this insanity, first world governments are supporting it and heavily pushing ANYTHING that might increase the rates of exclusive BF (regardless of it hurting individual moms and babies) and it’s hard for anyone to fight it when it’s being based off official health recommendations.

            I really wish the people in third world countries had access to more resources. I really do. But this push for BF in developed countries has reached the point of insanity. And I don’t know why medical associations, and governments, in developed countries, won’t stand up and just stop it, and say NO.

          • SuperGDZ
            April 22, 2015 at 5:24 am #

            I’m not sure who you’re railing at. The WHO is responsible for global health, and not only a handful of countries that theoretically have the capacity to look after themselves. The WHO made a recommendation that was, rightly or wrongly, thought to be of great benefit to the vast majority of the people living in this world. It does not determine policy in individual countries – that is up to those countries’ own policymakers. If public health policy in developed countries is flawed then those countries need to sort it out on their own.

          • rh1985
            April 22, 2015 at 3:25 pm #

            I am railing against the WHO and everyone who goes along with their medical recommendations in developed countries. This topic is very frustrating to me because this stance really IS harmful. I see so many women and babies who suffer because of it. Just because they don’t end up dying doesn’t mean their suffering doesn’t matter. So yes, it is very frustrating.

        • Sarah
          April 17, 2015 at 12:44 pm #

          Yes. And in some ways I can understand why they do it. But the flipside to that is, don’t publish junk science like this. Not separating recommendations for developed and developing countries might be a necessary evil, but this latest outrage certainly is not.

          • rh1985
            April 20, 2015 at 10:35 pm #

            I would hardly call it a “necessary evil” when it leads to things like the Baby Friendly Hospital Initiative (which harms individual moms with things like forced rooming in regardless of condition after birth or how much the mom needs to recover before caring for the baby, extreme pressure to BF or they are not a “good mom”, etc). It’s not in any way okay to harm people in first world countries with medical recommendations that are entirely unsuitable for their situations but that nonetheless influence policy, just because those in the third world have it worse. Look how pervasive BFHI and mandatory rooming in are now, even for moms who are not in the physical or mental condition to care for a new baby 24/7 immediately after a difficult birth – despite the fact that the benefits of breastfeeding for a healthy full term baby in developed country are TRIVIAL, especially in comparison to maternal mental health. Encouraging policies that cause women in first world countries to suffer (even if their suffering is not as great as the suffering in third world countries) doesn’t help anyone. It’s like when the parents tell their child to eat a food they hate because of the starving kids in Africa. The kid eating the disgusting food isn’t going to help any starving kids. And encouraging policies that lead to women who don’t want to breastfeed or room in or have a vaginal birth being given poor care in first world hospitals isn’t going to help any women or babies in the third world.

          • Sarah
            April 21, 2015 at 3:20 am #

            Those are mostly valid points. I agree that the WHO approach has led to lies being told to women in developed countries, and suffering because of this.

            The flipside is the way in which formula companies in the developing world have successfully marketed their product as aspirational white western. This has likely caused deaths (I formula feed through choice, for the record, and don’t disagree with you on the triviality at best of the benefits in the developed world). Indeed, this approach is used to market a huge number of things, everything from beauty products to soft drinks. Because it works. For this reason, it’s entirely understandable that the WHO would have concerns about having two different standards or sets of advice: because of the risk that the ones for developed countries would be seen as the gold standard, aspirational. With that in mind, the African starving child analogy isn’t quite accurate here.

          • rh1985
            April 21, 2015 at 7:34 pm #

            Then why don’t medical organizations and governments in developed countries at least stand up and say no? It makes it so hard for people to fight against these policies when they are the “official” medical recommendation. Instead they continue to obsessively promote exclusive BF regardless of circumstances despite benefits so small they are easily outweighed by the positives of formula for individual families.

          • Sarah
            April 22, 2015 at 9:18 am #

            I imagine it’s because it doesn’t look so great to be going against the WHO. Especially on stuff like breastfeeding, where you’d be going up against a lot of people who can’t/won’t analyse the issue any further than ‘Nestle are awful’ and women don’t get enough breastfeeding support. Which obviously are both true, but are not the only relevant facts in the discussion.

          • rh1985
            April 22, 2015 at 3:23 pm #

            which then goes back to why I find these one size fits all policies to be so harmful.
            I really hope this insanity about exclusive breastfeeding and how terrible formula is goes away before my daughter is old enough to consider having children.

          • Sarah
            April 23, 2015 at 3:56 am #

            I don’t dispute that they cause harm. The issue is whether having different standards for the developed and developing world would be more harmful. This is not a black and white issue- there doesn’t seem to be an option that won’t cause some effing over. Can’t blame the WHO for that, but it goes back to my point about them having a responsibility not to make things any worse than they already are with junk science and scaremongering.

  8. Mel
    April 13, 2015 at 11:46 am #

    I had never hit the term “ecologic” (well, except as a typo for ecological) before so I googled it.

    Simplified: A meta-study of groups rather than individuals.

    According to Morgenstern (1995) “Despite several practical advantages of ecologic studies, there are many methodologic problems that severely limit causal inference, including ecologic and cross-level bias, problems of confounder control, within-group misclassification, lack of adequate data, temporal ambiguity, collinearity, and migration across groups.”
    So, all the problems of a meta-analysis added to the complete loss of individual data.

    Let me put it in easier terms: We don’t have the time, resources or want to do an actual study so let’s just study other people’s studies and hope for the best.

    • April 13, 2015 at 12:42 pm #

      See the Cochrane collaboration.

    • Sullivan ThePoop
      April 13, 2015 at 8:17 pm #

      Meta-analysis are problematic, but very important. Individuals do not usually choose to do meta-analysis, but are chosen. Other than that I agree with you

  9. demodocus' spouse
    April 13, 2015 at 11:46 am #

    One of the other obs in the insurance group I got my pre-natal care from is Nigerian. He was the ob on duty when I went into labor, competent, and a nice fellow to boot. Anyway, it is a very different thing for Dr. K to be practicing in a Cleveland Clinic affiliated hospital than if he were practicing in the remote areas of his home country. Nigeria is by no means the worst off, either. Things are easily available here that just aren’t there. The clinic can and does make mistakes but they rarely have to make-do. I suspect many clinics in poor countries have to make-do a lot. It’d be nice if the WHO acknowledged that a bit more.

  10. Daleth
    April 13, 2015 at 10:22 am #

    The WHO apparently pays no attention to the fact that in at least one developed country (the UK), as shown by studying ALL BIRTHS over a fairly recent three-year period, elective c-sections are less likely to kill the MOTHER than attempting vaginal birth is.

    Here’s a major UK newspaper report on that study:

    And here’s a great letter about the study, published in the British Medical Journal–I think it was written by Pauline Hull:

    So that’s a massive and perhaps unexpected benefit on top of how many babies’ lives it saves.

    • Roadstergal
      April 13, 2015 at 12:02 pm #

      Simply unconscionable, teaching women in developed nations to fear C-sections instead of just giving them the numbers on outcomes and letting the ‘ideal’ number fall where it will.

      • Daleth
        April 13, 2015 at 12:07 pm #

        Yes. Unconscionable is a good word for it.

      • MegaMechaMeg
        April 13, 2015 at 1:24 pm #

        That would be trusting women to make intellegent decisions for themselves and their families and we can’t have that.

      • KarenJJ
        April 13, 2015 at 9:55 pm #

        Yes, exaggerating the risks to c-sections means that people become unable to advocate for safer c-section practices in developing countries because they end up focussing on trying to avoid something instead of making it safer. The focus should not be on reducing procedures but increasing safety for mothers and babies and making c-sections a safer option in countries of limited resources.

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