Anyone who claims there is an ideal C-section rate is lying … including the World Health Organization

long nose

Suppose I told you that research shows that the ideal C-section rate — the lowest rate compatible with the lowest rates of perinatal and maternal death — is 75%.

You’d balk, right? That couldn’t possibly be true.

Suppose I told you that research shows that the ideal C-section rate is 15%?

Most people, particularly non-obstetricians, would probably nod their heads in agreement. That sounds about right to them, confirming what everyone already “knows,” that that C-section rates in industrialized countries are “too high.”

Now let me tell you the truth:

There is no more evidence for an ideal C-section rate of 15% than there is for an ideal C-section rate of 75%. Indeed, there’s no evidence at all for ANY ideal C-section rate, a fact that has been acknowledged by the World Health Organization. Buried deep in its handbook Monitoring Emergency Obstetric Care, you can find this:

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 …

There no evidence for an ideal C-section rate of 10-15% because no industrialized country with low levels of perinatal and maternal mortality has a C-section rate of 10-15%.

So why did the World Health Organization recently reaffirm its commitment to a C-section rate no higher than 10%?

The answer is white hat bias.

As I explained recently, white hat bias was first described in reference to obesity research, including purported preventive effects of breastfeeding on subsequent obesity. White hat bias is a form of confirmation bias, the natural tendency of people to accept information that confirms what they believe. Confirmation bias is why Tea Party members watch Fox News. They want to have their beliefs, prejudices, and wishes always confirmed, never challenged.

White hat bias is confirmation bias in service of what are seen as laudable goals:

‘White hat bias’ (WHB) [is] bias leading to distortion of information in the service of what may be perceived to be righteous ends… WHB bias may be conjectured to be fuelled by feelings of righteous zeal, indignation toward certain aspects of industry, or other factors.

White hat bias leads scientists, doctors and public health officials to substitute what they fervently believe for what the actual scientific evidence shows. For example, obesity researchers, doctors and public health officials routinely claim that normal to low BMI is “healthiest.” But the scientific evidence shows, and has always shown, that people with higher than normal BMI, overweight but not morbidly obese, are the people who live the longest. So why don’t scientists, doctors and public health officials advise people that being slightly overweight is healthiest? Because white hat bias leads them to ignore the scientific evidence in favor of what they deeply believe: being overweight must be bad for your health.

Their motives are pure. They ignore what the scientific evidence shows because it doesn’t comport with what they are absolutely, positively certain must be true. Moreover, they believe, with some justification, that the current US epidemic of morbid obesity (which isn’t healthy at all) is the result of corporations placing profits ahead of creating healthy food options.

But if science teaches us anything it’s that what we believe may be very different from the truth. Paraphrasing Thomas Henry Huxley: The highest duty of scientists lies in submitting to the evidence however it may jar against their inclinations.

The problem of white hat bias in regard to C-sections is, if anything, worse than the problem of white hat bias in obesity research. Everyone “knows” that the C-section rate is too high despite the fact that the existing evidence for this belief is circumstantial at best. It goes something like this: if historically high C-section rates don’t lead to historically low mortality rates, there must be too many C-sections. In other words, since perinatal and maternal mortality rates haven’t dropped remarkably as the C-section rate has increased remarkably, those increases C-sections were unnecessary.

The belief that there is an ideal C-section rate, and that it is considerably lower than the C-section rates in contemporary industrialized countries is white hat bias at its most basic, resting as it does on other deeply held beliefs: The cost of health care is too high; we need to find a way to rein it in. Midwives are cheaper than obstetricians; we need to find a way to employ more of them and less obstetricians. C-sections are surgery; we should always avoid surgery whenever possible. But regardless of the pure motives of many of those promoting an idea C-section rate, their beliefs are a reflection of their biases and thoroughly ignore the scientific evidence.

As it happens, I also believe that the C-section rate is too high. I say this as a clinician who had a 16% C-section rate (and 0% forceps rate) during my years of private practice. But there’s a difference between what I might believe and what the scientific evidence actually shows.

There is simply NO EVIDENCE that a C-section rate of 10-15% is ideal because NO industrialized country with low levels of perinatal and maternal mortality has a C-section rate of 10- 15%! Indeed, the average C-section rate for countries with low rates of perinatal and maternal mortality is approximately 22%.

That’s an exceedingly inconvenient fact for those arguing that an ideal C-section rate of 10-15% will yield low levels of perinatal and maternal mortality. It’s just like the inconvenient fact in obesity research that those who are healthiest don’t have normal BMIs, but are actually overweight. However, as Neil de Grasse Tyson has noted:

The good thing about science is that it’s true whether or not you believe in it.

That applies equally to scientists as well as to purveyors of pseudoscience.

There is no scientific evidence for an ideal C-section rate and certainly no evidence for a C-section rate of 10-15%. Anyone who tells you otherwise, including the World Health Organization, probably has his, her or its heart in the right place, but that doesn’t make it true. It makes it white hat bias.

  • Eater of Worlds

    Yet they also state that there’s no set c-section rate, and the 10% refers only to mother and newborn mortality and doesn’t include the c-sections done to prevent birth injuries.

    http://www.who.int/reproductivehealth/topics/maternal_perinatal/faq-cs-section/en/

    It’s like they can’t get their information straight.

    • KeeperOfTheBooks

      Perhaps I’m just some crazy mom, but I’d totally have a C-section to prevent injury to my baby. Or, for that matter, me.

  • Kesiana

    Kinda-sorta related: can we talk about the Odón Device? As far as I can tell, it’s the first baby-extractor invented since the vacuum assist, and it’s showing a LOT of promise! Its website says it’s “a safe alternative to some Caesarean sections in settings with limited surgical capacity and human resource constraints,” and it’s backed by multiple medical science organizations.

    …I have no idea what my point is here. It’s awesome to see new childbirth-related technology? It may not have much impact in 1st world countries, but it could save a LOT of lives in areas where C-sections are basically not an option.

    On the other hand, I shudder to think of basically untrained FIRST-world midwives using them…

    • KeeperOfTheBooks

      That is an absolutely fascinating idea, and bravo on the mechanic for thinking so creatively! I hope it does do as well as it sounds it might.

    • untrained first world midwives already use vacuum extractors without patient consent so this wouldn’t really change anything. The honest midwife website mentions it, and subsequently a bunch of other midwives admitted seeing this behavior before. Valerie El Halta used one during a newborn fatality, and I really thought it was an anomaly.

      • Kesiana

        Point taken! At least the Odon Device looks safer than a vacuum or forceps? Of course, right now it’s only being used by people with training.

  • Amy

    There are so many confounding factors that the NCBs never bother to consider. How many older women are having babies– how does this affect the overall c-section rate? How many women are seeking/using fertility assistance to conceive, resulting in a higher percentage of twin and higher-order multiple births– something we KNOW increases the c-section rate? How many women who conceive naturally but go on to have high-risk pregnancies are able to carry to term when in years past they would have had miscarriages or stillbirths– again, something we know is going to result in more c-sections?

    Personally? My first pregnancy was textbook normal and healthy. I have a healthy BMI, I gained 30 pounds, my blood pressure, iron levels, and blood sugar were all excellent, I remained active throughout my pregnancy and adhered to a healthy diet full of whole foods. On the woo side, I hired a doula and committed myself to “trusting birth.” And my kid was asynclitic. No way she was coming out vaginally. My 100% c-section rate (my VBAC attempt with my second ended up in a c-section as well), to our family, means 100% healthy, happy mom and kids. I’m pretty sure my husband likes not being a childless widower.

    • RMY

      Also, saying something has an ideal rate for something that’s preventative medicine is worthless. It makes as much sense in the WHO setting an ideal statin use percentage. It’d be ridiculous to say “ideally only 25% of the population should be on medication for high cholesterol.”

      • Roadstergal

        And that if more than 25% of the population were on statins, their solution would be to pressure patients not to get them and doctors not to prescribe them.

  • Nathan127

    Did someone mention that the joint commission started to collect data on cesarean sections:
    https://manual.jointcommission.org/releases/TJC2014A/MIF0167.html
    This is part of data for their perinatal core measures.
    https://manual.jointcommission.org/releases/TJC2015A1/PerinatalCare.html

    It includes data on breastfeeding, antenatal steroids, and infections (but not maternal deaths [sic]),
    So what they are telling hospitals is that they will check the cesarean section rates, and those that are outside the range may be “punished”.

  • guest

    I had an ideal c-section rate! One c-section, one live mother and two live babies. 100% success.

  • The Computer Ate My Nym

    Let’s assume, just for the moment and just for the heck of it, that the WHO recommendation of 15% as “optimal” was correct in 1985. Things have changed since 1985 and, as far as I know, all the changes tip the risk/benefit balance in favor of c-sections: Greater maternal obesity and older maternal age=more women in whom vaginal birth is higher risk. Epidural anesthesia and “bikini” cuts=lower risk in c-section. Greater awareness of infection risk=safer post-operative period. In short, if 15% was correct in 1985, it is surely wrong now due to technical and social changes that change the risk/benefit ratio. So how did the WHO come up with a LOWER rate to recommend?

    • Sarah

      I believe the proportion of women giving birth who are HIV positive would also be higher.

      • Kesiana

        This is true! But for the record, if their viral loads are low enough, a c-section may not be needed:

        “The risk of mother-to-child transmission of HIV is low for women who take HIV medicines during pregnancy and have a viral load less than 1,000 copies/mL near the time of delivery. In this situation, a woman with HIV should have a vaginal delivery unless there are other medical reasons for a cesarean delivery.” (from aidsinfo.nih.gov)

  • Cobalt

    OT I’m looking for safety data for infants in bike trailers, specifically concerns about vibration/shaken baby syndrome. I’ve already got resolution for concerns about helmets and traffic, that information is everywhere.

    The AAP is clear on no on-bike seats before 12 months, but then says trailers are safer and doesn’t really address vibration as an issue.
    http://m.aapnews.aappublications.org/content/30/7/18.6.full

    The AAP then refers you to the Bicycle Helmet Safety Institute, which gives the impression that taking an infant or small toddler in a trailer will surely vibrate the brain into oblivion without citing any supporting evidence. http://www.bhsi.org/little1s.htm

    On the other hand, cycling enthusiasts all point to Europe, especially Amsterdam, and say “just about everyone does it there and I’ve never heard of anything bad happening”, but that doesn’t really tell me anything. Homebirth is popular there, too, that doesn’t mean it’s safe enough for me.

    Data for jogging strollers would probably have some comparability, I can’t see how the physics involved would be terribly different.

    • Roadstergal

      I can see organizations erring on the side of safety. There are just too many variables – trailer construction, tires, surface? Taking a baby on a trailer ride over a smooth-pave surface on a fat-tire trailer with low PSI is going to be a different matter from Paris-Roubaix cobblestones on high-pressure racing slicks…

      (FWIW, Topeak, who I adore, makes a non-trailer baby carrier:
      http://www.topeak.com/products/Child-Carrier-and-Racks )

      • Cobalt

        That looks like a great seat! I like the storage capacity and independent uprightness of the trailers, though. Good for groceries or if I need to get off my bike to help one of the older kids.

        I’m trying to get a good idea of the risks of pulling an almost eleven old along on a paved trail or sidewalk. There’s no traffic, he sits up, crawls, cruises, and could ride in a jogging stroller according to their guidelines. I like to err on the side of caution, generally, but I also like to support my decisions on good data.

        • Dinolindor

          I hadn’t heard the no bike seats until 12 months…Now I feel like a negligent monster. We have had our 11 month old daughter in this with no issues that we can see, and first had her try it when she was about 10 months old: http://ibert.bike/

          But it’s great because you can interact way more easily with your kid in front vs. behind. This one can be taken off and on pretty easily too and my husband doesn’t have to bow out his legs much to adjust for the seat.

          I don’t recall when we got this to take our now 4.5 year old son on rides…probably when he was about 18 months? His legs are now big enough to have trouble going under the handlebars, and we’re trying to get him to try his own bike/trike. But we got a nice long time out of the seat with just our son, and now beginning round 2 with our daughter.

          • Kelly

            I have a front riding one and only used it one time because I am a bit busty and if I stood up to get some more speed, I could not get my bust off of the top of my child’s helmet. She was not pleased and I had to stop to rectify the situation. My husband now uses it.

          • Cobalt

            The big risks of the seat seems to be falling over and/or not being strong enough to safely support a helmet, not that the seat or motion is injurious on its own or in a way that is not immediately obvious if injury occurs (you’ll know if you crash or if the helmet makes the kid’s head sit funny). I don’t think that qualifies for monster status unless you’re not being cautious of the potential for crashes. If you ride like an urban bike messenger there’s no way to make that safe for a kid.

            Trailers, according to some unsupported sources, transfer a potentially dangerous amount of vibration that results in injuries that are difficult to detect but could cause long lasting brain problems. That’s a claim I’d like to see either proven or debunked.

          • Dinolindor

            Well that’s a relief. I kind of like not being a monster, although I suppose there are perks. Extra horns could come in handy, I bet.

    • Who?

      Saw some amazing ones in Japan recently-great bikes, really solid looking trailers, negotiating footpaths, bikepaths and streets with no troubles. Might be worth checking them out.

  • Monkey Professor for a Head

    Since we’re on the subject of c sections, I have a question for the experts here. Would a history of a significant PPH (presumably due to uterine atony) be viewed as a reasonable indication for an elective C section with future pregnancies? Whilst I came through my vaginal birth without any long term damage, I’d prefer to avoid a major bleed in future – symptomatic anaemia with a newborn sucked! And my husband was quite traumatised by the whole thing- he was terrified he was going to lose me. I’m not sure how well he’d be able to handle another vaginal birth.

    • CanDoc

      You need to discuss this with your doctor. I have never (in 18 years) seen prior post partum hemorrhage used as an indication for elective cesarean section. Average blood loss is greater with cesarean section than vaginal delivery. A better plan may be to discuss proactive measures to help minimize your risk of post-partum hemorrhage, vigorous management should you have any extra bleeding, and aggressive treatment of symptomatic anemia, including transfusion if need be.

      Wishing you a healthy pregnancy and safe delivery.

      • Monkey Professor for a Head

        This is all theoretical at the moment, I’ve only just had my first child. Thanks for your reply. It’s certainly something I’ll be discussing with my obstetrician in the future if I have another pregnancy, I was just wondering what the usual procedure was with a history of PPH, so it’s helpful to know that it doesn’t usually impact on the choice of delivery mode for future pregnancies.

        • Who?

          The fact you would feel happier is a good enough reason on its own.

    • N

      I almost bled to death after my 3rd c-section. I needed another surgery with general anaesthesia. I needed blood…. seperation from my baby… traumatised family…
      So I would tend to say, c-section is no guarantee for not bleeding to death. So, discuss your options with your doctor, my personal situation might not be yours.

  • Maya Manship

    Before I go any further, in no way shape or form do I have a medical degree. I bow to the knowledge of the doctors that post here. Now, I have had 2 caesarian births. At this point “normal birth” should never happen for me. I’m rambling but my point is if I had not been given C-sections in the name of reaching some ideal C-section rate I believe, with everything in me, that I would have died. I further believe my first child would have died with me. My obgyn told me she turn sideways and that’s when she decided I needed an emergency C-section. Thank God for her.

    • Daleth

      Yes, if she was turned sideways, that means she was transverse–and from what I understand, it is impossible to deliver a transverse baby vaginally. If the baby doesn’t turn and stay turned, you have to have a CS or the baby will die.

  • Cobalt

    An ideal cesarean rate is whatever number is created by an ideal cesarean policy, and will vary from place to place and population to population. What would make an ideal cesarean policy? I’d go with informed consent as the only qualifier, with the final decision always being the mother’s. The tricky bit is making sure mothers get accurate information, preferably as far in advance of the birth as possible, so they are ready to respond should an emergency arise.

    • Allie

      A policy that helps care givers and parents decide when the scale has tipped and the risk of no c-section outweighs risk of c-section would be just about right… without all the pointless baggage about “natural” childbirth, of course. Yes, vastly more women will continue to have their babies vaginally because usually the risk of surgery is greater than the risk of vaginal birth, but in some cases (of undetermined percentage), that scale tips and c-section is indicated. Could some c-section babies have been delivered vaginally without permanent injury to mom and/or baby? No doubt. But I’d rather see errors on the side of caution in some cases, rather than the side of tragedy.

      • N

        “Could some c-section babies have been delivered vaginally without permanent injury to mom and/or baby? No doubt.” Yeah, my first was a breech position. I know second babies who came breech vaginally without any problems. But 1. first babies in breech position are not delivered vaginally here. And 2. even if it had been an option, would I have done it? I don’t know, I don’t think so. Perhaps it would have worked, probably not.

    • Just as each person is unique, the C-Section rate depends on the type of patient population one is working with. For me, for example, the ideal C-Section rate was 100%.

    • MegaMechaMeg

      Every once in a while you will hear about hospitals with a c-section rate of 70% or some crazy number. Invariably it will be because they specialize in correcting fetal defects that are inconsistant with a vaginal birth. It seems to me that in context their rates are just about perfect but that doesn’t stop people from freaking out.

  • mostlyclueless

    It seems that the data are available to simply plot the relationship between CS rate and perinatal death rate in wealthy / industrialized countries. It may be informative.

    • Daleth

      Is perinatal death the only valid reason for which c-sections can be performed? Unless the answer is yes, plotting perinatal death and CS rate won’t tell us an optimal CS rate.

      And of course, the answer is no. CS is also performed to protect the baby from brain damage, brachial plexus palsy, and herpes infection (which can be devastating for newborn babies), among other things. And it is also performed to protect mothers from severe pelvic floor damage, and to protect mothers with a history of rape/sexual abuse from emotional trauma. (Spending 10-20 hours in labor with random men you don’t know performing vaginal exams, standing between your legs to catch the baby, etc. can be incredibly traumatic to such women–the fact the men are doctors or L&D nurses doesn’t matter).

      • mostlyclueless

        Of course not, but if more CS correlated with less perinatal death that would shut down a lot of the blah blah about high CS rates.

        • Sue

          Exactly. Then the anticesareanists can be asked to nominate an acceptable perinatal mortality rate for CS rates to be matched to.

    • mostlyclueless

      Here: c-section rates according to the WHO (http://www.who.int/healthsystems/topics/financing/healthreport/30C-sectioncosts.pdf) vs. perinatal mortality rates according to the world bank (http://data.worldbank.org/indicator/SH.DYN.NMRT)

      http://i.imgur.com/GSNQk67.png

      Weirdly…it looks like c-sections save lives? Who knew? Should someone call Ina May Gaskin?

      • Angharad

        I could see this forming a U-curve, although the bottom would be fairly wide and flat and there isn’t much data for higher c-section rate. It definitely looks like a target of 10-15% would be inappropriate because that’s still in the downward trending area. It looks like 15-30% is correlated with the lowest perinatal death rate.

        • Cobalt
        • mostlyclueless

          Exactly my read on it. If an optimal point can be described by that graph it looks like it’s somewhere over 15%, not under.

          • Roadstergal

            There is sort of a ‘natural’ cutoff at ~15% where the downward trend flattens out. Still isn’t a good place to say ‘ideal rate’ – if anything, it suggests an ‘ideal minimum.’

          • The Bofa on the Sofa

            Yeah, based on these data, if you were to say anything (and I wouldn’t), it would be that the c-section rate should be between 15 and 40%.

      • Young CC Prof

        Because I always ask: What’s the outlier?

        • mostlyclueless

          You mean the three trending back up around 45%?

          • fiftyfifty1

            no. The point way in the upper right hand corner, off the graph paper.

          • mostlyclueless

            It’s not a data point, it’s google charts’ attempt to make a figure legend that didn’t apply.

          • Young CC Prof

            Ah, that makes more sense than the existence of a country with a 60% cesarean rate and a perinatal death rate ten times that of most wealthy countries.

          • Amy M

            Otherwise, that country would be performing Csections on most women, with no anesthesia or sterile equipment.

          • Roadstergal

            I’d be interested to know which is the 15/1000 at ~40% rate?

          • mostlyclueless

            Dominican Republic. 16/1000, 41.9% c-section rate.

      • Sue

        Eureka!

      • mostlyclueless

        Just a few observations looking at the raw data: Since 28 countries have achieved perinatal deaths of 2 or fewer per 1,000 live births, this seems to be an attainable goal for countries with ample resources. However, not a single one of those countries has a c-section rate under 15%.

        Of the countries that achieve the WHO’s “target” of 10-15%, the lowest perinatal mortality is in the Netherlands (3 per 1,000) and highest is in Namibia (22 per 1,000).

        Of the countries that achieve 1-2 perinatal deaths per 1,000 live births, the lowest c-section rates are in Iceland (15.6%) and Belgium (15.9%).

        So using the WHO’s own data, it seems that lowering the c-section rate to 10% would increase the perinatal death rate from 1-2 up to a minimum of 5 per 1,000 live births (achieved in the United Arab Emirates with a 10% c-section rate).

        But what’s an extra 3-4 dead babies out of every 1,000?

  • Megan

    Just out of curiosity. It does anyone know what the perinatal mortality rate is like in Brazil where the CS rate is higher? I would be curious to know if their babies actually do better. I realize that more goes into causes of perinatal death besides mode of birth but I was just wondering…

    • Ash

      brazil’s gov’t has recently required doctors to submit a partogram in order to justify a CS in order to lower the elective c-section rate, IIRC. this is quite recent though.

      • Megan

        And from what I understand there is great social inequality in Brazil and I’m sure that affects perinatal mortality. I don’t know a whole lot of details about Brazil and how their babies fare though. I wonder if this recent push to lower CS rates there will be a good thing or a bad thing for babies (and moms)?

        • SporkParade

          My understanding from speaking with Brazilians is that the main drivers of maternal request C-section in Brazil are: 1) that you can be certain to deliver at the private hospital of your choice (if you deliver vaginally, there may not be room when you show up); and 2) an unhealthy obsession with women’s physical appearance. Requiring justification for C-sections may help address the second factor, but the real issue is getting more hospital beds, and it’s a lot easier to take away maternal choice than it is to provide adequate hospital beds.

          • Cobalt

            The Brazilian CS rate is also a lot higher for wealthier moms than poorer moms. There’s a lot of disparity between rates and outcomes between classes.

    • Roadstergal

      I wonder what the rate of pelvic floor issues is for mums there?

    • Young CC Prof

      In many parts of Latin America, it’s not very good. That’s because half of women are getting a CS whether they really need one or not, and the other half might not have gotten such basic things as a tetanus shot.

    • Mariana Baca

      A better comparison might be Italy or Switzerland, that have high C-section rates in europe. And they have good perinatal mortality rates. But so do Iceland and Finland, which have some of the lowest. There are too many confounding variables there.

      • mostlyclueless

        Italy: 2 perinatal deaths per 1,000 live births, 38.2% c-section rate.

        Switzerland: 3 perinatal deaths per 1,000 live births, 28.9% c-section rate.

        • Mariana Baca

          Do you have a source you are using? Do you have more numbers, like the rates in countries with low c section rates?

        • Sue

          Italy now has one of the lowest replacement rates in the world. Smaller families tend to match with less risk for CS.

        • chiara

          Italy’s high c-section rate is due to the southern regions. Northern Italy hospitals have an average rate of under 30%, like the US and most other European countries.
          Southern Italy on the other hand has a c-section rate of around 50%. Campania has a 62% c-section rate, Sicily 50%.
          There’s a huge difference in the quality of healthcare and hospitals between the North and South Italy. Southern Italy has some very low quality hospitals and many people opt to go to private clinics to deliver, and in private clinics the c-section rate is higher. Also, hospitals get money refunds from the state for every surgery they do, so they are interested in doing more c-sections. This happens especially in the South were there is more corruption and hospitals are poorer.

      • I live in Switzerland. Overall the population is quite healthy (although a high smoking rate). But, I think (can’t prove it, though!) that one of the reasons for a higher c-section rate is the unwillingness of the hospital midwives to order epidurals.

        I’ve had one friend flat out refused an epidural. No way, no how. Weren’t going to give her one, no matter how much she begged. Another friend begged for hours and was only offered tea. When the shift changed, the new midwife “allowed” the epidural.

        I’ve heard Italy is even worse about it. So, at any hint of trouble, women are likely to jump on the c-section bandwagon in order to get out of excruciating pain.

        • Amy M

          That’s appalling and abusive. Could the women denied the epidurals complain to anyone about their treatment, and get anywhere?

          • I have no idea. The one that was denied was really angry about it. The midwives kept saying, “You’ll be so glad you did it naturally this time!” (It was her 4th–first 3 born in the US.) She was NOT glad she did it naturally.

            I shared this story with a Swiss friend (mother of 4, including a set of vaginally birthed twins). She thought I was crazy. “Swiss women don’t want epidurals,” she said.

    • mostlyclueless

      8 per 1,000 live births.

      • Megan

        Thanks!

  • Mel

    We are actually getting a control group for this experiment.

    When women birth in the hospital, there just aren’t that many women who are willing/able to continue to refuse a CS when the baby is showing distress- although it does happen.

    But if you include babies who magically were born “nearly dead” into midwives at home….

    I don’t think we could actually run the study – way too many confounding factors – but it’s depressing that it’s becoming theoretically possible.

  • Young CC Prof

    I really think that getting an “ideal” c-section rate from the WORLD health organization is a pretty silly idea. The ideal c-section rate for a population depends on:

    1) Demographics: At what age do women typically have their first baby? What is the average family size? A population of large families and young first-time mothers will have a lower c-section rate.

    2) Preexisting health status: A culture in which women with medical issues are discouraged from childbearing at all will mean a lower c-section rate. The prevalence of STDs matter, too.

    3) Technology level of the hospitals: In the poorest parts of the world, a woman is much more likely to suffer permanent harm or death as a result of surgical complications. In the developed world, it’s extremely rare for a woman to die of c-section complications, assuming she wasn’t direly ill beforehand.

    And a whole lot of other things.

    Different countries have different health issues and priorities. Deal with it.

    • Roadstergal

      #1 would also deal with the availability of reliable birth control. A woman who can’t control her own fertility is going to have to consider all of the future pregnancies she’s going to be forced to have when it comes to the current C-section. And IMO, the WHO should then be thinking less about ‘ideal C-section rate’ and more about ‘availability of reliable BC rate,’ FFS.
      “Different countries have different health issues and priorities. Deal with it.”

      This – for both C-section rates and BF.

    • FrequentFlyer

      I was starting to say something about the silliness of an ideal c-section rates when this popped up on my screen and I saw that you said it better. There is too much variation from population to population and person to person to say that there is an ideal rate. In the population of people in my house capable of getting pregnant (1) the ideal c-section rate turned out to be 100%. At my sister’s house the rate so far is 0%. That may change in a few months when she has her 2nd baby. Neither rate is good or bad. They just are.

    • Megan

      This. Exactly this. I have often wondered why the WHO gets to impose the same “ideal” on all countries, different though they may be.

      • Young CC Prof

        I don’t think the WHO leadership is doing it intentionally, I think a lot of it is people with an agenda misreading or deliberately misreading statements that were never intended to apply to them, for example, the statement about breastfeeding while HIV-positive, which was directed at sub-Saharan Africa! If you are HIV-positive but lack clean water and can’t afford real formula, breastfeed and hope. If you live in the USA and are HIV-positive, use some common sense and don’t breastfeed.

        • Megan

          “I think a lot of it is people with an agenda misreading or deliberately misreading statements that were never intended to apply to them”

          Kind of like Neel Shah pushing us to homebirth in order to lower CS rates and save money..

        • Esther

          Yep, the LLL put out a fuzzy statement to the effect of “There’s conflicting evidence, we can’t make a reommendation one way or another at this time”…the hell you can’t.

        • Sarah

          I think also a lot of otherwise well meaning people find it hard to see past previous wrongs. So eg Nestle et al have done some horrifying things in the developing world. People are rightly angry with them. However, that has nothing to do with the safety of formula in the developed world. The dead babies who were killed because of what formula companies did are actually completely irrelevant to that issue. But it’s hard to get past them, especially for people who undertook (necessary) work to curb some of the worst behaviour of formula companies. They don’t always understand that some of that necessary, well meant work is also having negative consequences.

    • Sarah

      On the subject of pre-existing health status, in lots of cultures women with sufficiently serious medical issues aren’t childbearing because they’re dead. There are whole cohorts of women who exist in richer countries because of medical science, whose equivalents in the poorest regions don’t make it to reproductive age.

    • Dr Kitty

      I did had obstetric training as a medical student in three places.

      1) The Coombe hospital in Dublin.
      The home of the active management of labour and VBAC. In the preceding 25 years the typical patient had changed from being a married, working class Irish Catholic with 10-18 month intervals between pregnancies, at least five children and a huge aversion to anything that might limit her family size to a single woman in her early twenties or married woman in her early thirties, possibly Irish, possibly from an ethnic minority, having two or three children, with no qualms about contraceptive use or limiting family size, and a spacing of 18-36 months between pregnancies.

      2) A hospital in rural NSW, five hours from the nearest NICU, surrounded by remote cattle and sheep stations and serving a large Aboriginal population, who had high rates of substance misuse, diabetes and hypertension with subsequently high rates of IUGR, Pre-eclampsia, GDM, macrosomia, FAS, and neonatal hypoglycaemia. Most pregnant women were encouraged to stay in the town for the last few weeks of pregnancy, and anyone obviously very tricky was hopefully sent to Adelaide, Sydney or Melbourne prior to labour ( although not always).

      3) A hospital in rural Maharashtra, India, a sister clinic to Jeevan Kuruvilla’s clinic. The patients were subsistence farmers, child marriage was common, illiteracy rates high, basic healthcare lacking. TB and malaria were endemic and most patients were severely anaemic. The hospital had no ventilator, no defibrillator, no blood bank. The latex gloves, needles, syringes and surgical tools were all boiled and re-used. Nothing was disposable. If we had to do a CS, it involved a spinal anaesthetic, some IV ketamine, a slash-and-grab midline laparotomy with a LSCS uterine incision and all the suturing was done with boiled silk sewing thread as quickly as possible to try and reduce the risk of bleeding. C sections were done on patients who had been in obstructed labour for days in their villages before being brought in as a last resort by their relatives. That clinic didn’t get ANY easy births; they stayed home and saved money- if a labouring woman came in it was guaranteed to be a train wreck.

      Anyone who thinks that the Coombe in 1975, the Coombe in 2005, the rural Australian hospital and the clinic in India should, or could, have had the lowest achievable perinatal mortality rates with the same “ideal” CS rate of 10-15% would need their head examined.

      • Monkey Professor for a Head

        Out of curiosity, since you mention the Coombe, did you go to Trinity college? I studied there, although I did my obstetric rotation in the Rotunda.

        • Dr Kitty

          Yep.
          Trinners. 🙂

      • CanDoc

        A fascinating and articulate response – thanks!

      • Allie

        I want to upvote this so many times!
        I understand that WHO can’t and shouldn’t recommend that women have elective or even semi-elective cesareans in places like Maharashtra. If the next births are going to be unassisted homebirths you need to do everything in your power to avoid scarring the uterus.
        But how does that have anything to do with European or American women who have access to state-of-the-art obstetrical and gynecological care and who will (statistically) only have 1,5 medically supervised pregnancies in their lifetime?
        As with breastfeeding and the Baby Friendly Hospital Initiative, WHO is misusing the situation in developing countries to push an ideological agenda that is not supported by science in the developed world.

      • Eater of Worlds

        Was the clinic sister to Jeevan’s old hospital, or his new one?

        I have no idea why this question seemed worth asking, but it did!

  • GuestWho

    I feel like using just the death rate is an incomplete analysis. I personally would take a c-section over the risk of severe pelvic floor damage. My abs have never been much to write home about but I like not pooping out of my vagina.

    • Daleth

      Bingo. Who here would NOT take a c-section over any of the following:
      – Urinary and/or fecal incontinence bad enough to consider surgery
      – Uterine rupture necessitating hysterectomy
      – Rectovaginal fistula (what you described as “pooping out of my vagina”)
      – Permanent nerve damage to mom’s genitals, such that sex is anywhere from pleasureless to painful for the rest of her life
      – Permanent nerve damage to the baby (a la brachial plexus palsy) due to difficulty in getting him out vaginally
      – Permanent brain damage to the baby due to cord compression, placental abruption, or any other type of hypoxic injury caused by vaginal birth
      – Temporary but very painful injury to the baby (e.g., a broken clavicle caused by desperate efforts to get him out during a shoulder dystocia; mild skull fracture due to forceps accident)

      Any takers??

      I didn’t think so. And THAT is why just looking at the relationship between c-section rates and rates of maternal and infant *mortality* does not and cannot tell us what an “ideal” c-section rate might be.

      • Fallow

        If I could have known I’d have a shoulder dystocia and my child would have a brachial plexus injury, I would have taken a c-section without question. My child recovered from that injury, but it took a lot of occupational therapy. And there was no guarantee she would recover.

        I’ve already told my ob-gyn that I will never put another baby through that. They can cut me open any day of the week to prevent that from happening again.

      • Angharad

        Some women would. I think I’ve mentioned before I have a friend whose daughter broke a bone during her vaginal breech birth. She still is thrilled with her birth story because she got her natural birth and the baby healed.
        Personally I wish I had had a c-section. Unfortunately I think talking about choice in delivery methods is mostly theoretical until insurance companies start covering maternal request c-sections, because most of us don’t just have an extra $10,000 to protect our pelvic floors and avoid fetal distress during labor.

        • Daleth

          Wow. Your friend is… messed up. I can’t imagine preferring to have my baby break a bone rather than have myself undergo a brief, safe operation.

          • Angharad

            I agree. I’ve felt more guilt/regret over not clipping my daughter’s fingernails so she scratched herself than this woman has ever expressed over a newborn in a cast. I don’t get it.

  • Azuran

    To reach the ‘ideal’ rate of c-section, we would need a time machine or the ability to see the future so we can see whether or not a baby and it’s mother are going to have birth complication.
    So, maybe in retrospective, we can see that X% of women actually needed those c-section. But we have no way of knowing for sure who are those X% women before the birth. When their is a baby’s life at stake, better safe than sorry.

    • superhappycamper

      I can’t figure out how someone will decide which ones are “unnecessarians.” I will grant that there probably are a few “too posh to push”/”tee time” c sections but I think that’s a tiny percentage of the total.

      • Roadstergal

        And what’s wrong with ‘too posh to push’? The inherent judginess of that statement really bugs me. So a woman doesn’t want to risk her continence and sexual function, and she chooses a birth method that’s very low-risk for the baby to accomplish that? And that’s something to look down on her for?

        • Daleth

          Seriously. It is SO nobody else’s business which method of childbirth a woman prefers. What’s next, “too posh to feel pain” being used to judge women who get epidurals?

          And PS not only is c-section “very low-risk for the baby,” it’s actually lower risk than vaginal birth. Which is another way of saying, BACK OFF, judgers!

          • superhappycamper

            I didn’t mean to impose personal judgment with the too posh thing; that’s why I put it in quotes. I was referring to c sections that were purely elective – somewhat tongue in cheek. I personally don’t care if a woman elects a c section just because.

          • Amy M

            I think that already happens, with the epidurals. Instead of “too posh”, its “too wimpy”, but basically the same kind of thing.

        • The Bofa on the Sofa

          And what’s wrong with ‘too posh to push’?

          EXACTLY!!!!!

          So what if someone is “too posh to push”? Why is that a problem?

          Oh, I know the answer. Because it’s not enough sacrifice.

          As a guy, I get held up to standards of he-manness, the tough guys like Rocky and Ahnold, who heroically and stoichally brush off the pain and win in the end. Guys are supposed to be tough and strong!

          This is just the same crap applied to women.

        • plath

          People will judge for any reason. I was accused of being too arrogant to want to “damage” my “perfect” (read: skinny) body with pregnancy, thus why I adopted. Actually, no, I don’t like babies and I wanted to adopt older children who were lingering in the foster system, but thanks for judging me when you don’t know anything about me.

          And I probably would have had an elective C-Section if I’d ever chosen to get pregnant. Why risk my sex life?

          • Sarah

            You selfish cow, looking after children who desperately needed a home and love. Not saving society loads of money in the process or anything. Clearly all you were thinking of was your figure!

          • Roadstergal

            Nice. Judging for adopting – an unselfish act with tremendous benefit to society – is a new low in my book. :

          • demodocus

            Adopting to avoid “damaging” your perfection? Sheesh. That is possibly the silliest thing I’ve heard in years. I’m sure that’s completely why Granny adopted Dad and Aunt.
            We’ve discussed adopting an older blind child at some point. Our house is already set up for blind people, after all, and handicapped kids have an even harder time than regular ones.

          • plath

            Yes they do. Unfortunately where we live is not set up for any kid of disability, but we adopted a sibling group of older kids who were not white. That’s apparently harder to place than a child with a disability.

      • Daleth

        Even for the “too posh to push” types, their c-sections are necessary if you have any respect for the concept of bodily autonomy. Telling a woman she has to give birth vaginally when she doesn’t want to is no better than telling her she has to have a medically non-indicated c-section when she doesn’t want to. Her body, her choice.

      • Allie

        And why do you believe women exerting their bodily autonomy by choosing not to have a vaginal birth worthy of so much disdain? Because that’s what you are saying by using that hateful phrase “too posh to push”.

        Am I “posh” for wanting to preserve my continence and sexual function? 10 to 25% of women who have an uncomplicated vaginal birth end up with urinary incontinence issues. For any surgical procedure that would be considered an astronomically high complication rate and no surgeon would dream of not obtaining fully informed consent before inflicting it on a patient. For the “natural” process of vaginal birth women are deliberately kept in the dark about this risk and they are derided and humiliated for seeking to avoid it.

        Am i “posh” for wanting to plan the time of birth so I can take care of everything that needs to be done in my self employed business before giving birth? You know, that business that supports my whole family? I guess wanting to keep my customers satiesfied and preserving my income must be so terribly posh?

        Promoting patient autonomy is an important goal and performance indicator everywhere in medicine. Obstetrics is the only exception: pregnant women are supposed to shut up, not ask any difficult questions and birth vaginally and breastfeed like their provider tells them to.

        • MegaMechaMeg

          I want to like this but I don’t want to make a Disqus account.
          So LIKE.

        • Jen

          Totally agreed! I had a consult with a urogynocologist to choose C-section vs vaginal. I had mild incontinence before ever having kids. He said “to be honest I went to a conference of urogynecologists and the question was asked if we would choose C-section or vaginal for ourselves and 100% would elect for the C-Section. We are a biased group because we deal with all of the patients that have complications after, but those complications make the small risks of a C-Section worth it. Given your history, I recommend one for you as well.” I said great thank you and scheduled my C-Section. I also find the term to posh to push a bit offensive. I think having an active lifestyle and healthy sex lift are reasonable expectations.

          • Monkey Professor for a Head

            I’d love to see the statistics on how many obstetricians/wives of obstetricians have maternal request c sections – I suspect the rate would be much higher than average.

            I also think it’s terrible that the topic of pelvic floor injuries so rarely comes up when birth is discussed, especially given how relatively common they are. It seems that a woman’s continence and sexual function are just not viewed as important – I think there’s something profoundly sexist about that.

        • superhappycamper

          I don’t. I merely used a phrase that is commonly thrown around, and I used it in a tongue in cheek way. I guess that didn’t come across well.

        • Mac Sherbert

          “. 10 to 25% of women who have an uncomplicated vaginal birth end up with urinary incontinence issues”
          In my group of friends the only moms jumping on the trampoline with the kids are the moms that had c-sections…Just saying…Your group might be different!

      • Azuran

        That’s really the whole problems with c-sections and trying to figure out the ideal rate.
        Most time, the best you can say, once the c-section is done and you have the baby in front of you, is that the baby looks fine, and that perhaps it would have been fine with a vaginal birth, but we’ll never know.

        Most people think that if their c-section baby are born healthy, than is was an unnecessarians. Maybe it was, or perhaps it would have died, are you really sure you wanted to find out?

        • The Bofa on the Sofa

          Most time, the best you can say, once the c-section is done and you have
          the baby in front of you, is that the baby looks fine, and that perhaps
          it would have been fine with a vaginal birth, but we’ll never know.

          And that doesn’t even make sense. If someone has a c-section because the baby is breech, it will very likely come out perfectly fine and healthy. That doesn’t mean that not having a c-section should have even been an option.

          • Azuran

            Actually it is an option, you can’t force a woman to have a c-section even if the baby is breech.

            What I’m saying is that, for example, Breech babies, most baby would have actually been fine if they were born vaginally. Technically, most elective c-section for breech are ‘unnecessary’ since they would have been just as fine without it, BUT, you have no way of knowing which one are going to be fine and which one aren’t.
            Same thing with fetal heart rate, if it goes down, it could mean that the baby is in distress, but it might also mean nothing and the baby is fine. But you can’t know that since you don’t have access to the baby. Of course you rush the mother for a c-section, because you don’t want to take any chances with a baby, but many times the baby was totally fine and the c-section was actually not needed.
            The point it you just don’t know. You cannot know. Which is why imposing people with a c-section rate is ridiculous. You cannot know beforehand (and most of the time, even after) if the baby would have been fine and if the c-section was actually ‘necessary’. It was medically recommended at that time, based on the evidence the doctors had at that time.

          • The Bofa on the Sofa

            Actually it is an option, you can’t force a woman to have a c-section even if the baby is breech.

            Yes, people have the right to make bad decisions. Doesn’t mean that we should consider them anything but bad decisions.

          • The Bofa on the Sofa

            but many times the baby was totally fine and the c-section was actually not needed.

            My point is, this sentence does not follow.

            Just because the baby was fine with a c-section says nothing about what would have happened without a c-section. Perhaps the baby was “totally fine” BECAUSE of the c-section?

            Again, the question is, how can you tell after a c-section whether the c-section was necessary or not? The simple fact that the baby was healthy does not mean it would have been without a c-section.

            There is almost no way that you can say, even after the fact, that “that c-section was not necessary”.

          • Azuran

            We are saying exactly the same thing. Many times the baby would have been fine, that is a fact. BUT, you DON’T KNOW if that baby would be fine. Maybe it’s fine thanks to the c-section, maybe it would have been fine without it.
            We know for a fact that many babies would probably have been fine without the c-section, just from looking at the statistics. We just don’t know which ones. The fact that we don’t know which one are necessary and which one aren’t does not chance whether of not they were.

          • Sue

            There IS a subtle difference. It could be that the baby comes out fine because it was never going to be harmed, or it could be that the baby was saved from harm by the CS. I think that’s what Bofa is saying.

          • Azuran

            and I totally agree. My point is that we don’t know which one is which. Which is the reason why we will never have an ‘optimal’ rate of c-section.

          • The Bofa on the Sofa

            And to put it even more strongly, it’s not that we “don’t” know, we CAN’T know which is which.

            There is no way we can know that a c-section that was done was unnecessary.

          • It feels like the uterus is Schrodinger’s box. You don’t know the outcome until you know the outcome. Until then it’s all probabilities.

          • Cobalt

            “It was medically recommended at that time, based on the evidence the doctors had at that time.”

            Because really the cesarean rate is a non-issue compared to morbidity/mortality rates. The issue is the criteria for referral to cesarean, and criteria that result in lower morbidity/mortality rates are preferred. In the absence of a “perfect test” for who needs a cesarean, we develop the best possible tests for who is likely to need one.

      • demodocus

        I had tea time scheduled for 2 hours after my kid’s birth. Glorious

    • Roadstergal

      And how do we define ‘needed’? Maybe for some women, even if their baby would have been born OK vaginally, avoiding an NICU stay would make a C-section worthwhile. Or avoiding the possibility of forceps. Or avoiding pelvic floor damage. Or avoiding the stress of the whole gamble of VB.

      • Azuran

        Well, after we invent magic crystals to see the future, we look up the outcome of both vaginal and c-section birth for all pregnant women and then we have a panel of trained doctors who discuss the different outcome with the mother.

    • The Bofa on the Sofa

      Actually, it is not possible to determine even in retrospect that a c-section would “not have been necessary.” How could you tell that there wouldn’t have been, for example, a SD? Or that there wouldn’t have been a PPH?

      The only way would be, for example, if you have a c-section because the baby is breach, but upon being cut open, the doctor discovers that it is not breech. But in the world of mobile US, that is pretty darn rare.

      Just because the baby is born healthy and happy by c-section does not mean that it would have been so not by c-section.

      It’s nothing crazy, it’s a fundamental issue of logic.

      You CAN, however, determine in retrospect if a c-section should have been done in the case where it wasn’t. For example, when the baby dies in a VB, that should have been done by c-section.

  • Amy M

    That’s some serious tunnel vision, right there. As though the only factor affecting neonatal and maternal outcomes was method of birth. Obstetrics is one area where the population is very heterogeneous, and what works for one mother/baby doesn’t necessarily suit another mother/baby. Blanket statements like “The C-section rate is too high” help no one.