Efforts to reduce C-section rates ignore quality of life outcomes women value

quality of life word under torn black sugar paper

Earlier this month I wrote about The Lancet series on reducing C-section rates that used a benchmark rate of 10-15%. This despite the fact that the World Health Organization, which made it up, acknowledges there is NO EVIDENCE to support the safety of a 10-15% rate and considerable evidence that the minimum safe C-section rate is 19%.

A recent editorial in PLoS Medicine challenges the 10-15% rate on additional grounds: it ignores the outcomes that women value most.

The authors discuss a new paper from China:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Women value improved long term safety for their babies over increased short term risks to themselves.[/pullquote]

Recent high cesarean section (CS) rates around the world have sparked intense interest in the underlying drivers, partly to inform efforts to reduce CS rates. This week in PLOS Medicine, Long and colleagues report on these trends from multiple perspectives in mainland China, Taiwan, and Hong Kong … These settings—with respective CS rates of 34.9%, 27.4%, and 35%—reside near the top of the CS birth rate tables …

The prospectively registered study stands out among related work because of the meticulous efforts made to understand and contextualise how nonclinical considerations lead to plans for CS births. In addition to detailing why many CS plans are made, the authors also report a recent shift towards placing greater value on vaginal birth in studies from mainland China. The latter observation supports previously reported impressions that removal of China’s one-child policy, in addition to multiple strategies to reduce CS rates, has led to an increase in vaginal births in women who previously gave birth by CS.

Women see C-section as a safer option particularly in light of China’s previous one child policy:

Multiple women described CS as the ‘safe’ choice for birth; quotes detailed CS as a means to avoid ‘any risk’ to their baby, whether ‘immediate complications’ or ‘longer-term child-development’ issues.

Despite the World Health Organization’s insistence that vaginal birth is safer than C-section, data out of China indicates the opposite:

Utilising the combination of large population databases of birth-related events and a high CS-on-maternal-request (CDMR) rate, researchers reported outcomes of over 66,000 first births in Shanghai between 2007 and 2013. Reduced offspring birth trauma, neonatal infection, meconium aspiration syndrome, and hypoxic ischaemic encephalopathy followed CDMR, with no difference in risk of serious maternal complications when compared with a plan for vaginal birth… Overall, these findings suggests that, where women are certain of their plan to have only one child, those with similar characteristics in equivalent healthcare settings may be justified in choosing CS on safety grounds.

In other words, women value improved long term safety for their babies over increased short term risks to themselves. Of course C-section also has long term risks for the mother such as increased uterine rupture and placenta accreta in future pregnancies. But vaginal birth has long term risks to continence and sexual function that are much more common than long term risks of C-section.

Efforts to reduce C-section rates ignore women’s preferences:

The agenda to lower CS rates appears to be driven by WHO’s position statement, which cites a lack of evidence for reduction in maternal and infant mortality at the population level for CS rates above 10%–15%. However, the WHO statement does not reflect the quality-of-life outcomes that appear to be important to women … Long and colleagues’ findings demonstrate that women and clinicians in these settings who plan CS may be voting with their feet to optimise both perceived safety and quality-of-life outcomes. In the United Kingdom and Singapore, where recent person-centred legal developments mean that informed consent to give birth requires that women are informed of (1) risks she considers to be important and (2) reasonable available options, decisions for CS based upon quality-of-life outcomes appear legitimate yet highlight the gulf between WHO priorities (saving lives) and those of women and clinicians making individual birth plans…

The WHO may claim that its priority is saving lives, but to my knowledge there is NO EVIDENCE that reducing C-section rates saves lives. It is theoretically possible, of course, but we should not be setting practice guidelines on theory that isn’t confirmed by scientific study.

The authors conclude:

China is in a strong position to use its high CDMR rates and its population-based birth registries to support studies of birth outcomes beyond mortality and to engage with women to identify outcomes that are important to them. Such a truly woman-centred approach would facilitate birth choices being made in the full knowledge of the balance of risks and benefits.

In contrast, aggressive efforts to reduce C-section rates are the opposite of a woman-centered approach that facilitates birth choices made with thorough information about risks AND benefits and taking into account quality of life outcomes that women value.