Why does The Lancet use an optimal C-section rate that has been debunked? Truthiness!

8960391D-A6A5-4602-BD12-AE6A3C9B4048

I’ve written many times about the obstetric lie that will not die: the unsubstantiated “optimal” C-section rate of less than 15%.

  • It was fabricated from whole cloth in 1985, apparently to suit the prejudices of the man behind it.
  • There was never any evidence to support it.
  • It was officially debunked in 2015 when it was shown that a minimal rate of 19% was necessary for safety.

Nonetheless, a series on C-sections just published in The Lancet uses the thoroughly discredited “optimal” rate of 10-15% as a benchmark. This despite the fact that the World Health Organization, which fabricated the “optimal” rate has acknowledged there was NEVER any evidence to support it.

They feel in their gut the optimal C-section rate must be 10-15%, damn the absence of evidence and the existence of research that shows they are wrong.

Buried deep in its 2009 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 …

Indeed Marsden Wagner, the WHO official who appears to be behind the fabricated rate acknowledged in a paper he wrote in 2007:

…[T]his paper represents the first attempt to provide a global and regional comparative analysis of national rates of caesarean delivery and their ecological correlation with other indicators of reproductive health…

In that paper Wagner found that nearly every country with a C-section rate less than 15% had appalling levels of maternal and neonatal mortality.

A 2015 paper Relationship Between Cesarean Delivery Rate and Maternal and Neonatal Mortality found that a minimum C-section rate of 19% is required for low levels of maternal and neonatal mortality.

National cesarean delivery rates of up to approximately 19 per 100 live births were associated with lower maternal or neonatal mortality among WHO member states. Previously recommended national target rates for cesarean deliveries may be too low.

Ironically, the press release accompanying The Lancet series was followed by this correction:

The level of C-section use required for medical purposes provided in the press release below is no longer a recommendation from the World Health Organisation (WHO). In the 2015 Statement on Caesarean Section Rates, WHO stated that “Every effort should be made to provide caesarean sections to women in need, rather than striving to achieve a specific rate”.

The 10-15% C-section use is still used as a practical indicator of underuse and overuse.

This line has now been corrected from:
It is estimated by the World Health Organisation that 10-15% of births medically require a C-section due to complications, suggesting that average C-section use should lie between these levels.

To:
It is estimated that 10-15% of births medically require a C-section due to complications, suggesting that average C-section use should lie between these levels.

Why is The Lancet still using the never empirically supported, withdrawn and now discredited “optimal” rate of 10-15%?

They have replaced scientific truth with truthiness.

Steven Colbert coined the term “truthiness.” According to Wikipedia:

Truthiness is the belief or assertion that a particular statement is true based on the intuition or perceptions of some individual or individuals, without regard to evidence, logic, intellectual examination, or facts. Truthiness can range from ignorant assertions of falsehoods to deliberate duplicity or propaganda intended to sway opinions.

In an out of character interview with the Onion’s A.V Club Colbert explained:

Truthiness is ‘What I say is right, and [nothing] anyone else says could possibly be true.’ It’s not only that I “feel” it to be true, but that “I” feel it to be true. There’s not only an emotional quality, but there’s a selfish quality.

For reasons that I do not fathom, the authors of The Lancet series, as well as many others working on the issue of C-sections, feel in their gut that the optimal C-section rate must be 10-15%, damn the absence of evidence and the existence of research that shows they are wrong.

The insistence on using a discredited optimal C-section rate puts the entire Lancet series in question. According to the press release:

Globally, the number of babies born through caesarean section (C-section) almost doubled between 2000 and 2015 – from 12% to 21% of all births – according to a Series of three papers published in The Lancet and launched at the International Federation of Gynecology and Obstetrics (FIGO) World Congress in Brazil. While the life-saving surgery is still unavailable for many women and children in low-income countries and regions, the procedure is overused in many middle- and high-income settings.

The authors insist that this is a crisis, but if they were to use the actual scientific evidence that a minimal C-section rate of 19% is necessary for low rates of maternal and neonatal mortality there wouldn’t be a crisis at all. The current C-section rate would be only slightly higher than the minimally acceptable rate, a reason for satisfaction not alarm.

By replacing truth with truthiness, the authors have ignored science in favor of personal belief. That is an unpardonable sin for anyone claiming to be a scientist.

  • Mel

    The idea of having an “ideal” CS rate scares the snot out of me and I needed a few days to figure out why.

    I hate the idea of someone – or a group of people – who has no skin in the game making health care decisions that have massive ramifications in my life.

    I know that I was a shoe-in for a CS when I had my son between my bad lab scores from HELLP syndrome and the fact that I was a FTM showing no signs of labor at 26 weeks – but what if I was only sort-of bad? Like the more standard less than great electronic monitoring strip on a term baby type of sort-of bad?

    I’ve seen enough parent-children combinations where birth hypoxia has caused enough damage that I end up feeling vaguely guilty that my kid and I have had it so easy – and we’ve not had an easy time! The people making decisions about the magical 10-15% CS rate aren’t offering respite care for that kiddo on a ventilator’s family. They are not offering helpful tips on coordinating care between medical professionals and community resources. Heck, I doubt they can even describe the resources available within 25 miles for children with developmental delays – so why do they get to make choices for the rest of us?

    I have no interest in rolling a dice on my child’s physical health and my mental health to let a hospital administrator brag about giving women a “normal” birth by keeping the CS rate artificially low.

  • Anna

    I asked on the ACM FB page if their gleeful sharing of a statement on this means they dont support MRC, c-sec for mental health or preventative measure. Crickets….

  • Russell Jones

    The Lancet . . . isn’t that the outfit that published, then later had to retract, Andy Wakefield’s fraudulent nonsense about the MMR vaccine and autism?

  • Ally

    Dr Amy,

    Would you please consider calling out the Guardian on this piece full of factual untruths?

    https://www.theguardian.com/society/2018/oct/11/use-of-caesarean-sections-growing-at-alarming-rate

    The contents are classic NCB/midwifery smear campaign against cesareans, copied verbatim and taken as truth without even the most basic fact-checking.

    The usual suspects are all there:

    – 15% optimal cesarean rate
    – That cesareans cause auto-immune disease in babies is presented as scientifically proven fact
    – That tale about cesareans altering the baby’s gut microbiome, and that those changes would be prognostically relevant
    – Another rendition of ‘cesareans cause obesity’ (and asthma, for some reason?) instead of ‘obese women need more cesareans than skinny ones’.
    – Dissimulation and dishonesty about the risks/disadvantages of vaginal birth
    – That old, nauseating adage that all women would choose vaginal birth “if only they had enough education/support”. “Support” which should, of course, consist of more midwives, with the power to curtail women’s access to obstetrician’s care, and a ban on maternal request cesareans.

    The whole thing is unworthy of a quality newspaper, and makes one wonder whether the Guardian actually bothers to fact-check what they publish or they simply print the opinion of whatever midwifery quacktivist they happened to interview that particular day.

  • fiftyfifty1

    OT: I’ve been laughing about Gisele Bundchen lately. She always swore she would never get cosmetic surgery, but a number of months ago she got caught sneaking into a plastic surgeon’s clinic wearing a burka as a disguise. What gave her away was her bare ankles and sandals. Anyway, after months of denying it, she finally admitted that she had actually gotten breast implants. She claims she hates having them, but had no choice because the appearance of her breasts had been so badly damaged by breastfeeding. This from the woman who said that at least 6 months of breastfeeding should be mandated by law.

    http://www.skepticalob.com/2010/08/giesele-bundchen-sanctimommy.html

    • Cartman36

      Hahahaha! She is such a smug jerk.

  • sara

    I seem to have recently heard something like 20-22% – anyone have any idea where that is coming from?