Quoted in the Times of London

An article entitled Don’t Push It, Who Says C-sections are Bad For You? by Helen Rumbelow, appeared recently in the Times of London. Rumbelow explores the genesis of the World Health Organization “optimum” C-section rate of less than 15% and finds that there is no scientific evidence to support it.

Whenever the [rising C-section rate] is discussed, one fact is wheeled out — the United Nations’ World Health Organisation recommendation that no more than 10 to 15 per cent of babies should be delivered by Caesarean. Everyone from the Royal College of Midwives to the NHS Institute for Innovation and Improvement — the NHS body that enforces best practice — trots out this target…

No one apart from the World Health Organisation has dared to put a target on the safe level of Caesareans — that’s why everyone uses its statistic. So where is the evidence that halving our C-section rate would be safe? Answer: there isn’t any.

Rumbelow interview several obstetricians, including me:

[Amy Tuteur] says that WHO figures actually suggest that a Caesarean rate of 15 per cent is “unacceptably low”. “There are only two countries in the world that have C-section rates under 15 per cent and low rates of maternal and neonatal mortality — Croatia and Kuwait — and neither is known for the accuracy of its data,” says Tuteur. “Even rates up to 32 per cent or more seem to be consistent with excellent outcomes.”

Ms. Rumbelow spoke with Marsden Wagner who presided over publication of the 15% rate as “optimal.”

I tracked down the man who set the target, Marsden Wagner, a retired American paediatrician who was for 15 years the director of women’s and children’s health at the World Health Organisation. Many of the obstetricians that I spoke to said that the 15 per cent statistic “was plucked out of the air”. Wagner denied this, saying that his team looked at the best data available.

Yet Wagner could not provide any such data for Ms. Rumbelow. That’s not surprising since Wagner himself has acknowledged that no data existed at the time the recommendation was issued. As I discussed in my post What’s the right C-section rate? Higher than you think. , Wagner noted that his paper Rates of caesarean section: analysis of global, regional and national estimates (Paediatric and Perinatal Epidemiology, 2007; 21:98–113) is the first to compare international C-section rates with maternal and neonatal mortality.

Since publication of the WHO consensus statement in 1985, debate regarding desirable levels of CS has continued; nevertheless, this 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.

It is Wagner’s paper, in fact, that I referenced in my quote above. He found that only two countries in the world, Croatia and Kuwait had C-section rates less than 15% and low maternal and neonatal mortality. Indeed, the average C-section rate for countries with low maternal and neonatal mortality is 22%, although rates as high as 32% or higher are consistent with low rates of maternal and neonatal mortality.

The WHO has recently withdrawn the 15% “optimum” C-section rate. Rumbelow writes:

I discovered that the World Health Organisation (WHO) quietly withdrew its target last year.No one noticed, which must have been a relief, because its reason for doing so is embarrassing. In its handbook Monitoring Emergency Obstetric Care, it states that its figure was not based on solid evidence. “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 …”

When Rumbelow informed Marsden Wagner that the WHO has reversed its position, he characteristically offered a conspiracy theory:

Wagner was shocked that the WHO target had been withdrawn. “The authors of this handbook are the WHO physicians who are so damned scared of making physicians angry so they come up with a pathetic waffling statement. There is good international data that going over 15 per cent increases maternal deaths.”

Yet Wagner offers no such “international data”, not surprising, since there isn’t any.