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.