In 1985 WHO organised an inter-professional and lay Inter-Regional Conference in Fortaleza, Brazil, to consider ‘Appropriate Technology for Birth’. During the conference a search was made of the relevant medical research and as a result the conference agreed that there was no health improvement for either mother or baby when caesarean section rates exceed 10%. The obstetricians from North and South America threw their hands up in horror
and said that they could not possibly return to their countries with such a recommendation. They proposed that it should be amended to 10-15%. I objected on the grounds that if they did that everyone would focus on 15% and not on 10%. I was voted down, and the following statement was agreed: ‘There is no justification in any specific geographic region to have more than 10-15% caesarean section births.’ Since then,15% figure is commonly quoted. Fortunately, in 2015 WHO amended its statement to reflect the evidence:
• ‘…. when the rate [of caesareans] goes above 10%, there is no evidence that mortality rates improve.’(WHO, 2015).
WHO has also pointed out that ‘Although it can save lives, caesarean section is often performed without medical need, putting women and their babies at-risk of short and long-term health problems.’ (WHO, 2015).
This is the second in a series of blog posts in which Beverley Beech discusses the modern problem of the ‘cascade of intervention’ that occurs for many birthing women and looks at the short and long term impact of this upon women and babies. You can read the introduction to this series here.
The wide range of caesareans is an example of medical abuse. If at least two thirds of men (and in some countries three quarters) were subjected to unnecessary major abdominal surgery (which is what a caesarean operation is) there would be a national outcry about the abuse, the risks, and the waste of money. It is really an international disgrace that these caesarean operation rates are simply accepted and, in some countries, hardly questioned.
Between 1990 and 2013 the maternal mortality ratio for the USA more than doubled from an estimated 12 to 28 maternal deaths per 100,000 births, and about half were preventable (Agrawal 2015). In Europe, however, the maternal mortality rate has decreased by almost half between 2000 to 2015, from 33 to 16 deaths per 100 000 live births, a figure that includes some countries where the deaths are not well reported. http://www.euro.who.int/en/health-topics/Life-stages/maternal-and-newborn-health/data-and-statistics
A Dutch prospective cohort study found that the incidence of severe acute maternal morbidity was 23 out of 1,000 in the planned caesarean group compared with 6 out of 1,000 of those who had a vaginal delivery. The maternal mortality outcomes were also increased in the caesarean group (9.7 v 6.4). (van Dillen J, et al 2010).
A systematic review of 21 studies across the world, including over 2 million births (Marshall et al, 2011), showed that repeat routine CS causes:
An increase in rates of blood transfusions; hysterectomy; surgical injury and adhesions as the number of caesarean births increase.
“Women who have a caesarean section have a higher chance of not becoming pregnant again, and a greater chance of future pregnancy complications,” Sarah Stock, of the University of Edinburgh’s MRC Centre for Reproductive Health.
High levels of surgical birth are costly in every sense. A study of women who had elective repeat caesarean sections compared with those who had a vaginal birth after a previous caesarean found that elective caesarean sections cost approximately €3,400 (£3,003) more than a vaginal births (Fawcitt CG et al. 2013). In the UK rates have been reduced in recent years but are still higher than expert opinion advises.
Agrawal P (2015), Maternal mortality and morbidity in the United States of America, Editorial, Bulletin of the WHO. 93:135. doi: http://dx.doi.org/10.2471/BLT.14.148627
Blustein J and Liu J (2015). Time to consider the risks of caesarean delivery for long term child health, BMJ, 350.h2410 : https://doi.org/10.1136/bmj.h2410
Lavender T, Hofmeyr GI, Neilson JP et al (2006). Caesarean section for non-medical reasons at term, The Cochrane Database of Systematic Reviews, issue 3.
Marshall NE, Fu R, Guise J-M (2011). Impact of multiple cesarean deliveries on maternal morbidity: a systematic review, Am Journal of Obstetrics and Gynecology, Vol 205, Issue 3, p262.e1-262.e8.
WHO (2015). Caesarean sections should only be performed when medical necessary, Geneva, 10 April 2015. http://www.who.int/mediacentre/news/releases/2015/caesarean-sections/en/