Friday, April 30, 2010

U.S. Rate Reduction Campaigns - Frightening News

I came across news of two new campaigns in the United States that aim to reduce their local hospital cesarean rates to between 10 and 15%. I've described this as frightening news because that's exactly what it is.

Not that I believe the campaigners have any hope of achieving such low rates; I don't. But I am concerned that in their efforts to make such drastic reductions, it will be at the cost of numerous mothers' and babies' health.

20% by 2020
The first is in Sarasota, where '20% by 2020' describes itself as "an initiative to encourage elected officials, hospital staff, maternity care practitioners and consumers to reduce Sarasota's epidemic cesarean section rates to 20% by the year 2020."

Worst to First 2010
The second is in New Jersey (where both of my children were born - by elective cesarean), which is called 'Worst to First 2010'. Evidently, the State's current cesarean rate is deemed too high, and this campaign aims to reverse the situation.

It states that all but two hospitals have agreed to re-educate their staff to achieve cesarean rates of 10%-15% and episiotomy rates of 5%. But as you'll see from the figures posted, they have a long way to go...

A 10-15% cesarean rate is unachievable, undesirable and dangerous
The World Health Organization recommended this rate back in 1985, but in 2009, it finally admitted that there is no empirical evidence for such a range of numbers, and that in fact, there is no known optimum rate for cesarean delivery.

The campaign organizers above are most likely unaware of the 2009 update by the WHO, and therefore believe that they are helping women by trying to reduce cesarean rates to this level. However, they are in real danger of doing more harm that good if they're not careful; while I agree that there probably are cases where an unwanted cesarean delivery may be avoided (although I would add that hindsight is usually the most beneficial tool in deciding what was and wasn't medically necessary - obviously not available during labor), there are undeniably grave risks at stake when cesareans are delayed or avoided 'at all costs'.

Finally, I would urge these campaigners to focus on trying to reduce unwanted cesarean rates, and leaving those of us who want our cesareans well alone. After all, it should be positive, happy and healthy birth outcomes that matter - and not simply a % figure at each year end.


Laura said...

The press release to which you refer was retracted in error by Medical News Today. The World Health Organization continues to recommend a c-section rate not to exceed 15%, and stated as recently as January 2010 that cesarean sections put women at increased risk, and should only be performed when medically necessary.

I launched the 20 by 2020 campaign in Sarasota, Florida, because our c-section rates are 42%. I must respectfully disagree that my efforts to reduce this number will "be at the cost of numerous mothers' and babies' health." On the contrary, as our numbers have risen, so has our preterm birth rate, NICU admissions and maternal mortality and morbidity. The reduction I propose is not drastic at all, but merely 2.2% annually--about the same rate at which the surgeries are increasing today.

I am, as you suggest, focusing on unwanted cesarean rates. I support informed choice for all patients. Many of the surgeries, however, within my community's 42%, were the result of failed inductions, lack of VBAC access, or lack of education (about risks and benefits of surgery, about preconception and prenatal nutrition, about the benefits to mother and baby of spontaneous labor). These all play a part in lack of true informed consent.

cesarean debate said...

Laura, Medical News Today stands by its publication of our press release, hence its statement that it was originally 'retracted in error'. Our press release is factually correct, and it is a fact that the WHO finally admitted that it has no evidence for its 1985 cesarean recommendation. You can read my rebuttal to the original complaints here:

You also refer to the WHO's most recent publication on cesarean delivery in January 2010. You may not be aware, but this has been the subject of strong criticism. For example:

30 Jan 10 Nigel Hawkes: A bad case of bias against Caesareans, Independent
26 Jan 10 Funny Figures from WHO on Caesareans, Straight Statistics
12 Jan 10 Study advises against non-medial cesareans but how accurate is the advice?

I genuinely believe that you cannot safely reduce your cesarean rate to 20% even if you aim to do it slowly. That's not the same as saying that you can't reduce it safely at all; I'm sure you can. But you must accept that it's going to be a challenge for anyone (without the aid of hindsight) to be 100% sure of identifying all the 'unnecessary' cesareans prior to delivery without missing any of the absolutely 'necessary' ones. The law courts are full of cases where cesareans were adversely delayed or not carried out, and these would likely increase if cesareans were at 20% in a general U.S. maternal population.

Laura said...

It can be done. It is being done. Millions of dollars are being saved. And outcomes are not sacrificed.