Ask 10 different obstetricians what the optimal cesarean delivery rate is and you’ll likely get 10 different answers. But there is widespread agreement that 32.2 percent, the U.S. average in 2014, is too high. Way too high in light of research out Tuesday that finds no benefit in preventing death for the mother or infant when C-section rates rise above approximately 19 percent.
The findings, published in the Journal of the American Medical Association, are based on 2012 mortality rates from the 194 World Health Organization (WHO) member countries. There’s a dramatic range, from South Sudan where just 0.6 percent of deliveries were by C-section, to Brazil where the rate was 55.6 percent.
Study authors say they are not presenting 19 percent as an ideal rate, but rather as a benchmark above which doctors need to consider: “We’re unlikely to be improving maternal mortality or neonatal mortality, are there other benefits or harms to doing cesarean sections?” says Dr. Alex Haynes, a lead author on the study who works in the safe surgery program at Boston-based Ariadne Labs. The research was done in collaboration with Stanford University Medical School.
In the U.S., and in Massachusetts where the C-section rate is 31.6 percent, doctors say having a number, like 19 percent, will make a difference in doctor’s offices and in hospitals.
“This will push all of us to say, what general practices contribute to inappropriate cesarean deliveries and how, with individual patients, can we make decisions about when it’s necessary?” said Dr. Jeffrey Ecker, a high-risk obstetrician at Massachusetts General Hospital and chair of the committee on obstetric practice for the American College of OBGYNs, which does not have a target number for cesarean delivery.
Nineteen percent is higher than a 10 to 15 percent C-section range recommended by the WHO for roughly three decades. The WHO revised its recommendation in April, and no longer suggests an optimal or ideal rate, Dr. Ana Pilar Betrán, with the WHO’s Department of Reproductive Health and Research, said in an email.
“The important message,” Betrán said, “was that rather than striving to achieve a specific rate, every effort should be made to provide cesarean sections to women in need.”
Betrán did not comment on the paper’s findings or the value of using 19 percent as a C-section benchmark. And it makes some leaders in the U.S. movement to measure health care quality nervous.