By Jill Arnold
World Health Organization’s oft-cited cesarean proportion “recommendation” of no more than 15% of all deliveries comes from a passage in a handbook titled Monitoring emergency obstetric care [PDF].
Contrary to popular belief, World Health Organization no longer recommends a target cesarean proportion or rate as it did in an earlier version of the same handbook, specifically stating that the optimum rate is unknown. The proposed upper limit of 15% is not a target to be achieved but rather a threshold not to be exceeded, according to authors of the handbook.
About Monitoring emergency obstetric care
Monitoring emergency obstetric care is a handbook authored in 2009 by World Health Organization, UNFPA, UNICEF, Mailman School of Public Health and Averting Maternal Death and Disability (AMDD).
According to the Sexual and reproductive health page on the WHO web site, “[t]his handbook is an update of an earlier publication on monitoring the availability and use of obstetric services, issued by UNICEF, WHO and UNFPA in 1997. The indicators defined within the publication have been used by ministries of health, international agencies and programme managers in over 50 countries around the world. This revision incorporates changes based on monitoring and assessment conducted worldwide and the emerging evidence on the topic over the years, and has been agreed by an international panel of experts.”
The following table found on page 5 lists the original six EmOC (emergency obstetric care) indictors, including “Caesarean sections as a proportion of all births.” Much of the handbook focuses on the collection of data for these and additional indicators and their analysis.
The bulk of the text on the 15% threshold is found on page 25 of the handbook.
Minimum and maximum acceptable levels
Both very low and very high rates of caesarean section can be dangerous, but the optimum rate is unknown. Pending further research, users of this handbook might want to continue to use a range of 5–15% or set their own standards.
The proportion of births by caesarean section was chosen as the indicator of provision of life-saving services for both mothers and newborns, although other surgical interventions (such as hysterectomy for a ruptured uterus or laparotomy for an ectopic pregnancy) can also save maternal lives. Of all the procedures used to treat major obstetric complications, caesarean section is one of the commonest, and reporting is relatively reliable (124).
Earlier editions of this handbook set a minimum (5%) and a maximum (15%) acceptable level for caesarean section. Although WHO has recommended since 1985 that the rate not exceed 10–15% (125), there is no empirical evidence for an optimum percentage or range of percentages, despite a growing body of research that shows a negative effect of high rates (126-128). It should be noted that the proposed upper limit of 15% is not a target to be achieved but rather a threshold not to be exceeded. Nevertheless, the rates in most developed countries and in many urban areas of lesser-developed countries are above that threshold. Ultimately, what matters most is that all women who need caesarean sections actually receive them.