Betran, AP

Guelmezoglu, AM

Temmerman, Marleen

Torloni, MR

WHO Working group Caesarean Section, for the

Zhang, JJ

English

Ghent University Academic Bibliography

WHO Statement on Caesarean Section RatesAP Betran,a MR Torloni,b JJ Zhang,c AM G€ulmezoglu,a for the WHO Working Group on CaesareanSection*a UNDP, UNFPA, UNICEF, WHO, World Bank Special Programme of Research, Development and Research Training in HumanReproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland b Brazilian CochraneCenter and Department of Obstetrics, S~ao Paulo School of Medicine, S~ao Paulo Federal University, S~ao Paulo, Brazil c Ministry of Education–Shanghai Key Laboratory of Children’s Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai,ChinaCorrespondence: AP Betran, UNDP, UNFPA, UNICEF, WHO, World Bank Special Programme of Research, Development and ResearchTraining in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.Email betrana@who.intAccepted 13 May 2015. Published Online 22 July 2015.Please cite this paper as: Betran AP, Torloni MR, Zhang JJ, Gu¨lmezoglu AM for the WHO Working Group on Caesarean Section*. WHO Statement onCaesarean Section Rates. BJOG 2016;123:667–670.In 1985 when a group of experts convened by the WorldHealth Organization in Fortaleza, Brazil, met to discuss theappropriate technology for birth, they echoed what at thatmoment was considered an unjustified and remarkableincrease of caesarean section (CS) rates worldwide.1 Basedon the evidence available at that time, the experts in Fort-aleza concluded: ‘there is no justification for any region tohave a caesarean section rate higher than 10–15%’.1 Overthe years, this quote has become ubiquitous in scientific lit-erature, being interpreted as the ideal CS rate. Althoughthis reference range was intended for ‘populations’, whichare defined by geopolitical boundaries, in many instances ithas been mistakenly used as the measurement for health-care facilities regardless of their complexity or other charac-teristics. In addition to the case mix of the obstetricpopulation served, the use of CS at healthcare facilities isalso affected by factors such as their capacity to handlecases, availability of resource and the clinical managementprotocols used locally.Since its publication and for the last 30 years, this refer-ence rate for CS has received intense criticism and has ledto controversy, concern, polarised opinions and heateddebates, while in parallel, the use of CS as a mode of deliv-ery has continued its worrying rise worldwide. The need torevisit the recommended CS rate has been considered moreand more necessary in view of the significant improve-ments in clinical obstetric care and in the methodology toassess evidence and issue recommendations in the last threedecades.The global concern around CS rates is understandable.When medically justified, a CS can prevent maternal andperinatal mortality and morbidity. There is no evidence,however, showing the benefits of the procedure for womenor infants where it is not required. CS is associated withshort- and long-term risk, which can extend beyond thecurrent delivery and affect future pregnancies. In addition,the increase in CS rates seems uncontrollable, with no signsthat it is slowing down. The situation is aggravated by thefact that the causes of the rise are not fully understood butemerge as a complex multifactorial labyrinth involvinghealth systems, health care providers, women, societies, andeven fashion and media.2–6 Lastly, non-clinical interven-tions to reduce unnecessary CS have shown limitedeffectiveness to date.7In light of these issues, WHO convened a meeting inGeneva, Switzerland, on 8–9 October 2014 with the objec-tive of (1) establishing the current WHO position on theCS rate or range for optimal maternal and perinatal out-comes at population level, and (2) agreeing on a proposalfor a tool to monitor CS rates at facility level. The State-ment on Caesarean Section Rates recently released by WHOsummarises the results of the systematic reviews and analy-ses conducted for this purpose and conveys the thinkingemerging from the discussions of the meeting.8A systematic review and an ecological analysis were per-formed and concluded that at population level, CS rateshigher than 10% were not associated with reductions inmaternal and newborn mortality rates.9,10 The Statementnotes, however, that the association between CS rates andother relevant outcomes such as stillbirths, maternal and*WHO Working Group on Caesarean Section are in Appendix 1.667ª 2015 World Health Organization licensed by John Wiley & Sons Ltd on behalf ofRoyal College of Obstetricians and Gynaecologists.This is an open access article distributed under the terms of the Creative Commons Attribution IGO License which permits unrestricted use,distribution and reproduction in any medium, provided that the original work is properly cited.DOI: 10.1111/1471-0528.13526www.bjog.orgCommentaryperinatal morbidity, paediatric outcomes and psychologicalor social well-being could not be determined due to thelack of data on these other outcomes at the populationlevel. This lack of data represents a limitation of theseanalyses that needs to be borne in mind.Beyond numbers and rates, the Statement emphasisesthat the critical role played by the quality of care in thisequation cannot be overstated. As with any surgery, CSis associated with short- and long-term risks, particularlyin settings that lack the facilities or capacity to conductsafe surgery or treat surgical complications properly, orwhere access to labour care or repeat CS in subsequentpregnancies cannot be taken for granted. On the otherhand, inadequate access to timely CS may result in peri-natal asphyxia, stillbirth, uterine rupture or obstetric fis-tula, a marker for exceptionally prolonged, obstructedlabour.11 Thus, CS should be undertaken when medicallynecessary, and rather than striving to achieve a specificrate, efforts should focus on providing caesarean sectionto all women in need. How to define the woman ‘inneed’ can only be ascertained by the health care provid-ers caring for the woman on a case-by-case basis.Most importantly, at the healthcare facility level, clini-cians and administrators struggle to monitor CS rates in ameaningful, reliable and action-oriented manner. Histori-cally, caesarean sections have often been categorised usingits indications as the unit being classified. Using indica-tions to classify CS has always been problematic due to thelack of uniform definitions for most common indicationsand has resulted in poor reproducibility and unsatisfactorycomparisons.12 In 2001, Dr Michael Robson proposed asystem of 10 groups that classifies all women admitted fordelivery (and not indications) according to five obstetriccharacteristics that are generally routinely collected in mostmaternities.13 Two systematic reviews conducted at WHOidentified this classification as the most appropriate systemto fulfil current international and local needs.12,14 TheWHO Statement proposes the use of the Robson classifica-tion as the global standard for assessing, monitoring andcomparing CS rates within healthcare facilities over time,and between facilities. In the last decade, this classificationhas witnessed an extraordinary expansion in its use world-wide, particularly in healthcare facilities, due to its intrinsicappealing characteristics: simplicity of design, validity ofpurpose, ease of implementation and directness of initialinterpretation.14 WHO envisions that the informationstemming from the classification can be a powerful tool toinform practice. The classification will allow not only forstratification of CS rates in more uniform groups ofwomen but also the assessment of CS rates in relation toother perinatal outcomes and processes (e.g. rates of oxyto-cin usage, postpartum haemorrhage, newborn outcomes,length of labour).WHO will guide and support countries in the use,implementation and interpretation of the classification sothat we can start comparing CS rates in a meaningful, tar-geted, transparent and useful manner. By endorsing theRobson classification, this Statement should become a cata-lyst for action. The time has come to put the debate aboutthe preferable rate of CS on hold. Let’s start to collect datauniformly so that in the near future we will be able tomove our focus from CS rates at population level to moni-toring and discussing CS rates and outcomes in each groupof the Robson classification. Only then will we have thedata and evidence that will lead us more clearly to actionsto improve care.15 Ultimately, we hope the debate canrecommence with more valuable, solid and informativedata to support our discussions.Disclosure of interestsNone declared. Completed disclosure of interests formavailable to view online as supporting information.Contribution to authorshipAll authors contributed to the writing of the commentary.FundingThis commentary has been written without any externalfunding.Details of ethics approvalNo ethical approval was sought for the writing of thiscommentary.DisclaimerThe authors alone are responsible for the views expressedin this publication and they do not necessarily representthe decisions or policies of the World Health Organizationor other organizations.&References1 Appropriate technology for birth. Lancet 1985;2:436–7.2 Fioretti B, Reiter M, Betran A, Torloni M. Googling caesareansection: a survey on the quality of the information available on theInternet. BJOG 2015;122:731–9.3 Torloni M, Campos MB, Merialdi M, Betran A. What do popularSpanish women’s magazines say about caesarean section? A21-year survey BJOG 2014;121:548–55.4 Mazzoni A, Althabe F, Liu NH, Bonotti AM, Gibbons L, Sanchez AJ,et al. Women’s preference for caesarean section: a systematicreview and meta-analysis of observational studies. BJOG 2011;118:391–9.5 Fuglenes D, Oian P, Kristiansen IS. Obstetricians’ choice of cesareandelivery in ambiguous cases: is it influenced by risk attitude or fearof complaints and litigation? Am J Obstet Gynecol 2009;200:48.e1–8.6 Hellerstein S, Feldman S, Duan T. China’s 50% caesarean deliveryrate: is it too high? BJOG 2015;122:160–4.668 ª 2015 World Health Organization licensed by John Wiley & Sons Ltd on behalf ofRoyal College of Obstetricians and Gynaecologists.Betran et al.7 Khunpradit S, Tavender E, Lumbiganon P, Laopaiboon M, Wasiak J,Gruen RL. Non-clinical interventions for reducing unnecessarycaesarean section. Cochrane Database Syst Rev 2011;(6):CD005528.8 World Health Organization. WHO Statement on CaesareanSection Rates. Geneva: World Health Organization; 2015 (WHO/RHR/15.02).9 Betran AP, Torloni MR, Zhang J, Yu J, Deneux-Tharaux C, OladapoOT, et al. What is the optimal rate of caesarean section atpopulation level? A systematic review of ecologic studies ReprodHealth 2015;12:57.10 Ye J, Betran AP, Torloni MR, Mikolajczyk RT, Gulmezoglu A, ZhangJ. Association between caesarean section and maternal andneonatal mortality: a worldwide population-based ecologic study.BJOG 2015; doi: 10.1111/1471-0528.13592. In press11 Ahmed S, Tuncalp O. Burden of obstetric fistula: from measurementto action. The Lancet Global Health 2015;3:e243–4.12 Torloni MR, Betran AP, Souza JP, Widmer M, Allen T, GulmezogluM, et al. Classifications for cesarean section: a systematic review.PLoS ONE 2011;6:e14566.13 Robson MS. Classification of caesarean sections. Fetal Matern MedRev 2001;12:23–39.14 Betran AP, Vindevoghel N, Souza JP, Gulmezoglu AM, Torloni MR.A systematic review of the Robson Classification for caesareansection: what works, doesn’t work and how to improve it. PLoSONE 2014;9:e97769.15 Robson M, Hartigan L, Murphy M. Methods of achieving andmaintaining an appropriate caesarean section rate. Best Pract ResClin Obstet Gynaecol 2013;27:297–308.AppendixWHO Working Group on Caesarean Section: HA Aleem(Department of Obstetrics and Gynecology, Women’sHealth Center, Assiut University Hospital, Assiut, Egypt), FAlthabe (Institute for Clinical Effectiveness and Health Pol-icy, Buenos Aires, Argentina), T Bergholt (Department ofObstetrics, University of Copenhagen, Copenhagen, Den-mark), L de Bernis (United Nations Population Fund, Gen-eva, Switzerland), G Carroli (Centro Rosarino de EstudiosPerinatales, Rosario, Argentina), C Deneux-Tharaux(INSERM U1153, Obstetrical, Perinatal and Pediatric Epi-demiology Research Team, Center for Epidemiology andStatistics Sorbonne Paris Cite´, Paris Descartes University,Paris, France), R Devlieger (UZLeuven, Campus Gasthuis-berg, Department of Obstetrics and Gynecology, Leuven,Belgium), S Debonnet (International Confederation ofMidwives, 2517 AN The Hague, the Netherlands), T Duan(Shanghai No.1 Maternal & Infant Health Hospital, Shang-hai, China), C Hanson [International Federation of Gyne-cology & Obstetrics (FIGO), London, UK], J Hofmeyr(Department of Health, Effective Care Research Unit, Uni-versity of Fort Hare, East London, Eastern Cape, SouthAfrica), R Gonzalez Perez (Department of Maternal andGynaecological Health, Pontificia Universidad Catolica deChile, Santiago de Chile, Chile), A de Jonge (MidwiferyScience, AVAG and the EMGO Institute of Health andCare Research, VU University Medical Center, Amsterdam,the Netherlands), K Khan (Women’s Health Research Unit,Multi-disciplinary Evidence Synthesis Hub, The BlizardInstitute, London, UK), S Lansky (Ministry of Health, BeloHorizonte Minas Gerais, Brazil), G Lazdane (WHO Regio-nal Office for Europe, Copenhagen, Denmark), P Lumbig-anon (Department of Obstetrics and Gynecology, Facultyof Medicine, Khon Kaen University, Khon Kaen, Thailand),D Mackeen (Department of Obstetrics and Gynecology,Division of Maternal–Fetal Medicine, Geisimger HealthSystem, Danville, PA, USA), R Mahaini (WHO Office forthe Eastern Mediterranean Region, Cairo, Egypt), S Many-ame (Department of Obstetrics & Gynaecology, HarareHospital & University of Zimbabwe, Harare, Zimbabwe),M Mathai (Department of Maternal and Child Health,World Health Organization, Geneva, Switzerland), RMikolajczyk (ESME – Epidemiological and Statistical Meth-ods Research Group, Helmholtz Centre for InfectionResearch, Braunschweig, Germany), R Mori (Departmentof Health Policy, National Center for Child Health andDevelopment, Tokyo, Japan), B De Mucio (Latin AmericanCenter for Perinatology, Women and Reproductive Health(CLAP/WR), WHO Regional Office for the Americas,Montevideo, Uruguay), OT Oladapo (UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme ofResearch, Development and Research Training in HumanReproduction, Department of Reproductive Health andResearch, WHO, Geneva, Switzerland), E Ortiz-Panozo(Center for Population Health Research, National Instituteof Public Health, Cuernavaca, Mexico), L Ouedraogo(WHO Regional Office for Africa, Brazzaville, Congo), CParker (Obstetrics and Gyneacology Department, Baragw-anath Maternity Hospital, Johannesburg, South Africa), MRobson (National Maternity Hospital, Dublin, Ireland), SSerruya (Latin American Center for Perinatology, Womenand Reproductive Health (CLAP/WR), WHO RegionalOffice for the Americas, Montevideo, Uruguay), JP Souza[Department of Social Medicine, Ribeira˜o Preto MedicalSchool, University of Sa˜o Paulo, Ribeira˜o Preto (SP), Bra-zil], CY Spong (Deputy Director, Eunice Kennedy ShriverNational Institute of Child Health and Human Develop-ment National Institutes of Health, Bethesda, MD, USA),C Stanton (Johns Hopkins Bloomberg School of PublicHealth, Baltimore, MD, USA), ME Stanton (USAID, Wash-ington DC, USA), EA Sullivan (Faculty of Health, Univer-sity of Technology, Sydney, Australia), M Temmerman(UNDP-UNFPA-UNICEF-WHO-World Bank Special Pro-gramme of Research, Development and Research Trainingin Human Reproduction, Department of ReproductiveHealth and Research, WHO, Geneva, Switzerland), A Tita(Department of Obstetrics and Gynecology, Division ofMaternal–Fetal Medicine, University of Alabama at Bir-mingham, Birmingham, AL, USA), Ӧ Tuncalp (UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme669ª 2015 World Health Organization licensed by John Wiley & Sons Ltd on behalf ofRoyal College of Obstetricians and Gynaecologists.WHO Statement on Caesarean Sectionsof Research, Development and Research Training inHuman Reproduction, Department of Reproductive Healthand Research, WHO, Geneva, Switzerland), P Velebil (Peri-natal Center of the Institute for the Care of Mother andChild, Prague, Czech Republic), JP Vogel (UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme ofResearch, Development and Research Training in HumanReproduction, Department of Reproductive Health andResearch, WHO, Geneva, Switzerland), M Weber (WHORegional Office for Europe, Copenhagen, Denmark), DWojdyla (Duke Clinical Research Institute, Durham, NC,USA), J Ye (Ministry of Education–Shanghai Key Labora-tory of Children’s Environmental Health, Xinhua Hospital,Shanghai Jiao Tong University School of Medicine, Shang-hai, China), K Yunis (Department of Pediatrics & Adoles-cent, Medicine and Department of Pediatrics, AmericanUniversity of Beirut, Beirut, Lebanon), J Zamora (ClinicalBiostatistics Unit, Hospital Ramon y Cajal, Madrid, Spain),A Zongo (Research Institute for Development, UniversiteParis Descartes, Sorbonne Paris Cite, UMR 216, Paris,France and Direction de la sante de la famille, Ministere dela Sante, Ouagadougou, Burkina Faso)670 ª 2015 World Health Organization licensed by John Wiley & Sons Ltd on behalf ofRoyal College of Obstetricians and Gynaecologists.Betran et al.

WHO Statement on caesarean section rates

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WHO Statement on caesarean section rates

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