Searching for a benchmark for cesarean section rates: Let's not forget the healthy mother

The 1985 World Health Organization statement "There is no justification for any region to have caesarean section (CS) rates higher than 10–15%" has been revisited several times over the last 25 years. Recently Betran et al. again found that 15% was a marker below which there is a correlation with increased maternal mortality and perinatal mortality but above which “risks to reproductive health outcomes may begin to outweigh benefits.” Developed globally, these rates apply to all women whether or not they live in high and low resource countries or whether or not they have high or low risk pregnancies. In high resource countries the rates are over-inflated; in low resource countries, caesareans are not acceptably accessible.

Pregnancy and birth are normal bodily functions. Yet in a prosperous country, where nutrition and life style should provide adequately for all to “go well,” hospital caesarean rates in the U.S. have soared to over 30%, -- twice the recommended upper limit set by the WHO. With recent analyses that demonstrate a higher neonatal mortality among women who have caesareans in the absence of labour complications and other labour/delivery procedures, we sought a benchmark for low risk women in a high resource country. We sought low risk women in settings where we could be assured that caesarean section is not tied to business endeavours , liability, or hospital policy. Out-of-hospital-birth studies were the most reliable to establish a benchmark for caesarean section that is safe with respect to perinatal mortality. It is between 2-7%.