Caesarean section: the paradox

In todays Lancet Carine Ronsmans and colleagues present strong evidence for inequalities in access to caesarean sections in developing countries. Their thorough analysis of data from Demographic and Health Surveys in 42 low-income and middle-income countries comparing caesarean section rates in quintiles of wealth showed that women of low income received significantly fewer interventions compared with the highest. However fewer caesarean sections do not necessarily mean lower health-care quality. The appropriate range for the caesarean section rate in a country remains a matter of debate. The recommended lower limit ranges from a minimum of 1% to an optimum target of 5% to avoid death and severe morbidity in the mother. Although these figures are good estimates based on complication rates in the mother and on historical data whether the frequency of intervention is enough to prevent avoidable perinatal deaths is unknown. The best known recommended upper limit is 15% suggested by WHO. (excerpt)