Is a 6.7% cesarean section rate significantly different from 5% for low-risk women in the years 2001-2003?

Abstract

Sir, I would like to comment on the recent article by Nesheim et al., which proposed to compare the need for emergency cesarean section (CS) in a hospital unit for low-risk women to a higher risk hospital unit (1). Both Norwegian hospitals deserve a hearty commendation for achieving 5–6.7% CS rates for low-risk women in the years 2001–2003; since during the same time period, hospital section rates for the same criteria of low-risk women, in an environment also staffed by midwives, were 12% in Israel (2). Both Norwegian hospitals are producing rates comparable to the 5, 6 and 7% CS rates reported among low-risk women who planned homebirths versus 8, 15 and 11% rates among low-risk women who planned hospital births with the same midwives in Canada (3-5). Hospital emergency CS rates for low-risk US women during those years have not been studied; however, are probably over 12%, extrapolating from the primary cesarean rates of 17 (2001) and 19% (2003) (6) minus the known 5.5% (2001) US primary cesarean rate reported in no-risk pregnancies with no complications of labor or delivery (7). The article lacks a comparison of how the two maternity units manage labor, that is whether either or both hospitals provided one-on-one attention, continuous fetal monitoring, the percentage of epidural use and if either or both use high-dose oxytocin along with epidurals or only low-dose oxytocin protocols, which is known to increase section rates. The article lacks a description of protocols for labor augmentation, dilation necessary to be admitted in labor, the number of hours a woman is allowed to labor or push before section is resorted to. Since 50–70% of emergency CS is due to ‘dystocia’ (8), it is critical to define those criteria for each unit in order to draw a meaningful conclusion. Both 6.7 and 5% are admirable hospital CS rates in the time period studied and not ones that are interesting to compare unless you compare management protocols.