Monday, October 13, 2008

Understand the facts

Vaginal delivery - GOOD
Cesarean delivery - BAD
Emergency cesarean - REALLY BAD
Elective cesarean - BETTER (BUT STILL BAD)

Broadly speaking, this is the way choice in childbirth is often portrayed - both in the media and in the majority of antenatal literature. A simple guideline to be ignored at your own peril, and more importantly, that of your unborn child. Except it's really not that simple. In fact, the truth is far more complex, and as difficult to retrieve from existing national data, hospital records and medical research as a Voldemort-encrypted horcrux.

Why? Largely because of two main problems in the collection, recording and reporting of birth data (there are actually numerous problems but let's start with the worst offenders).

1) In many hospitals (and consequently any medical research that relies on the data contained therein), little or no distinction is made between planned cesarean and emergency cesarean outcomes. This means that any risk appraisal of planned cesarean delivery is muddied by the morbidity outcomes associated with emergency surgery. Furthermore, no distinction is made between the outcomes of a planned cesarean for medical reasons and a planned cesarean with no medical indication (e.g. maternal request). This is important to recognize, as the presence of any pre-existing medical condition could lead to worse morbidity outcomes than those experienced by a healthy pregnant woman and her baby.

2) There is a huge difference between analyzing birth plans and birth outcomes, and since it is IMPOSSIBLE TO PREDICT any birth outcome, all analysis for the purposes of informing pregnant women (i.e. while they are in the birth planning stage) should compare infant and maternal morbidity and mortality outcomes as they relate to the original birth plan - rather than the eventual birth outcome. Let me explain...

A planned vaginal delivery (PVD) may have the outcome of a spontaneous vaginal delivery with no tearing, episiotomy or intervention, and no adverse health outcomes for mother and baby... or it may not. The outcome could be an assisted vaginal delivery (forceps, ventouse, episiotomy or all three), an emergency cesarean delivery (possibly following a forceps/ventouse/episiotomy attempts) or even a planned cesarean delivery decided in the very late stages of pregnancy. Similarly, a planned cesarean may have the outcome of a planned cesarean... or it could result in a spontaneous (or assisted) vaginal delivery or an emergency cesarean delivery.

What's important to note here is that planned cesarean deliveries result in the desired outcome far more often than planned vaginal deliveries. So, when comparing elective cesarean delivery with PVD for the purposes of informing healthy women of the risks and benefits of each, it is at best ineffective and at worst, misleading to only measure the successful outcome morbidity and mortality rates of each. In fact, the vast majority of emergency cesarean deliveries (which are associated with the greatest incidence of infant and maternal morbidity and mortality) are the consequence of an unsuccessful PVD attempt. Therefore, these outcome measures should be attached to PVD data prior to comparison with elective cesarean delivery - and for an even greater degree of accuracy, the elective cesarean delivery outcome measures should be separated into those with medical and non-medical indications.

In my view, research and analysis combining elective and emergency cesarean outcomes should be eliminated from all future studies that set out to compare PVD with planned cesarean delivery.

Advocates of cesarean delivery with no medical indication as a legitimate choice for pregnant women (myself included) have already looked at the data available and been able to deduce what's been suspected for a long time - that the risks and benefits associated with elective cesarean delivery are favorably comparable with those of PVD (there'll be more detail on this in future blogs, but you can check out if you want to read more now), and women should be advised of this during antenatal appointments.


The most successful birth outcome is that of a healthy and happy mother and baby, and in survey after survey, women cite satisfaction with their birth outcome as a valued psychological benefit. For some women that outcome is vaginal delivery while for others it is cesarean delivery; arguing the case 'vaginal delivery for all' is as ignorant and damaging as suggesting 'cesarean delivery for all.' Here's why:


...there are risks and benefits with every possible birth plan choice
...but ultimately, it's the woman, her baby and her family who experience the birth outcome
...and they might simply fear or value one set of risks and benefits more than the other.

We're already delivering more healthy babies than at any time in human history


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