The International Cesarean Awareness Network (ICAN) has published its response to our press release with a statement that disappointingly demonstrates a lack of awareness and understanding in the specific area of cesarean delivery without medical indication.
It states that "While ICAN supports both updated research on this topic and an increase in patient education and autonomy, we maintain that many women who are choosing a cesarean are making that decision without full informed consent." I would argue that certainly the women who register at my website are informed (it lists hundreds of medical studies in risk-benefit categories), and I cannot imagine a patient-doctor consultation in which the risks associated with cesarean delivery are not presented to women. IN FACT, if you read the experiences of women who set out to have a planned vaginal delivery (PVD), it becomes clear that rather it is this birth group that is not always fully informed of the risks associated with PVD.
Inaccurate citation of risks
ICAN claims (in the context of cesarean delivery with no medical indication) that research shows an increased risks of "death, hysterectomy, blood clots, increased pain & recovery time, infection, and post-partum depression." And for the infant, additional risks of "respiratory problems, breastfeeding problems, asthma in childhood and type 1 diabetes." It also cites future risks of "infertility, ectopic pregnancy, placenta abnormality, uterine rupture, preterm birth, and stillbirth."
The overwhelming majority of this list is completely untrue in relation to healthy women planning a small family and delivering via cesarean at 39 weeks confirmed gestation (as recommended by ACOG and the NIH), as demonstrated in a growing number of medical studies. Many of the risks above are associated specifically with emergency cesarean delivery (the majority of which occur as an outcome of a PVD) or planned cesareans for medical reasons. They are not specifically relevant to cesareans with no medical indication and as such, should not be used as an argument against surgical autonomy.
The truth is that in 2004, the UK's NICE found that the only directly attributable increased maternal risks associated with an elective cesarean compared with PVD are abdominal pain and a longer hospital stay. There is still some debate over the link with asthma, so yes, women need to be aware of the potential risk, and also the risk of subsequent placenta complications with multiple pregnancies (although research to date includes first cesarean births that were emergency or planned medical surgeries and this of course adversely affects the final data).
Instead of referencing actual medical studies (as we have done in our press release and as I have done on my website), ICAN cites a 2004 book by the Maternity Center Association as its primary source of reference. Unfortunately, this does not help inform women (or indeed journalists) who are trying to better understand both sides of this argument unless they are expected to locate a copy of this book in order to examine the evidence. I think it would be more helpful if ICAN listed actual medical studies (with website links) so that women can go and read the evidence for themselves and make up their own minds about their relevance.
With regard to the risk of type 1 diabetes, ICAN does cite a specific reference, and this is very helpful because I can provide the link to it for readers to see here. You can then see that again, this study is flawed in relation to non-medical cesareans. Why? Because the study looked at all cesarean deliveries, and such a mixed body of data means that we cannot associate this risk with healthy pregnancies specifically. It is possible (as in so many other areas of reported cesarean risks) that maternal or obstetrical characteristics are more likely associated with the baby's health outcome than the delivery method itself.
It's not just an issue of 'fear of birth'
ICAN also states that it does "not believe that cesarean should be the typical solution for fear of childbirth. With appropriate counseling, most women who fear childbirth are comfortable attempting a vaginal birth. Most show long-term satisfaction with their decision to change modes of delivery, and with intensive therapy, labor times were shorter."
First of all, this statement misses the point that many women decide to have a planned cesarean in order to avoid the unpredictability of PVD and all the morbidity risks that are associated with it. For example, urinary and fecal incontinence, pelvic floor prolapse, perineal pain, instrumental delivery and emergency surgery following a prolonged labor. The prophylactic nature of cesarean delivery is often understated, largely because the risks associated with PVD are also understated.
Secondly, although ICAN cites two (2001 and 2006) studies as evidence of successful management of the fear of birth, I would also encourage women to read the studies below that report greater satisfaction in women who have a planned cesarean delivery than those who have a PVD. Remember - some women do not want their issues of 'fear' resolved; they simply prefer to accept the risks of one birth type over another.
*Elective caesarean delivery at maternal request: A preliminary study of motivations influencing women's decision-making. Robson et al, Australian and New Zealand Journal of Obstetrics and Gynaecology, Volume 48, Number 4, August 2008 , pp. 415-420(6). Australia.
*Cesarean section on maternal request: reasons for the request, self-estimated health, expectations, experience of birth and signs of depression among first-time mothers. Wiklund et al, Acta Obstet Gynecol Scand. 2007;86(4):451-6. Sweden.
*Psychologic effects of traumatic live deliveries. Pantlen and Rohde. Zentralbl Gynakol. 2001 Jan;123(1):42-7. Germany.
*An investigation of women's involvement in the decision to deliver by caesarean section. Graham et al. BJOG 1999, vol. 106, no3, pp. 213-220 (34 ref.). UK.
*Psychological Aspects of Emergency Cesarean Section. Ryding EL. Linköping University Medical Dissertations No. 576, 1998. Sweden.
*Women's involvement with the decision preceding their caesarean section and their degree of satisfaction. Mould et al. Br J Obstet Gynaecol. 1996 Nov;103(11):1074-7. UK.
*More in hope than expectation: a systematic review of women's expectations and experience of pain relief in labour. Lally et alBMC Medicine 2008, 6:7. doi:10.1186/1741-7015-6-7. UK.
Ethical and evidence-based autonomy
Finally, ICAN says it "will continue to work to improve maternal-child health and to protect a woman's right to ethical and evidence-based care during pregnancy and childbirth." As far back as 2003, an ACOG ethics committee stated that cesarean delivery on maternal request is medically ethical, and in 2006, the NIH concluded that there is sufficient evidence to support this birth decision following individualized consultation.
I have always understood ICAN's desire to reduce the number of unwanted cesareans, and I think it's important to encourage best-practice care to support women who want to deliver vaginally. However, its insistence on refusing to support wanted cesareans is extremely disappointing, and a stance I hope it is willing to review in the near future.