Thursday, October 30, 2008

ICAN's response to press release contains disappointing inaccuracies

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).

Weak references
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.


Anonymous said...

ICAN does offer a wonderful white paper on how to plan a family centered cesarean. You are fortunate to have easy access to OBs offering planned cesarean. Women who seek spontaneous vaginal delivery have fewer choices, which is why organizations like ICAN are growing. I live in SC where women travel to bordering states to see providers who support VBAC. Some who can't afford this stay home and deliver without the benefit of medical support. I'm glad you were able to plan and achieve the birth you wanted. I wish there was more medical support for spontaneous vaginal birth, especially for VBAC women. I don't like the way the media pits women against each other regarding birth. Each type of birth carries its own set of risks. It should be the pregnant woman who ultimately decides since she'll live with the outcome. Unfortunately, few providers support VBAC, leaving too many women without access to local medical care.

labortrials said...

There is compelling information readily accessible that fleshes out the numerous physical and emotional problems that can occur following cesareans. Additionally, cesarean birth does compromise the healthy function of the mother-baby dyad. It's not to say that women who have cesareans DON'T bond, don't breastfeed, etc., but certainly medicalized birth puts mother and baby individually and collectively at risk.

I willingly consented to a cesarean after being unable to push my baby out. I wasn't fully aware of the risks and complications that would plague me during the rest of my reproductive life and beyond. I had a mass of adenomyosis removed recently from above my cesarean scar. The surgeon said it was likely caused by the cesarean. Has that alone contributed to my recurrent pregnancy losses?

The fact of the matter is that women aren't encouraged to look at their reproductive LIFE when contemplating cesarean or vaginal birth. I wasn't too upset about my cesarean until I started thinking about having another baby. Now I realize that the cesarean has changed everything, possibly compromised my fertility, and has DEFINITELY limited MY CHOICES for the future. That super safe major surgery changed everything, compromises my future, and has potentially left me bankrupt.

cesarean debate said...

Anonymous - I really appreciate your more balanced view on this issue and in particular, your agreement that women should be able to decide individually on which set of risks and benefits are most acceptable to them.

I understand that women are finding it difficult to arrange a VBAC in some areas of the country, but the 'easy access' to cesarean delivery that you refer to is, I'm afraid, not true either. I am often contacted by women who are struggling to have their cesarean choice respected, and this is precisely why I don't think it serves anyone well for ICAN to be publicly criticizing their choice.

In fact, VBAC is associated with incontrovertible risks, and yet ICAN (and other groups like it) supports it as a legitimate birth choice. I therefore cannot understand ICAN's decision NOT to support another birth choice (cesarean delivery) on the grounds that there are risks involved.

There are risks associated with EVERY birth type, and while it is perfectly acceptable that different women will make different decisions based on these risks, I believe it is unhelpful and unethical for a national birth group to decide, on behalf of women, that only risks associated with vaginal birth (be they primary PVD or VBAC) should be supported.

cesarean debate said...

labortrials - I am very sorry that your birth experience and subsequent pregnancies have been so traumatic, and I deeply sympathize with everything you have gone through. I can completely understand why you feel so negatively about cesarean delivery.

With that in mind, I write my next words very tentatively; I hope that you are not offended by them, but rather see them as a proffered alternative perspective on birth experiences such as yours.

Have you ever considered what might have happened had you not had your first cesarean delivery? You say that you were 'unable to push' your baby out, and this is just one of the many reasons why emergency primary cesareans are performed. I'm sure you are aware of highly publicized cases in which a timely cesarean is not performed and the baby or mother are severely injured, or even worse, die.

I think that as a modern society, we have become so reliant on medical emergency care that there is sometimes a danger that we take it for granted - particularly in the case of childbirth. It is easy to forget that generations of women before us were all too aware of the possibility of death in childbirth, and today, we have a tendency to over-romanticize the process of giving birth.

You blame your 'super safe major surgery' for everything that has happened to you since your baby's birth, but nothing about childbirth is inherently 'safe' and it never has been. Your cesarean may have served no other purpose than to save your life or your baby's life on a day that (without access to a 24-hour operating theater) could have ended very differently.

So if indeed you did have an emergency cesarean, there are two main issues here in relation to criticizing women whose preference is planned cesarean delivery. First of all, an emergency cesarean is associated with far greater morbidity risks (both short- and long-term) than planned surgery, and secondly, it remains a fact that for some women, if they HAD to choose between one child delivered via cesarean or more than one child delivered vaginally, they would still choose a cesarean.

Now, let me stress that the latest research shows that subsequent stillbirth and infertility are NOT risks associated with planned cesarean delivery with no medical indication, but that said, I entirely agree with you that the decision to have a cesarean should involve consideration of future planned surgeries.

ACOG and the NIH recommend that only women planning small families should really consider cesarean delivery as a birth choice.