Vitamin D deficiency may make cesarean delivery more likely

Although quite a small study, this may be of interest to women who are trying to avoid needing a cesarean delivery. Researchers discovered that women with vitamin D levels less than 37.5 nmol/L were 3.8 times as likely to have a cesarean as women with levels greater than that.

Of 253 women, 43 (17%) had a primary cesarean, and the reasons for their cesareans included failure to progress, non-reassuring fetal tracing, malpresentation such as breech, a cephalopelvic disproportion, and variable fetal heart rate.

In addition, it was reported that caucasian women and those who reported any alcohol use during pregnancy were also more likely to have a cesarean. Other studies however, have found that women of other ethnicity are more likely to have a cesarean.

Ireland's cesarean rate has risen to 24.3%

An article in the Irish Times by medical correspondent Dr Muiris Houston reports that Ireland's cesarean rate in 2006 rose to 24.3%.

Here are some of the other facts he cites from the latest Economic and Social Research Institute (ESRI) perinatal statistics report:

*50.8% of multiple births were delivered by cesarean
*The average age of all mothers was 31 years
*The perinatal mortality rate was 7 per 1,000 live and stillbirths compared with 8.4 in 2002
*The number of stillbirths dropped from a rate of 5.6 per 1,000 to 4.7 over the same period
*An infant's length of stay in hospital decreased from an average of 3.9 days in 2002 to 3.7 days in 2006
*A mother's average total length of stay in hospital fell from 4.1 days in 2002 to 3.7 days in 2006

Necessary or Unnecessary cesarean - only hindsight makes the safest judgement call

My focus in these blogs is usually in relation to non-medical cesarean deliveries, and the legitimacy of informed, educated women making the decision to choose this birth plan. However, there seems to be so much negative reporting recently on the subject of unnecessary cesareans that I wanted to wanted to post my thoughts.

Firstly, I sympathize with the many angry and disappointed women for whom their preferred birth plan of vaginal delivery did not result in a vaginal delivery outcome. Unwanted cesareans are undoubtedly more difficult to recover from (at the very least from a psychological perspective) than wanted cesareans. I am also open to the possibility that there are cases of unwanted cesarean deliveries where - had early prophylactic surgery not occurred - the vaginal birth plan may well have had the outcome of a vaginal delivery without injury to the baby or mother.

But the question is - at what point precisely does an unnecessary cesarean become a necessary one? Listed below are examples of litigation cases (2008 updates to be added) in which it was concluded that a cesarean delivery should have been carried out/ sooner.

*06 Sep 07 Jury Awards Parent $13.5M In Malpractice Case ...Gardner's pregnancy was allowed to continue for 42 weeks, two weeks past her due date. Gardner and her lawyers claimed that when Nathaniel was born in 2002, the doctor failed to monitor him during the cesarean section procedure. They said Nathaniel was deprived of oxygen for up to 25 minutes, resulting in cerebral palsy... Broadlawns attorney David Brown said they will challenge the $13 million verdict.
*01 Sep 07 Doctor found guilty of misconduct A doctor has been found guilty of misconduct for trying to force a baby's delivery 12 times, as the mother begged for a caesarean. The baby boy died as Dr Avanti Patil delayed the operation and battled with forceps and suction cups. The young mother, known only as Miss A, had been in labour for 24 hours at Southend Hospital.
*31 Jul 07 MEC to pay after baby's death Gauteng MEC for Health Brian Hlongwa has agreed to pay R103 488 in damages to a Johannesburg couple who claimed their first child, a baby boy, died in his mother's womb while she was waiting for a caesarean section to be performed.
*25 Jul 07 Payout victory at last for boy A 10-year-old boy will be paid compensation running into millions of pounds after Swansea health bosses lost the right to appeal the claim. Jac Richards, who was left paralysed following a 10-minute delay in his caesarean delivery...
*18 Jul 07 Boy,14, £2.6m for injuries suffered at birth A 14-year-old boy left facing a lifetime of catastrophic disability by injuries suffered during his birth has won a £2.6m compensation deal at London's High Court. Callum Halliday, of Hunter's Chase, South Godstone, was born by caesarean section at East Surrey Hospital, Redhill, in May 1993. But oxygen starvation has left him a victim of quadriplegic cerebral palsy, confined to a wheelchair and totally dependent on others for all his care needs. His legal team argued that, had it not been for a negligent delay in his delivery, Callum would have escaped serious injury.
*06 Jul 07 Team 4: Family Awarded $23M In Malpractice Settlement ...The lawsuit said a fetal heart rate monitor showed significant abnormalities from the time Jordan was admitted to the hospital. Despite the problems, doctors allowed her to continue laboring for eight hours. Grady was delivered by cesarean section, limp and pale, with no heart rate... Grady suffers from cerebral palsy.
*30 Jun 07 Lifelong care girl sues hospital trust ...Writ: failed at 23.30 hours to proceed to emergency caesarean section... it should already have been clear that a caesarean operation was urgently needed.
*15 Jun 07 Minister sued for R5m Alleged: ignored nursing staff's requests to perform a caesarian section. The doctors and the minister have denied allegations of negligence. The case has not yet gone to court.
*11 Jun 07 Hospital accused in baby death Alleged: refused to call a doctor, agree to a caesarean delivery, administer painkillers or even a give her a glass of water... The inquest continues.
*08 Jun 07 Birth tragedy - mum ‘ignored' ...Her mother told an inquest she had not been offered a caesarian, which she would have agreed to.
*05 Jun 07 Woman in post-delivery stroke sues CHC, doctor Alleged: failing to recommend or perform a caesarian section...
*02 Jun 07 Air Force must pay $24.5M in baby delivery case ...eventually called in and performed surgery, finding the baby half extruded from Evelyn Tremain's uterus and into her abdominal cavity.
*13 Mar 07 Compensation for Caesarean delay A 10-year-old boy left disabled after a delay in his caesarean delivery has won the right to receive compensation. Jac Richards suffered oxygen starvation before his birth at Swansea's Singleton Hospital, causing brain damage. London's High Court ruled he would have escaped injury had he been delivered 10 minutes earlier, and guaranteed Jac, from Llanelli, full compensation.
*28 Feb 07 NHS Trust to pay out over birth error A Seaford mother whose child suffered devastating brain damage after the hospital refused to deliver him by caesarean is to receive massive compensation.
*27 Feb 07 Hospital sorry for blunder at birth A family whose baby suffered brain damage when doctors refused to deliver him by caesarean section is set to be paid millions of pounds in compensation. Alison Jones, 46, had asked for the caesarean for the birth of her fourth child, Ellis, after complications during her previous pregnancies. She feared a scar on her uterus could rupture and put the baby at risk. Hospital staff played down her worries and induced labour but the scar burst and Ellis received devastating brain injuries.
*19 Feb 07 £6.6m for boy, 15 injured at birth ...Ryan was starved of oxygen towards the end of his mother's labour, but the signs were not heeded and his delivery delayed. By the time he was born by emergency caesarean section, he had already suffered brain damage.
*08 Feb 07 'I'd rather have nothing and my baby boy back' Parents of a baby that died just days after being born have been given £32,000 in compensation... The tot was starved of oxygen and suffered 99% brain damage during his birth... A problem with his heartbeat had been spotted during labour - however, it was not acted upon and the baby was delivered normally about 3 hours later. The hospital has now admitted, though, that had it acted earlier - such as carrying out a Caesarian section - Jake would probably not have been brain damaged and died as a result.
*24 Jan 07 Illinois Medical Negligence Attorneys Represent Birth Injury Claim [Judge]: approved the $9,500,000 settlement of a medical negligence case... [doctors] failed to recognize the significance of changes in the fetal heart rate as evidenced on the fetal monitor strips... [The baby] was delivered by emergency caesarean section on October 24, 2001... she was diagnosed with severe cerebral palsy, spastic quadriplegia, and seizure disorder.
*13 Jan 07 Mother, child awarded $1.8 million for injuries during childbirth Virginia Beach: A child and his mother were awarded $1.8m... The lawsuit alleged that Uy failed to order a sonogram at 38 weeks of the pregnancy, failed to deliver the child by cesarean, failed to manage the mother's behavior during delivery, and failed to properly manage a problem during delivery. A problem with the shoulder obstructed Twan Johnson's birth and resulted in Uy gripping the baby's head and pulling during delivery. Defense attorney Dante Filetti said Friday that the case came down to the amount of force used by Uy during the birth.
*22 Dec 06 Couple sues doctor over baby's delivery Morgantown: A Kanawha County couple says their doctor caused injury during the birth of their child by using forceps... Complaint says: ‘As a direct result of the forceps, Plaintiff Stacy suffered permanent injuries requiring surgery which relieved but did not eliminate her injuries.'... No judge has been assigned the case yet.
*28 Nov 06 Brain-damaged girl to get £4million pay-out A girl left brain damaged after being starved of oxygen in the womb today won a compensation deal worth more than £4m and an apology from the NHS Trust who managed her birth. The Chesterfield girl, now aged 12... suffered hypoxia during her delivery at Chesterfield Royal Hospital in November 1994, and has been left with devastating cerebral palsy as a result. Through her parents, she sued Chesterfield and North Derbyshire Royal Hospital NHS Trust, claiming she should have been delivered by emergency CS and that staff negligently failed to heed warning signs that her position in the womb was irregular. The trust denied responsibility but, at London's High Court, agreed to pay damages on the basis of 96% of a full valuation of her claim.
*23 Nov 06 Why did my baby die A nurse claims a refusal by doctors to give her a cesarean in time lead to the death of her baby... She urged medical staff to give her a cesarean explaining her first child had been delivered that way because of complications. But doctors refused, told her to go home and wait for contractions. Two days... unable to feel the baby moving. She returned to the hospital and her baby girl was delivered by emergency cesarean... The child was put into a ventilator but died 2 days later.
*23 Nov 06 Why did my baby die Recent malpractice suit yielded $8m settlement: The child now lives with an intractable seizure disorder - seizures that cannot be controlled with medication... The hospital resident tasked with measuring the fetal heart rate encountered the baby's face in the birth canal. This revealed that a cesarean was indicated, as opposed to a vaginal birth. However, when she relayed this information to the attending physician, he summarily dismissed it, insisting upon delivering the baby ‘naturally.' As a result, the baby suffered facial abrasions due to his facial skin being stretched excessively while being forced down the birth canal face-first. Upon his delivery, it also became obvious that his neurological status was compromised by both the blunt force trauma of the delivery and the deprivation of oxygen.
*10 Nov 06 Couple speak of heartache During the labour hospital staff failed to act on signs of distress on a trace of Lucy's heart rate shortly after 5pm and, instead of arranging for Mrs Walker to undergo a cesarean as was appropriate, encouraged her to go to the hospital canteen... [The NHS Trust] has agreed to settle the claim out of court.
*02 Nov 06 Windsor boy, injured at birth, wins millions Hartford Superior Court jury: awarded a medical malpractice verdict of almost $2.6m to a 4-year-old Windsor boy who has permanent limitations on the use of his right arm due to injuries he suffered as he was born, according to the boy's lawyer. [In addition,] the jury awarded $108,000 to his mother... for the emotional distress she suffered... the lawsuit alleged that Anastasi made 2 mistakes during the April 2002 delivery: *He pulled on Omar's head about 6 times with a vacuum extractor. *Once Omar's head had emerged, his shoulders got stuck in the birth canal... [he] put his hand on Omar's cheekbone and pushed his head sideways in an effort to dislodge him - but used too much force... the jury found Anastasi negligent in his use of the vacuum extractor but didn't find unanimously that he should have performed a cesarean.
*15 Oct 06 Baby death mum to sue hospital Ms Rees: believes the hospital delayed the delivery and treatment of her son... ‘I was considered high-risk because of my age from the start. I believe I should have been monitored more closely and a cesarean should have been performed sooner.'
*13 Oct 06 Detroit: Monroe couple wins $15.8 million in malpractice suit Monroe couple won a $15.8m medical malpractice judgment... involving the birth of their son in 2001... Their lawyer, Brian McKeen of Detroit, said the boy suffered profound brain damage because doctors at Riverside Osteopathic Hospital in Trenton failed to perform a cesarean delivery after Julie Lowe encountered serious problems after going into labor in June 2001.
*30 Aug 06 Brain defect boy gets money, but what use is it? The NCDR forum has ordered the Cosmopolitan Hospital here and 2 doctors to pay Rs.1.1m ($24,300) to the parents of Chakkara... The first mistake took place when the senior gynecologist did not do an immediate cesarean... Geetha was left alone.
*28 Sep 06 Parents win stillborn twin case The parents of a baby boy who was stillborn after clinical negligence have won an out of court settlement... The couple maintained doctors should have performed a caesarean to help Joshua, who was a twin.
*26 Sep 06 Belleville OB sued for not performing emergency C-section
*27 Aug 06 Medical Negligence Case: Justice After 17 years A 17 year-long battle against medical negligence... hospital to pay a compensation of Rs 11.29 lakhs to a couple for causing permanent mental retardation to their son right from his birth in 1989... The commission said the doctors should have gone in for cesarean when there were clear indications of distress to foetus.
*12 Aug 06 Docs get blame for tot death Doctors were yesterday blamed by a coroner for being too slow helping a mother whose child died after she had difficulties during labour... for delaying a caesarean...
*06 Aug 06 Delhi hospital fined for death of baby in womb Finding a Delhi-based hospital guilty of ‘gross medical negligence', a city consumer court has asked it to pay Rs 75,000 as compensation to a woman whose baby died in the womb as the doctors did not opt for cesarean mode of delivery.
*24 May 06 'Breach of duty' in childbirth death Her family claimed she was not seen by a consultant obstetrician for several crucial hours. They argued the medical team should have delivered the baby by emergency caesarean once it was realised Miss Price was in danger of losing her life.
*13 Apr 06 Hospital settles childbirth case A $5m settlement was reached... a Skokie family whose 6-year-old son was born with brain damage at Evanston Hospital in July 1999... Proceeds of the settlement will pay for the care of the boy, who suffers from cerebral palsy.
*03 Apr 06 Brain damage boy, 6, awarded £3m Tzar Stevens Macmillean suffers from severe cerebral palsy caused by a lack of oxygen during his birth at St Mary's Hospital, Manchester, in June 1999.
*18 Mar 06 Award against naval hospital reduced A Fort Lauderdale federal judge...reduced his own verdict in a negligence case against a naval hospital by $20m. But at more than $40m, the judgment still could be the largest personal injury award against the federal government... The judge ruled that doctors and nurses at Jacksonville Naval Hospital waited hours too long to perform a cesarean... As a result, Kevin Rodriguez was born ‘with no heart rate, no respirations, no muscle tone and no muscle reflex.'
*13 Mar 06 Court awards mother compensation A Ballymena woman who was left acutely brain damaged after giving birth in a London hospital has been awarded £500,000 by the High Court... alleged staff were negligent because a caesarean birth was not carried out after his wife developed complications.
*02 Mar 06 Settlement Reached Over C-Section Lawsuit [The woman] was in labor for 27 hours before the decision was made to perform a cesarean.
*05 Oct 02 Mom awarded $8.5 million, Hospital botched son's birth He got stuck in the birth canal for three minutes and was deprived of oxygen. As a result, the baby, Yakeim Donald, was born with severe brain damage. Now 4, he has been diagnosed with cerebral palsy. He cannot speak or walk.

Consider this: it may indeed be possible to reduce the elective cesarean rates in many hospitals, but how many of these will become emergency cesareans instead (which are associated with greater morbidity and mortality risks), and how many will result in injury or death? In fact, the numbers may actually be very small, but for the doctor, midwife and family who are affected by severe complications, that number quickly becomes 100% - because it's happening to them.

Consider too, the implications for birth costs: Planned cesarean deliveries are often criticized for being too costly, but a UK report in 2000 illustrated just how much planned vaginal deliveries cost the NHS when litigation is taken into account: "as much as £50m a year"
*13 Jun 00 An organisation with a memory, Department of Health authored report Every year approximately 50% of the NHS litigation bill relates to claims arising from brain damaged babies. Target set: Negligent harm in obstetrics and gynaecology to be reduced 25% by 2005. It has been estimated that that this could save as much as £50m a year.

And in Los Angeles:
*26 Jan 98 Antonovich ‘shocked' at caesarian policy - calls for investigation
Los Angeles County supervisor: ‘The result of a vaginal birth theory was babies being born deformed, retarded, and in a few cases, dead. In an effort to save money by avoiding cesareans, we cost the taxpayers about $24m so far.'

Medical intervention halves incidence of brain-damaged babies

A new report by Lisa Hitchen, and published in the BMJ, says that following the 2000 introduction of mandatory annual training for all staff at the maternity unit at North Bristol NHS Trust, deaths and brain damage among newborn babies have fallen considerably.

Between January 1998 and December 1999, 27.3 infants per 10,000 births were born with brain damage, and 86.6 infants per 1000 births needed resuscitation at birth. But after the introduction of the new surveillance methods (between January 2001 and December 2003) these rates were halved.

Staff are trained in "the interpretation of electronic fetal monitoring" and must complete "forms for reporting the number of infants that needed resuscitation at birth and the incidence of severe hypoxic-ischaemic encephalopathy". The hospital also developed "a surveillance system to detect periods when standards slipped."

Special note: In the abstract available on 12th December, it reads that the number of babies born with brain damage fell from 27.3 infants per 10,000 to 13.6 per 1,000 births. Clearly, one of these 'per 1,000/10,000' is a misprint, since the number is said to have halved.

Must-see video discussing elective cesarean delivery

I was sent this link to a TV discussion on an Australian Channel Nine program titled 'The cesarean debate'. In it, Dr Kerryn Phelps discusses why women are increasingly opting for cesarean births in Australia, but what's great about it is that it touches on many of the issues I talk about in my blog.

For example, women being allowed to choose whichever birth they want, including planned cesarean delivery, and discouraging criticism of each other for the birth plans we choose. I don't agree with absolutely everything that is said, but on the whole, this is a very refreshing discussion to see being aired on TV, particularly in a country where the rate of elective cesareans is being heavily scrutinized just now. Watch it if you can.

Non-medical cesarean delivery should wait until 39 weeks EGA

This is not new news, but today's Science Daily report on new research into the risks of late pre-term births is a useful reminder that the safest time to deliver a baby by cesarean delivery is at confirmed 39 weeks gestation in order to ensure that the baby is fully developed.

I have no doubt that this research will be misinterpreted by some bloggers and used to criticize women who choose to have a cesarean delivery with no medical indication. But on the contrary, what it actually shows is that non-medical cesareans at 39 weeks are in fact far safer for the baby than other types of cesarean deliveries (i.e. emergency and planned medical surgeries).

What the research found
Petrini et al's research, 'Increased Risk of Adverse Neurological Development for Late Preterm Infants', "evaluated the babies’ neurological development and found that late preterm babies were more than three times as likely to be diagnosed with cerebral palsy as full term babies. They also found that late preterm babies were at an increased risk for developmental delay or mental retardation."

But commenting in the article, editorialist Dr. Michael Kramer of McGill University said that "the increased risks may not always come from early delivery itself, but from other underlying problems, such as gestational diabetes, that may lead to early delivery."

This last remark emphasizes why 'general' reported risks associated with cesarean deliveries are not always applicable to planned cesarean deliveries with no medical indication in healthy pregnancies, and should not be used as an argument to prevent birth plan autonomy.

Shocking cesarean controversy in Turkey

In a December 2nd article on Today's Zaman website, reporter Ayse Karabat writes about a shocking policy on cesarean delivery in Turkey, and one that disturbingly echoes some of the calls for cesarean delivery restriction in countries like the UK, U.S. and Australia.

The report says that Turkey's Ministry of Health wants to reduce its cesarean rate from 42.5% to 25% by restricting cesarean deliveries only to those who medically need them.

In a statement issued this year, it declared that from Sept. 1, the number of cesareans at a health institution "will be taken into consideration when calculating the performance of hospitals. Pursuant to this statement, [cesareans] should be no more that 20% of all births in research and training hospitals and no more than 15% for other hospitals. If the [cesareans] in a hospital are higher than these levels, hospital funding and staff pay will be cut."

You may remember our press release back in October 2008, when the Coalition for Childbirth Autonomy warned of the dangers of forcibly or artificially reducing a nation's cesarean rate to the outdated level recommended by WHO in 1985. Well, perhaps the shocking practices now taking place in Turkey might be a lesson to other government health strategists:

UNETHICAL, FALSE ECONOMY and ultimately UNSUCCESSFUL approach
Comments by doctors working in the obstetric field highlight many of the points I have made in the past about the repercussions of reducing cesarean deliveries simply in order to achieve a 'magic number' - rather than making the best decision in each individual case.

Avoidable mortality and morbidity with PVD costs more than CS
*The news report states that "since the implementation of this program, doctors have been discussing the subject. Some are claiming that the money which is being spent to deal with complications resulting from normal births is higher than the expenditure" for cesarean deliveries.
Critical health care decisions belong in the room the birth takes place
*"Doctors are critical of the program from the Ministry of Health, claiming that decisions regarding [cesareans] can be taken only by doctors and to question it is unethical."
Litigation pressure and costs should not be ignored or underestimated
*"Professor Turgay Şener, the chairman of the Turkish Perinatology Association, has said any directions from the Ministry of Health will not be useful in reducing the amount of [cesareans]. "Restrictions can lead to disagreements between doctors and patients. If there is even a small problem, the patient will ask the question if it was because of the normal birth."
Enhanced health outcomes are missed when a valid delivery route is avoided
*"The doctors will feel pressured and will choose normal births in some cases where cesarean sections are better," [Professor Şener] underlined.
Financial reward (or fear of financial loss) influences doctors' decisions
*"Turkish Gynecology and Obstetric Association Chairman Bülent Tıraş has suggested that the number of [cesareans] will affect the performance of the whole of the hospital and have an impact on other doctors' pay, so this may put pressure on gynecologists to choose normal births."

Does all this really help women and their babies?
No, of course not. It's interesting to read though, that Turkey's strategy uses the slogan: "Every pregnant woman should be given the chance to give birth naturally." I think it would make a lot more sense, save a lot more lives, and avoid a lot more birth injuries if Turkey altered its slogan to this one:

"Every pregnant woman should be given the chance to give birth in the way she chooses to."

And if the woman doesn't have a particular choice one way or the other (some don't), then it should be a case of providing the best possible health care on the day of the birth, regardless of how that birth outcome might affect a table of statistics on a desk somewhere in the hospital.

Study: a quarter of female OBGYNs prefer and suggest cesarean delivery

New research from Iran, 'Caesarean or normal vaginal delivery: overview of physicians' self-preference and suggestion to patients' has found a correlation between a physician's self-preferred mode of delivery and the mode of delivery they suggest to their patients.

Hantoushzadeh et al sent questionnaires to 1,000 female obstetricians and gynaecologists practicing in Tehran in the winter of 2007. They were asked their preferred mode of delivery and the mode they suggest when being consulted by parturient. 785 cases (78.5%) responded to the survey, with 60.8% in favor of suggesting normal vaginal delivery, 25.8%, cesarean section, and 13.6%, painless vaginal delivery.

The study conclusions
The authors clearly have concerns about the 25.8% figure above: "Physicians normally suggest to their patients as the safe mode of delivery what they prefer for themselves. This preference and subsequent suggestion is influenced by different factors including their age, marital status, and previous modes of delivery. As conclusion, it is inferred that informing a physician to choose the right mode of delivery for herself leads to better suggestions to the patients."

What the conclusion says, in effect, is that we not only need to educate women that planned vaginal delivery is a "better suggestion" than planned cesarean delivery, but we also need to tell obstetricians and gynecologists (who are surely sufficiently educated and 'informed' in the subject of birth risks and benefits) what's "better" for them personally too.

Please - It is one thing to argue that ordinary pregnant women are incapable of TRULY understanding the risks involved in a planned cesarean delivery or of coming to terms with the complexities of birth method comparisons (which incidentally, I disagree with), but to imply that OBGYNs are not capable of making their own informed decisions is ludicrous.

Ethical considerations
What I find most interesting about this study is the link between a health worker's personal preferred delivery method and what they suggest to others. I am sure that this element of the survey will illicit stern criticism from groups who are already concerned that physician pressure is one of the factors behind unwanted cesareans.

However, while I would agree that physicians should not coerce healthy women into choosing a birth that is not what they really want, I would also point out that this preference/suggestion behavior is not exclusive to doctors or for that matter, cesareans. I receive emails from many women who are under unwanted pressure to plan a vaginal delivery from their midwife or doctor (when their own preferred mode of delivery is a cesarean) , and this is not ethical either.

Different women want different births. Doctors and midwives should be trying to accommodate ALL women's different birth preferences rather than pressuring them into mirroring their own personal preferences.

Midwives report a 32.2% cesarean rate in Switzerland

I haven't been able to locate the official national data to confirm the data in this December 4th news story, but according to the report, the Swiss Midwives Association are calling for "more controls... to counter the rising number of caesarean births".

The Association advises that "Doctors should only recommend a caesarean for medical reasons, as the operation confers more risk than a normal birth and has an impact on the health of the baby and the mother". It says: "Twice as many children born by caesarean are transferred to intensive care with breathing problems, compared with naturally born babies." And: "Twice as many mothers also have to return to hospital for treatment after a caesarean and many have problems breastfeeding... They are also more likely to have serious complications in later pregnancies."

Of course anyone who's read my blog or website will know that the NICU transfer risk for babies is largely associated with premature or emergency cesarean deliveries - not deliveries at 39 gestational weeks. Similarly, the complications cited above for the mother are more greatly associated with emergency surgery and/or pre-existing medical conditions that led to a planned cesarean.

Asthma has NOT been specifically linked with non-medical cesareans

Virtually every media outlet has reported on the latest study from researchers in the Netherlands, 'Asthma at 8 years of age in children born by cesarean section', in which Roduit et al found an increased prevalence of asthma in children who were born via cesarean delivery. Before I talk about the research itself, I'd just like to point out the biggest misunderstanding of the findings by some reporters. Here is an example:

On December 2nd, Angus Howarth, writing in The Scotsman, began his report with the sentence: "WOMEN who choose to give birth by Caesarean section should be warned it could almost double their baby's chance of developing asthma, researchers said today."

In fact it is ALL pregnant women that should be warned of the risk, including those who choose to give birth vaginally. Why? Because the researchers looked at children born via ALL TYPES of cesarean delivery (e.g. emergency, medical and non-medical), and therefore the risk is actually applicable to all birth methods.

Limitations of the research
The best place to read a more balanced review of this research is here, at the NHS' Behind the headlines website. It reports that: "The study has some limitations, including the broad method it used to diagnose asthma which may not be accurate. In addition, the researchers did not consider several factors known to raise the risk of asthma such as smoking in pregnancy. Further research is needed. Asthma has a range of potential risk factors, both genetic and environmental, but it is unlikely that its sole ‘cause’ is mothers having a caesarean section."

Previous research has found NO LINK between childhood asthma and cesarean delivery
*In 2005, researchers in the U.S., Juhn et al, published 'Mode of delivery at birth and development of asthma: a population-based cohort study.' They followed all children born in Rochester, Minn, between 1976 and 1982, determining the mode of delivery from their birth certificates, and asthma status during the first 7 years of life was ascertained from comprehensive medical record reviews. They found that: "The cumulative incidence rates of asthma among children who were born by cesarean section and vaginal delivery were 3.2% versus 2.6%, 4.6% versus 4.6%, 4.6% versus 5.8%, and 5.7% versus 6.7% at the 1st, 3rd, 5th, and 7th years of life, respectively. The adjusted hazard ratios for cesarean section in predicting asthma and wheezing episode were 0.93 and 0.93 respectively." They concluded: "Mode of delivery is not associated with subsequent risk of developing childhood asthma or wheezing episodes. Because the effect of mode of delivery on a risk of developing asthma or wheezing episodes varies over time (ie, age), selection of the study subjects according to their ages may have influenced the findings of previous studies with a shorter follow-up period."

*In 2004, researchers in the UK, Maitra et al, published 'Mode of delivery is not associated with asthma or atopy in childhood.' The study selected 12,367 children born to mothers resident in a defined area and delivered in one of two major obstetric hospitals between 1991 and 1992, of which 10,980 (88.8%) were delivered vaginally and 1387 (11.2%) by caesarean section. Primary outcomes were parental report of asthma or wheezing between 69 and 81 months of age, physician-diagnosed asthma (PDA) at 91 months of age and atopy at 7 years by skin prick testing. They concluded: "Delivery by caesarean section was not associated with the subsequent development of asthma, wheezing or atopy in later childhood in this population."

But what about the recent Norwegian study that DID find a cesarean/asthma link?
It is true that earlier this year, that in another study, 'Cesarean Section and Risk of Severe Childhood Asthma: A Population-Based Cohort Study', researchers Tollånes et al "found a moderately increased risk of asthma in the children delivered by CS." However, they also write in their conclusion that: "The possibly stronger association with emergency CS compared with planned CS could be worth pursuing to investigate possible causal mechanisms."

Why? Because in their study of 1,756,700 children born between 1967 and 1998 and followed up to age 18 years or the year 2002, those born via emergency cesarean delivery had the greatest risk of asthma. "The prevalence of asthma was 2.3% in the women who delivered by CS, 1.9% in those who had instrumental vaginal delivery, and 1.4% in those who had spontaneous vaginal delivery." This clearly demonstrates (given that the majority of emergency cesareans occur as an outcome of planned vaginal delivery) that healthy women planning cesarean deliveries should not be 'warned' about the risk of asthma any more than other pregnant women.

What else should I know about this latest study from the Netherlands?
The points below are taken from the NHS Knowledge Service's conclusions:
*Asthma is always difficult to diagnose in children. The criteria for diagnosing asthma in this study were broad, and likely to introduce some inaccuracy in the numbers categorised as having asthma. The wheezing and shortness of breath recorded in this study do not necessarily mean that the child has asthma, as they are extremely common in childhood and particularly during viral infections.
*Researchers adjusted their analysis for risk factors related to asthma but several known risk factors were not adjusted for. These include childhood viral infections, smoking during pregnancy and around the child, and number of people living in the house. As highlighted by the results, parental allergy did have considerable effect upon risk estimates.
*The proportions of children born by caesarean section, or who had asthma were relatively small (8.5 and 12.4% respectively), which reduces the power of statistical tests, particularly in the further analysis of subgroups that was conducted.
*Only 70% of children who were included at the beginning of the study completed the eight year follow up and were included in the analysis. The reliability of the results may have been greater had more children completed follow up.
*Women have caesarean sections for many different reasons, including emergencies. The reasons behind having a caesarean delivery may be an important factor in why asthma develops. Possible reasons for any association between childhood asthma and caesarean section have not been clarified by this study and still require further research.

Background info on the Dutch study: 2,917 children participated in a birth cohort study and were followed for 8 years. In total, 12.4% (362) of the children had asthma at the age of 8 years. Cesarean section, with a total prevalence of 8.5%, was associated with an increased risk of asthma, and this association was stronger among predisposed children (with one or more allergic parents) than in children with non-allergic parents. The association between cesarean section and sensitization at the age of 8 years was significant only in children of non-allergic parents.