New Canadian research: planned cesareans are safer for babies than natural birth

How much media attention has this study received? As far as I can see online, none.

Yet the conclusions of researchers Leanne S. Dahlgren et al, just published in 'Caesarean Section on Maternal Request: Risks and Benefits in Healthy Nulliparous Women and Their Infants', are of huge importance in the debate over whether women should be offered the option of planned cesarean delivery in favor of a trial of labor.

They found that, after looking at 1,046 pre-labour cesareans deliveries (with breech presentation)and 38,021 spontaneous labour with anticipated vaginal deliveries:

"An elective pre-labour Caesarean section in a nulliparous woman at term has a lower risk of life-threatening neonatal morbidity than spontaneous labour with an anticipated vaginal delivery."

Unpredictability of planned vaginal delivery is evident
The researchers point out that "the increased risk of life-threatening neonatal morbidity in the spontaneous labour group was associated with an operative vaginal delivery or emergency intrapartum Caesarean section and not a spontaneous vaginal
delivery', and this doesn't surprise me in the least.

But the fact remains that is is extremely difficult, if not indeed impossible, to predict precisely which women will have a spontaneous vaginal delivery outcome with no complications.

More than a third of PVDs did not result in spontaneous VDs
In this particular study, 63% of women with achieved a spontaneous vaginal delivery, and the researchers conclude therefore that these women "would not have benefited from delivery by Caesarean section."

But they too admit the difficulty in isolating these cases at the birth planning stage: "Further research is needed to better identify women with an increased likelihood of an operative vaginal or intrapartum Caesarean section, as this may assist maternity caregivers in decision-making about childbirth."

WHO admits: There is no evidence for recommending a 10-15% caesarean limit

This is the latest press release from the Coalition for Childbirth Autonomy (CCA), one year after it officially called on the World Health Organization to provide evidence for its recommended 15% limit:

WHO admits: There is no evidence for recommending a 10-15% caesarean limit

NCT choice focuses on WHERE, not HOW women give birth

This article in The Guardian reports on the latest report from the NCT about women's birth choices. The NCT is upset that women are not being given the choice about where they give birth, although its figures are disputed by the Department of Health in the article.

What concerns me though, is the NCT's focus on the word 'where' rather than 'how.' Surely 'how' a woman gives birth is just as important in terms of her access to choice??

NCT ignores many women
When will women who request cesarean deliveries (and percentage-wise, there are many more of them than there are women who request a homebirth) get the same attention (or even any attention) from the NCT?

Soon I hope, because if it truly believes in choice and access to choice, it cannot continue to ignore the women who make the valid decision to give birth via cesarean delivery.

Cesarean rate in England remains the same at 24.6%

The interesting thing about this newly published data is that it shows a breakdown of all emergency and elective cesareans in various hospitals around the country.

In its coverage, the Guardian has published the byline: 'Section delivery accounts for third of Chelsea and Westminster trust babies, indicating 'too posh to push' outlook persists'.

Private patients

It continues: 'The figures, from the NHS Information Centre, show that a third of babies born at London's Chelsea and Westminster NHS trust are delivered by caesarean section, a figure more than double that in Nottingham, suggesting the rates for the procedure in England could still be influenced by well-off women dubbed "too posh to push".

The Chelsea and Westminster trust, which tops the league at 33.3% of births by caesarean, said that its numbers were swollen by women giving birth in its private delivery wing.'

Reasons behind the rates

I think that there are a number of reasons for the differences in percentages of surgery in different hospitals - particularly with elective cesareans. I already know from the women I receive emails from that it is much, much harder to arrange an elective cesarean with no medical indication outside of the London area. It has also been shown in research that it tends to be more affluent and educated women who request cesareans, so it is indeed possible that these women are affecting rates in certain hospitals.

The other reason, in my opinion, is the attitude of the doctors working in the hospitals. I don't believe that all doctors in the UK are on board with the drive to reduce cesarean rates, and I also know from conversations 'off-the-record' that some of them support cesarean delivery on maternal request, but do so quietly in order to avoid criticism from their NHS Trust.

Postcode lottery

Finally, medical reasons for cesareans aside, and again, particularly in the case of elective cesareans, the differences in rates published today highlights the fact that arranging a cesarean in the NHS is very much a postcode lottery for the women who request it.

There are those lucky enough to find the support they're looking for, and there are those who are being caught up in efforts to reduce cesarean rates - whatever the psychological or physical health costs may be.

Dr Michel Odent blames fathers for cesareans now

I've never been a great fan of the opinions of Dr Michel Odent, and his particular preoccupation with the role of (the hormone) oxytocin during birth, and his latest suggestion, that men should 'stay away from childbirth' in order to help women, simply confirms my belief that he is out of touch with what pregnant women actually want.

You can read the full story in The Telegraph today, in which he is quoted as saying:

The 'tensions caused by the presence of men at birth could lead to more adrenalin, slowing the production of the hormone oxytocin, which assists effective contractions, making labour longer and more painful and increasing the chance of a caesarean section.'

'Mum dies of swine flu after her planned cesarean

The Mirror reported yesterday on the news of a 'Mum killed by swine flu after planned caesarean birth'.

It reports: 'The woman, 21, from Monmouthshire was admitted to hospital in Abergavenny for a planned caesarean but her condition deteriorated after she safely gave birth. She was transferred to intensive care and later to a specialist unit in Leicester where she died last week.

'Another women, 43, from Carmarthenshire, also succumbed to the disease but was said to have underlying health problems. The latest cases bring the number of swine flu-related deaths in Wales to three, although another death is being investigated.'

Infection risk
Infection following surgery is an undisputed risk with a planned cesarean. Other cases of infections have been reported too, such as the risk of contracting MRSA after giving birth in hospital. But the risk exists with both planned surgery and emergency surgery, and since emergency mostly occurs after a trial of labor, it means that post-surgery infection is a risk associated with a planned vaginal delivery too.

£7.1m payout for 10-year-old boy whose cesarean delivery was delayed

A BBC article today, 'Brain damage boy gets £7m payout', reports on a '10-year-old Oxfordshire boy who suffered severe brain damage at birth... [His] lawyers said he was delivered by Caesarean section, in February 1999, four hours later than he should have been after his heart rate had slowed.'

It continues, 'Harry Snowdon, from Witney, will always need 24-hour care after being starved of oxygen at Oxford's John Radcliffe Hospital...'

How many more babies will die in the UK like this?

I find stories like this one, 'Couple compensated for baby death', published today on the BBC News website, so distressing, and they make me so angry that mistakes like this can happen in a UK hospital in 2009.

According to the report, Ms Rees, 44-years-old at the time of the birth, was '32 weeks into a "high risk" pregnancy [and] told by a doctor she was not in labour but needed a toilet.'

Previously told that her breech baby would need a cesarean delivery
'She said: "I just couldn't understand why they weren't doing anything to help me and my baby. At my last antenatal visit I was told my baby was breech and I would need a caesarean section.'

The BBC reports: 'An emergency caesarean was performed an hour-and-a-half later on a second doctor's recommendation and baby Arun was taken to the special baby care unit. The baby had been starved of oxygen during the birth and had suffered irreversible brain damage.'

RCM says: 'the most important thing is for women to be able to choose'

As it happens, Cathy Warwick, General Secretary of the Royal College of Midwives was talking more about homebirths in this BBC News article back on July 29th, but the language she uses could so easily have been taken from the Coalition for Childbirth Autonomy website.

Warwick concludes that, 'The bottom line here is that what women want is to be able to make a real choice, for the health service to offer them that choice, and for that choice to be based on having all the information needed to make an informed decision.'

Equality of choice
What I'd like to see now is more midwives from the Royal College of Midwives listening to and respecting the informed decision of some women to choose elective cesarean delivery as their preferred birth plan - in the same way that they listen to and respect women's decisions to homebirth.

Czech doctor: 'Vaginal delivery will disappear in evolution'

In this 18th May news article in the Prague Daily Monitor (Respekt: Cesarean section rate rising unnecessarily), Ales Roztocil, head doctor of the obstetrical ward in the Jihlava Hospital, south Moravia is reported to have told the political weekly Respekt, that: 'In my opinion, a vaginal delivery will disappear in evolution.'

For the record, this is not an opinion I share, but I thought it was interesting to record some of the views and opinions on cesarean delivery coming out of the Czech Republic, where cesarean rates are '20% on average'.

Irrational thinking is needed for natural birth

Another doctor, Helena Maslova, expressed her concerns about the increased involvement of medical technology during the birth process, coupled with issues related to women's own behaviour. She believes, ''Women have lost the ability of instinctive behaviour since they have been raised to suppress it and behave rationally for the whole life. Yet during a child delivery the irrational side must be used, which is almost impossible for many women' ...adding it was the result of the obstetrics' technical development since the 1960s.'

Wealthy women
Dr Roztocil also reveals that 'among those who demand a caesarean section unnecessarily are often well-off women, businesswomen and wives of businessmen living in cities.'

Maternal request is against the law

Interestingly, the report notes: 'Under the Czech law, a Caesarean must not be performed without medical reasons. Yet it can apparently be arranged with an obstetrician. According to Internet discussions, such women pay a couple of thousands of crowns unofficially for such 'service''.

Clearly concerned about this law, Dr Roztocil says that the 'introduction of the possibility of Caesarean at request or rather on the basis of psychological indications would prevent medical hypocrisy and frauds'.

I would add that it might also prevent a situation in which only women for whom a maternal request cesarean is financially viable are able to enjoy the birth outcome of their choice.

Financial cost of vaginal delivery is high - and unaccounted for

I've just come across this letter, published in the BMJ back in 2006, titled: 'Consider the value of a functionally intact perineum', and written in response to the study, ''Caesarean delivery in the second stage of labour'.

It's written by Michelle J Thornton, a consultant colorectal surgeon at the Wishaw General Hospital in the UK, and in it, she talks about so many of the issues I've raised with respect to the unaccounted cost of a planned spontaneous vaginal delivery - specifically, when things don't go accoring to plan and an instrumental delivery is necessary.

This is what she has to say (with references listed below):

'Spencer et al say that instrumental delivery may reduce the caesarean section rate in the second stage of labour.1 Although this may be important for the 2006 NHS budget—saving anaesthetic, operating theatre, and hospital costs in the short term—the longer term health outcomes and costs of a high forceps delivery are concerning and go unmentioned.

Recognised third and fourth degree perineal tears occur in 0.5-6% of vaginal deliveries in the western world.2 3 A further 30-44% are estimated to be unrecognised.1 One of the most significant factors, clinically and statistically, to be associated with perineal injury is an instrumental delivery.2 3

Up to a quarter of women with a tear will experience faecal incontinence.3 Although perineal injury during childbirth may not be the sole factor for faecal incontinence, perineal damage increases its likelihood.3 The economic costs of faecal incontinence are large, lifetime cost estimates ranging from £7000 to £43000, depending on treatment.4 The social implications are immeasurable. In a questionnaire of their personal birthing choices even female obstetricians chose caesarean section over an instrumentally assisted delivery.5

To advocate obstetric management that has been declined by educated colleagues is worrying, particularly when the social and economic costs are so great and the idea of gaining valid informed consent is increasing.'

1. Spencer C, Murphy D, Bewley S. Caesarean delivery in the second stage of labour. BMJ 2006;333: 613-4. (23 September.)[Free Full Text]
2. Sultan AH, Kamm MA, Hudson NH, Thomas JM, Bartram CI. Anal-sphincter disruption during vaginal delivery. N Engl J Med 1993;329: 1905-11.[Abstract/Free Full Text]
3. Abramowitz L, Sobhani I, Ganasia R, Vuagnat A, Benifla JL, Darai E, et al. Are sphincter defects the cause of anal incontinence after vaginal delivery? Results of a prospective study. Dis Colon Rectum 2000;43: 590-6.[CrossRef][ISI][Medline]
4. Adang EM, Engel GL, Rutten FF, Geerdes BP, Baeten CG. Cost-effectiveness of dynamic graciloplasty in patients with faecal incontinence. Dis Colon Rectum 1998;41: 725-34.[CrossRef][ISI][Medline]
5. Al-Mufti R, McCarthy A, Fisk NM. Obstetrician's personal choice and mode of delivery. Lancet 1996;347: 544.[Medline]

Delay of an 'emergent' rather than 'emergency' cesarean led to baby's death

This report in the Bristol Evening Post today describes how an inquest heard that a 'baby girl who died within days of being born in Bristol could have lived if her birth by Caesarean section was carried out sooner...

Natasha Knowles was just four days old when she died at Southmead Hospital on February 11, 2005. When she was born on February 7 she had no heartbeat and was not breathing.'

Reducing cesarean rates at what cost to women?

Yesterday, I was browsing the website 'mybirth.tv' to see what they had to say about elective cesareans. On my first search, the video clip that came up was this one: elective caesarean

The woman being interviewed had had two vaginal deliveries and she had torn during both of them (the second birth making the first tear even worse). Fearful that her third pregnancy could result in even further damage, she requests an elective cesarean.

The Royal Sussex County Hospital however, is taking measures to reduce its cesarean section rate, and although in the end, the video shows that this woman does have a cesarean, just listen to what the hospital has to say to her during her maternal request consultation.

Vaginal reconstructive surgery versus planned cesarean surgery
It is suggested that she may want to consider operative perineal repair after the birth in order to avoid a cesarean, and the midwife says, '...if they had a terrible time last time, they haven't thought about the things they could do differently next time and still have a vaginal birth.'

What many obstetricians and midwives don't always appreciate is that the number one goal for every pregnant woman is not necessarily 'natural birth.' On the contrary, a healthy outcome for baby and mother is most likely top of the list. Efforts to reduce cesarean rates for the sake of reducing rates is of great concern to me because I genuinely believe that that in some cases, women and babies are bearing the physical and psychological cost of such arbitrary policies.

I don't believe in underestimating the risks of cesarean surgery - that would be irresponsible. But to underestimate the risks of vaginal delivery is, in my opinion, just as bad.

Jennifer Hudson did not find cesarean recovery difficult

Just a few days after writing my blog on the fact that African American women are more likely to have a cesarean with their first baby, I've read that Jennifer Hudson has given birth to her beautiful baby David by emergency cesarean.

Fortunately, she appears to have had a very positive experience, which is great, and while I'm not suggesting for one minute that her description of recovering from surgery is every woman's experience, I feel that it remains worthy of note.

Jennifer was asked: Your son was delivered via C-section, what was your recovery like?

"Everybody told me how much it was going to hurt afterwards but I think I have a different tolerance for pain than others. By that night after I had the baby, I'm like, 'Look, I can’t sit in this bed anymore. I’ve got to get up!’ I’ve been up and about since he was born. To me, the pain is no different than when you work out a muscle you’ve never worked out before and it’s sore."

Finally: WHO admits there is no evidence for a 10-15% cesarean threshold

Here is an extract from my article, "WHO Finally Admits - the 'Optimum Rate [of Caesarean Section] Is Unknown' and 'There Is No Empirical Evidence' for Its 1985 Recommendation of 10-15%", published on freelibrary.com today:-

In its latest 2009 publication, 'Monitoring Emergency Obstetric Care: a handbook', the WHO states that, 'Both very low and very high rates of caesarean section can be dangerous, but the optimum rate is unknown. Pending further research, users of this handbook might want to continue to use a range of 5-15% or set their own standards.'
The statement continues, 'Earlier editions of this handbook set a minimum (5%) and a maximum (15%) acceptable level for caesarean section. Although WHO has recommended since 1985 that the rate not exceed 10-15%, there is no empirical evidence for an optimum percentage or range of percentages, despite a growing body of research that shows a negative effect of high rates.'

Evidently, there is now a degree of ambiguity in what the WHO recommends. It recommends that regions 'use a range of 10-15%' (even though there is no empirical evidence for such a range) or implement their own standards. Consequently, it is perhaps inevitable that different birth advocate groups will take a different view on what the new handbook statement actually means, and arguments over the credibility of an optimum caesarean rate (emergency and/or elective) will continue.

Emergency cesareans more likely for older mothers

I've just been searching the internet to no avail, trying to find the actual Irish study being referred to in this Irish Times article published yesterday by Lorna Siggins. It appears in the European Journal of Obstetrics and Gynaecology and Reproductive Biology, but may not yet be available online.

I wanted to find out what age range 'older women' refers to, but in any case, the conclusion drawn in this new study (led by Professor John Morrison in Galway) should be of interest to many first-time pregnant women because they may 'run a much higher risk of emergency Caesarean section, even if pregnancies are not complicated (my italics)'.

The birth outcomes of 45,000 mothers at University College Hospital between 1989 and 2005 were analysed and advanced maternal age was found to have a 'strong bearing' on the likelihood of emergency surgery.

What does this tell us?
Prof Morrison told The Irish Times: "The findings indicate that the uterus does not work so well in older women, when one takes out the standard factors for epidurals, inductions, etc.” He continues: "There has been a lot of controversy over Caesarean sections, here and abroad, and their increasing frequency."
“The confirmation that age is a key factor in surgery is not because obstetricians are taking an ageist approach. The clear message from this is that age has an impact on ability to deliver normally."

Just as I commented in a recent post about pregnant African American women, what readers decide to do with research like this is a personal choice - and one to be discussed with your own midwife or OBGYN - but certainly for some women, in the light of research like this, the decision to avoid the risk of emergency surgery, and schedule a planned surgical birth instead, is a perfectly legitimate one.

Likelihood of a primary cesarean delivery is greatest for African Americans

Reuters reports, October 2nd, on a new Kaiser Permanente study examining the racial and ethnic disparities that occur with cesarean delivery, and notes that the study found 'disproportionately higher rate of primary c-sections among African-American women'.

The Californian study, Racial and Ethnic Disparities in the Trends in Primary Cesarean Delivery based on Indications, found that 'compared to Caucasian women, African-American women had significantly higher rates of primary CS while the increase in rates among
Hispanic women was smaller'.

What the study found
Further, it is reported that the disparity 'cannot be explained by education, smoking
during pregnancy, when prenatal care began or maternal age at delivery', and the lead author, Darios Getahun, MD, MPH, continues: 'This study underscores the importance of educating expectant women about the potential impact of CS on the outcome of future pregnancies.'

The figures published in the study's Abstract look at percentage increases in the primary cesarean rate, rather than percentage actual occurence, and it is unclear at first glance what women should do with this information. Perhaps the Full Text would prove a more useful read for African Americans - for example, it would be useful to know how many of these primary cesareans were emergency and how many were planned.

What the study tells African American women
This is the big question, and the answer is quite complex. Does the research call for better preparation for and best practice support during labor, in order to increase the likelihood of vaginal delivery? Or does it suggest that, if a women is likely to 'very likely to end up having surgery anyway', perhaps she'd be better having planned rather than emergency surgery?

Obviously, part of the answer can be found in the woman's personal birth preference, if she has one, and also, very importantly, how many children she is planning to have over the course of her life. Because however her primary cesarean occurs, through medical necessity or through choice, it is highly likely that she will go on to have further surgery in future pregnancies, and of course the health risks increase with multiple cesareans.

As a final note, the study results also note that 'Indication subtypes-specific rates of primary cesarean section varied markedly across race/ethnicity', and again, access to the study's Full Text would be useful for these women.

20% of Israeli babies born by cesarean

This is a very short report, with no details on the breakdown of emergency versus elective or planned cesareans, and no context in terms of whether there is a difference in rate in the private sector compared with public hospitals, but informs us that:

"Every fifth child in Israel is delivered by a Caesarean Section operation, according to a report published in the Hebrew-language daily Haaretz."