Thursday, April 23, 2009

Cesareans in Cyprus: doctors defend high rates

In her Cyprus Mail report, 'Doctors defend C-sections figures', Alexia Saoulli writes: "Private doctors said last week they had been unfairly lambasted in the press for favouring c-sections over natural births. Recent reports of doctors “blackmailing” women into booking their delivery at convenient times prompted outpourings of outrage from women, government health authorities and lawmakers."

Dr George Leontiades, head of the Gynaecological Association: “If there is one doctor who encourages his patients to have c-sections you can’t make a generalisation that all doctors do it.” ...He said comparing Cyprus’ private c-section rate of 55% to England’s 25% was wrong... In England, in the private sector, the figures are almost as high as Cyprus,” he said.

...Leontiades said there were very many reasons why Cypriot women chose to have caesareans, starting from how affluent the country had become. “Affluence in societies affects c-section demand. Also women have a mistaken understanding of the hardship of labour. They don’t want to be put out. The way they have three cars, a big house and can buy everything in the supermarket, they think they shouldn’t suffer any hardship in bringing a child to life.”

...The doctor said there was also an increasing trend in repeat c-sections. He said most women who had a c-section for their first child wanted to follow the “tried and tested” method and “don’t want to embark on an adventure that will not guarantee they will have spontaneous vaginal delivery”.

...He said some doctors were also afraid of increased cerebral palsy risks during labour despite the fact that only one in 400 developed cerebral palsy, only 10 per cent of which accounted for events taken place during delivery. Nevertheless in a society where women only had one or two children, some doctors preferred not to chance it, he said."

Dr Gabriel Kalakoutis, a Nicosia’s Aretaeio hospital gynaecologist-obstetrician: "said although women were not encouraged to have a c-section, there was greater sensitivity to a woman’s wants. “A lot of women prefer to have a c-section because they are afraid of childbirth and the pain. I’m more prone to take the woman’s feelings into consideration and what makes her feel more psychologically comfortable. C-sections are much safer now, with very small risks and only slightly more dangerous than natural births.”

...Kalakoutis said the attitude that a c-section was a “failed” delivery no longer held true and that if there were medical indications for why one should be performed he no longer insisted on going the natural route.

...“Some women want to have a natural birth and I encourage that. If some are afraid and from the beginning think they want to have a c-section then I am more open to that. I don’t tell them from the beginning that they should have a c-section,” he said.

Numbers of women asking for cesareans in Cyprus
...The gynaecologist said in his experience four out of 10 pregnant women asked for c-sections. He also said culturally women had changed and were having fewer children. “Women have two or three children, not five or six. If they had that many caesareans it would be dangerous but up to two or three is safe,” he said."

Cesareans in Cyprus: why women choose surgery

In her recent report, 'The big question: to cut or push', Alexia Saoulli begins: "Gynaecologists in the private sector have been accused of advocating caesarean sections at times convenient to them and without sound medical reasons, but when you talk to mothers themselves a slightly more complex picture emerges. While some doctors do actively encourage caesareans, all too often it is the mothers themselves who opt for the procedure."

It's certainly worth a read, and below, I've highlighted some of the reasons cited by women who did choose cesarean delivery:

Aileen: “I wanted to have a caesarean. I had one with my second son and it was just so easy that I decided I was going to have another one when I was pregnant with my daughter... You know exactly when your due date is. There’s none of this waiting around for your water to break. You plan it, you set a date, pack your bag and that’s it. A few hours later you’ve got a baby."

Katerina: “I was terrified of natural childbirth. I just couldn’t take the thought of the pain. I then thought that it would be more convenient to know the specific date so that I could have everything ready. I discussed it with my doctor and he agreed to perform a c-section... I don’t regret it for a minute. It was painless and harmless. They say the recovery time takes longer but a friend of mine who gave birth naturally developed an infection after they had to cut her during labour and took even longer to recuperate. I don’t think I could have handled being cut. I just couldn’t bear thinking about it."

Joanna: admitted that she’d asked for caesarean just so that she could have a Virgo baby rather than a Libra. Her doctor did nothing to dissuade her, she said. “I’d heard that Virgo boys are easier going than Libra boys and so I asked to be booked in for a c-section on September 20. My due date was September 22 which was too close to the cusp and I didn’t want to risk it.”

Maria: said her doctor encouraged her to examine her options but was very supportive when she finally decided to go ahead with the c-section. “I was so nervous about the pain. I know some cynics think the doctors are in it for the money, and maybe some are, but my doctor was definitely supportive of me and my decision. She took into account my fear, which was important... A friend of mine said this was because it would be less hassle for the doctor rather than having to talk me through my fear. I don’t know if this is true or not but I’m just glad that my doctor bothered to really listen to me and do what I wanted.”

Wednesday, April 22, 2009

UK study finds 3% CDMR rate

New research to be published in BJOG "suggests that ‘choice’ may not be the best way to understand women’s decision-making about birth method. The results of the study question the current focus on choice in UK maternity care policy, and challenge prevailing notions about caesarean delivery for maternal request."

You can also read more in these two news articles on the research:
'Pregnant women prioritise safety over choice' and 'Women 'do not choose Caesareans as too posh to push'.

The researchers tracked 454 women at the Liverpool Women's Foundation NHS Trust, and found that by the end of their pregnancies, the number of women still requesting cesarean delivery had fallen to 2%.

Tuesday, April 14, 2009

Countries where more cesareans are needed

An IRIN news article last week asked the question, 'Can subsidised caesareans cut maternal deaths?'

It explains that some doctors in Benin have begun performing near-free caesareans, and the government is in its first week of helping women pay for caesarean operations in an effort to reduce the number of women dying during childbirth every year (estimated at 2,000).

"The government has linked the country’s high level of maternal and infant deaths in childbirth to long hospital waits for caesarean operations as underfunded hospitals scrambled to assemble the necessary equipment."

Will this be enough?
"A government health inspector who works with midwives in Cotonou, Ad├ękambi Adjovi, told IRIN that even a steeply-subsidised caesarean operation may not be enough for some women. “The circuit [of health care costs] for women who have caesarean operations should be covered entirely because now they pay post-operative costs themselves.”

...The Ministry of Health reported 14,000 women giving birth through caesarean in 2008 and has estimated an additional 3,000 mothers will need the operation in 2009, based on population estimates."

Wednesday, April 8, 2009

The 'natural' cesarean

You might be interested in reading an article published in The Times this week, 'The new 'natural' caesarean', which reports on "a new movement campaigning to make [cesarean delivery] a more "natural" experience."

The delivery process has been developed by Professor Nicholas Fisk, and his two colleagues, Dr Felicity Plaat, a consultant anesthetist, and Jenny Smith, a senior midwife and author.

Readers might also be interested that both Professor Fisk and Dr Felicity Plaat have expressed their support for a woman's decision to choose a planned cesarean delivery in preference to a trial of labor, and in 2005, I interviewed Dr Plaat for my website. You can read her comments in full in the section 'Medical opinion, Exclusive interviews'.

Hysterectomy risk with multiple cesarean deliveries

The fact that risks increase with multiple cesarean deliveries is well documented, and it is important that anyone considering choosing a planned cesarean delivery in preference to a trial of labor is aware of these increased risks. In fact, this is why the NIH, ACOG and others all stress that CDMR is not recommended for women planning large families.

One of the risks often cited with multiple surgeries is the chance of needing an emergency hysterectomy, and a recent Irish news article has highlighted this risk:

The Sunday Times' 'Caesarean link to surge in hysterectomies', on April 5, reports:

"The problem is caused where the placenta, or afterbirth, attaches too deeply into the wall of the womb. The risk of the condition is increased by the presence of scar tissue from previous caesareans. Doctors from the Rotunda, Holles Street and the Coombe hospitals analysed charts of all patients who had emergency hysterectomies after giving birth in the 40 years between 1966 and 2005. Of the 320 cases, 43 of them were due to placenta accreta. It accounted for only one in 20 emergency hysterectomies from 1966 to 1975 but 47% of those between 1996 and 2005 when almost half (20) the cases occurred. The caesarean rate rose from 6% to 19% over the same period and now stands at about one in four births."

It is similar to an article that appeared in January 2008 in Australia's The Age, 'Caesars raise risk of losing womb', which reported on research from the University of Oxford:

"For most women giving birth normally for the first time, a hysterectomy is rare - only one in 30,000 will need surgery to remove their womb because of bleeding complications. But the risk of having to undergo surgery to remove the womb rises in the subsequent pregnancy for those who had a caesarean. One in 1300 women who have had one previous caesarean will have a hysterectomy. If the woman has had two or more previous caesareans, the risk rises to one in 220. Researchers estimate that more than 80 women a year have been forced to have a hysterectomy in Britain as a result of having a caesarean. But with the popularity of the procedure on the rise this figure is likely to increase. The study of 775,000 women who gave birth in Britain between February 2005 and February 2006 also found that women with twin pregnancies, older mothers and those who already had three or more children were also at higher risk of needing a hysterectomy."

Limitations of the research
The main problem with the research cited above is that the nature of the primary cesarean deliveries (that occurred prior to the subsequent surgery in which the hysterectomy is required) are not specified.

In fact, all cesarean delivery types tend to be pooled together and then the health outcomes of their subsequent pregnancies are looked at together. This means that primary cesareans that may have been an emergency delivery (which has greater morbidity risks than a planned delivery) are treated the same as planned deliveries.

Therefore, healthy women choosing a planned primary cesarean delivery should not be criticized or deterred from making their valid decision on the basis of mixed data outcomes. Yes, they should be informed of the risk of subsequent placenta complications, but every effort should be made to evaluate how many hysterectomies occur in cesarean deliveries that follow primary planned surgeries - not primary emergency surgeries.