Wednesday, November 25, 2009

'New mums 'abandoned' during labour'

Sky News is just one media outlet to report on a survey of 3,500 mums by The Royal College of Midwives and parenting website

The survey found that 35% of mums said they had been 'abandoned' during or after labour, and Sally Russell, co-founder of, says, 'It shows that our members want, need and deserve one-to-one care from midwives but they are not getting this and are left alone and feeling abandoned during labour, and especially in the vital post-natal period.'

Pros and cons of different birth types
I am not about to advocate that women choose surgery in order to avoid some of the harrowing labors and inadequate maternity care experienced by some of these mums (and many more have posted comments on various websites today), but I do believe that avoiding this type of unpredictability and trauma is viewed as a benefit by many women who do choose surgery.

Speaking personally, and obviously my experience was somewhat different since I had my children in America rather than here in England, but one of the things I valued most was the relationship I built up with my OBGYN throughout my pregnancy. I also met with her surgical partner, who would have delivered my babies in the event that I went into labor early and she was not available, so I always knew I wouldn't end up with a stranger who may or may not understand or support my chosen birth plan.

Continuity of care
I enjoyed a fantastic continuity of care; all antenatal appointments with the same doctor, delivered by the same doctor and then postnatal appointments with the same doctor. In fact, I still keep in touch with her now, as do many of her patients.

But unfortunately, today's story is not a new one, and complaints of midwife shortages and inadequate care have been reported for more than 20 years at least (read more here). So aside from the fact that I felt that a planned cesarean was the safest option for my babies and for me, I would have hated to rely on this kind of NHS service in the event that vaginal delivery was my preferred birth plan.

Monday, November 23, 2009

Calculating 39 weeks for a full-term cesarean is a shared responsibility

Numerous studies have stressed the importance of planning a cesarean delivery after 39 weeks, and despite accusations to the contrary, I don't believe that obstetricians are arbritarily scheduling surgery ahead of this date unless there is an indicated medical need (either for the mother or the baby). That is - despite the risks of respiratory distress with preterm births, there is a greater risk of (for example) the baby or mother dying if it remains in utero any longer.

I also don't believe that the vast majority of women choosing a cesarean - despite accusations to the contrary - would urge their doctor to deliver their baby early for convenience, vanity reasons or to bring an end to their pregnancy.

Blame game
But now a study, reported in the media on Friday, suggests that one possible reason behind the U.S.' climbing pre-term delivery rate is that 'Many Women Miscalculate Time to Full-Term Birth'.

The report continues: 'When asked, "What is the earliest point in pregnancy that it is safe to deliver the baby, should there not be other medical complications requiring early delivery?", more than half chose 34 to 36 weeks, 41 percent chose 37 to 38 weeks and less than 8 percent chose 39 to 40 weeks.

However, experts warn that any delivery short of 39 weeks puts a baby at higher risk of respiratory distress, sepsis (blood infection) and needing to be placed in the neonatal intensive care unit, according to background information in the study. Only one-quarter of new moms realized 39 to 40 weeks was safest.'

Education, Access to Early Ultrasound and Less Confusion please
For what it's worth, here are my suggestions for improving this situation:

1) Educate women that when it comes to planning a cesarean delivery, the ideal gestational age is 39 weeks. Ideally, that means taking responsibility for recalling your last menstrual cycle date before you became pregnant - not always possible or indeed accurate, but the more information a doctor has at hand for calculating your gestational age, the better.

2) Arrange an early ultrasound. This is easier said than done sometimes - and you, your doctor, your hospital, and if applicable, your insurance company, must all take responsibility for this. With my second pregnancy, one of the hospitals I was going to go to said they didn't do the first ultrasound until 12 weeks, but my OBGYN insisted that I had it done earlier because research has shown that the most accurate calculation of gestational age can be made during an early ultrasound (read more here).

3) Stop confusing women by quoting data from medical studies with 'full-term' gestational ages described as 34 or 37 weeks one minute, and then 39-40 or 41-42 weeks the next. Women could be forgiven for not knowing the definition of 'full-term', especially in the context of planned cesarean delivery, because there is so much confusion in the presentation of planned cesarean risks and benefits in any case.

For example, when natural birth advocates want to highlight respiratory distress problems in babies born via elective cesarean, they will frequently include studies that invlude 'full-term' getational ages much earlier than 39 weeks. Equally, they are less inclined to present data from medical studies that have found greater fetal demise post-39 weeks.

Delivery at 39 weeks is optimal - for the baby's sake, we should all be working together to make sure that wherever possible, this date is reached.

Sunday, November 22, 2009

And another baby dies.

Just one day after my blog on Friday of the same subject, I read again - this time in The Irish Times - how a baby boy suffered severe head injuries and died after a failed attempt at an instrumental vaginal delivery.

Georgina O'Halloranan writes that 'Parker Meredith Doyle died just one day and 10 hours after his birth by emergency Caesarean section on April 18th, 2008' at the National Maternity Hospital, Holles Street in Dublin. He was 'left severely brain damaged due to brain haemorrhage as a result of 'an attempted instrumental vaginal delivery' using a vacuum cup and forceps.'

What makes it worse
It is reported that the baby's mother, Caroline Meredith, had endured a 'failed forceps delivery 13 years earlier which had resulted in injuries to her baby'.

With the benefit of hindsight, it is evident that this baby's life would have been saved with a planned cesarean delivery, but surely in this case at least (i.e. with the mother's previous birth experience) the medical team might have made a safer delivery decision even without this benefit?

Media headline irony
It is also worthy of note that on the same day that the above article was published in The Irish Times, The Irish Independent published an article titled, 'C-section birth rate still too high', criticizing Irish hospitals for failing to reduce their cesarean rates.

Does Ireland really want to see its cesarean rates fall to dangerously low levels? Or are its obstetricians going to ignore media pressure (and other pressure from natural birth advocates), and concentrate solely on the best outcomes for mothers and their babies - regardless of where that leaves percentage rates?

I hope for the sake of babies like Parker Doyle that it is the latter...

Friday, November 20, 2009

Another delayed cesarean. Another baby dies.

In the NHS in England, as many as 14.9% of planned vaginal deliveries result in an emergency cesarean. Time and time again, we hear that this number is too high, that national cesarean rates should be lowered, and that some of the 9.7% planned cesareans are unnecessary too.

Well, reading this story in The Telegraph today, it becomes all too clear what can happen when a cesarean is delayed (or not carried out):

Tragically, 'Lewis Connolly lived for just four hours and died in the arms of his mother Eleni, 33. Mrs Connolly and her husband Steven, 29, were told at an inquest that their baby's death was avoidable.'

Prevent this happening to another child
The report explains how 'Lewis ended up lodged so firmly in the womb that a doctor at North Middlesex Hospital in Edmonton, north London, fractured his skull in a desperate bid to free him with a pair of forceps.'

'Guidelines state a baby should be delivered within three hours of the mother reaching second stage. But an emergency Caesarean section was not carried out until 2.36pm, more than five hours later.

The parents have said they 'hope that these events will prevent it from happening to anybody else', and I would completely agree with them.

Unfortunately, I'm not convinced that they will, and I remain concerned that women in antenatal classes are simply not being fully informed of the true and real risks of planning a vaginal delivery. Not that all women should or would want to choose surgery instead; only that both types of delivery have their own set of risks, and to over-exaggerate one set and under-state another is wrong.

Monday, November 16, 2009

Surrender to our birth experience? Rely on medical intervention? Or both?

I simply don’t understand the article I read in The Telegraph on Saturday. In it, Laura Donnelly writes that 'maternity guru Sheila Kitzinger says 'fairytale' expectations of childbirth end with dashed hopes for women, and warns that new mothers are often consumed by guilt when they do not experience said fairytale.

Ok, nothing new there…

But who is Mrs Kitzinger blaming for raising women’s expectations of birth in this way? Could it be herself, who has in the past described childbirth as a ‘potentially orgasmic experience’. Or natural birth advocates, who often employ language that encourages women to trust in their innate ‘empowerment’ and a body that’s ‘designed to know exactly what to do’ during the birth process?

No. It’s our ‘consumerist agenda’, our tendency to ‘test everything’ and ‘see birth as a performance’. In addition to the over-medicalization in hospitals, she says that ‘many modern women, accustomed to taking control of their careers, made a mistake in applying the same thinking to childbirth.’ Rather, they should ‘surrender to the experience’.

Yet in every other aspect of a woman’s reproductive life, control is precisely what it’s all about. Is it really feasible that on the day of our baby’s birth, we should all want to simply surrender to Mother Nature? Maybe for some women this is a desirable approach, but I doubt it’s the case for the majority. After all, Mother Nature has a nasty habit of engineering the most undesirable and traumatic experience just as easily as the orgasmic one Mrs Kitzinger suggests.

I never expected nor did I desire an orgasm during the birth of my baby, but in terms of fairytale expectations, is it really fair to blame everyone and everything else (for women’s negative feelings when their birth doesn’t go according to plan), and shoulder no responsibility yourself Mrs Kitzinger? I’m not so sure…

Friday, November 13, 2009

Why are more women pushing for Caesareans?

This is the title of an article written by Dr Mark Porter in The Times last week (2nd November). In it, I'm interviewed by journalist Peta Bee about my own two cesarean deliveries, but what I'd like to draw attention to is the comments written by readers at the bottom of the article.

I submitted two comments in response to Dr Porter's article on the 3rd November, and was very pleased to read his personal response a day later, which read:

"Pauline - I wholeheartedly agree."

Why is this important? Because I was writing about maternal request cesareans in the context of the NHS, where currently, it can be extremely difficult to find support for a cesarean birth. If more doctors in the UK could not only move towards accepting planned cesarean delivery as a legitimate birth choice, but also be willing to open up a public dialogue about it in the way that Dr Porter does here, I hope that we might see positive change in the UK sooner rather than later.

For ease of access, I have copied and pasted my comments here:

I am so glad that Dr Porter recognizes the importance of separating maternal request health outcomes to those of emergency or planned cesareans for medical reasons. When bias against surgical birth is removed, and studies containing mixed cesarean data are excluded, there is evidence that maternal request cesareans can result in better outcomes than planned vaginal deliveries. Read the stories posted on any birth trauma website (physical and psychological trauma) and you will struggle to find a single complaint from a woman who has had a maternal request cesarean, yet there are thousands from women who planned vaginal deliveries. This is also backed up by research such as the 2007 Swedish study involving 357 women; those with maternal request cesareans ‘reported a better birth experience compared to those with planned vaginal deliveries.’ Women are simply not being informed about the whole truth. Just two examples: 1. The latest CEMACH report in the UK showed that women were less likely to die following a planned cesarean than any other birth type. 2. A 2009 Canadian study of 40,000 deliveries concluded that ‘elective pre-labour caesarean section…at full term decreased the risk of life-threatening neonatal morbidity compared with spontaneous labour with anticipated vaginal delivery’.

I would also like to pick up on the issue of NHS resources, and to state that studies demonstrate that ‘convenience’ is very low down the list of reasons for maternal request - when it appears as a reason at all. Reasons are more likely to be tokophobia, concerns for their baby's safety and avoidance of pelvic floor injuries.
Firstly, current cost comparisons are flawed in terms of maternal request, as they contain medical and/or emergency surgical costs, but more crucially, vaginal delivery costs repeatedly fail to include the financial impact of: 1. all planned vaginal delivery outcomes, including spontaneous, instrumental AND emergency cesareans. 2. short and long-term perineal and pelvic floor repair (e.g. prolapse) and counseling when trauma occurs. 3. huge litigation bills when vaginal delivery goes wrong and a baby/mother is injured or dies. In fact, the 2004 NICE guideline discusses one cost model in which ‘maternal request would lead to savings’ (not that I’m suggesting this is a motivation), but promptly dismisses the finding as ‘not a realistic conclusion’. The bottom line is: there are risks and benefits with both birth plans - vaginal and cesarean - and women should be allowed to make their own informed decision.

Counseling against a cesarean delivery

For some reason, I was thinking about this today as I drove home from my daughter's toddler group, and I came up with an analogy for why counseling against a (chosen) cesarean doesn't always work - and why it would certainly never have worked for me.

To take a step back, let me explain when counseling might be used: if a woman has tokophobia - fear of childbirth - and says to her doctor that she would prefer to have a planned cesarean delivery instead of a vaginal delivery, it is often suggested that she should be given counseling (therapy) in order to help allay her fears.

Fear or simply a different choice?
I am not against this idea; if resources are available and the woman is keen to give counseling a try, then I would agree that it should do no harm. In fact, there is some evidence that women can change their minds about their cesarean birth decision and go on to plan a vaginal delivery (unfortunately, these studies don't follow up after the birth to find out if the women were happy with their decision, which might be an idea for future studies).

However, the women I'm concerned about are these: women for whom no amount of counseling will dispel their intense fear of natural birth, and women for whom counseling is viewed as a completely unnecessary - i.e. their decision to choose a cesarean is grounded in a personal health risk-benefit analysis that favors planned surgery.

It's like trying to piece together a broken marriage when one of you is in love with someone else
You see, to me, counseling can only work when the person being counseled is one hundred percent on board, and they WANT to move towards the same goal as the counselor. For example, if a couple is having problems and both of them want to make another go of things, counseling can have very positive results.

If on the other hand, one of the partners has met someone else, fallen in love, and is just itching to move out and start a whole new life elsewhere, the likelihood is that no amount of counseling is going to help.

Therapy during pregnancy
When I became pregnant with my first child, Charlotte, I already knew I wanted a planned cesarean. My decision was not based on a now suddenly impending birth day, and nor was it influenced by the hormonal changes taking place in my body. I firmly believed that a cesarean was the safest route of delivery for my baby and for me, and I would have hated to be marched off to see a counselor for weeks of therapy before a decision was finally made for me.

I was one of the lucky ones. My pregnancy was never impeded by the 'unknown' (would I be allowed to have a cesarean or would I be forced to deliver vaginally?). But this is what happens to many women around the world, in countries where 'maternal request' is a dirty word(s). In fact, one woman in England contacted me through my website, after she was made to jump through every counseling and cognitive therapy hoop available on the NHS in an attempt to cure her of a severe case of tokophobia.

And the result?

She was told at the end of it all that she would still have to endure a trial of labor - either she hadn't sufficiently convinced her therapists of her fear of childbirth or they couldn't accept that the therapy hadn't worked (I don't know) - and she made the deeply traumatic decision to terminate her pregnancy. It's time we started caring as much about women like this as we do about women who want to give birth vaginally and avoid a cesarean delivery. Their desires may be different but they are surely equal.

Wednesday, November 4, 2009

My response to WHO Press Release criticism

Henci Goer, representing Lamaze International, has criticized the CCA's latest press release, 'WHO admits: There is no evidence for recommending a 10-15% caesarean limit'. Her criticism can be read here, and this is my response.

Firstly, inside the red circle in the WHO table that Henci has highlighted, you will see a small letter 'c', and the note beneath the table reads: 'See Section 2.5 for a discussion of this range.'

Since Henci has not reproduced this discussion, I will do so here. It reads:

"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% (125), 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 (126-128). It should be noted that the proposed upper limit of 15% is not a target to be achieved but rather a threshold not to be exceeded. Nevertheless, the rates in most developed countries and in many urban areas of lesser-developed countries are above that threshold. Ultimately, what matters most is that all women who need caesarean sections actually receive them."

With regard to minimum and maximum acceptable levels, it says:"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."

My response to Henci
1. The WHO handbook states (above) that users 'might' want to continue to use a range of 5-15% or set their own standards. Given that the WHO itself states (also above) that 'there is no empirical evidence for an optimum percentage or range of percentages', it is entirely your prerogative to choose to continue advocating a percentage threshold that has no basis in evidence.
I do not. I prefer to advocate countries setting their own standards, and in doing so, to explore a far wider body of research than the three studies that you (and the WHO) refer to in your post (more on these below).

2. This is an indisputable fact: On the subject of cesarean rates, the WHO has said in 2009 that 'the optimum rate is unknown'. This is what our press release states and while this fact may not fit in with your birth ideology, that does not make it any less factual.

3. You infer that our press release did not go far enough in terms of quoting the WHO handbook accurately, and in this context, you refer specifically to the extract 'despite a growing body of research that shows a negative effect of high rates'. Please look again - our release does include this line of text and we made no attempt to avoid or hide it.

4. I am open to debating the subject of cesarean deliveries, and in particular, my focus is on demonstrating that a planned prophylactic cesarean at 39 weeks for women planning a small family is a perfectly legitimate birth choice in preference to a trial of labor (since these women are adversely affected by strategies to reduce cesarean rates to 15%).
But what I object to strongly is your effort to censor a press release that does not agree with your point of view. Medical News Today and have both been contacted with the specific request to remove our press release from the internet, and to use your own words, 'shame on you' for resorting to such tactics.

5. Furthermore, in your chat with visitors to your site at the bottom of the page, you are praised for contacting Medical News Today, and you write: 'Your welcome! This is my idea of fun.' Again, I don't think there's anything funny about attempts to censor an opposing viewpoint to your own.

6. In March this year, I spoke at a seminar on the subject of cesarean rates, and my presentation included many studies to support the point of view that a 15% rate is unrealistic and unwarranted (as you know, the CCA is not the first to criticize the WHO's 1985 recommendation). I can provide you with a copy of this, and would like to note here that I received very positive feedback from many midwives and natural birth advocates in the room that day - and that the doctor with the 'opposing viewpoint' to mine in our seminar even admitted that a 15% rate is unachievable. Here is an extract on the subject of infant mortality for example:

"Since extraneous socioeconomic factors affect the U.S. infant mortality rate (deaths <1>Singh and Kogan, 2007), it is less relevant to the delivery method than the fetal mortality rate (deaths at 20-27 gestational weeks or ≥28 gestational weeks), neonatal mortality rate (deaths <28>MacDorman and Kirmeyer, 2009), (Kung et al, 2008)
Northern America, together with Australia (which has a cesarean rate of 30.8%), has the lowest regional stillbirth rate and one of the lowest regional neonatal mortality rates worldwide. The WHO says it has 'shown that one third of stillbirths take place during delivery - deaths that are largely avoidable and closely linked to the place of and care provided at delivery.' (Neonatal and perinatal mortality: country, regional and global estimates, WHO, 2006)
A UK study of 65 maternity units incl. 540,834 live births and stillbirths found that a 'higher intervention score and higher number of consultant obstetricians per 1000 births were both independently and significantly associated with lower stillbirth rates.' (Joyce et al, UK, 2004)

My criticism of WHO's 2009 handbook
1. Its recommendation on cesarean rates is now open to ambiguity. While I am glad that (after much lobbying) the WHO has finally put in print that it has no evidence for recommending an optimum cesarean rate, it is a pity that its statement remains open to this type of debate.

2. It refers to 'a growing body of research that shows a negative effect of high rates' and references three studies, '(126-128)', but there are numerous other large and contemporary studies that demonstrate very positive outcomes with cesarean deliveries, and these are not mentioned in this area of the WHO's discussion at all.

How can the WHO ignore (for example) that women in the UK (where national data on elective and emergency outcomes is separated, unlike the U.S., which only separates primary and subsequent cesareans) are less likely to die following a planned cesarean than any other birth type? Or studies from Sweden that demonstrate greater levels of satisfaction following planned cesarean births than planned vaginal deliveries? Or the latest study from Canada - of 40,000 births - that concludes: ‘elective pre-labour caesarean section… at full term decreased the risk of life-threatening neonatal morbidity compared with spontaneous labour with anticipated vaginal delivery’. And the cesarean group in this latter study were breech deliveries (understandably more complicated than cesareans with cephalic presentations) while the vaginal delivery group were cephalic presentations...

3. When I interviewed Dr Monir Islam, Director of the WHO’s ‘Making Pregnancy Safer’ program last year, he told me that he agrees with the ACOG’s 2007 and NIH’s 2006 statements on maternal request cesareans: that they are ethically justified following individualized consultation.

His exact words were: 'A woman should have the right to decide. Why should she not have the right to decide? 'It should be an informed decision; the doctor needs to give the woman all the information she needs, and then the woman should decide whether she wants a cesarean section or she doesn’t want a cesarean section.'

Clearly, maternal request cesareans add to national percentage rates of cesareans, and this is another reason why a 15% threshold is unrealistic in North America and the UK.

4. The three studies referred to as 'a growing body of evidence' are seriously flawed in the context of this debate when quoted in isolation, and particularly in any debate about maternal request cesareans with no medical indication (the notes below refer to maternal request because this is the context I first wrote about them in, but they are still relevant here because any attempt to reduce national cesarean rates to 15% would have to involve the refusal of maternal request).

*Issues with the Deneux-Tharaux et al study
If you read the research in full, it is evident that in the two causes of death where the majority of maternal mortality occurs, CD does not result in more cases of death than VD. For example, the risk of postpartum hemorrhage (the most common cause of death here, at 38.5%; n.25) is as high with VD as it is with CD. In fact, the maternal mortality risk is higher for CD in the three causes of death that occur least: Venus thromboembolism (n.7 of 10 total); Puerperal infection (n.4 of 5 total) and Complication of anesthesia (n.4 of 5 total), which equates to 15 out of 20 deaths in these areas (the total number of deaths was 65). This is the source of the 'triple the risk' headlines.

Furthermore, Deneux-Tharaux writes: 'It must be noted that 3 of the 4 deaths due to complications of anesthesia in this study occurred after general anesthesia, whereas the 4th death occurred after spinal anesthesia. This suggests that general anesthesia at cesarean delivery is associated with a much greater mortality risk than regional anesthesia.'

PMHull: General anesthesia is usually administered in an emergency CD, not an elective CD. Therefore, any deaths following the use of general anesthesia in an emergency CD should not be used to analyze the safety of an elective CD where spinal anesthesia is used.

Deneux-Tharaux: 'Cause specific mortality could not be analyzed separately for prepartum and intrapartum CD because the numbers of deaths were too small.'

PMHull: The separate analysis of prepartum and intrapartum CD is vital in any research that draws conclusions on the comparative safety of elective CD versus VD. The mix and match of analysis, results and conclusions of 'all CD' and 'elective or maternal request CD' is not an effective measure. Furthermore, maternal mortality following intrapartum CD is a measure of risk that needs to be applied to the category of 'planned vaginal delivery' and not a planned CD. This is important because risk can only be assessed at a birth 'planning' stage, and whether desired or not, the fact is that a planned spontaneous VD can have the outcome of instrumental and/or emergency cesarean delivery.

PMHull: It is also worth pointing out that the three mortality areas, where greater risk with cesarean is demonstrated, are largely preventable in quality hospitals with competent surgical personnel, using medical knowledge that has existed for many years. The data used in this study was from a period spanning 1996 to 2001. It is inadequate to make any conclusive statements using data that is over a decade old, especially when data exists in other studies from births that have occurred more recently.

*Issues with the MacDorman et al studyAlthough the researchers applied the NIH's 'intention-to-treat' recommendation, they have not accounted for one of the most important recommendations by the NIH, which is to wait until 39 weeks EGA for planned cesarean delivery with no medical indication. Instead, the study defines low-risk births as "singleton, term (37-41 weeks' gestation), vertex births, with no reported medical risk factors or placenta previa and with no prior cesarean section." This is important, because while a baby delivered at 39 weeks EGA is certainly not risk free, the neonatal mortality rate is most likely lower than the 1.73 reported here; and this is especially relevant since it is cases of 'no medical indication' that MacDorman et al are questioning.

Planned vaginal deliveries (even those for low risk women) can last beyond 41 weeks, and there is documented evidence of a 'small but significant' risk in fetal mortality beyond this point (Divon et al, 1998), and also after 40 weeks. (Caughey et al) Measuring mortality up to 41 weeks alone may have provided PVD with improved statistical outcomes in this study.

Self-reported limitations of the study include concerns about the accuracy of reporting specific data items on the birth certificate.
MacDorman et al: 'Reporting for the major variables in this study (neonatal mortality and method of delivery) is generally considered to be excellent; however, underreporting of individual medical risk factors and complications of labor and delivery on birth certificates has been documented. is possible, based on either poor reporting or because the risks involved items not recorded on the birth certificate, that the group including cesarean delivery with no labor complications or procedures was still an inherently higher risk group, and those risks accounted for both the decision to perform a cesarean section and the subsequent neonatal death. It is also important to note that birth certificate data cannot be used to infer the intentions of either mothers or their practitioners, so these data do not address 'maternal request' cesareans.'

Dr Marian MacDorman said at the time of the study: ‘Even though we don't know exactly that it's elective cesarean delivery, it is probably the best approximation we can make.'...

PMHull: Critics noted in media reports that because birth records often don't accurately reflect whether a CD was medically necessary, this study could be comparing apples to oranges.

Also, again, death that occurs following an emergency CD follows an 'attempted' or 'planned' vaginal delivery (VD). Therefore, while clinicians and women are being advised to use study data to inform their birth planning, then the mortality results should be compiled in such a way that reflects original birth plans. Grouping all CD outcomes together (i.e. emergency and elective) cannot help inform the birth planning stage, and in fact grouping emergency CD outcomes with VD outcomes would be more accurate than grouping them with planned CD.

Issues with the Villar et al study
This study focused on countries in Latin America, where there are differences in standards of health care as a whole compared with North America and the UK. That is not to say the research should be dismissed; only that there are other studies in North America and the UK (that demonstrate more positive outcomes with cesarean delivery), and these should surely be included in any WHO referenced 'body of evidence'.

As a final note, readers may be interested to know that another study by Villar et al (Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study), published one year later in 2007, met with a great deal of criticism in the form of Rapid Responses on the BMJ wesbite. Headlines included:

A prospective study is still needed Maureen Treadwell (1 November 2007)
Definition of "elective" is misleading Amy B. Tuteur, Sharon, MA USA (2 November 2007)
Avoid interfering with physiology when possible David JR Hutchon (2 November 2007)
Term and preterm deliveries Gordon C S Smith (3 November 2007)
Not much help, really Robert G Buist (17 November 2007)
Somewhat misleading Zhong-Cheng Luo (19 November 2007)
Caesarean section risks and maternal choice Jonathan H West (20 November 2007)
Elective Caesarean section safest form of childbirth Michael P Wyldes (23 November 2007)
Contrary to Epidemiological Logic Dr Mudassir Azeez Khan (19 December 2007)
Anesthesia Effects Martin Dauber (27 December 2007)
New research finds lowest maternal mortality rate with elective cesarean delivery Pauline M Hull (30 July 2008)

5. To reiterate, it is not that I am suggesting that these three studies should not be used in an evidence-based assessment of cesarean outcomes; only that they should not appear as a group in isolation and defined as a 'body of research' that proves negative outcomes with high rates. They belong as part of a much larger body of evidence, which includes studies with very positive birth outcomes following cesarean delivery (including mortality and severe morbidity for both mothers and babies).

Henci, we may just have to agree to disagree on the issue of 'optimum' cesarean rates, and unfortunately, it would appear that the WHO's handbook lends itself to encouraging such an arrangement.

If you wish to engage in respectful dialogue about this issue please contact Penny Christensen at She has volunteered to respond to any concerns or questions regarding the CCA's release. You may wish to read BTCanada’s website at for background information first.