Tuesday, January 19, 2010

China's cesarean rate high but birth trauma and asphyxia reducing

The media news is chock-a-block with news that China has the highest rate of cesarean deliveries in the world (46%), of which one quarter (11.7% of all births) are on maternal request without medical indication.

What you may not read about however, are two very interesting studies conducted in China, published in 2007, which report on an interesting development in health outcomes for newborn babies there:

In the first, titled: 'Unexpected reduction in the incidence of birth trauma and birth asphyxia related to instrumental deliveries during the study period: was this the Hawthorne effect?' (Leung et al), researchers noticed "a significant reduction in the incidence of birth trauma and birth asphyxia related to instrumental deliveries during the study period (0.6%) when compared with that (2.8%) in the pre-study period (1998 and 1999)".

The second, titled: 'Continued reduction in the incidence of birth trauma and birth asphyxia related to instrumental deliveries after the study period: was this the Hawthorne effect?' is even more interesting.

Cesarean rate, UP, instrumental VD, DOWN, Asphyxia and trauma DOWN too

The same researchers discovered that in addition to the above reduction from 2.8% to 0.6% "this phenomenon continued into the post-study period (2001-2003) when the incidence of 1.0% was similarly lower than that in the pre-study period".

"The instrumental delivery rate decreased further in the post-study period (13.5%) compared with those in the study (16.6%) and pre-study (19.5%) periods", and there was "a marked increase in the direct second-stage Caesarean section rate in the post-study period (7.1%) compared to those in the study (0.4%) and pre-study (0.7%) periods".

They conclude that "A change in obstetric practice was identified that may explain the continued reduction in the incidence of birth trauma and birth asphyxia related to instrumental deliveries in the post-study period."

Chinese women are informed about pelvic floor disorders

Add into the mix the fact that Chinese women learn about the potential risk of pelvic floor damage with vaginal delivery (during antenatal appointments), and is it any wonder that the country has higher than average rates of maternal request cesareans?

There are scores of studies that demonstrate the protective benefit of planned cesarean delivery (even WHO admits in its 2010 survey that for 3rd- and 4th-degree perineal tears, "as expected caesarean section had a protective effect compared with vaginal delivery (data not shown)".

That WHO chose not to reveal the data is questionable in itself...

Other influential studies

Here are just five medical studies that might influence women's birth choice in China:

*2008 Beijing (120 women) concluded that pelvic organ prolapse (POP) prevalence is significantly higher after vaginal delivery than cesarean
*2008 Hong Kong (259 at 6 months postpartum) found that 24% of women changed from preferring a planned VD to an preferring an elective cesarean after their first birth
*2007 Beijing (3,750 women) concluded that selective cesarean delivery is safer than induction and spontaneous onset of labor (lower neonatal asphyxia and birth trauma) but costs the most
*2004 Beijing (548 women) concluded that cesarean delivery decreases the risk of urinary incontinence and big babies increase the risk
*2002 Taiwan (275 women) concluded that following cesarean delivery, women had a significantly higher level of positive psychosocial outcomes than after vaginal delivery - possibly due to the normalizing effect of such a high cesarean birthrate and greater social support

WHO makes wholly unsubstantiated conclusion

Despite the facts above, in the WHO's latest survey of nine Asian countries, its researchers conlcude: "To improve maternal and perinatal outcomes, caesarean section should be done only when there is a medical indication."

Yet its own findings report:
*There were no maternal deaths in this group.
*There were no cases of neonatal mortality up to hospital discharge.
*There were no cases of hysterectomy.
*Only infants delivered by antepartum cesarean had a significantly lower risk of fetal death than those born vaginally.

It also admits:
*The calculated odds ratio might overestimate the risk of caesarean section."
*"some outcomes might therefore have been underestimated, especially for women delivering vaginally”

Chinese cesarean birth date concern

Most Chinese women only have one baby (reducing the risk of future surgeries), and if you think about the fact that studies have shown an increased risk of emergency cesarean with larger maternal weight, bigger babies and smaller stature, while other studies have shown an increased risk of infant asphyxia, trauma and injuries with a trial of labor, should people really be so shocked and surprised that the country's cesarean rate is so high?

And does anyone have the right to criticize those women who make the legitimate decision to request and plan a cesarean birth?

The real concern is the reported incidences of women choosing a "lucky" date for the birth of their child. If this birth date occurs after the recommended 39th gestational week is reached (i.e. women make a choice between 3 or 4 days falling within the recommended period for lung maturity), then it is not an issue, but to risk premature birth unnecessarily is surely indefensible.


Marcy said...

Hi, I wanted to clarify something. It sounds as if you're saying those first studies on infant trauma and asphyxia conclude that those complications have decreased in ALL deliveries in China, in spite of the high c-section rate. However if you read the abstracts for the studies carefully:

"There was a significant reduction in the incidence of birth trauma and birth asphyxia related to instrumental deliveries during the study period (0.6%) when compared with that (2.8%) in the pre-study period... The instrumental delivery rate decreased during the study period. The caesarean section rate for no progress of labour, the incidence of direct second stage caesarean section and the incidence of failed instrumental delivery did not increase during the study period"

It sounds like they were only looking at trauma directly related to "instrumental deliveries" (separate from c-sections). It then only makes sense that if the number of instrumental deliveries goes down, the trauma/complications FROM those kinds of deliveries would also go down. Maybe I'm confused, but it doesn't look like those studies even looked at complications from c-sections themselves.

For the record, I fully support every mother's right to make her own decisions about where and how she wishes to birth her child. But, that decision needs to be made after carefully weighing all the risks and benefits of all options. C-sections do have some benefits, but they also include some serious risks (especially for women planning future pregnancies)

cesarean debate said...

Thank you for your comment, and I agree completely that planned cesareans have serious risks too – just as planned vaginal deliveries do. The point I was making in this blog is that one of the reasons there have been a reduction in complications related to instrumental vaginal deliveries in China – since there are now fewer of them – is likely to be at least partly because of the increase in planned cesarean deliveries. Studies don’t necessarily have to be a direct comparison of different birth types (vaginal versus cesarean) in order for us to be able to draw conclusions about what is happening in a given population of births. China’s planned cesarean rate has been increasing and its instrumental vaginal delivery rate (and the trauma for babies and women resulting from this) has been decreasing. I believe that these two facts are not coincidental. Others may disagree. I hope that helps clarify things.

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