Tuesday, March 16, 2010

Science should guide decisions on your health

I've just read and posted comments on this online article by Roger W. Harms, M.D. of the Mayo Clinic. This is what I've said:

I am a firm advocate of women 'looking to scientific information to inform their decisions', but I think it's also important to be aware of flaws that exist in the presentation of some cesarean data, and I would offer the following reports as evidence of a recent example where this has occurred:

*30 Jan 10 Nigel Hawkes: A bad case of bias against Caesareans, Independent
*26 Jan 10 Funny Figures from WHO on Caesareans, Straight Statistics
*12 Jan 10 Study advises against non-medial cesareans but how accurate is the advice?

When bias against surgery 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’s had a maternal request cesarean, yet there are thousands from women who planned vaginal deliveries (this is also backed up by research such as a 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 cost and resources. 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 UK’s 2004 NICE guideline discusses one cost model in which ‘maternal request would lead to savings’ (not that I’m suggesting this as 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.

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