Do cesareans increase the risk of celiac disease?

In a Reuters' report this week on new cesarean research, the headline at least asks the question, 'Do c-sections increase the risk of celiac disease?', but unfortunately, many more media reports and blogs are stating that there IS a significant association between the two, and no doubt it'll soon start to appear on lists of 'reasons why women shouldn't choose a cesarean.'

Probably not
This is what I took away from the report. Firstly, as always, it's a good idea to take a look at the research yourself (click here), and if celiac disease is a particular risk that concerns you (e.g. perhaps it already affects a family member), you might want to get hold of a copy of the full text of the research.

Secondly, from what I can ascertain, the research involved children who had been delivered by ALL types of cesarean delivery - including both planned and emergency surgery - so as always, it's very difficult to make a judgment about how much women having planned cesareans need to worry.

Thirdly, the report states that Dr. Daniel Leffler, director of clinical research at the Celiac Disease Center at Boston's Beth Israel Deaconess Medical Center, said that "many of the children's mothers may have had undiagnosed celiac disease. Given that celiac disease can be inherited, and that undiagnosed celiac disease increases the risk of cesarean section, undiagnosed disease 'would be more than enough to explain the increased number of cesareans'. Enough said.

Identify celiac disease in women
It's worth reading the report yourself of course, but personally, I'm not convinced that this reported increased risk (28% versus 19%) is specifically related to planned cesareans on maternal request in otherwise healthy pregnancies, and I think the most important message we should take from Dr. Leffler's research is this:

The results "may mean we need to be looking for celiac disease in young women who want to become pregnant... He noted that when celiac disease is treated with a gluten-free diet, the risk for cesarean section is no higher than for the average woman. Untreated celiac disease, Leffler added, can have effects on the fetus as well, including slowing its growth and a higher risk of premature birth."

Cesareans on the rise in Iran

In this online report a member of Supreme Council of Islamic Republic of Iran Medical Council (IRIMC) warns about the risk of a rising maternal mortality rate in line with a rising national cesarean rate.

The report does not specify what the cesarean rate is or what the split is between elective and emergency.

$18.5m New Jersey payout for delayed cesarean

This story is yet another example of how much a planned vaginal delivery can cost (physically, emotionally and financially). Yet this is rarely, if ever, factored into delivery cost comparisons.

Largest in NJ's history
On April 29, 2010 an Essex County, New Jersey jury awarded a verdict of $18.5 million in a medical malpractice case against an obstetrician who delayed a C-section while the baby was in fetal distress.

This is believed to be one of the largest birth injury cerebral palsy lawsuit recoveries in New Jersey history.

Recently, I read an article that asked, "Why is the cesarean rate so high in New Jersey?".

Mmmm...

Further treatment restrictions on NHS caesareans

I've just come across this outrageous news from Derbyshire - that treatment restrictions are being imposed as management looks to reduce NHS costs.

Apart from the issue of maternal request cesareans in healthy pregnancies, which continue to be a thorny (and misunderstood) issue within large parts of the NHS, this report states that cesareans "will not be routinely offered to women who have hepatitis, are pregnant with twins, have small babies or go into an early labour".

A concerned grandmother made some good points in the comments section, and this is what I've just added:

The news about caesarean delivery here is outrageous and unethical.
Why should a woman (even one with a healthy pregnancy) be forced to give birth via a TRIAL of labour?

Policy makers in the NHS constantly fail to see the obvious when they attempt cost-cutting.

Litigation following obstetric complications, the overwhelming majority of which are an outcome of a planned vaginal delivery and NOT a planned caesarean delivery (see the NHSLA website), costs the NHS more money than any other area of health litigation. Furthermore, injuries to babies and mothers during vaginal delivery (spontaneous and assisted) and emergency caesareans have to be treated, both in the short-term and the long-term (e.g. pelvic organ prolapse), yet these associated treatment costs are never included in cost comparison analysis.

Research has shown that at 39+ gestational weeks, it is safer for a baby to be born via planned caesarean delivery than to undergo a trial of labour – and while this will not be every woman's choice, for those whose choice it IS, they should not be refused on the basis of ill thought out cost-cutting efforts.

This is a disgrace, and one I continue to fight against.

Response to Lamaze International on U.S. maternal deaths

This week, the U.S. organization Lamaze International issued a press release titled: 'Despite International Decline, Maternal Deaths a Growing Concern in U.S.'.

It states that women can reduce their risk of dying by using healthy birth practices, and lists these 'Six Healthy Birth Practices' as such:

*Let labor begin on its own
*Walk, move around and change positions throughout labor
*Bring a loved one, friend or doula for continuous support
*Avoid interventions that are not medically necessary
*Avoid giving birth on your back and follow your body's urges to push
*Keep mother and baby together; it's best for mother, baby and breastfeeding

Also in the press release, Lamaze International points to the use of cesarean surgeries or induction without a distinct medical need as increasing the risk of death and injury in childbirth.

The Reality
However, aside from one sentence in the press release that suggests women try to be 'as healthy as possible prior to getting pregnant', there is no acknowledgment of some of the biggest challenges facing maternity care in the U.S. (and indeed many other developed world countries).

Namely: 'OVERWEIGHT', 'OBESITY', 'MATERNAL AGE' and 'BIRTH WEIGHT'.

As long as birth groups like Lamaze continue to ignore these elephants that are sitting squarely in the majority of antenatal rooms, we are never going to help reduce maternal mortality rates. Yes, the U.S. spends a huge amount of money on maternity care and yes, we would expect to see that translate into record low rates of maternal mortality.

Let's be honest
But the fact is that doctors across the country are battling with maternal characteristics that previous generations simply didn't have to. Women are older, women are fatter and women are less ready for LABOR (the definition of which is not always appreciated) than their ancestral and developing world counterparts.

We can have all the money in the world, but if women themselves are not healthy to start with, pregnancy and delivery is going to be more difficult - and indeed more dangerous.

We need to be HONEST with women about their chances of achieving a spontaneous vaginal delivery, and we also need to remember that if a healthy woman WANTS a cesarean delivery, she should not be dissuaded using mortality and morbidity data that is entirely unrelated to her particular circumstances.