Saturday, January 30, 2010

Independent: 'A bad case of bias against Caesareans'

...says Nigel Hawkes, director of Straight Statistics, writing in The Independent today. More fallout from the WHO survey, 'Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007-08'; this time published by a national newspaper, so hopefully it might reach a wider readership.

Article highlightsOn cesarean maternal mortality and morbidity
"So how many women died? None. How many suffered complications? Eight: five needed treatment in an intensive care unit (ICU), and three needed a blood transfusion. The risks for women who completed a normal birth were significantly higher. One in a thousand died, five times as many required a blood transfusion, and twice as many were admitted to an ICU.

Overall, if deaths and complications are added up to make a "Maternal mortality and morbidity index", risks to mothers in the Caesarean group were 60 per cent lower than in the normal birth group.

So how, from this, does the team conclude that risks to mothers who have Caesareans are actually 2.7 times greater? There's a hefty difference between 60 per cent smaller and 270 per cent greater, but statistical manipulation is a powerful tool."

On babies born by planned cesarean..."And what about the babies? Those born by elective Caesarean without medical indications were seven times less likely to suffer death or complications (raw data) or less than half as likely if you believe the corrected data. Understandably, the authors don't make much of this."

On the WHO's final conclusion and The Lancet's role as publisher"Did none of the 23 think this an odd conclusion to have reached? Did no one check the arithmetic in the tables, which are full of errors? The Lancet is a distinguished journal - were its referees asleep?"

Friday, January 29, 2010

Three cheers for Professor Steer (BJOG Editor-in-Chief)

In May 2009, the British Journal of Obstetrics and Gynaecology editor-in-chief, Professor Philip Steer, is quoted in a wonderful article on the BBC News website, supporting a woman's decision to give birth surgically in preference to opting for a trial of labor. In it, he describes cesarean delivery as "a rational choice."

He doesn't say that all women would or should make this decision; rather, he defends their logic for doing so. Of course it is unfortunate that his views have not been taken on board by many of the NHS Trusts in England and Wales - quite the opposite according to the women who email me describing the difficulties they are having in trying to arrange a cesarean birth - but nevertheless, it takes a brave professional to speak out on this issue in the current political climate, and I for one, would like to applaud his efforts.

Below are just a few extracts from the BBC article, but you can read it in full here.

"Until as recently as the 1930s, maternal mortality around the globe was horrendous. In the early 1930s, one in 250 women in UK who became pregnant would die as a result - the same as in India today... Advances in the technology of surgery, anaesthesia, blood transfusion and antibiotics have so dramatically improved outcomes in developed countries that mortality is now one in 10,000 or fewer...

"You would think that these technological advances would be greeted with universal acclaim, but many women see childbirth as an essential "rite of passage" and exhort others of their gender to eschew technological assistance (is this "the female macho"?)...

"In BJOG (an international journal of obstetrics and gynaecology), the majority of valid science we publish goes unnoticed by the mass media. But publish something about home-birth, and we are guaranteed to get onto the national news. The discussions that ensue are repetitive, predictable and fail to distinguish emotional wish-lists from practical reality.

"Delivery by Caesarean section now accounts for almost a third of all births in many developed countries, and is remarkably safe - certainly as safe as many of the cosmetic operations that do not excite similar criticism. And yet many still argue against allowing women the autonomy to choose their mode of birth, either on spurious economic grounds or by suggesting that "birth is natural so we mustn't become dependent on technology". Without the technology of agriculture, transport, housing and energy generation, how many of the world's population would survive?"

Mother cut 'like meat' by midwife during home birth

I usually steer clear of stories related to home birth; as far as I'm concerned, it's simply another birth method that happens to be on the opposite end of the choice spectrum to my own (planned surgery), and as long as a woman is fully informed of the risks and has not been medically advised against it for the safety of her unborn child (e.g. the pregnancy is deemed high risk), then I respect her choice.

I just had to blog about the story that appeared on the BBC News website this week though, because the outcome for mother and child were so devastating. You can read it here.

High risk, high price - physically and financially
What stands out for me is the fact that the independent midwife attending the home birth had no insurance, and it reminded me of a programme I heard on Radio 4's Woman's Hour once (I think it was last year...), which discussed how independent midwives find it difficult to arrange insurance for home birth deliveries because insurance providers consider the event too high risk.

The irony for me is that women choosing cesarean delivery on maternal request are often accused of wasting tax-payers' money, and yet when the cost of litigation and subsequent surgery for babies and mothers following planned vaginal delivery morbidity (whether the birth is in hospital or at home), the truth about which delivery plan costs the NHS more money is different to what many people might think.

Wednesday, January 27, 2010

British research: C-sections 'do not affect how long a mum breastfeeds'

The BBC reports today on new British research that suggests: "Having a Caesarean or instrumental birth does not appear to impact upon how long a mother breastfeeds".

In a study of 2,000 mothers who received breastfeeding support (conducted by the University of Manchester and East Lancashire Primary Care Trust), there was also "little association with how soon after birth the baby was put to the breast", but what "did have an impact was ethnicity, and the number of previous births,".

Maternal request breastfeeding study
This is good news for women planning a cesarean delivery birth, and indeed there are a number of studies that indicate positive breastfeeding experiences are more likely to follow positive birth experiences (regardless of whether the birth is vaginal or cesarean).

However, in the interests of balance, and since the above research focuses on breastfeeding longevity, I would remind readers of a Swedish study - specifically looking at women following cesarean delivery on maternal request - that found these women "were breastfeeding to a lesser extent three months after birth" when compared with a vaginal delivery group.

Voluntary end to breastfeeding?
I guess the other question to ask in these types of studies is whether the cessation of breastfeeding is voluntary or not. Anecdotally for example, I breastfed my first child for 3 months, but was not distressed by switching to 100% formula at that time, and in fact with my second child, I chose not to breastfeed; it had nothing to do with my delivery method.

Incidentally, the 2007 Swedish study I refer to, 'Cesarean section on maternal request: reasons for the request, self-estimated health, expectations, experience of birth and signs of depression among first-time mothers', by Wiklund et al, also found that:

"After planned cesarean section women in this group reported a better birth experience compared to women planning a vaginal birth ."

63 surgical instruments sewn up inside New Jersey hospital patients

I came across this report by Mike Ferrara on (21 Jan), and this is what caught my eye:

"When it comes to patient safety, it’s important to note New Jersey ’s record: doctors, nurses and other health care staff committed 9,381 preventable medical errors in 2007. Sixty-three times, a foreign object was left inside a patient’s body after surgery. (The expected number is zero.) Doctors and health care workers caused preventable injury to more than 900 women during a vaginal birth requiring forceps or other instruments."

I don't deny that medical errors occur during cesarean surgery too; of course they do - but how often do we really think about the huge number of women that suffer preventable morbidity during a vaginal delivery? How often is it reported in the media?

This is 900 women in New Jersey in 2007. How many women and how many preventable injuries have there been throughout the whole United States - not to mention the UK, Canada and Australia? These are injuries that many women who choose cesarean delivery are seeking to avoid (myself included).

Inquest: death of baby occurred after difficult birth

These stories are always heart-wrenching, and one of the reasons I post them here on my blog (aside from highlighting that planned vaginal delivery is entirely unpredictable and often mismanaged) is to demonstrate that when a baby dies or is injured, it's not just a 'number' in a set of 'mortality data'.

It's the child of a real-life mother and father. The mother carried the baby inside her for nine long months, looking forward to the day she and her husband would meet their son or daughter, only to experience a personal loss and devastation only barely imaginable by anyone else.

In this case, Georgina O'Halloran writes in The Irish Times how:
"The poor condition at birth of a baby boy who died as a result of brain damage due to lack of oxygen “would be best explained” by “issues” which occurred during labour and delivery...

Baby Nathan Molyneaux of Columbas Place, Tullamore, Co Offaly, was born at Portlaoise General Hospital on July 27th, 2008 in poor condition. He never recovered and died seven days later of brain damage due to lack of oxygen to the brain, known as hypoxic ischaemic encephalopathy, at the Coombe hospital, Dublin on August 2nd, 2008. The death was not reported to the coroner’s office at the time and no postmortem was carried out...

Dublin City Coroner’s Court heard there were variable decelerations - temporary drops in the foetal heart rate - during the first stage of labour, with a prolonged second stage and a difficult delivery with a number of attempts... There was no evidence of any pre-existing abnormality of the brain or heart to explain the baby’s condition at birth..."

Newborn's arm cut during C-section, dies

This is a terrible story from India; the article in Hindustan Times explains how:

"In an apparent case of negligence by doctors, a newborn died after his arm got cut during a C-section delivery at a government hospital in Udaipur. Ranjit Meghwal, a resident of Kelwara town in Rajsamand district, about 100 km from Udaipur, alleged that the doctors at Pannadhay Hospital accidentally cut the arm of the baby while conducting the caesarian on his wife Babli, 25, on Wednesday. The baby's condition became critical on Friday and he was put on artificial respiration. However, at 8 p.m., he was pronounced dead."

As readers of my website will know, I list 'human error' as one of the risks of cesarean delivery - even planned cesarean delivery. The competence of any medical team looking after you is vital, and while I am as horrified by the above story as anyone else, I'd like to think that the risk of something like this happening in the UK, Europe, North America or Australia (for example) is extremely low.

Funny Figures from WHO on Caesareans

Yesterday, statistician Nigel Hawkes wrote the first journalistic article I've seen that exposes the truth about the recent WHO cesarean survey. I'm ecstatic! Writing for the website Straight Statistics, in 'Funny Figures from WHO on Caesareans', Hawkes firmly concludes:
"The findings should be ignored."

Basic premise for comparison was all wrong
Hawkes agrees with the point I made in my blog on 12 January, that (aside from the incorrect interpretation of data), using spontaneous vaginal delivery as the survey 'reference' is irrelevant. He writes:
"One final point: the comparison they make is an unfair one. The proper comparison to have made would be between women who attempt a natural birth, and women who have an elective Caesarean.
Many of those who set out to have a spontaneous birth fail, for one reason or another, and require intervention. By choosing only those who succeed and ignoring the others, the authors are failing to make their comparison on an “intention to treat” basis.

The Lancet's role in publishing the WHO's survey
Hawkes not only questions the WHO's erroneous interpretation of its own data, but also the role of the survey's reviewers. It is unclear whether he is referring to the researchers' review of their own data prior to submitting it to The Lancet, or The Lancet's review prior to accepting the text for publication, but the question he raises is valid either way:
"“The most important finding of the survey is the increased risk of maternal mortality and severe morbidity which was analysed as a composite outcome in women who undergo Caesarean section with no medical indication”, write the authors. “We conclude that Caesarean section should be done only when there is a medical indication to improve the outcome for the mother and the baby.”
Their data do not bear such a conclusion. The statistical analysis is almost certainly where the error arose. Did no referee raise the alarm?

Undeniable BiasHawkes writes: "WHO believes too many Caesareans are done without proper cause. But in interpreting these data, the authors appear to have bent over backwards to prove the point – a classic illustration of White Hat bias."

Data actually shows that cesarean delivery is safer than vaginal delivery"The records showed just 1,515 of these deliveries were by Caesarean section chosen in advance without medical indications to justify them. The vast majority (1,356) were in China; the other countries had very low numbers.
Of these 1,515 women, none died. Five were admitted to an intensive care unit (0.3 per cent) while three (0.2 per cent, though the figure published in the paper is 0.3 per cent, presumably a mathematical error) needed a blood transfusion – a total of eight out of 1,515. None required a hysterectomy.
In mothers who had vaginal deliveries, these risks were all greater: for spontaneous vaginal delivery 0.1 per cent of mothers died, 0.6 per cent were admitted to an ICU (the paper says 0.5 per cent, another miscalculation) and 1.0 per cent required a blood transfusion. A small number, 0.04 per cent, (though I make it 0.05 per cent) required a hysterectomy.

FYI (because I didn't know about it until I read this article today):-Straight Statistics is a pressure group whose aim is to detect and expose the distortion and misuse of statistical information, and identify those responsible. It has been formed by a group of legislators, statisticians and journalists, chaired by the Labour peer Lord Lipsey.

I may be accused by some as being an advocate for cesarean delivery at the expense of vaginal delivery, but the truth is, I'm an advocate of informed birth decisions, and I believe that in order for women to have access to worthwhile information in making their birth decisions, I need to continue working hard to expose the outrageous bias that exists in much of the medical and media reporting of cesarean delivery. I'm glad to have discovered today that Straight Statistics exists, and that its statisticians have confirmed my concerns about the WHO's motives.

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.

Friday, January 15, 2010

Interviewed on Beijing's 'Today' radio show on elective cesarean

At 2am this morning I was involved in a one-hour discussion on elective cesareans with CRI Beyond Beijing's Flagship News Magazine. The 'Today' news programme was exploring the reasons for such high rates of elective cesareans in China, and also talking about the risks and benefits of planned cesarean delivery versus planned vaginal delivery.

It was presented by Chris Gelken and Qinduo Xu, and I was interviewed alongside two other panelists, Dr Chen Zhe, Chief Resident Doctor and Obsterician from Renmin Hospital, and Prof Lynn Callister from the School of Nursing at Brigham Young University.

To listen to the programme, click here.

Tuesday, January 12, 2010

Study advises against non-medical cesareans but how accurate is the advice?

I am utterly perplexed by the conclusions drawn in this latest report from the World Health Organization, 'Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007-08, Lumbiganon et al', but not in the least bit surprised.

[Note added 7 February 2010]
Further to my blog below, the following two articles have been published:Nigel Hawkes: A bad case of bias against Caesareans, The Independent, 30 Jan 2010Funny Figures from WHO on Caesareans, Straight Statistics, 26 Jan 2010

It's bad enough that the presentation of data is skewed in order to make planned vaginal delivery appear safer than it actually is, but the authors have decided to single out "the increased risk of maternal mortality and severe morbidity" in cesarean deliveries with no medical indication as the "most important finding of the survey".

Pregnant women and ALL JOURNALISTS - I urge you to please read the study in full and make up your own mind about which delivery type is the most risky.

If you don't have time, here are some extracts from the study that you won't see in today's media reports:

*The authors write: "Our study has some limitations. First, we had information about mortality and morbidities only until discharge from hospital; some outcomes might therefore have been underestimated, especially for women delivering vaginally who are usually discharged earlier than women having caesarean section."
This is important because damage to the pelvic floor (both in the short- and long-term) leads to physical and psychological trauma, financial costs and hospital readmissions that this study completely ignores. It also ignores the huge cost of litigation that can follow vaginal delivery complications.

*"The calculated odds ratio might overestimate the risk of caesarean section. Although we had adjusted for many potential confounding factors, there might be some other factors that we did not have information about and could not adjust for."
An admission of underestimating vaginal delivery risks and overestimating cesarean delivery risks - and yet this is ignored in the conclusion, perhaps because it does not suit the authors' own birth ideology.

*"Second, data were abstracted from the patients' records. We were not able to confirm the absence of some of the risk factors if they had not been recorded.
This is an issue that has been written about by doctors in the past (and indeed critics of studies such as this) because there may well have been medical indications for some of the 'without indications' cesarean group, and these were simply missing from the patients’ records. This would adversely affect the results for this group; again, potentially causing an over-estimation of its risks.

*"Third, our survey included only hospitals with caesarean facilities having 1000 or more deliveries every year. The results therefore cannot be generalised to smaller facilities."
In the UK especially, some of the highest numbers of cesarean delivery on maternal request occur in small, private hospitals. It is also worth noting here that the quality of hospital care in countries like the UK, USA, Canada and Australia (e.g. infection control through prophylactic antibiotics) may be of a higher standard than some of the regions's hositals included in this study.

*The conclusions drawn about poorer outcomes with cesarean delivery with no medical indication are "analysed as a composite outcome (the maternal mortality and morbidity index)".
This is crucial - because depending on what researchers include in such an "index", this will affect comparative results. Here is what the WHO's index includes:

"We assessed the association of each maternal outcome of death, admission to ICU, blood transfusion, hysterectomy, and mortality and morbidity index (which was defined as the presence of at least one of: maternal mortality, admission to ICU, blood transfusion, hysterectomy, or internal iliac artery ligation); and perinatal outcomes of perinatal mortality, fetal deaths, neonatal mortality up to hospital discharge, stay in neonatal ICU for 7 days or longer, and perinatal mortality and morbidity index (defined as the presence of perinatal death or stay in neonatal ICU for 7 days or longer)"
Notice what is missing: for example, pelvic floor damage; urinary and fecal incontinence; postpartum sexual health; long-term injuries to babies such as Erb's Palsy; psychological outcomes; degree of birth satisfaction. All of these potential birth outcomes are relevant in a truly 'informed' birth risk-benefit analysis, and for many women, they may have a lower tolerance for these risks than the risks associated with planned surgery.

*Referring to planned cesareans without indications, the WHO writes: “The findings for the individual outcomes that make up the composite outcome suggest that the increased risk is mainly attributable to increased admission to ICU and blood transfusion. Although we acknowledge that both ICU admission and blood transfusion depend on the availability of those services and the potentially differing thresholds for giving blood and for admission of women to ICU or referral to higher levels of care, this outcome is nevertheless important.”
This is important because effectively, it is the high occurrence of just two risks within the WHO’s “composite” and self-appointed “index” that leads to this type of cesarean delivery ending up with such a high overall negative score by the end of the study. This has occurred in previous studies too – namely, the 2006 Deneux-Tharaux et al study.

Which delivery type do YOU think has the most risks?

FYI, the study’s data is separated into six birth categories:

- Spontaneous vaginal delivery (reference category)
- Operative vaginal delivery
- Antepartum (before labor) cesarean delivery with indications
- Antepartum (before labor) cesarean delivery without indications
- Intrapartum (during labor) cesarean delivery with indications
- Intrapartum (during labor) cesarean delivery without indications

“Risk of perinatal mortality was significantly increased compared with spontaneous vaginal delivery in infants born by operative vaginal delivery and intrapartum caesarean section with indications. Only infants delivered by antepartum caesarean section with indications had a significantly lower risk of fetal death than those born vaginally, whereas risk of fetal death did not differ significantly for other methods of delivery compared with spontaneous vaginal delivery. For neonatal mortality up to hospital discharge, infants born by operative vaginal delivery, antepartum caesarean section with indications, and intrapartum caesarean section with indications had significantly increased risk compared with spontaneous vaginal delivery. We recorded no cases of neonatal mortality up to hospital discharge for women delivering by caesarean section without indication, and the risk compared with spontaneous vaginal delivery could not be estimated.”

“Infants born by operative vaginal delivery and intrapartum and antepartum caesarean section with indications had significantly increased risk of stay for 7 days or longer in neonatal ICU compared with spontaneous vaginal delivery. Operative vaginal delivery and antepartum and intrapartum caesarean section with indications had significantly increased risk of perinatal mortality and morbidity index. For breech and other abnormal presentation, caesarean section with indication, either antepartum or intrapartum, significantly reduced risk of perinatal mortality but had significantly increased risk of stay in neonatal ICU for 7 days or longer.”

“For maternal mortality, only operative vaginal delivery had significantly increased risk compared with spontaneous vaginal deliveries. The risk for antepartum caesarean section without indication could not be estimated because there were no maternal deaths in this group. Operative vaginal delivery and all types of caesarean section had significantly increased risk of admission to ICU compared with spontaneous vaginal delivery. Operative vaginal delivery, antepartum caesarean section with indications, and intrapartum caesarean section with and without indication had significantly increased risks of blood transfusion compared with spontaneous vaginal delivery. The risk of hysterectomy was increased in mothers who delivered by operative vaginal delivery, antepartum caesarean section with indications, and intrapartum caesarean section with indications. We recorded no cases of hysterectomy in women who delivered by antepartum caesarean section without indications and intrapartum caesarean section without indications, so the risk could not be estimated. Operative vaginal delivery and all types of caesarean section were associated with significantly increased risk of maternal mortality and morbidity index compared with spontaneous vaginal delivery. Intrapartum caesarean section (both with and without indications) had higher risk of maternal mortality and morbidity than did antepartum caesarean section. Deliveries by all types of caesarean section had significantly increased risks of maternal mortality and morbidities except for perineal tears of third and fourth degree, for which as expected caesarean section had a protective effect compared with vaginal delivery (data not shown).”

In summary:
There are NO RECORDED NEONATAL OR MATERNAL DEATHS following cesarean deliveries without medical indications – yet this is absent from the study’s conclusion. Why?

There are NO RECORDED CASES OF HYSTERECTOMY following cesarean deliveries without medical indications - yet again, this is absent from the conclusion. Why?

Cesarean delivery PROTECTS AGAINST SEVERE PERINEAL TRAUMA – yet not only is this fact absent from the conclusion, the researchers decided not to omit the data from its public report entirely. Why?

The WHO uses “spontaneous vaginal delivery” as its comparative “reference” in this study. This in itself is nonsensical. The data is going to be used to advise pregnant women about different risks during the PLANNING stage of their births - not once the birth is over. The problem is, a spontaneous delivery can never be absolutely predicted or guaranteed. Even the healthiest woman with the healthiest pregnancy can suffer a physically and psychologically traumatic labor involving instrumental assistance and ultimately surgical delivery. Therefore, the WHO should have compared birth PLANS – i.e. compared all planned vaginal deliveries (and their ultimate mortality/morbidity outcomes) with all planned cesareans (with and without indications). That said, even with the current vaginal delivery bias, I think it’s clear from the extracts above that maternal request cesareans fair better in the study than the conclusion would have us believe.

The WHO insists that “Assisted vaginal delivery represents a high-risk situation, and combination of such deliveries with spontaneous vaginal deliveries as the reference group might not be appropriate.” Firstly, we know that operative vaginal delivery does NOT always represent a high-risk situation. But even if I accept that argument, other comparative studies frequently mix the data of planned cesareans with and without medical indications, and then compare them in a negative light with vaginal delivery outcomes (and these studies are cited in WHO reports). Perhaps a fairer approach in the WHO's study (or as an additional footnote) would be to compare ALL vaginal delivery outcomes (incl. operative and emergency cesareans) with ALL planned cesarean outcomes (incl. with and without indications groups)?


**Advocates of vaginal delivery should focus their efforts on improving best practice care for women choosing vaginal delivery, and reducing the number of unwanted cesarean deliveries. They should not concern themselves with women who want a cesarean delivery. Numerous medical studies demonstrate high levels of post-birth satisfaction in women who choose a cesarean delivery and I think it’s unethical to try to stop these women enjoying a birth plan that is their legitimate choice.
Millions of women throughout the world plan to have a spontaneous delivery but you only have to look at any birth trauma website to see that many of these plans result in unhappy, traumatic stories of physical and psychological damage. From what I can see (both in studies and in emails I receive from women), those of us that choose cesareans are a generally happy bunch in terms of our birth outcome, and with the clocks turned back, would make the exact same birth decision all over again.

**The WHO is not entirely reliable in terms of making recommendations on cesarean delivery. Back in 1985 it suggested that national rates of cesarean delivery should maintain an upper limit of 15%, and then finally (after much insistence from critics, including the CCA), in its 2009 handbook it admits that "no empirical evidence for an optimum percentage" exists, an "optimum rate is unknown," and world regions may choose to "set their own standards." You can read more about this here.

**There have been a large number of media reports on this study, and what concerns me most is that if perhaps even journalists don’t have time to read a study in full (and in fairness, many don’t), then it’s unlikely that readers of their newspapers will read the study in full either. Therefore, we are in danger of effectively ‘misinforming’ whole nations of women about the true risks of different birth types. Here are a few examples:

Rebecca Smith writes for The Telegraph:
Perform caesarean deliveries only where medical problem: researchers’… Hospitals should only perform caesarean sections if there is medical problem and not just because women simply choose the procedure because they are 'too posh to push', experts said.

Bella Battle writes for The Sun:
Cesareans a ‘risk’ to mums’… MUMS dubbed 'too posh to push' were given a stark health warning on caesareans today.

Emily Cook writes for The Mirror:
Don't have a caesarean unless it's essential, warms news study’…Mums to be should only give birth by caesarean when strictly necessary, insists a new study.

Some of the reports do provide criticism of the WHO’s study, but this tends to come further down in the page. The Telegraph for example notes that “experts in Britain said the study was conducted in Asia and so was not as relevant to practice in Britain. They said the findings had been 'over sensationalised'.” For example, Dr Virginia Beckett, spokesman for the Royal College of Obsestricians and Gynecologists, said: "These findings are actually quite reassuring for women opting for caesarean sections. They found that three in 1,500 women who had a c-section without medical indication before labour needed a blood transfusion and I would expect elective caeseareans to be even safer in Britain… "There are some very big conclusions drawn from some very small numbers.”

**This study is relatively small; an analysis of just 107,950 deliveries throughout nine countries - Cambodia, China, India, Japan, Nepal, Philippines, Sri Lanka, Thailand and Vietnam, and is receiving maximum media exposure in the UK, Australia and North America. Yet where are the vast swathes of media reports on studies like the ones I’ve cited in this blog in the past or in the various press releases I've written (highlighting very positive health outcomes with maternal request cesareans) - many of which are conducted in countries far closer to home than Asia?

I don’t necessarily blame the media here; after all, a powerful natural birth ideology PR machine ensures its message gets reported, but isn’t it time that more journalists looked afresh at the easy target of ‘too posh to push’ mothers and consider for just one second an alternative truth – that these women are in fact making educated and informed decisions about their babies and their bodies?

And while I’m on my soapbox, could the natural birth lobby get busy making suggestions about how we deal with the extremely challenging maternal landscape that obstetrics has to deal with in the developed world – namely, mothers giving birth at increasingly older ages and with heavier body weights, and babies being born larger and heavier too. It’s all too easy to seek a reduction in cesarean rates by trying to encroach on my right to plan the birth of my choice, but what are your plans to encourage a reduction in the number of unwanted cesareans? Do they include an uncomfortable discussion on issues such as earlier parenting or pre-pregnancy weight loss? Your responsibility lies more in counseling women about vaginal delivery risks – help them achieve the delivery of their choice and allow me, and other women like me, to enjoy our own personal choice.


The WHO reports that the “most important finding of the survey is the increased risk of maternal mortality and severe morbidity [analysed as a composite outcome using the maternal mortality and morbidity index] in women who undergo caesarean section with no medical indication.

And it concludes that to “improve maternal and perinatal outcomes, caesarean section should be done only when there is a medical indication.

Well, I find myself heading to bed now and still wondering, how on earth can WHO researchers conclude from the data results above that a planned cesarean delivery with no medical indication is any more risky than a planned vaginal delivery? And moreover, how can it claim that of all the data it accumulated in nine countries, that this particular finding was "the most important"?

What about the risks associated with operative vaginal delivery? What about the protective benefit of a planned cesarean with regards third and fourth degree perineal tears? What about the low number of deaths and absence of hysterectomy? What about the positive outcomes with cesarean breech deliveries? Do these areas of risk not warrant our attention?

The WHO’s goal – and that of all true birth autonomy advocates – should be POSITIVE BIRTH OUTCOMES FOR ALL WOMEN in all walks of life. Millions of women and babies continue to die in childbirth despite the WHO’s best efforts, so I would suggest that it focus more on INCREASING cesarean rates for these women and decreasing rates of UNWANTED cesareans for others, and focus less on reducing access for women that WANT cesarean surgery and don't want a trial of labor.

Friday, January 8, 2010

Induced birth research is irrelevant to maternal request cesareans

An article on the Citizens Report website yesterday, 'New Study Warns of Risks from Unnecessary Cesarean Births, and while I don't have an issue with efforts to reduce cesarean rates for women who desperately want to have a vaginal delivery (unless the surgery is needed in order to save the baby's or mother's life), I am critical of reports that make a connection between the term 'unnecessary cesarean' and women who 'choose' cesarean delivery.

My comment on the article
As far as I can ascertain, this research relates to planned vaginal deliveries that were induced (it is stated that the researchers “excluded women who had scheduled or previous cesarean deliveries”). Therefore, it is irrelevant to make a connection between this research and the legitimate decision made by women to plan a cesarean delivery and avoid a trial of labor. The research does not even include the latter type of birth in its analysis.

The advice for women considering a maternal request cesarean delivery is to ensure that they do not have surgery prior to 39 weeks (in order to ensure that the baby’s lungs have developed properly). This research reinforces the established medical opinion that risks are lower for women delivering after 39 weeks gestation.

Hospital readmissions after cesarean delivery - are they really higher than after vaginal delivery?

I've just posted a comment at the bottom of yesterday's Modern Medicine article 'Readmissions After Cesarean Higher Than Vaginal Delivery' because I think that the conclusions drawn - both in the media report and in the medical study itself - are not particularly helpful for women who are deciding which birth 'PLAN' to choose.

The article reports on a new U.S. study by researchers Michael Belfort et al: 'Hospital readmission after delivery: evidence for an increased incidence of nonurogenital infection in the immediate postpartum period', and here are my concerns:

The conclusion reported here (that readmission rates are higher following cesarean delivery than vaginal delivery) is a typical example of the flaws apparent in comparative medical studies – particularly in the U.S. Why? Because the research combines all cesarean outcomes (emergency and elective) together - rather than attributing health outcomes of an emergency cesarean to the planned vaginal delivery it originated as.

Actually, vaginal delivery is a risk factor for readmission
In fact, if you read this study in full, Belfort et al explain: “Potential explanations as to the reason that a primary cesarean section delivery represents a greater risk for readmission than a repeat cesarean delivery may include such factors as increased risk of infection from prolonged labor (repeated vaginal examinations, chorioamnionitis), increased blood loss with emergency surgery, and higher use of general anesthesia.”

So in effect, issues related to the trial of labor and subsequent emergency surgery are risk factors for postpartum readmission to hospital – and the risk of readmission with planned cesareans (even repeat surgeries) is lower.

My concern is that studies like this are used to deter women who request a primary elective cesarean at 39 weeks, when evidently the research has very little to do with their chosen birth plan. Rather, if the data was separated (with readmissions following emergency cesarean attributed to planned vaginal deliveries), it is likely that the reality of these readmissions in relation to the delivery method planned is different to that concluded here.

Balance of risks
In addition to the above, I think it's worth remembering that an emergency cesarean is often carried out in a life or death situation (whether it's the mother's life, the baby's life, or both, that is at risk), and while subsequent hospital readmissions are unpleasant and undesirable, they are certainly preferable to the alternative - mortality or severe morbidity if an emergency cesarean is not carried out.

Thursday, January 7, 2010

Special 'cesarean wing' is opened in Utah hospital

The Standard-Examiner reports that Ogden Regional Medical Center has a new 'first of its kind' wing dedicated solely for women having caesarean-section deliveries.

I think that this is a very exciting development, and I imagine that the women having cesarean deliveries there will enjoy their postpartum surroundings. Obviously, the quality of surgical care in any hospital is of paramount importance, but these efforts to make women feel more comfortable after they've had their surgery should surely be commended.

Comfortable hospital surroundings
In the report, the hospital's marketing director Craig Bielik describes eight c-section/ postpartum suites, single-room maternity care, newborn and transitional nurseries, larger than normal hospital rooms and rooms fully equipped to handle emergencies. In addition, the new C-wing includes flat-screen televisions, Wi-Fi access, a sleeper chair and access to the new Ronald McDonald family room.

I'm sure that I will receive criticism for my interest in this area of hospital provision, but I know that from my own cesarean experiences, I really enjoyed recovering in my own private room. I also enjoyed the fact that I had access to the internet as I was able to send photos of our new children to friends and relatives via email. I could also make outgoing calls on Skype and Google any 'new mother' questions I had in the days following the birth.

Friday, January 1, 2010

Australia: 3.2% of all births are maternal request cesareans

In the first publication on the subject for 2010, researchers Robson et al in Australia have calculated that - even 'using the lowest estimate (8,553 women) in calculations, maternal request [cesareans] accounted for 17.3% of all elective cesareans and 3.2% of all births' in 2006.

'Estimating the Rate of Cesarean Section by Maternal Request: Anonymous Survey of Obstetricians in Australia' concludes that its 'findings support the hypothesis that maternal request cesareans make a significant contribution to the overall rate of cesarean deliveries in Australia.'

Rate expected to increase in future too
Of the 1,239 specialist obstetricians surveyed, it was estimated that between 8553 and 12,434 maternal request cesarean sections were performed in 2006, and the likelihood of specialists agreeing to perform maternal request cesarean deliveries was higher among those who were 10 or less years from qualification.

Of the 317 registered obstetric trainees (residents) surveyed, two-thirds expressed the intention of doing such cesareans in their future practice.

Research background
'The findings of a recent population-based study in Australia suggested that elective cesarean delivery of a singleton pregnancy at term without medical or obstetric indications (cesarean delivery by maternal request) may represent a significant proportion of cesarean births in that country... [read more here].