Tuesday, June 29, 2010

Finally: The news media reports on WHO's lack of evidence for a 15% cesarean rate threshold

Great news! Today in The Times, you can read the report "Pressure off to cut Caesarean births as ‘myth’ of too many demolished", written by Helen Rumbelow and David Rose.

As readers of this blog will know, ever since I first wrote an article in October 2009 about the WHO's quiet admission in its 2009 handbook that "there is no empirical evidence for an optimum percentage or range of percentages" for cesarean deliveries, I have been trying to get the information made more public.

A press release with my colleagues at the Coalition for Childbirth Autonomy in October 2009 was published on the Medical News Today website (causing great controversy at the time), as was our original official call for evidence from the WHO in October 2008, but until today, the news had really not reached a wider audience.

I hope that this Times article will be the catalyst for an open debate about the true risks and benefits of all birth plans, and an understanding that arbitrary cesarean rate targets in any country is both dangerous and unethical.

Monday, June 28, 2010

My natural birth wrecked my body - one woman's story

The story below appeared on the BBC News website last week, and I wanted to post it here in its entirety as an example of the terrible reality of childbirth that some women endure. That is not to say that this story should scare women away from giving birth vaginally if that is what they would like to do, but when informing women about the risks and benefits of ALL delivery types, I think that it is unethical if we fail to mention the possibility of pelvic floor problems such as incontinence and prolapse.

BBC News story: "It should have been the most perfect day of Nicki James-Eyer's life.

Just three hours after her first contraction the flight attendant gave birth to Jessica.

It had been the natural birth Nicki had expected, but the strain on her body had been intolerable.

Within six months she was faecally incontinent and over a decade later Nicki, from South Glamorgan, is still having problems.

Taken seriously

"As she was my first baby, I didn't really know what to expect after the birth. But a few weeks later I could hardly walk," said Nicki.

Her doctor was unsympathetic and simply put it down to the birth.

Over the next three months she saw a number of GPs who dismissed her concerns.

Finally she was diagnosed with a prolapse of the bowel and given surgery, but this left her incontinent.

"I was just 31-years old having what should have been the time of my life. I had just got married, I had a baby, and then my life just fell apart.

"It was horrendous."

Further surgery

She had further surgery in 2000 to enlarge her rectum and solve the incontinence and for a while things were better. She even managed to have a second child by caesarean.

But in 2006 she suffered a bowel infection and now needs further surgery, and her incontinence continues.

"I think childbirth is not the natural thing everyone says it is. There are problems that can happen and I think that people don't talk about them - women's bits and poo are taboo.

"My birth was very simple, so I should not really have had any problems, but nobody knows what is going to happen putting your body through that.

Up to one in every 10 new mums, like Nicki, have bowel problems as a result of childbirth.

But many do not know that they can get help, or where to go.

Common problems

Mr Charles Knowles, consultant colorectal surgeon, agreed that problems after childbirth were more common than expected.

"As many as one in 10 may have some degree of problem.

"Problems as severe as those experienced by Nicki are fortunately rare but there are few studies that have surveyed just how widespread such problems are."

He said the body was put under severe pressure.

"A number of changes occur to the pelvic floor muscles in late pregnancy due to the physical pressure of the baby. These combined with any trauma (tears or episiotomy) that may occur during delivery can result in weak sphincter muscles and laxity of the pelvic floor causing problems of incontinence."

Deborah Gilbert of the charity Bowel and Cancer Research said: "Childbirth is the commonest cause of faecal incontinence worldwide.

"The frequency of occurrence of incontinence and the problems that it causes for the thousands of women who suffer it are greatly underestimated because they are either too embarrassed to come forward or because they feel that doctors will be unable to help them.

"We are making the first steps to identifying the scope of the problem by running a survey for women on our website."

"We urge anyone who is suffering in this way to visit the site and complete the survey which we hope will lead to better service provision for women like Nicki in future."

€4.25m award over claim of birth negligence - no cesarean

This article appeared in The Irish Times last Wednesday [my bold]:

"A Severely disabled young man has secured €4.25 million in settlement of his High Court action over alleged negligence in the circumstances of his birth at a Cork hospital. The settlement is without admission of liability.

Dermot Moylan, Firville, Mallow, Co Cork, now aged 20, suffered severe mental and physical injuries as a result of his brain being deprived of oxygen shortly prior to his birth and will require lifelong care, it was claimed.

Through his mother Anna Moylan, Mr Moylan had sued the Southern Health Board; Erinville Hospital, Western Road, Cork, and two doctors – David Jenkins of Erinville Hospital and John McKiernan of the Cork Clinic, Western Road, Cork.

He claimed the defendants were negligent and breached their duty of care towards him during his birth at the hospital on the morning of August 7th 1989.

Mr Justice Iarfhlaith O’Neill said yesterday he was “more than happy” to approve the settlement offered.

In his claim, it was alleged the defendants failed to take measures including early delivery by Caesarean section which would have prevented him suffering injuries.

It was claimed that due to alleged negligence, a disruption to the child’s blood supply in the course of labour was not detected and, as a result, his brain was deprived of oxygen causing damage to his nervous system.

It was further claimed that despite the detection of an irregular heartbeat following his mother’s admission to the hospital, the defendants failed to take appropriate action.

The defendants had denied the claims.

Recommending acceptance of the settlement offer, Denis McCullough SC, for the plaintiff, said Ms Moylan was admitted to Erinville Hospital at about 3am on August 7th, 1989, and Dermot was born at approximately 7.17am.

As a result of a lack of oxygen to his brain, Dermot suffered brain damage and epilepsy, it was claimed. He has limited learning skills, mobility problems and attends a care centre five times a week, the court was told..."

Cesareans and baby immunity

You may have read about a new study that investigated the different types of bacteria found in the mouths of babies born by cesarean and vaginal delivery. I'm not going to write too much about it here, as I blogged about a similar subject earlier this year (infection and asthma), but also because I think there is a very useful website that summarizes the details very well without the need for me repeating them here.

"NHS Choices" begins:

"Children born by caesarean section are more likely to have allergies, such as asthma, because they pick up less “natural immunity” from their mother, The Daily Telegraph reported.

The story is based on a small laboratory study which investigated whether the mode of delivery affected the type of bacteria found on 10 newborn babies. Babies born by normal vaginal delivery were found to have types of bacteria that mainly resembled those found in their mothers’ vagina, while those delivered by caesarean had microbes normally found on the skin surface.

This study provides a useful contribution to our knowledge of the possible effects on babies of having a caesarean rather than vaginal delivery. However, on its own, the study is too small to offer any conclusions about the exposure of newborns to particular types of bacteria at birth, and has no implications for the long-term health of babies delivered by caesarian. Another drawback is that it did not look at any other possible differences between the mothers or their babies that may have contributed to the differences in types of bacteria, such as the use of antibiotics. As the researchers say, longer-term, larger studies are needed."

The only thing that I would add is this.

Even IF studies in the future turn out to be conclusive in establishing a link between cesarean delivery and infection and /or asthma - and even IF that link is established with maternal request cesareans at 39+ weeks' gestation too (i.e. not a link with ALL cesareans including babies born in emergency conditions or prematurely due to medical issues during pregnancy), as an expectant mother, I would still weigh this risk against other (albeit small) risks to babies that are associated with a planned vaginal delivery (e.g. stillbirth, asphyxia, shoulder dystocia), and I would personally, still choose to have a cesarean delivery.

Saturday, June 12, 2010

UK Health Secretary promises broader childbirth choice

On the 8th June 2010, the Rt Hon Andrew Lansley CBE MP, Secretary of State for Health, set out his ambition for "patient-centred care".

I really don't wish to speak too soon, but I can't help feeling very excited about the tone and content of the Health Secretary's comments on maternity care, and in particular, choice for women.

For too long, maternity groups in the UK have been obsessed with focusing on choice in terms of where a woman gives birth - at home, in hospital, in a midwifery-led unit - and women like me have been crying out to have our voices heard too.

HOW (e.g. vaginal or cesarean delivery) we give birth and WITH WHOM (e.g. midwife or obstetrician) are equally valid choices. See what you think when you read the extract from Lansley's speech below, and rest assured that I will be following this up and continuing my campaign to ensure that a woman's legitimate decision to have a planned cesarean at +39 weeks' gestation is one day supported throughout all NHS hospitals.

"And what about the relationship of information to choice? The expectation of choice has been a feature of maternity services going back to Julia Cumberlege’s 1993 report, “Changing Childbirth”. But choosing between a home delivery, a midwife-led service and an obstetric delivery is a limiting concept of choice.

Mothers-to-be should have information about the different aspects of maternity care including choices of location, but also issues like pain-relief, choice of providers as well as risk assessments – because not all choices will be appropriate or safe for all women. They should have the ability not only to compare key aspects of care, like continuity of midwifery support and one-to-one midwifery support in labour; but they should also be able to see what other mothers’ experiences have been and to hear their views of the safety and quality of care.

Mothers must have this information not only to exercise choice when originally booking their maternity care, but to be able to be in control of their childbirth, exercising safe choices at each stage.

Because, like that process of choice, listening to patients is at the heart of what we should be doing.

And listening to patients – asking, reporting, and learning from patient experience – will be of great importance in designing and improving services, including achieving greater efficiency. Just look at the high levels of patient-reported satisfaction in productive wards."

He concludes:

"Reform has stalled. Targets have trumped quality. On too many key areas our health outcomes lag behind our European neighbours.

We need change. We need to set the service free to deliver high-quality care, based on evidence of what works. Accountable for results. Answerable to informed and engaged patients. Focussed on what matters most to those patients – safe, reliable, effective care. The best care for each patient and the best outcomes for all patients.

That is my ambition, and I have been delighted today to be able to share it with you.

Thank you."

Friday, June 11, 2010

Maternal Request is Scientifically Credible and Ethically Legitimate

"At last an article that uses an 'intention to treat' type of analysis to show that primary caesarean section on maternal request is not only ethically legitimate but also has some scientific credibility. This article has demonstrated that, for healthy primiparous women, planned caesarean delivery decreases maternal morbidity whilst, not surprisingly, emergency caesarean section increases maternal risks compared with both vaginal delivery and primary elective caesarean section."

Full story:

Maternal Outcomes Associated with Planned Vaginal Versus Planned Primary Cesarean Delivery. F1000: "Changes Clinical Practice"
Geller EJ, Wu JM, Jannelli ML, Nguyen TV, Visco AG. Am J Perinatol 2010 Mar 16

Commentary from Faculty Member John Svigos
26 April 2010, Faculty of 1000 Medicine

Changes Clinical Practice: There is insufficient evidence to refuse a woman her legitimate right both ethically and now scientifically to request an elective primary caesarean section at 39 weeks gestation.

At last an article that uses an 'intention to treat' type of analysis to show that primary caesarean section on maternal request is not only ethically legitimate but also has some scientific credibility. This article has demonstrated that, for healthy primiparous women, planned caesarean delivery decreases maternal morbidity whilst, not surprisingly, emergency caesarean section increases maternal risks compared with both vaginal delivery and primary elective caesarean section.

The National Institutes of Health (NIH) statement re caesarean delivery on maternal request in 2006 that there was insufficient evidence to evaluate fully the benefits and risks of elective caesarean delivery[1] stimulated many workers to try to find this elusive evidence. Most studies before and after this statement and until the publication of this article were fundamentally flawed by including outcomes from emergency and elective surgeries in women (and babies) with pre-existing medical conditions and not including in the vaginal delivery group those that did not deliver vaginally and their respective morbidity and mortality. Additionally, there was a tendency to place more emphasis on caesarean morbidities such as haemorrhage and infection and less emphasis on the more commonly occurring post-delivery pelvic floor dysfunction and pain. The continued use of morbidity/mortality statistics from primary caesarean for breech presentation as the surrogate for caesarean section on maternal request can no longer be justified and is positively misleading if one analyses the paper by Liu et al.[2] Furthermore, the most recent paper by Lumbiganon et al.[3] after detailed analysis demonstrates the bias directed against the proposal of primary elective caesarean on maternal request. Whilst there has been considerable emphasis placed on examining maternal morbidity and mortality in this context, it would seem that the study by Hankins et al.[4] has reassured most practitioners that perinatal morbidity and mortality is not compromised and indeed may be improved in women requesting elective caesarean section at 39 weeks gestation. I believe that there is now a legitimate case for women to request elective caesarean section at 39 weeks gestation and that, as responsible obstetricians, we should be striving to reduce the number of caesarean sections in women who do not wish to have a caesarean section, particularly increasing our resolve against the flawed Term Breech Trial and the impaired retrospective studies favouring elective caesarean section for twin pregnancies and giving these women a choice to deliver vaginally!

Also see:

Maternal Outcomes Associated with Planned Vaginal Versus Planned Primary Cesarean Delivery. Geller EJ, Wu JM, Jannelli ML, Nguyen TV, Visco AG. Am J Perinatol. 2010 Mar 16. Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology.

"We compared maternal morbidity between planned vaginal and planned cesarean delivery. A university hospital's database was queried for delivery outcomes. Between 1995 and 2005, 26,356 deliveries occurred. Subjects were divided into two groups: planned vaginal and planned cesarean delivery. This was based on intent to deliver vaginally or by cesarean, despite actual route of delivery. Planned vaginal delivery included successful vaginal delivery and labored cesarean delivery intended for vaginal delivery. Planned cesarean delivery included unlabored and labored cesarean delivery and vaginal delivery intended for cesarean. Chart abstraction confirmed the delivery plan. Primary outcomes were chorioamnionitis, postpartum hemorrhage, and transfusion. Secondary outcomes were also measured. A subanalysis compared actual vaginal delivery, labored cesarean delivery, and unlabored cesarean delivery. There were 3868 planned vaginal deliveries and 180 planned cesarean deliveries. Planned cesarean delivery had less chorioamnionitis (2.2% versus 17.2%), postpartum hemorrhage (1.1% versus 6.0%), uterine atony (0.6% versus 6.4%), and prolonged rupture of membranes (2.2% versus 17.5%) but a longer hospital stay (3.2 versus 2.6 days). There were no differences in transfusion rates. For healthy primiparous women, planned cesarean delivery decreases certain morbidities. Labored cesarean delivery had increased risks compared with both vaginal delivery and unlabored cesarean delivery."

Neonatal outcomes associated with planned vaginal versus planned primary cesarean delivery. Geller EJ, Wu JM, Jannelli ML, Nguyen TV, Visco AG. J Perinatol. 2010 Apr;30(4):258-64. Epub 2009 Oct 8. Division of Urogynecology and Reconstructive Pelvic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7570, USA.

"Objective: To determine whether planned route of delivery leads to differences in neonatal morbidity. Study design: Analysis was based on planned route of delivery, not actual route of delivery. A total of 4048 subjects were divided into two groups: planned vaginal delivery and planned cesarean delivery. Primary outcomes were neonatal intensive care unit (NICU) admission, respiratory morbidity and neurologic morbidity. Result: There were 3868 planned vaginal and 180 planned cesarean deliveries. Planned vaginal delivery had decreased NICU admission... Conclusion: Planned vaginal delivery led to more meconium passage and low 1 min Apgar but less NICU admissions, oxygen resuscitation and jaundice. Multicenter trials are needed to assess rare but serious outcomes based on planned route of delivery."

Thursday, June 10, 2010

Special needs risk: 4.7% at 39 weeks and 4.4% at 40 weeks

There is a great deal of publicity in the media at the moment regarding a Scottish study that has investigated the risk of a baby developing special educational needs if it is born too early. In particular, conclusions are being drawn along the lines of how this new data should be used to inform women planning an elective cesarean.

I agree - HOWEVER - let's inform women properly and honestly.
This is the comment I submitted to Medical News Today this morning:

Difference is actually negligible

The presentation of the results of this research is very misleading, particularly in relation to the risks associated with cesarean delivery at 39 weeks’ gestation.

This is the actual percentage of children with SEN by gestation of delivery

37 weeks - 6.1%
38 weeks - 5.4%
39 weeks - 4.7%
40 weeks - 4.4%
41 weeks - 4.1%

As you can see, the difference between 39 and 40 weeks is negligible; the higher risk is present in the 37th and 38th week, which we know from other research increases other risks for babies too, such as respiratory distress.

The collective risk of all babies at 37-39 weeks is being used to disparage the legitimacy of choosing to deliver your baby at or after 39 weeks (many doctors, my own included, advise delivery at 39 and a half weeks with maternal request - i.e. during the 40th week).

Three final points worthy of note:

The authors state that while it's reported that early term births (at 37-39 weeks) account for 5.5% of SEN cases and preterm deliveries account for 3.6% of cases, this is because of the higher numbers of babies born between 37 and 39 weeks.

In the population of children studied (407,503), just 16.2% were born by cesarean delivery; therefore I would argue that the risk of SEN is just as likely, if not more, with a planned vaginal delivery (where Mother Nature decides on the gestational age or delivery is induced)
as a planned cesarean at or after 39 weeks.

The relatively small percentage of cesareans includes both planned and emergency surgeries, thereby further reducing the data pool of the very delivery type that such stark warnings are being given in reports like this one.