Worrying mahurat cesarean trend in India

'Are you planning a mahurat C-section?' asks Zeenia Baria in The Times of India today.

Baria reports on a worrying trend for some planned cesareans in India, and that is the decision by couples to insist on a particular time and date for the birth of their babies. It's unclear from the report whether parents are being influenced within days or weeks of their advised delivery date, but if it's the latter, this can mean serious health consequences for a newborn baby (e.g. respiratory distress).

"Obstetrician, Gynaecologist and infertility specialist Dr Faram Irani says... “Unlike the West where women request for a c-section because of the pain associated with vaginal birth or fear of damage to the pelvic floor; in India many c-sections are performed on the basis of mahurat..."

What do they hope to achieve?
"Longevity, health, marital harmony, career prospects, eclipses and domestic peace of the offspring are the biggest motivators for such couples. The astrologer formulates the most auspicious time for delivery after asking the would-be parents for the tentative delivery dates, place, time zone and DST (daylight saving time). Due to the astrological factors involved, the mahurat differs for every couple. Although they cost more than double, deliveries at sunrise are among the most auspicious."

"Gynaecologist Dr Rishma Pai Dhillon says that the trend of having mahurat babies or a planned caesarean section on an auspicious date, is getting increasingly popular among patients and is giving doctors a headache because it comes with its share of complications.

“I recently had to rush to the hospital at an unearthly hour to deliver a mahurat baby. If one refuses, one is flooded with phone calls from senior politicians and affluent bureaucrats to oblige. Mahurat babies or mahurat c-section is a controversial trend that middle and upper class women across the country are increasingly opting for. It involves planned deliveries and surgical caesarean sections in the hopes of having babies on a specific date and time predicted lucky by their astrologers. Families are so particular about the exact time of delivery that they create a ruckus if the previous surgeon is delayed in the operation theatre. This puts tremendous stress on doctors. It isn’t fair to hurry up such a delicate procedure,” she says.

“The reasons for having a mahurat baby are often credulous. One patient’s astrologer said that if her child was delivered at the right time, it would be a fair-skinned boy, who would look after his parents in their old age. How can the time of delivery change a baby’s gender, which is decided at conception itself!” asks Dr Pai.

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.

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.

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."

Calculating 39 weeks for a full-term cesarean is a shared responsibility

Numerous studies have stressed the importance of planning a cesarean delivery after 39 weeks, and despite accusations to the contrary, I don't believe that obstetricians are arbritarily scheduling surgery ahead of this date unless there is an indicated medical need (either for the mother or the baby). That is - despite the risks of respiratory distress with preterm births, there is a greater risk of (for example) the baby or mother dying if it remains in utero any longer.

I also don't believe that the vast majority of women choosing a cesarean - despite accusations to the contrary - would urge their doctor to deliver their baby early for convenience, vanity reasons or to bring an end to their pregnancy.

Blame game
But now a study, reported in the media on Friday, suggests that one possible reason behind the U.S.' climbing pre-term delivery rate is that 'Many Women Miscalculate Time to Full-Term Birth'.

The report continues: 'When asked, "What is the earliest point in pregnancy that it is safe to deliver the baby, should there not be other medical complications requiring early delivery?", more than half chose 34 to 36 weeks, 41 percent chose 37 to 38 weeks and less than 8 percent chose 39 to 40 weeks.

However, experts warn that any delivery short of 39 weeks puts a baby at higher risk of respiratory distress, sepsis (blood infection) and needing to be placed in the neonatal intensive care unit, according to background information in the study. Only one-quarter of new moms realized 39 to 40 weeks was safest.'

Education, Access to Early Ultrasound and Less Confusion please
For what it's worth, here are my suggestions for improving this situation:

1) Educate women that when it comes to planning a cesarean delivery, the ideal gestational age is 39 weeks. Ideally, that means taking responsibility for recalling your last menstrual cycle date before you became pregnant - not always possible or indeed accurate, but the more information a doctor has at hand for calculating your gestational age, the better.

2) Arrange an early ultrasound. This is easier said than done sometimes - and you, your doctor, your hospital, and if applicable, your insurance company, must all take responsibility for this. With my second pregnancy, one of the hospitals I was going to go to said they didn't do the first ultrasound until 12 weeks, but my OBGYN insisted that I had it done earlier because research has shown that the most accurate calculation of gestational age can be made during an early ultrasound (read more here).

3) Stop confusing women by quoting data from medical studies with 'full-term' gestational ages described as 34 or 37 weeks one minute, and then 39-40 or 41-42 weeks the next. Women could be forgiven for not knowing the definition of 'full-term', especially in the context of planned cesarean delivery, because there is so much confusion in the presentation of planned cesarean risks and benefits in any case.

For example, when natural birth advocates want to highlight respiratory distress problems in babies born via elective cesarean, they will frequently include studies that invlude 'full-term' getational ages much earlier than 39 weeks. Equally, they are less inclined to present data from medical studies that have found greater fetal demise post-39 weeks.

Delivery at 39 weeks is optimal - for the baby's sake, we should all be working together to make sure that wherever possible, this date is reached.

39 is the magic number

It's been the recommended time of delivery for cesarean-born babies for many years now, but a new study has reiterated the importance of waiting until confirmed 39 weeks gestation before commencing surgery. Tita et al's American study, 'Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes', concludes that "Elective repeat cesarean delivery before 39 weeks of gestation is common and is associated with respiratory and other adverse neonatal outcomes."

What the research found
The researchers "studied a cohort of consecutive patients undergoing repeat cesarean sections performed at 19 centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network from 1999 through 2002. Women with viable singleton pregnancies delivered electively (i.e., before the onset of labor and without any recognized indications for delivery before 39 weeks of gestation) were included. The primary outcome was the composite of neonatal death and any of several adverse events, including respiratory complications, treated hypoglycemia, newborn sepsis, and admission to the neonatal intensive care unit (ICU)."

"Of 24,077 repeat cesarean deliveries at term, 13,258 were performed electively; of these, 35.8% were performed before 39 completed weeks of gestation (6.3% at 37 weeks and 29.5% at 38 weeks) and 49.1% at 39 weeks of gestation. One neonatal death occurred. As compared with births at 39 weeks, births at 37 weeks and at 38 weeks were associated with an increased risk of the primary outcome... The rates of adverse respiratory outcomes, mechanical ventilation, newborn sepsis, hypoglycemia, admission to the neonatal ICU, and hospitalization for 5 days or more were increased by a factor of 1.8 to 4.2 for births at 37 weeks and 1.3 to 2.1 for births at 38 weeks."

Obviously, some of these early deliveries are necessitated due to emerging or pre-existing medical conditions (either with the mother and/or the baby), but certainly wherever possible, doctors advise waiting until 39 weeks to deliver.

Breathing difficulties are worse PRIOR TO 39 weeks gestation

This new study from Norway is a perfect example of how the risks associated with cesarean delivery are not necessarily relevant in a comparison of risks and benefits between planned vaginal delivery and planned cesarean delivery in healthy pregnancies with no medical indication in countries that follow the medical guidelines of waiting until 39 confirmed gestational weeks before performing surgery.

In Torkil et al's study, 'Cesarean section is associated with more frequent pneumothorax and respiratory problems in the neonate', the authors demonstrate that among 5,957 cesarean deliveries (20.3% of all 29,358 deliveries) between 2001 and 2005, "among the 26,664 neonates born at term (≥37th gestational week), 4,546 were delivered by CS (17.0%), of whom 0.5% by elective and 0.6% by emergency CS with NP [neonatal pneumothorax]. The incidence of diagnosed NP was significantly higher after CS than after vaginal delivery [0.6% vs. 0.10%]... In addition, the need for MV [mechanical ventilation] was significantly increased [0.41% vs. 0.19%] but use of CPAP [Continuous Positive Airways Pressure] was not [0.28%vs. 0.15%]."

This simply confirms recommendations by ACOG and the NIH (among others) to wait until confirmed 39 weeks getstaional age before scheduling planned cesarean deliveries. The respiratory outcomes for babies at 39 weeks are greatly improved and therefore this study should not be used as an argument against cesarean delivery on maternal request in healthy pregnancies.

Medical intervention halves incidence of brain-damaged babies

A new report by Lisa Hitchen, and published in the BMJ, says that following the 2000 introduction of mandatory annual training for all staff at the maternity unit at North Bristol NHS Trust, deaths and brain damage among newborn babies have fallen considerably.

Between January 1998 and December 1999, 27.3 infants per 10,000 births were born with brain damage, and 86.6 infants per 1000 births needed resuscitation at birth. But after the introduction of the new surveillance methods (between January 2001 and December 2003) these rates were halved.

Staff are trained in "the interpretation of electronic fetal monitoring" and must complete "forms for reporting the number of infants that needed resuscitation at birth and the incidence of severe hypoxic-ischaemic encephalopathy". The hospital also developed "a surveillance system to detect periods when standards slipped."

Special note: In the abstract available on 12th December, it reads that the number of babies born with brain damage fell from 27.3 infants per 10,000 to 13.6 per 1,000 births. Clearly, one of these 'per 1,000/10,000' is a misprint, since the number is said to have halved.

Non-medical cesarean delivery should wait until 39 weeks EGA

This is not new news, but today's Science Daily report on new research into the risks of late pre-term births is a useful reminder that the safest time to deliver a baby by cesarean delivery is at confirmed 39 weeks gestation in order to ensure that the baby is fully developed.

I have no doubt that this research will be misinterpreted by some bloggers and used to criticize women who choose to have a cesarean delivery with no medical indication. But on the contrary, what it actually shows is that non-medical cesareans at 39 weeks are in fact far safer for the baby than other types of cesarean deliveries (i.e. emergency and planned medical surgeries).

What the research found
Petrini et al's research, 'Increased Risk of Adverse Neurological Development for Late Preterm Infants', "evaluated the babies’ neurological development and found that late preterm babies were more than three times as likely to be diagnosed with cerebral palsy as full term babies. They also found that late preterm babies were at an increased risk for developmental delay or mental retardation."

But commenting in the article, editorialist Dr. Michael Kramer of McGill University said that "the increased risks may not always come from early delivery itself, but from other underlying problems, such as gestational diabetes, that may lead to early delivery."

This last remark emphasizes why 'general' reported risks associated with cesarean deliveries are not always applicable to planned cesarean deliveries with no medical indication in healthy pregnancies, and should not be used as an argument to prevent birth plan autonomy.

Asthma has NOT been specifically linked with non-medical cesareans

Virtually every media outlet has reported on the latest study from researchers in the Netherlands, 'Asthma at 8 years of age in children born by cesarean section', in which Roduit et al found an increased prevalence of asthma in children who were born via cesarean delivery. Before I talk about the research itself, I'd just like to point out the biggest misunderstanding of the findings by some reporters. Here is an example:

On December 2nd, Angus Howarth, writing in The Scotsman, began his report with the sentence: "WOMEN who choose to give birth by Caesarean section should be warned it could almost double their baby's chance of developing asthma, researchers said today."

In fact it is ALL pregnant women that should be warned of the risk, including those who choose to give birth vaginally. Why? Because the researchers looked at children born via ALL TYPES of cesarean delivery (e.g. emergency, medical and non-medical), and therefore the risk is actually applicable to all birth methods.

Limitations of the research
The best place to read a more balanced review of this research is here, at the NHS' Behind the headlines website. It reports that: "The study has some limitations, including the broad method it used to diagnose asthma which may not be accurate. In addition, the researchers did not consider several factors known to raise the risk of asthma such as smoking in pregnancy. Further research is needed. Asthma has a range of potential risk factors, both genetic and environmental, but it is unlikely that its sole ‘cause’ is mothers having a caesarean section."

Previous research has found NO LINK between childhood asthma and cesarean delivery
*In 2005, researchers in the U.S., Juhn et al, published 'Mode of delivery at birth and development of asthma: a population-based cohort study.' They followed all children born in Rochester, Minn, between 1976 and 1982, determining the mode of delivery from their birth certificates, and asthma status during the first 7 years of life was ascertained from comprehensive medical record reviews. They found that: "The cumulative incidence rates of asthma among children who were born by cesarean section and vaginal delivery were 3.2% versus 2.6%, 4.6% versus 4.6%, 4.6% versus 5.8%, and 5.7% versus 6.7% at the 1st, 3rd, 5th, and 7th years of life, respectively. The adjusted hazard ratios for cesarean section in predicting asthma and wheezing episode were 0.93 and 0.93 respectively." They concluded: "Mode of delivery is not associated with subsequent risk of developing childhood asthma or wheezing episodes. Because the effect of mode of delivery on a risk of developing asthma or wheezing episodes varies over time (ie, age), selection of the study subjects according to their ages may have influenced the findings of previous studies with a shorter follow-up period."

*In 2004, researchers in the UK, Maitra et al, published 'Mode of delivery is not associated with asthma or atopy in childhood.' The study selected 12,367 children born to mothers resident in a defined area and delivered in one of two major obstetric hospitals between 1991 and 1992, of which 10,980 (88.8%) were delivered vaginally and 1387 (11.2%) by caesarean section. Primary outcomes were parental report of asthma or wheezing between 69 and 81 months of age, physician-diagnosed asthma (PDA) at 91 months of age and atopy at 7 years by skin prick testing. They concluded: "Delivery by caesarean section was not associated with the subsequent development of asthma, wheezing or atopy in later childhood in this population."

But what about the recent Norwegian study that DID find a cesarean/asthma link?
It is true that earlier this year, that in another study, 'Cesarean Section and Risk of Severe Childhood Asthma: A Population-Based Cohort Study', researchers Tollånes et al "found a moderately increased risk of asthma in the children delivered by CS." However, they also write in their conclusion that: "The possibly stronger association with emergency CS compared with planned CS could be worth pursuing to investigate possible causal mechanisms."

Why? Because in their study of 1,756,700 children born between 1967 and 1998 and followed up to age 18 years or the year 2002, those born via emergency cesarean delivery had the greatest risk of asthma. "The prevalence of asthma was 2.3% in the women who delivered by CS, 1.9% in those who had instrumental vaginal delivery, and 1.4% in those who had spontaneous vaginal delivery." This clearly demonstrates (given that the majority of emergency cesareans occur as an outcome of planned vaginal delivery) that healthy women planning cesarean deliveries should not be 'warned' about the risk of asthma any more than other pregnant women.

What else should I know about this latest study from the Netherlands?
The points below are taken from the NHS Knowledge Service's conclusions:
*Asthma is always difficult to diagnose in children. The criteria for diagnosing asthma in this study were broad, and likely to introduce some inaccuracy in the numbers categorised as having asthma. The wheezing and shortness of breath recorded in this study do not necessarily mean that the child has asthma, as they are extremely common in childhood and particularly during viral infections.
*Researchers adjusted their analysis for risk factors related to asthma but several known risk factors were not adjusted for. These include childhood viral infections, smoking during pregnancy and around the child, and number of people living in the house. As highlighted by the results, parental allergy did have considerable effect upon risk estimates.
*The proportions of children born by caesarean section, or who had asthma were relatively small (8.5 and 12.4% respectively), which reduces the power of statistical tests, particularly in the further analysis of subgroups that was conducted.
*Only 70% of children who were included at the beginning of the study completed the eight year follow up and were included in the analysis. The reliability of the results may have been greater had more children completed follow up.
*Women have caesarean sections for many different reasons, including emergencies. The reasons behind having a caesarean delivery may be an important factor in why asthma develops. Possible reasons for any association between childhood asthma and caesarean section have not been clarified by this study and still require further research.

Background info on the Dutch study: 2,917 children participated in a birth cohort study and were followed for 8 years. In total, 12.4% (362) of the children had asthma at the age of 8 years. Cesarean section, with a total prevalence of 8.5%, was associated with an increased risk of asthma, and this association was stronger among predisposed children (with one or more allergic parents) than in children with non-allergic parents. The association between cesarean section and sensitization at the age of 8 years was significant only in children of non-allergic parents.

Premature delivery rather than cesarean surgery itself increases respiratory illness risk

Unfortunately, I haven't been able to view an abstract or full text of the latest study by Borgwardt et al on respiratory illness in babies born by cesarean, but given the Danish study's title, 'Elective caesarean section increases the risk of respiratory morbidity of the newborn', the conclusion drawn is perhaps evident.

It will be interesting to find out what the gestational age of the babies involved in the above study were, but just in case there is any similarity with that of the well-publicized Anne Kirkeby Hansen et al study, I would like to re-emphasize what I said then.

Planned cesarean delivery with no medical indication is only advisable at 39 weeks confirmed gestation
This is in order to ensure that the baby's lungs are fully matured, since numerous studies have found that the lowest prevalence of respiratory morbidity occurs at 39 weeks gestation or more (some studies actually state that 38 weeks is acceptable, but the NIH and ACOG advise 39).

With the 2007 publication of Anne Kirkeby Hansen et al's study in the British Medical Journal, a number of responses followed, of which mine was one: 'Further evidence of reduced infant morbidity with cesarean delivery on maternal request at 39 weeks EGA.' This response explains in more detail why early gestational age, rather than surgery itself, increases the risk of respiratory illness in newborn infants.

New study finds no allergy risk for cesarean born babies

A Norwegian study involving more than 500 children has found no increased prevalence of childhood allergies in babies born via cesarean delivery. Bente Kvenshagen et al begin by stating the theory that is most often expressed by researchers who believe there is such a link: That cesarean born babies "do not get the same contact with their mother's gut flora as babies delivered vaginally. Theoretically, lack of exposure to maternal vaginal and perineal bacteria might change the gut flora, with secondary changes in the immune system."

However, of 512 children at the age of two (171 delivered by cesarean and 341 born vaginally), those reported to have symptoms consistent with possible food allergy were examined at the outpatient clinic, and there "was no over representation of children born by caesarean section."