Finally: WHO admits there is no evidence for a 10-15% cesarean threshold

Here is an extract from my article, "WHO Finally Admits - the 'Optimum Rate [of Caesarean Section] Is Unknown' and 'There Is No Empirical Evidence' for Its 1985 Recommendation of 10-15%", published on freelibrary.com today:-

In its latest 2009 publication, 'Monitoring Emergency Obstetric Care: a handbook', the WHO states that, 'Both very low and very high rates of caesarean section can be dangerous, but the optimum rate is unknown. Pending further research, users of this handbook might want to continue to use a range of 5-15% or set their own standards.'
The statement continues, 'Earlier editions of this handbook set a minimum (5%) and a maximum (15%) acceptable level for caesarean section. Although WHO has recommended since 1985 that the rate not exceed 10-15%, there is no empirical evidence for an optimum percentage or range of percentages, despite a growing body of research that shows a negative effect of high rates.'

Evidently, there is now a degree of ambiguity in what the WHO recommends. It recommends that regions 'use a range of 10-15%' (even though there is no empirical evidence for such a range) or implement their own standards. Consequently, it is perhaps inevitable that different birth advocate groups will take a different view on what the new handbook statement actually means, and arguments over the credibility of an optimum caesarean rate (emergency and/or elective) will continue.

Emergency cesareans more likely for older mothers

I've just been searching the internet to no avail, trying to find the actual Irish study being referred to in this Irish Times article published yesterday by Lorna Siggins. It appears in the European Journal of Obstetrics and Gynaecology and Reproductive Biology, but may not yet be available online.

I wanted to find out what age range 'older women' refers to, but in any case, the conclusion drawn in this new study (led by Professor John Morrison in Galway) should be of interest to many first-time pregnant women because they may 'run a much higher risk of emergency Caesarean section, even if pregnancies are not complicated (my italics)'.

The birth outcomes of 45,000 mothers at University College Hospital between 1989 and 2005 were analysed and advanced maternal age was found to have a 'strong bearing' on the likelihood of emergency surgery.

What does this tell us?
Prof Morrison told The Irish Times: "The findings indicate that the uterus does not work so well in older women, when one takes out the standard factors for epidurals, inductions, etc.” He continues: "There has been a lot of controversy over Caesarean sections, here and abroad, and their increasing frequency."
“The confirmation that age is a key factor in surgery is not because obstetricians are taking an ageist approach. The clear message from this is that age has an impact on ability to deliver normally."

Just as I commented in a recent post about pregnant African American women, what readers decide to do with research like this is a personal choice - and one to be discussed with your own midwife or OBGYN - but certainly for some women, in the light of research like this, the decision to avoid the risk of emergency surgery, and schedule a planned surgical birth instead, is a perfectly legitimate one.

Likelihood of a primary cesarean delivery is greatest for African Americans

Reuters reports, October 2nd, on a new Kaiser Permanente study examining the racial and ethnic disparities that occur with cesarean delivery, and notes that the study found 'disproportionately higher rate of primary c-sections among African-American women'.

The Californian study, Racial and Ethnic Disparities in the Trends in Primary Cesarean Delivery based on Indications, found that 'compared to Caucasian women, African-American women had significantly higher rates of primary CS while the increase in rates among
Hispanic women was smaller'.

What the study found
Further, it is reported that the disparity 'cannot be explained by education, smoking
during pregnancy, when prenatal care began or maternal age at delivery', and the lead author, Darios Getahun, MD, MPH, continues: 'This study underscores the importance of educating expectant women about the potential impact of CS on the outcome of future pregnancies.'

The figures published in the study's Abstract look at percentage increases in the primary cesarean rate, rather than percentage actual occurence, and it is unclear at first glance what women should do with this information. Perhaps the Full Text would prove a more useful read for African Americans - for example, it would be useful to know how many of these primary cesareans were emergency and how many were planned.

What the study tells African American women
This is the big question, and the answer is quite complex. Does the research call for better preparation for and best practice support during labor, in order to increase the likelihood of vaginal delivery? Or does it suggest that, if a women is likely to 'very likely to end up having surgery anyway', perhaps she'd be better having planned rather than emergency surgery?

Obviously, part of the answer can be found in the woman's personal birth preference, if she has one, and also, very importantly, how many children she is planning to have over the course of her life. Because however her primary cesarean occurs, through medical necessity or through choice, it is highly likely that she will go on to have further surgery in future pregnancies, and of course the health risks increase with multiple cesareans.

As a final note, the study results also note that 'Indication subtypes-specific rates of primary cesarean section varied markedly across race/ethnicity', and again, access to the study's Full Text would be useful for these women.

20% of Israeli babies born by cesarean

This is a very short report, with no details on the breakdown of emergency versus elective or planned cesareans, and no context in terms of whether there is a difference in rate in the private sector compared with public hospitals, but informs us that:

"Every fifth child in Israel is delivered by a Caesarean Section operation, according to a report published in the Hebrew-language daily Haaretz."

25.9% of births in Scotland are now cesarean deliveries

Scotland's Daily Record reports today that 15.2% of the 56,821 babies born last year were delivered by emergency surgery, while 10.7% were scheduled for surgery.

Mother's death blamed on failures - £410,000 damages awarded

This story is so distressing to read, and evidently, the hospital have admitted that human error was at fault:

"Joanne Lockham, 45, died at Stoke Mandeville Hospital at Aylesbury in October 2007 during the birth of her first child. She was given a general anaesthetic when the baby's heart rate dropped. The oxygen supply to Mrs Lockham, of Wendover, was not put into her windpipe and she suffered cardiac arrest."

The headline of the updated story today reads: 'Payout over nurse Caesarean death', and is an example of when a caesarean delivery can be publicly associated with high risk.

However, it's important to point out that this was not a planned caesarean, and it was not spinal anaesthesia being used (both of which carry fewer risks than an emergency caesarean with general anaesthetic). This birth was a planned vaginal delivery (PVD) that ended in one of the worst birth outcomes of all.

42% of Canadian obstetricians support maternal request cesarean

A report on a nationwide survey of maternity care providers in Canada has found that 42% of obstetricians support cesarean delivery on maternal request, "even in the absence of a medical indication", "despite a push by their own professional body to "normalize" childbirth and reduce Canada's rising C-section rate."

549 obstetricians, 897 family physicians, 545 nurses, 400 midwives and 192 doulas from across Canada were surveyed in 2008-2009, and here are some of the findings reported:

*42% of obstetricians were in favour of a woman's right to choose a C-section without medical indication
*21% agreed with the statement that a C-section is as safe as a vaginal birth for women
*8% would choose C-section over vaginal delivery for themselves or their partners
*25% of obstetricians and family doctors believed sexual problems and urinary incontinence could be prevented by C-sections
*43% of obstetricians disagreed with the statement, "For a woman, having a vaginal birth is a more empowering experience than delivery by cesarean section."

The study is published in the Journal of Obstetrics and Gynaecology Canada.

Do women choose or consent to caesarean delivery?

You may read the full article here - published 11th September 2009.

Problems pasting text

I have read online that other people have been having this problem with Blogger (and if anyone has any information on how to fix it, please let me know), but currently, I am unable to copy and paste text into my Blog posts.

This makes commenting on articles and studies extremely difficult as I simply don't have time to write the text out manually. Therefore, for the time being, I am just going to post links to news articles and medical studies that I think may be of interest to you in the context of the ongoing debate over caesarean deliveries.

My apologies for this.

Australia: 1 in 4 caesareans by maternal request

You may read the article here - published 11th September 2009 - and the medical study here.

Update on activities

In the time that has passed since my previous post, our family has moved back to the UK from the U.S., which, with a newborn baby and a toddler, has left me too busy even to Twitter!

I have managed to make some progress in my caesarean (it's a different spelling here in England!) work however. For example, as editor of my website, I've been accepted as a Stakeholder for the upcoming review of the 2004 NICE Clinical Guideline on Caesarean Delivery.

I've also contacted the All Party Parliamentary Group on Maternity to request membership to the Maternity Care Working Party, as I feel that women who choose caesarean delivery need a voice in an environment where discussions on maternity care are taking place, and more importantly, where decisions are being made.

So watch this space and I'll let you know how I get on with both of these.

The website
I've also updated my website homepage (although there is still more to do!), and have been keeping busy with email correspondence from ec members with questions, comments and concerns.

Our new baby boy!

It's been over a month since my last blog (I know - sounds more like something you'd hear in a Catholic confessional box...!), but things have been extremely hectic in our lives recently, to say the least, and my blog has had to take a back-seat for a little while.

One of the reasons though is a wonderful one. Our little boy Jack - a gorgeous baby brother for our daughter Charlotte - was born this morning at 9.04am, weighing 8lbs 15oz.

This is 'night one' in the hospital, so I'm looking forward to getting a few hours zzz's starting right about now!

Goodnight all... I'll be back soon...

Cesareans in Cyprus: doctors defend high rates

In her Cyprus Mail report, 'Doctors defend C-sections figures', Alexia Saoulli writes: "Private doctors said last week they had been unfairly lambasted in the press for favouring c-sections over natural births. Recent reports of doctors “blackmailing” women into booking their delivery at convenient times prompted outpourings of outrage from women, government health authorities and lawmakers."

Dr George Leontiades, head of the Gynaecological Association: “If there is one doctor who encourages his patients to have c-sections you can’t make a generalisation that all doctors do it.” ...He said comparing Cyprus’ private c-section rate of 55% to England’s 25% was wrong... In England, in the private sector, the figures are almost as high as Cyprus,” he said.

...Leontiades said there were very many reasons why Cypriot women chose to have caesareans, starting from how affluent the country had become. “Affluence in societies affects c-section demand. Also women have a mistaken understanding of the hardship of labour. They don’t want to be put out. The way they have three cars, a big house and can buy everything in the supermarket, they think they shouldn’t suffer any hardship in bringing a child to life.”

...The doctor said there was also an increasing trend in repeat c-sections. He said most women who had a c-section for their first child wanted to follow the “tried and tested” method and “don’t want to embark on an adventure that will not guarantee they will have spontaneous vaginal delivery”.

...He said some doctors were also afraid of increased cerebral palsy risks during labour despite the fact that only one in 400 developed cerebral palsy, only 10 per cent of which accounted for events taken place during delivery. Nevertheless in a society where women only had one or two children, some doctors preferred not to chance it, he said."

Dr Gabriel Kalakoutis, a Nicosia’s Aretaeio hospital gynaecologist-obstetrician: "said although women were not encouraged to have a c-section, there was greater sensitivity to a woman’s wants. “A lot of women prefer to have a c-section because they are afraid of childbirth and the pain. I’m more prone to take the woman’s feelings into consideration and what makes her feel more psychologically comfortable. C-sections are much safer now, with very small risks and only slightly more dangerous than natural births.”

...Kalakoutis said the attitude that a c-section was a “failed” delivery no longer held true and that if there were medical indications for why one should be performed he no longer insisted on going the natural route.

...“Some women want to have a natural birth and I encourage that. If some are afraid and from the beginning think they want to have a c-section then I am more open to that. I don’t tell them from the beginning that they should have a c-section,” he said.

Numbers of women asking for cesareans in Cyprus
...The gynaecologist said in his experience four out of 10 pregnant women asked for c-sections. He also said culturally women had changed and were having fewer children. “Women have two or three children, not five or six. If they had that many caesareans it would be dangerous but up to two or three is safe,” he said."

Cesareans in Cyprus: why women choose surgery

In her recent report, 'The big question: to cut or push', Alexia Saoulli begins: "Gynaecologists in the private sector have been accused of advocating caesarean sections at times convenient to them and without sound medical reasons, but when you talk to mothers themselves a slightly more complex picture emerges. While some doctors do actively encourage caesareans, all too often it is the mothers themselves who opt for the procedure."

It's certainly worth a read, and below, I've highlighted some of the reasons cited by women who did choose cesarean delivery:

Aileen: “I wanted to have a caesarean. I had one with my second son and it was just so easy that I decided I was going to have another one when I was pregnant with my daughter... You know exactly when your due date is. There’s none of this waiting around for your water to break. You plan it, you set a date, pack your bag and that’s it. A few hours later you’ve got a baby."

Katerina: “I was terrified of natural childbirth. I just couldn’t take the thought of the pain. I then thought that it would be more convenient to know the specific date so that I could have everything ready. I discussed it with my doctor and he agreed to perform a c-section... I don’t regret it for a minute. It was painless and harmless. They say the recovery time takes longer but a friend of mine who gave birth naturally developed an infection after they had to cut her during labour and took even longer to recuperate. I don’t think I could have handled being cut. I just couldn’t bear thinking about it."

Joanna: admitted that she’d asked for caesarean just so that she could have a Virgo baby rather than a Libra. Her doctor did nothing to dissuade her, she said. “I’d heard that Virgo boys are easier going than Libra boys and so I asked to be booked in for a c-section on September 20. My due date was September 22 which was too close to the cusp and I didn’t want to risk it.”

Maria: said her doctor encouraged her to examine her options but was very supportive when she finally decided to go ahead with the c-section. “I was so nervous about the pain. I know some cynics think the doctors are in it for the money, and maybe some are, but my doctor was definitely supportive of me and my decision. She took into account my fear, which was important... A friend of mine said this was because it would be less hassle for the doctor rather than having to talk me through my fear. I don’t know if this is true or not but I’m just glad that my doctor bothered to really listen to me and do what I wanted.”

UK study finds 3% CDMR rate

New research to be published in BJOG "suggests that ‘choice’ may not be the best way to understand women’s decision-making about birth method. The results of the study question the current focus on choice in UK maternity care policy, and challenge prevailing notions about caesarean delivery for maternal request."

You can also read more in these two news articles on the research:
'Pregnant women prioritise safety over choice' and 'Women 'do not choose Caesareans as too posh to push'.

The researchers tracked 454 women at the Liverpool Women's Foundation NHS Trust, and found that by the end of their pregnancies, the number of women still requesting cesarean delivery had fallen to 2%.

Countries where more cesareans are needed

An IRIN news article last week asked the question, 'Can subsidised caesareans cut maternal deaths?'

It explains that some doctors in Benin have begun performing near-free caesareans, and the government is in its first week of helping women pay for caesarean operations in an effort to reduce the number of women dying during childbirth every year (estimated at 2,000).

"The government has linked the country’s high level of maternal and infant deaths in childbirth to long hospital waits for caesarean operations as underfunded hospitals scrambled to assemble the necessary equipment."

Will this be enough?
"A government health inspector who works with midwives in Cotonou, Adékambi Adjovi, told IRIN that even a steeply-subsidised caesarean operation may not be enough for some women. “The circuit [of health care costs] for women who have caesarean operations should be covered entirely because now they pay post-operative costs themselves.”

...The Ministry of Health reported 14,000 women giving birth through caesarean in 2008 and has estimated an additional 3,000 mothers will need the operation in 2009, based on population estimates."

The 'natural' cesarean

You might be interested in reading an article published in The Times this week, 'The new 'natural' caesarean', which reports on "a new movement campaigning to make [cesarean delivery] a more "natural" experience."

The delivery process has been developed by Professor Nicholas Fisk, and his two colleagues, Dr Felicity Plaat, a consultant anesthetist, and Jenny Smith, a senior midwife and author.

Readers might also be interested that both Professor Fisk and Dr Felicity Plaat have expressed their support for a woman's decision to choose a planned cesarean delivery in preference to a trial of labor, and in 2005, I interviewed Dr Plaat for my website. You can read her comments in full in the section 'Medical opinion, Exclusive interviews'.

Hysterectomy risk with multiple cesarean deliveries

The fact that risks increase with multiple cesarean deliveries is well documented, and it is important that anyone considering choosing a planned cesarean delivery in preference to a trial of labor is aware of these increased risks. In fact, this is why the NIH, ACOG and others all stress that CDMR is not recommended for women planning large families.

One of the risks often cited with multiple surgeries is the chance of needing an emergency hysterectomy, and a recent Irish news article has highlighted this risk:

The Sunday Times' 'Caesarean link to surge in hysterectomies', on April 5, reports:

"The problem is caused where the placenta, or afterbirth, attaches too deeply into the wall of the womb. The risk of the condition is increased by the presence of scar tissue from previous caesareans. Doctors from the Rotunda, Holles Street and the Coombe hospitals analysed charts of all patients who had emergency hysterectomies after giving birth in the 40 years between 1966 and 2005. Of the 320 cases, 43 of them were due to placenta accreta. It accounted for only one in 20 emergency hysterectomies from 1966 to 1975 but 47% of those between 1996 and 2005 when almost half (20) the cases occurred. The caesarean rate rose from 6% to 19% over the same period and now stands at about one in four births."

It is similar to an article that appeared in January 2008 in Australia's The Age, 'Caesars raise risk of losing womb', which reported on research from the University of Oxford:

"For most women giving birth normally for the first time, a hysterectomy is rare - only one in 30,000 will need surgery to remove their womb because of bleeding complications. But the risk of having to undergo surgery to remove the womb rises in the subsequent pregnancy for those who had a caesarean. One in 1300 women who have had one previous caesarean will have a hysterectomy. If the woman has had two or more previous caesareans, the risk rises to one in 220. Researchers estimate that more than 80 women a year have been forced to have a hysterectomy in Britain as a result of having a caesarean. But with the popularity of the procedure on the rise this figure is likely to increase. The study of 775,000 women who gave birth in Britain between February 2005 and February 2006 also found that women with twin pregnancies, older mothers and those who already had three or more children were also at higher risk of needing a hysterectomy."

Limitations of the research
The main problem with the research cited above is that the nature of the primary cesarean deliveries (that occurred prior to the subsequent surgery in which the hysterectomy is required) are not specified.

In fact, all cesarean delivery types tend to be pooled together and then the health outcomes of their subsequent pregnancies are looked at together. This means that primary cesareans that may have been an emergency delivery (which has greater morbidity risks than a planned delivery) are treated the same as planned deliveries.

Therefore, healthy women choosing a planned primary cesarean delivery should not be criticized or deterred from making their valid decision on the basis of mixed data outcomes. Yes, they should be informed of the risk of subsequent placenta complications, but every effort should be made to evaluate how many hysterectomies occur in cesarean deliveries that follow primary planned surgeries - not primary emergency surgeries.

Caesarean beliefs 'misguided' - says misinformed article

Late last night, I arrived home from speaking at the Controversies in Childbirth conference in Texas, and while there is much to write about my (very positive) experience there, I must first comment on an article I came across today - 'Caesarean beliefs 'misguided'', published in The Sydney Morning Herald.

In it, Associate Professor Stephanie Brown, from the Murdoch Children's Research Institute, is quoted as saying she is "concerned that long-term protection against pelvic dysfunction had been used increasingly to justify elective caesareans by patients and obstetricians "with very limited information"."

The article continues: "Women who choose to have an elective caesarean in the belief that it will prevent incontinence and genital prolapse are "misguided" and may be putting their health, and that of their baby, at unnecessary risk. That is the view of Jenny King, a urogynaecologist at Westmead Hospital, who questions the right of women to choose surgical births to avoid pelvic floor problems.

HERE IS JUST SOME EVIDENCE that demonstrates protection against pelvic floor disorders and incontinence with planned cesarean delivery:

Pelvic organ prolapse (POP)
*Swedish study of a total 1.4million women found the ‘strong and statistically significant association’ that CD ‘is associated with a lower risk of POP than VD.’ (Larsson et al, 2009)
*Norwegian population-based study of 2,001 randomly selected women found that 118 (6%) women reported symptomatic prolapse. In multivariable analysis, the risk of prolapse was significantly increased in women with one, two, and three or more VDs compared with nulliparous women. (Rortveit et al, 2007)
*Australian study of 801 women with a mean age of 55.3 years (range 17–90) found 79% complained of SUI and 28% of symptoms of prolapse. The risk of levator trauma increased for every year of delay in child-bearing and operative VD was associated with a near-doubling of the odds of trauma. ‘The global trend towards delayed child-bearing may result in an increased prevalence of pelvic floor disorders in coming decades.’ (Dietz et al, 2007)
*London review concluded that perineal injury sustained during childbirth is a major aetiological factor in the development of perineal pain, sexual dysfunction, prolapse and disturbance in bowel and bladder function, and selective CD for high risk women can be beneficial in preventing complications. (Fernando RJ, 2007)
*Dutch study concluded that VD may stretch and or load beyond the physiological properties of the pelvic floor tissue and in this way may lead to irreversible changes in tissue properties which play an important role in the urethral support continence mechanism. (Wijma et al, 2007)
*U.S. survey on POP found that only 1 in 5 (19%) of women aged ≥21 are aware of POP, and that 68% of those diagnosed with POP were not aware of it before experiencing symptoms. Also, 81% of women who gave birth did not receive education about it from their OBGYN (only 15% did) and yet the greatest risk factor for POP is a VD at any age. (ICR, Ethicon, 2007)

Stress urinary incontinence (SUI)
*Swedish study of 220 elective CDs and 215 VDs 9 months after delivery found prevalence of SUI after VD significantly increased both at 3 and 9 months follow-up, and in the multivariable risk model, VD was the only obstetrical predictor for SUI and for urinary urgency at 9 months. ‘VD is associated with an increased risk for lower urinary tract symptoms 9 months after childbirth when compared to elective CD.’ (Ekstrom et al, 2008)
*Indian study comparing CD and spontaneous VD found that ‘definitely normal delivery has association with urinary incontinence’. (Mahajan N, 2008)
*Canadian systematic review of MEDLINE (1966-2005) and CINAHL (1982-2005) databases found that CD reduced the risk of postpartum stress urinary incontinence from 16 to 9.8% in 6 cross-sectional studies and from 22 to 10% in 12 cohort studies, and differences persisted by parity and after exclusion of instrumental delivery. (Press et al, 2007)
*Israeli study comparing 52 women aged 40+ with spontaneous VD, 42 women aged 40+ with elective CD and 92 women (mean) aged 26 with spontaneous VD interviewed 1-2 years postpartum. None had SUI before pregnancy. The prevalence of SUI 1-2 years after spontaneous VD was significantly higher in the older women (38.5% vs. 9.8%) and women with elective CD had a significantly lower prevalence of postpartum SUI than VD (16.7% vs. 38.5%). Therefore, ‘elective CD in these women has a protective effect and lowers the risk of developing postpartum SUI.’ Groutz et al, 2007)
*Swedish study of 200 spontaneous VDs and 195 CDs at 10 years postpartum. When compared with CD, VD was associated with an increased frequency of SUI and an increased use of protective pads as well as an increased frequency of fecal urgency and gas incontinence. (Altman et al, 2007)
*U.S. interview follow-up from the CAPS study, comparing 759 primiparous women with clinically recognized anal sphincter tears after VD, no recognized tears after VD or a CD before labor at 6 months postpartum. ‘Postpartum FI and UI are associated with few modifiable risk factors.’ FI at 6 months was associated with white race, antenatal UI, 4th versus 3rd degree tear, older age at delivery, and higher body mass index (BMI). No factors were associated with FI in the VD or CD control groups. Across all groups, risk factors for postpartum UI were antenatal UI, less education, and higher BMI; CD was protective. (Burgio et al, 2007)

Fecal incontinence (FI)
*Finish study of 99 nulliparous and pregnant women at 4 weeks (mean) before and 4 months (mean) after delivery, with 76% VD and 24% CD. The symptoms of mild anal incontinence, mainly gas incontinence, increased after VD more than after CD. Occult anal sphincter defects were noted in 23% of the VD women. No new sphincter defects were found in the CD group. (Pinta et al, 2004)
*UK retrospective cohort analysis of 475 elderly women found that the principal risk factor for FI was childbirth (91%), and in most cases at least one VD had met with complications such as perineal injury or the need for forceps delivery. (Lunniss et al, 2004)
*Canadian questionnaire of 949 women in 5 hospitals in Quebec, 1995/96, 3 months postpartum found that 3.1% (n.29) reported incontinence of stool and 25.5% (n.242) had involuntary escape of flatus. ‘Anal incontinence is associated with forceps delivery and anal sphincter laceration.’ The latter is strongly predicted by first VD, median episiotomy and forceps or vacuum VD. (Eason et al, 2002)
*German study of 42 women at 32 weeks EGA and 6 weeks postpartum, with a follow-up at 12 weeks postpartum for those with occult sphincter defects after VD were compared with 10 elective CD controls. VD leads to direct mechanical trauma to the anal sphincters, while stretch and distension of the pudendal nerve seem to be of minor importance. After CD there were no changes in continence, anal pressures or rectal sensibility. (Willis et al, 2002)
*German study of 71 women 6 weeks before and 52 women 4-6 weeks after delivery, plus all patients with occult sphincter lesions 3 months postpartum. The overall incidence of anal incontinence after VD was 4.8% and occult sphincter defects, 19%. ‘Elective CD should be recommended for women at increased risk for anal incontinence.’ (Faridi et al, 2002)
*Irish study of 184 women at 6 weeks, with 9% (n.16) CD. After VD, 25% (n.42) women had impairment of fecal continence and 45% (n.76) had abnormal anal physiology. None of the CD women had altered fecal continence. (Donnelly et al, 1998)
*Irish study of 234 women in Dublin with 34 CDs, and 200 spontaneous VDs. ‘No woman delivered by CD had altered fecal continence postpartum. Anorectal physiology was unaltered in women delivered by elective CD or CD in early labor. Pudendal nerve terminal motor latency was prolonged, anal squeeze pressure increment reduced, but vector symmetry index was unchanged in women delivered by CD late in labor, indicating neurologic injury to the anal sphincter mechanism.’ (Fynes et al, 1998)

Unethical
According to this same article, a "25% increase in elective caesareans from 2001 to 2005 led NSW Health to ban elective surgical birth without a medical reason in public hospitals in 2007."

Why should women with legitimate prophylactic reasons to choose a planned cesarean delivery be denied this birth plan? The evidence I've listed above is just a small selection of studies that justify a woman's decision to choose a surgical delivery, and I see no justification at all for forcing a woman to deliver vaginally against her will.

Cesarean rate in U.S. is now at 31.8%

New figures reported by Reuters today show that the 4.3 million babies born in 2007 was the most ever recorded in the United States, topping even the peak of the baby boom in 1957.

It says there was another record high in the cesarean delivery rate too; it rose for an 11th straight year - up 2%, to 31.8% of births.

I think that the figures would be more informative if the cesarean rate was broken down further into different cesarean types and reported as such - e.g. planned cesareans for medical reasons, emergency cesareans, cesareans on maternal request, repeat cesareans etc.

The debate over whether the overall 31.8% figure is too high is meaningless without first doing this.

Cesarean delivery has a lower risk of pelvic organ prolapse than vaginal delivery

Unlike studies that heavily criticize health outcomes of cesarean delivery, this new study from Sweden, on 'Cesarean section and risk of pelvic organ prolapse...', has had minimal exposure in the media.

But I think that its conclusion is important to highlight - not to encourage more women to choose cesarean delivery - but in defense of all those women who do choose planned surgery. I refer to primary planned cesarean delivery on maternal request as 'prophylactic' in my online petition, and this study is just one of many that exemplifies this particular word choice.

The authors, Christina Larsson et al, conclude that: "Cesarean section is associated with a lower risk of pelvic organ prolapse than vaginal delivery."

And it wasn't a small study either.
The Swedish Hospital Discharge Registry was used to identify women with an inpatient diagnosis of pelvic organ prolapse, and the data were linked to the Swedish Medical Birth Registry, which meant that a total of 1.4 million women were investigated.

Memory of childbirth pain intensifies over time for some women

The first thing to say about this report on new research from Sweden is that women who elected to have a cesarean section were excluded. This is a great pity, as it would be interesting to compare their long-term memory of childbirth pain (albeit post-surgery) with women who delivered vaginally.

Reuters reports how "Dr. Ulla Waldenström, from the Department of Woman and Child Health at the Karolinska Institute, Stockholm and colleagues queried 1383 mothers about their memories of labor pain at 2 months, 1 year and 5 years after giving birth.

Five years after the women had given birth, 49% remembered childbirth as less painful than when they rated it 2 months after birth, 35% rated it the same, and 16% rated it as more painful.

"A commonly held view," Waldenström noted in an email to Reuters Health, "is that women forget the intensity of labour pain. The present study...provides evidence that in modern obstetric care, this is true for about 50% of women."

However, a woman's labor experience was an influential factor. Women who reported labor as a positive experience 2 months after childbirth had the lowest pain scores, and their memory of the intensity of pain had declined by 1 year and 5 years after giving birth."

Maternal deaths drop by 59% in China

I am highlighting this article by Wang Zhuoqiong of the China Daily, because I am aware that an increasing number of women in China are now choosing planned cesarean delivery as their preferred birth plan.

The reported 59% drop in maternal deaths has occurred mainly in urban areas as opposed to rural, and while I have no evidence to prove it, I wonder aloud whether this improvement in maternal outcomes may be as a result of increased planned cesareans...?

Obviously in China, women tend to only have one baby, which reduces or even avoids the risks associated with future surgeries, and as I have written about in the past, China could make a very interesting case study of planned primary cesarean risks and benefits. Unfortunately, there is the issue of setting delivery dates due to superstitions related to lucky numbers, but aside from that, the data could be very revealing.

True stories behind natural birth versus caesarean debate

I came across this article in the The Daily Telegraph over the weekend, 'True stories behind natural birth versus caesarean debate', by Erica Watson.

She describes the experience of mother of two, Kath Leary, who had initially wanted a vaginal delivery but needed to schedule a planned cesarean for medical reasons:

"Preparing herself for what she thought would be a not-so-pleasant and clinical procedure, Leary says she was surprised at how wonderful her birthing experience was. "Within what seemed like a few seconds I had both my kids in my arms after giving birth. There wasn't this detachment or anything like that," she says. "I didn't expect to really love the whole caesarean experience but I really did. It was a bit of a shock.""

Also worthy of note in the article is a quote form obstetrician Dr Keith Hartman:

"I think women are cruel to each other in making these value judgments," he says. While a natural birth might be an innate need for some mothers, Dr Hartman says for others it can create intense feelings of fear. "(Natural birth) is a lovely thing to see and a very exhilarating experience for women but for some they just don't want to do it," he says. "I respect that and I certainly would never criticise them for it and if other women criticise them for it I don't know where they are coming from. It's about a healthy mother and a healthy baby. As long as they are aware of their choice and not pressured into it."

Where cesareans are too few

Amidst talk about the increasing cesarean rates in the developed world, it is all too easy to forget the plight of women in other countries where access to cesarean surgery is dangerously low.

An article this week in the International Herald Tribune, 'Project works to improve lives scarred by childbirth injury', describes the devastating injury fistula that occurs as a result of obstructed labor during vaginal delivery.

Denise Grady writes: "If prolonged, obstructed labor often kills the baby, which may then soften enough to fit through the pelvis, so that the mother delivers a corpse. Obstructed labor can kill the mother, too, or crush her bladder, uterus and vagina between her pelvic bones and the baby's skull. The injured tissue dies, leaving a fistula: a hole that lets urine stream out constantly through the vagina. In some cases, the rectum is damaged and stool leaks out. Some women also have nerve damage in the legs."

She continues: "Fistulas are a scourge of the poor, affecting two million women and girls, mostly in sub-Saharan Africa and Asia - those who cannot get a Caesarean section or other medical help in time."

Risk of postpartum psychosis increases with age

This report appeared on the website EMax Health last week, and talks about new research led by Christina M. Hultman, PhD, of the Karolinksa Institutet, in Stockholm, Sweden.

Researchers found that half of women diagnosed with postpartum psychosis have no history of mental illness, and that the risk of postpartum psychosis is greater in women over age 35 who give birth for the first time.

Why is this important?
Other research has shown that women who achieve their preferred delivery method enjoy better psychological post-birth outcomes than women who don't. So if a woman plans a vaginal delivery and ends up needing an emergency cesarean, she may feel more negative about her birth experience than if she has a spontaneous vaginal delivery. Similarly, it has been shown that women who choose a cesarean delivery, and go on to have a cesarean delivery, have a much greater level of post-birth satisfaction than those who don't.

Women are not homogeneous creatures, and we should focus on supporting the individual's delivery preference rather than trying to enforce a 'one size fits all' approach to maternity care.

Deaths of 6 women giving birth raise concerns in the NHS

On February 11th, Madeleine Brindley's report: "Serious concerns raised at NHS trust after six women die" appeared on WalesOnline. It perfectly illustrates the unpredictability of vaginal delivery that exacerabates an already unpredictable Mother Nature. I believe that it is not unreasonable that some women (myself included) decide to opt for a planned surgical delivery with a dedicated, guaranteed-to-be-present during the birth, team of health carers.

"The review team found that there was no common link between the deaths, although in two of the cases, if the women’s deteriorating condition had been spotted earlier and better advance preparations had been in place, the outcomes may have been different... The report revealed:

*The trust had the highest proportion of women reporting that they were left alone and worried, in labour or shortly after the birth of their child;
*Staff from lower risk wards are frequently transferred on shift to the higher-risk labour areas, leaving the areas from which they were drawn under staffed;
*Community midwives are frequently required to work in the hospital throughout their on-call shifts after doing a full days work in the community;
*Low-risk labouring women are sometimes left alone while staff attended to higher risk women - the HIW inspectors heard of occasions when induced labour had been halted to allow staff to be rescheduled to other work;
*The numbers of midwives on the labour ward at the Royal Gwent Hospital appear “inadequate” for the size and activity levels on the ward."

UK hospitals restrict cesareans based on inaccurate cost calculations

The weekend's Sunday's Times article, 'Hospitals curb caesarean births' (by Health Editor, Sarah-Kate Templeton) was just one of many to report on the decision by hospitals in the Greater Manchester area to "ration" cesarean deliveries so that only "women with specific medical conditions" are eligible to deliver their babies via this method.

The Daily Mail's Daniel Martin's report, 'Caesareans rationed: Women denied procedure on safety grounds - and because it's too dear', and The Telegraph's Sarah Knapton's report, 'Caesarean births rationed by hospitals in order to cut costs' were two others.

Personally, I think that this decision is a national disgrace, and I can only hope that there are more doctors in the UK that will ignore such irresponsible guidelines and support the views of Doctor Christoph Lees, an obstetrician and gynaecologist at Addenbrooke's hospital in Cambridge, who is quoted in these stories saying:

"I strongly disagree with this prescriptive condition setting. Sometimes well-informed women, often older and very unlikely to have further children, do request caesarean sections and it is unreasonable to refuse if they are fully informed."

Some reasons why COST is not a valid reason for cesarean rationing
The main issue is the inaccurate cost comparison between PLANNED vaginal delivery (PVD) and PLANNED cesarean delivery. I highlight the word planned because it is no use in comparing spontaneous delivery outcomes with cesarean delivery outcomes alone. The fact is that a PVD can have many different outcomes for mother and baby - regardless of how much a spontaneous delivery is desired or encouraged - such as instrumental delivery and most importantly, emergency cesarean delivery. The cost of the latter in particular is rarely, if ever, factored into the cost of a PVD, yet it should be.

Worse still, traditional cost comparisons actually take these PVD emergency cesarean outcomes and add them to all planned cesarean costs in order to demonstrate 'hospital cesarean costs'. More recent studies have at least separated emergency and planned cesarean costs, but even then, in the argument against healthy women being able to choose a planned cesarean delivery, they do not recognize that the vast majority of these planned cesareans were for medical reasons and were therefore likely to have extra costs associated with them that would not be the case in a healthy pregnancy. The best example of this is studies that look at the NICU costs of babies born at 38 weeks gestation and earlier - obviously these costs are high, but in a healthy pregnancy where a woman delivers at 39 weeks gestation (repeatedly shown to reduce respiratory distress - see ACOG and NIH statements and others), these costs are not applicable.

The truth about birth costs
No one wants to do the study that needs to be done - an analysis of cost of women who plan a vaginal delivery (and all their actual outcomes - short and long-term) and women who plan a cesarean delivery. Doctors in Australia in 2003 looked into whether such a study would be a good idea and raised concerns that one of the biggest dangers would be the fact that planned cesarean delivery may be proven to be safer than PVD - "what a disaster" that would be, they said.

It's also worth looking at Appendix C of the NICE 2004 Clinical Guideline on Caesarean Delivery - they actually admit that it is possible to take current cesarean cost data and demonstrate that
planned cesarean delivery can be cheaper than vaginal delivery, but in the very next sentence, they dismiss it as being an 'unrealistic conclusion' to draw. It is not referred to again.

When vaginal deliveries go wrong
The cost of obstetrics litigation in the NHS is enormous and yet this is also not accounted for in any cost analysis of PVD. When a cesarean is not done in time or is not done at all, and the baby dies or is severely injured, there is a financial cost associated with that - as well as a psychological cost.

When women suffer severe pelvic floor injuries, there is a financial cost associated with post-birth surgical repair, and even more minor injuries can result in long-term damage such as incontinence or pelvic organ prolapse. Again, not to mention the psychological trauma and need for post-birth counselling that many women experience.

Perhaps hospitals would do better to concentrate on supporting positive birth experiences, and rationing negative ones - and believe me, research shows that this is not achieved by forcing all women to have a vaginal delivery.

20-30% of women in Ludhiana request cesarean delivery

'For kids’ bright future, city women give thumbs up to caesarean' read the expreesindia.com headline by Sameer Kumar Sharma earlier this week. The article reports that women in Ludhiana, "with the knowledge of medical science making caesarean deliveries much safer, more urbane women are opting for caesarean on request even though they could have a normal delivery."

Sharma writes: "For the fear of labour pains, many ‘educated’ women are thronging hospitals to deliver babies without having to go through 10 to 12 hours of labour pain. The rough estimates suggest a sizeable chunk of expecting mothers - as much as 20 per cent - want to go in for caesarean delivery rather than normal vaginal delivery."

Gynaecologists there say that in the last 5 years, "there has been a major shift in the way women respond to childbirth. “Today more women ask on request to have a caesarean rather than waiting for the normal delivery,” says Dr Promila Jindal, professor and unit head, department of gyaenocology, Dayanand Medical College and Hospital."

Requests have doubled in the last few years
"Dr Mini Ahuja, consultant gyneacologist at Iqbal Nursing Home, says about 30 per cent of the pregnant women approaching them talk about the possibility of caesarean even though there are no complications involved. “Such queries and requests have almost doubled in the last couple of years,” she adds."

But Dr Vaneet Kaur, senior consultant and head of the department of obstetrics and gynaecology at SPS Apollo Hospitals, says: “We counsel such women who are afraid of labour pains and condition them to prepare for normal deliveries. Moreover, the normal delivery can also be made a painless experience through epidural analgesia and all they need is a little bit of more knowledge than they already have. Normal deliveries are a natural way of delivery and one should always prefer that.”

My view
Naturally, I don't agree with the idea that all women should share the same delivery preference, but I decided to blog about this article largely because it illustrates that women choosing cesarean delivery is a reality. The issue is not going to go away by pretending it isn't happening and in my opinion, it is unethical to brush aside women's concerns over the unpredictability of vaginal delivery or to dismiss their informed decision to choose cesarean surgery instead.

50% cesarean rate in Canada can't be ruled out, says Dr

I recently came across a September 2008 article on the Vancouver Sun's website, 'Canada's caesarean capital' (a report by Katherine Dedyna on the country's 26% cesarean rate), in which Dr. Jerome Dansereau, chief of obstetrics at the Vancouver Island Health Authority, says he "doesn't rule out the rate going to 50 per cent, given the continuing upward swing. "There is no one who could have predicted what we see today," he says, "and there is no one who can predict when it will stop.""

In the same article, midwife Lyons Richardson says she "won't be surprised if eventually women walk in cold with their first pregnancy and demand a C-section for any reason they want. "Give it 10 years and I don't think it's going to be that unusual.""

Victoria General Hospital is reported to have the highest rate in the country at 37%, and some of the reasons cited by doctors for this are: "older, heavier mothers; increasing numbers of women who don't want to labour long; technology that shows potential fetal problems; mothers who have had previous C-sections returning for a second; and the presence of worried fathers in the labour room."

Luba Lyons Richardson, vice-chairwoman of midwifery at VGH, remarks on a "culture shift in her 30 years of practice. "Women themselves have less tolerance for longer labours, for a baby that's a little bit in distress." ...She knows of women who ask for elective caesarean sections and get them, depending on extenuating circumstances. "That's another debate that rages on. If women have choice, then shouldn't they have that choice?""

Also of interest in the article: "Surgeons in Victoria will do C-sections rather than traumatic forceps delivery. Only 10 per cent or fewer of VGH births involve instruments such as forceps, far lower than the national average of 16 per cent."

The doctors cited in this report do not necessarily agree with prophylactic cesarean delivery with no medical indication, but it is clear that they do not expect to see Canada's cesarean rate being reduced to the WHO's controversial recommendation of 10-15% any time soon.

Top 5 reasons prophylactic elective caesarean delivery with no medical indication is a legitimate decision for informed women

As a speaker at a seminar on cesarean delivery the upcoming 'Controversies in Childbirth' conference in Fort Worth, Texas (March 27, 2009), I was asked to write my 'Top 5 reasons prophylactic elective cesarean delivery with no medical indication is a legitimate decision for informed women', and here they are:

1. There are risks and benefits associated with all birth plans. A healthy spontaneous vaginal delivery (even when desired) is never guaranteed since labor, even with healthy pregnancies, is entirely unpredictable.

2. The oft-quoted risks associated with cesarean delivery frequently refer to emergency surgery or deliveries with pre-existing medical indications. These risks are not the same in healthy pregnancies with delivery at 39 weeks gestation for women planning small families.

3. Birth data compiled in the U.S. does not separate emergency and planned cesareans, only primary and repeat cesareans, which muddles the true assessment of risk as it relates to birth PLAN and the corresponding birth OUTCOME. Research from overseas demonstrates vastly reduced risks with planned surgeries, although we are yet to witness a move towards research that applies emergency cesarean outcomes to the planned vaginal delivery data set, which would be more relevant.

4. The risks (and costs) associated with planned vaginal delivery are grossly underestimated, both in the short- and long-term (in fact long-term risks and costs, financial and psychological, are rarely applied in comparative birth analysis). For example, shoulder dystocia, Erb’s palsy, fetal trauma, neonatal encephalopathy, asphyxiation, intrauterine fetal demise; damage to pelvic floor, POP, sexual health; infant and maternal severe morbidity associated with emergency cesareans; litigation trauma and cost following death or injury.

5. Research has shown high levels of birth satisfaction with planned cesarean delivery and birth trauma websites illustrate high levels of dissatisfaction with planned vaginal delivery. A ‘good birth outcome’ is not commensurate with ‘vaginal delivery for all women’ and genuine birth educators should not make this assumption. For true birth autonomy to exist, cesarean delivery must not be viewed as a second-rate outcome, and at a time in history when maternal and fetal characteristics are leading to more cesarean deliveries (e.g. increased maternal age and obesity; also birth weights), it is not only potentially dangerous to focus on drastically reducing the numbers of ‘unwanted’ surgeries, it is moreover unethical to reduce rates by discouraging or denying those surgeries that are in fact ‘wanted’.

Cesarean complications rise in line with changes in mothers

A number of studies have been published recently, which, if read in the context and knowledge of other applicable studies, would inform women more accurately than many media reports have managed to do.

Take for example this week's highly publicized U.S. report, 'Severe Obstetric Morbidity in the United States: 1998-2005', by EV Kuklina et al. They found that the "prevalence of delivery hospitalizations (per 1,000) complicated by at least one severe obstetric complication increased from 0.64% (n=48,645) in 1998-1999 to 0.81% (n=68,433) in 2004-2005." And that

Perception of risk - actual increase versus percentage increase
Clearly, these numbers in real terms - especially when you consider that they take into account ALL delivery complications (including emergency cesareans) - are relatively small (less than 1%), but what many media reports concentrated on was the '% increase' number, which of course looks a lot higher - and riskier - when reported without the 'per 1000' figures.

For example, renal failure increased "by 21% (from 0.23 to 0.28), pulmonary embolism by 52% (0.12 to 0.18), adult respiratory distress syndrome by 26% (0.36 to 0.45), shock by 24% (0.15 to 0.19), blood transfusion by 92% (2.38 to 4.58), and ventilation by 21 % (0.47 to 0.57).

The authors conclude that: "Rates of severe obstetric complications increased from 1998-1999 to 2004-2005. For many of these complications, these increases were associated with the increasing rate of cesarean delivery.

But is cesarean surgery the reason for greater severe morbidity - or are other factors to blame?
Adding to a growing body of evidence on this subject, a Scottish review this month by A Poobalan et al, 'Obesity as an independent risk factor for elective and emergency caesarean delivery in nulliparous women - systematic review and meta-analysis of cohort studies' tells us that cesarean delivery "risk is increased by 50% in overweight women and is more than double for obese women compared with women with normal BMI."

And in 2003, KS Joseph et al's Canadian study, 'Changes in maternal characteristics and obstetric practice and recent increases in primary cesarean delivery', which set out to "estimate the contribution of changes in maternal characteristics (namely, age, parity, prepregnancy weight, weight gain in pregnancy, smoking status) and obstetric practice (namely, labor induction, epidural anesthesia, delivery by an obstetrician, midpelvic forceps delivery) to recent increases in primary cesarean delivery rates", concluded that "Recent increases in primary cesarean delivery rates are a consequence of changes in maternal characteristics. Obstetric practice, which has altered due to changes in maternal characteristics and concerns related to fetal and maternal safety, has also contributed to increases in primary cesarean delivery."

Specifically, the researchers noted a 14% increase in cesarean deliveries for dystocia, 24% for breech, 21% for suspected fetal distress, 47% for hypertension, and 73% for miscellaneous indications between 1988 and 2000. Importantly: "Adjustment for maternal characteristics reduced the temporal increase" in cesarean rates from 21% to 2% [and] Additional adjustment for obstetric practice factors further reduced period effects."

The future of cesarean rates
A review by Rebecca Simmons, MD., 'Perinatal Programming of Obesity', published in the U.S. in October 2008, reminds us that the prevalence of obesity "has risen dramatically over the last decade [and a] number of epidemiological studies have shown that there is a direct relationship between birth weight and BMI in childhood and in adult life." I would suggest that with no sign of a decline in obesity rates (in fact, quite the opposite) and with women continuing to have their babies later and later in life, we are not going to see any significant reduction in primary cesarean rates at all, and we need to be very careful about implementing strategies to drastically reduce them since this will result in greater morbidity and mortality for these women and their babies.

New research on cesarean surgery techniques

Hypotension and Nausea during surgey
When I saw this new study from Canada by M Tanaka et al, 'ED95 of phenylephrine to prevent spinal-induced hypotension and/or nausea at elective cesarean delivery', it reminded me of my own experience during the birth of my daughter in 2007. The anesthetist had warned me prior to the start of surgery that I may experience some nausea, and to let him know if I did as he would be able to administer something for it. Well, I did, and he did, and in truth, I have no idea what the drug was, but I felt better almost immediately.

For those of who would like to be able to discuss this occurence of nausea and its treatment during your cesarean surgery in more detail (with your OBGYN or anesthetist), you might find this study interesting. It set out to "determine the 95% effective dose (ED95) of phenylephrine by intermittent i.v. bolus, to prevent spinal-induced hypotension and/or nausea at elective cesarean delivery" and involved 50 patients undergoing elective cesarean delivery under spinal anesthesia.

The study results
"The ED95 of phenylephrine was estimated as 159 mug (95% confidence interval: 122-371 mug), although the largest dose given in the study was only 120 mug. Hypertension (systolic blood pressure >120% of baseline) was observed in 14 cases, immediately after intrathecal injection and prophylactic phenylephrine administration in all cases." The authors conclude that the "safety of this dose warrants further studies."

Blood loss following surgery
This second study from Iran, 'Efficacy of tranexamic acid in reducing blood loss after cesarean section' by L Sekhavat et al, was conducted on 90 primiparas divided into two groups who underwent cesarean delivery. "The study group, 45 women, received tranexamic acid immediately before CS, whereas the control group, 45 women received placebo" and then blood loss volume for each group was measured from the end of surgery to 2 hours postpartum.

Study conclusions
The authors conclude that: "Tranexamic acid statistically reduces blood loss from end to 2 h after CS and its use was not associated with any side effects or complications. Consequently, tranexamic acid can be used safely and effectively to reduce bleeding resulting from CS." My second baby is due shortly, and a cesarean delivery is planned, so I will certainly be asking my doctor about whether the findings in this study are relevant to my potential recovery experience.

Pelvic organ prolapse risk with vaginal delivery - are women made aware of it?

A new American study, Relation between vaginal birth and pelvic organ prolapse (by Eddie H. M. Sze and Gerry Hobbs), set out to "evaluate the relation between vaginal birth and pelvic organ prolapse quantification (POPQ) stages III and IV prolapse and whether each additional vaginal birth is associated with an increase in pelvic support defects."

Study conclusions
The researchers conclude that "Vaginal birth is not associated with POPQ stages III and IV prolapse, but it is associated with an increase in POPQ stage II defect."

Birth risk/benefit analysis
This study demonstrates that there IS a link between vaginal delivery and subsequent pelvic organ prolapse (POP), and is in fact one of a number of studies to do so. Unfortunately, women planning vaginal deliveries are not always advised of this risk. In fact, in the U.S. December 2006 'Pelvic Organ Prolapse Topline Summary by ICR', an Ethicon Women's Health & Urology survey found that among the total female population age 21 and older, only 1 in 5 (19%) are even aware that such a female condition exists.

Furthermore, 2 out of 3 (68%) women diagnosed with POP were not aware of its existence before experiencing symptoms, and the majority (81%) of women who have given birth did not receive education about the relationship between a vaginal delivery and possible pelvic organ prolapse from their OB/GYN.

Are we truly informing women of the risks associated with vaginal delivery?
"Only 15% of women who have given birth report that their OB/GYN educated them about the relationship between a vaginal delivery and the condition [yet the] greatest risk factor for pelvic organ prolapse is a vaginal delivery, at any age."

Study results
Sze and Hobbs analyzed 458 nulliparas (first-time mothers) and 892 multiparas, including 272 with one, 299 with two and 321 with at least three term vaginal deliveries, and found that the "prevalence of POPQ stage II defect among nulliparas and multiparas that had one, two, and at least three term vaginal deliveries was 25% (119/458), 50% (137/272), 66% (198/299), and 69% (220/321), respectively (p<0.001), p="0.618)." style="font-weight: bold; color: rgb(0, 0, 102);">

Severe vaginal tears common during birth in Utah

An article by Heather May in The Salt Lake Tribune on January 7th reports on a study in which "almost 4,000 Utah women suffered severe vaginal tears last year while giving birth after their doctors used forceps or vacuum devices to deliver the baby." This number translates to a reported "14% injury rate".

In releasing the figures, the Utah Department of Health is reported as saying that 14% is "lower than expected compared to national figures. But the tears can cause long lasting problems, including painful sex and fecal incontinence."

The article also cites comments from Ashley Nelson, a women's health physical therapist in Salt Lake City, who says: "It's hush, hush. Most people don't talk about this". She sees women seeking help to strengthen their pelvic floor muscles or who have irritated or damaged nerves because of scarring from tearing or subsequent care. "A lot of times they may sew them up too tight [and women experience] pain [from] penetration. Or just the way they've been sewn back up - it's irritated nerves and [they] constantly have pelvic pain," she said.

14% is the risk for SEVERE tears - many more women experience "minor tearing"
"...While minor tearing during delivery is common, the health department report focused on third and fourth-degree lacerations, which extend from the vagina to the anus. Using instruments increases the risk of severe tears. So does delivering large babies or having an episiotomy, a surgical cut between the vagina and anus. Doctors use instruments if the baby's heart beat drops dangerously or if the mother is worn out from pushing.

Some Utah hospitals have a 29% vaginal tear rate
"Utah hospitals' rate of vaginal tears range from 4.5 percent at Ogden Regional Medical Center to nearly 29 percent at Uintah Basin Medical Center in Roosevelt. "

The full report, '2007 Utah Hospital Comparison Report: Maternity and Newborns', can be accessed here.

Long-term benefits outweigh risks, says Malaysian doctor

You may have read my criticism of recent reports on the increased risk of asthma in children born by cesarean delivery, and how research in this area is still incomplete and inconsistent. Now the president of the Obstetrical and Gynaecological Society of Malaysia, Dr A. Baskaran, has criticized a media report by Datuk Dr Rajen M, titled 'C-Section babies risk becoming asthmatic'.

He says: "The article gives the impression that Caesarean section is detrimental to the health of the baby and should not be resorted to at all. Our greatest concern is that mothers may refuse to give consent when a Caesarean section is indicated in times of emergency after reading the article."

He continues: "In any operative delivery or, for that matter, in any operation, the benefits from the operation must be weighed against the short-term and long-term risks of the operation. Perhaps, one of the long-term risks to a baby born by Caesarean section may very well be a higher incidence of asthma but this must be balanced against the immediate and long-term risks to the baby when there is delay or no intervention by Caesarean section.

We do not want a baby to be forever mentally handicapped for fear of a higher risk of asthma.

The study quoted in the report, from the Dec 3 issue of the medical journal Thorax, showed that Dutch children born by Caesarean section were 80 per cent more likely to develop asthma by the time they are 8 years old. This study, together with another Norwegian study published in June last year in the Journal of Pediatrics, has shown an increased risk.

However, previous studies have shown conflicting evidence. More prospective, multi-central studies from many different countries need to be done before this risk is accepted into evidence-based practice. More importantly, other aspects such as failure to breast-feed a baby after a Caesarean section need to be considered.

Nevertheless, the increase in Caesarean section rates in the past couple of decades cannot be denied. It has always been an important and heavily debated topic of discussion in practically every obstetrics conference all over the world. The reason for this is complex and every attempt has been made by the fraternity to reduce this rate. But its judicious use has saved many a mother and baby."

My thoughts
I agree with a great deal of what Dr Baskaran says, but it would be interesting to learn more about his views on planned cesarean delivery with no medical indication. He does mention above that "every attempt has been made by the fraternity to reduce this [cesarean] rate" and it concerns me that women making legitimate decisions to choose one set of birth risks and benefits over another may be not be supported in Malaysia. I only hope that this is not the case.

More Women Choosing Birth Without Labor

Dr. Michael J. McGlynn of the Eden Medical Center in Castro Valley has written an article on the Castro Valley Forum this week, in which he comments on changes he's noticed in recent years. He says: "More and more pregnant women are requesting caesarean sections without labor. This is especially true for first-time mothers who are apprehensive about the pain associated with labor as well as injury to the birth canal with a vaginal birth. Many mothers also want a Csection to control the delivery date."

Dr. McGlynn makes the valid point that "information about choices to make as pregnant women enter into labor and delivery is not... straightforward." He says, "Questions about the birth process and whether to accept pain medication during labor or bypass labor altogether and have an elective caesarian section are very personal choices."

His advice?: "With so many decisions to make, pregnant women should be comfortable enough with their obstetricians to make sure they [are] even writing questions down in advance. After all, a healthy mom and a healthy baby is everyone’s ultimate goal."

My thoughts
I completely agree with Dr. McGlynn's advice; in fact, this is exactly what I did ahead of my visits with my OBGYN. I read as many medical studies on cesarean risks and benefits as I could find, and was fortunate enough to have a doctor who was willing to answer all my questions and help me to understand my own individual health risks. Pregnancy and childbirth are not without risk, but understanding and feeling comfortable with the decisions you make has been shown in studies (10,11,13,15) to help increase women's likelihood of post-birth satisfaction.

Support for a cesarean/vaginal delivery comparative trial?

Australian Researchers Catherine Turner et al have recently published 'Willingness of pregnant women and clinicians to participate in a hypothetical randomised controlled trial comparing vaginal delivery and elective caesarean section', in which they conclude that a "randomised controlled trial comparing vaginal delivery and elective caesarean section may not be feasible due to low levels of willingness to participate, particularly among pregnant women."

This type of comparative trial has been criticized for being unethical and/or unfeasible in the past (by other researchers and doctors), but this latest research from Australia isn't all negative. The authors begin by stating that "Elective caesarean section is controversial in the absence of compelling evidence of the relative benefits and harms compared with vaginal delivery. A randomised trial of the two procedures to compare outcomes for women and babies would provide the best quality scientific evidence to confirm this debate but it is not known whether such a trial would be feasible."

They set out to ascertain what proportion of pregnant women and clinicians would participate in a hypothetical randomised controlled trial comparing the two delivery methods by asking pregnant women (via interviews) and midwives, obstetricians, urogynaecologists and colorectal surgeons (via a mailed, self-administered questionnaire).

How many support a hypothetical trial?
Out of 100 pregnant women, 84 midwives, 166 obstetricians, 12 urogynaecologists and 87 colorectal surgeons, 14% of pregnant women and 31% of clinicians indicated that they would participate in a randomised controlled trial.

Is this enough?
14% is a very low number, but I would be interested to learn whether the 100 women questioned already had a birth plan in mind, and also whether the hypothetical trial (as explained to them) meant that they would get to choose between each delivery or whether that delivery method would be allocated to them. These factors are crucial and could make a huge difference to the final percentage tally.

31% is almost a third of clinicians saying 'yes', and this is actually a sizeable proportion. If nothing else, it indicates that aversion to such a trial is no longer in the minority.

Trial alternatives?
The number of healthy women electing to have cesarean deliveries with no medical indication is reportedly low. However, these women do exist and their health outcome data is on record at hospitals (especially private hospitals) throughout the world. If we could gather the data available for some or all of these deliveries, this would go a long way to informing risk and benefit analysis as compared to planned vaginal deliveries in healthy women (the data of which is readily available at numerous large hospitals).

Trial fears?
In 2003, doctors in Australia asked the question 'Should obstetricians support a 'term cephalic trial'? (Robson S, Ellwood D. Aust N Z J Obstet Gynaecol. 2003 Oct;43(5):341-3.) In subsequent media reports, they were quoted as saying:

Dr Robson: 'What a disaster it would be if it was found elective cesarean was safer than vaginal birth.'
Dr Ellwood: 'There is an increasing trend towards elective cesareans, and there have been discussions over the last couple of years about mounting the so-called term-cephalic trial, which would be a randomised trial comparing cesarean versus planned vaginal birth for women having their first babies. We're concerned that the impact of such a trial could well be quite far reaching, and that it needs to be well thought through before such a trial is mounted.' [The reporter continued:] His fear is that if caesarean sections were found to be safer in such a trial, doctors and patients might feel compelled to go that way.

When Childbirth Was Natural, and Deadly

This January 10th article by Druin Burch in Natural History Magazine concentrates on the history of diseases that were associated with deaths in childbirth, but if nothing else, it provides yet another reminder that while women may indeed have been giving birth since the beginning of time with bodies that were designed to do so, natural birth has always been inextricably associated with death too.

Pregnancy is risky; childbirth is risky. It is a woman's progagative to decide which set of delivery risks (vaginal or cesarean) is most tolerable to her.

0.5% risk of deep vein thrombosis with cesarean delivery

A new North American study by Winnie Siaa et al, 'The incidence of deep vein thrombosis in women undergoing cesarean delivery', set out to determine the incidence of deep vein thrombosis (DVT) post cesarean delivery since venous thromboembolism (VTE) is one of the leading causes of maternal mortality in the United States and Canada, and cesarean delivery is a known risk factor.

The autors found an incidence proportion of DVT post cesarean delivery of 0.5% and say this is the largest study to date that uses Doppler compression ultrasound to diagnose DVT in women after cesarean deliveries.

Study highlights
The research is certainly worth a read, but I've highlighted some of the interesting points made by the researchers in the 'Comment' section of their presentation:

*A Swedish prospective study found an incidence of DVT post cesarean delivery at 1.8% using impedance plethysmography, which is known to have high false positive rate compared to Doppler ultrasound. However, four other studies using Doppler ultrasound did not find any DVT in their cesarean delivery population... [many more studies are cited]

*This incidence of post cesarean delivery DVT is much lower than that reported among general surgical patients... This disparity between general surgical patients and patients undergoing CD may be due to many factors. First, patients undergoing CD are generally younger. This is still true even though 20% of our population would be described as “advanced maternal age” for being over 35 years old. Age is both an independent risk factor of VTE and is associated with increased likelihood of co-morbidities. Second, most cesarean deliveries are now performed under regional anesthesia, which is known to have a lower risk of postoperative DVT compared with general anesthesia. Third, postpartum mothers are more likely to be out of bed early and frequently (because of the needs of their newborn) as compared to patients who have undergone other abdominal surgeries.

*It is interesting to note that while our study population appears to have few VTE risk factors, 78% would have warranted thromboprophylaxis after cesarean delivery per RCOG guideline. The preeclampsia rate of nearly 10% in our study is higher than that of the general obstetric population likely because preeclampsia increases the risk of cesarean delivery and our participants all had cesarean deliveries.

Epidural risk lower than thought

A BBC News article on the 12th January reports on a study by researchers at Bath's Royal United Hospital, which suggests that the "risk of epidurals and spinal anaesthetics to expectant mothers and patients undergoing surgery may be being overstated."

The researchers analysed the complications from the 700,000 pain-killing injections given each year and "found the risk of harm was at least as low as one in 23,000 - 10 times less than tends to be estimated. Experts said it was important patients were told about the true risk."

You can read the article in full here, but it continues: "Researchers said expectant mothers, in particular, should not be overly concerned as their risk of permanent harm was as low a one in 80,000."

Spinal anesthesia
Spinal anesthesia rather than an epidural is often used in planned cesarean deliveries today, but this research is worth being aware of for both cesarean and vaginal delivery risk information.

Rate of Unnecessary C-Sections Far Lower Than Thought

This December article by Serena Gordon of HealthDay News is a fascinating glimpse at what might be closer to the truth about cesarean delivery rates in the U.S: That the term 'unnecessary' may be being overused and based on inaccurate data.

Gordon reports that current estimates put the figure of unnecessary cesareans at nearly 60%, while the real number may be as low as 4%. Why the huge difference?

Mainly because of inaccuracies cited on birth certificates. When government experts analyzed birth certificates and hospital discharge data, they found the actual number of [unnecessary cesarean] deliveries was closer to 4%. The study author, Emily Kahn, an epidemiologist with the U.S. Centers for Disease Control and Prevention's division of reproductive health, explains that "You can't use the birth certificate alone to determine whether or not a woman is at risk for primary caesarean delivery."

"...The CDC researchers sifted through data on 565,767 births from women who were considered at low risk for needing a C-section. The women were all 37 weeks' to 41 weeks' pregnant when they went into labor and had singleton pregnancies. All of the women delivered in Georgia hospitals between 1999 and 2004. More than 70,000 of these women ended up having a Caesarean delivery, and almost 41,000 were listed on the birth certificate as having no risk factors. Yet, in the hospital discharge data, nearly 90 percent of these women had a risk factor listed. Overall, 58.3 percent of birth certificates suggested no risk factors. But when the researchers pooled the data and combined both birth certificate data and hospital discharge data, they found the rate of Caesareans with no reported risk factors at just 3.9 percent."

Doctors don't touch birth certificates
..."Kahn said there are several possible reasons for this discrepancy. One is that the main purpose of a birth certificate is simply to record the birth. Birth certificates aren't completed by physicians, but instead rely on worksheets filled out by the mother. And, she said, hospital discharge data is used to bill the insurance companies and doctors must be very detailed on these reports to get paid, which might make them more accurate. "Doctors don't touch birth certificates," said Dr. Miriam Greene, an obstetrician at New York University Langone Medical Center and author of the book Frankly Pregnant. "The person who writes up the birth certificate might not be knowledgeable about all the risk factors for C-section, and they see the baby is fine and may think there was no issue."

My view - U.S. birth data collation is unhelpful
The story above illustrates one disadvantage with the reliance on birth certificates for analyzing cesarean delivery occurence in the U.S., but I have long talked about another area for improvement. That is, separating the number of elective/planned cesarean deliveries and the number of emergency cesarean deliveries. Many European countries already separate these types of cesarean deliveries, and this has helped to inform research into the differences in risks between the two.

Even better would be to separate 'planned cesarean deliveries in healthy women with no medial indication' (since we now know they DO exist), as this would help us to compile actual outcome data of this group without waiting for agreement to a controversial clinical trial comparing planned vaginal and cesarean deliveries in healthy women.

On a positive note, the U.S. does separate primary and repeat cesarean deliveries, which has been useful for researching health risk outcomes in multiple deliveries. It now just needs to go a few steps further in order to ensure clarity and accuracy in its cesarean data collation.

Cesarean section rate growing in Czech Republic

The Prague Daily Monitor has reported that that in "2007, 114,632 children were born in the Czech Republic with one-fifth of them being born by cesarean section... According to the Institute of Medical Information and Statistics (UZIS), 22,428 women gave birth to their babies via cesarean section in 2007, which is 1.4 percent more than in 2006."

Interestlingly, the report state that according "to medical statistics, some doctors perform cesarean section at women's requests or when they need to ensure successful delivery, but some specialists disagree with the practice."

Other 2007 statistics cited
With 1.44 children per woman being born, this is a record high since 1993.
Women's average age at delivery has increased by 0.2% to 27.1 years at first delivery and 29.1 years in general.

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.

Fear drives growth in cesareans in Australia

The article, 'Fear drives growth in caesareans' that appeared in Australia's The Age on the 6th January, describes Dr Jennifer Fenwick's opinion that "overblown fears about childbirth are a driver of Australia's rising rate of caesarean sections [and not] a case of women being 'too posh to push'."

She also believes that the country's national cesarean rate is "absolutely too high", and says that "women's fears and a culture of negative talk around vaginal birth - both in the medical profession and broader community - should be addressed." The article continues: "The messages are that birth is dangerous; you're better to have a caesarean section," says Dr Fenwick, who is Associate Professor of Midwifery at the University of Technology Sydney.
"What we haven't done is say (to women) 'let's talk about your fear .. Let's try and help you understand that birth is a really normal, healthy life event and your body is very good at having babies'."

As many readers of my website will know, I carried out research into this area myself, and it is true that women often cite 'fear of birth' and/or 'fear of vaginal delivery pain - during and after the birth' as reasons for choosing cesarean delivery. While I agree with Dr Fenwick that it can be helpful to try and address this fear in the case of some women, it should not be forgotten or dismissed that many women do not wish to go through counselling or therapy for fear, and have made a valid and measured decision to choose the risks and benefits associated with a planned cesarean delivery instead of those associated with a planned vaginal delivery.

Don't assume that fear can or needs to be overcome
Dr Fenwick may describe birth as a "normal, healthy life event and your body is very good at having babies" but the fact is that many planned vaginal deliveries result in adverse outcomes for mother and baby, and it is perfectly reasonable for women to make the decision to avoid these risks.