I have some catching up to do on the blogging front as I have been unusually busy over the last six weeks, but I want to start back on the keyboard by making a plea to everyone that is involved with 'Cesarean Awareness' during the month of April.
Could you please be equally aware of these facts:
*There are women for whom a planned cesarean delivery is their number 1 preferred birth choice - we do exist, and we are capable of making independent, informed decisions about our births.
*For many women, a cesarean birth is a fulfilling, exciting and satisfying experience.
*Many cesareans are very much WANTED by mothers - so while it may be relevant to talk in terms of necessary or unnecessary cesareans for women whose cesareans are unwanted, it is entirely irrelevant to apply these labels to all cesarean births.
*There is still a great deal of confusion and misinformation about the specific risks involved with emergency cesareans, planned cesareans for medical reasons and planned cesareans on maternal request. Mixed data provides unreliable information.
*As long as a cesarean birth takes place after the start of the 39th gestational week and the mother is planning a small family, then she should not be bombarded with risks that are associated with surgery following a prolonged trial of labor or surgery carried out prematurely for medical reasons unrelated to the surgery itself. It is neither helpful nor ethical to confuse the very different degrees of risk that are applicable to each.
Monday, April 26, 2010
Australia reports maternal request cesarean rate of 3.2%
This latest survey (published in January) from Australia, 'Estimating the Rate of Cesarean Section by Maternal Request: Anonymous Survey of Obstetricians in Australia' by Stephen J Robson et al, provides us with some interesting new information - both about maternal request cesarean rates and Australian obstetricians' views on them - so I have copied the abstract text below (with my bold text)."The findings of a recent population-based study in Australia suggested that elective cesarean delivery of a singleton pregnancy at term without medical or obstetric indications (cesarean delivery by maternal request) may represent a significant proportion of cesarean births in that country. Maternal request cesarean section has been the subject of much debate in both the lay and the medical press, but there is little useful data on this issue in the medical literature. Worldwide estimates on its frequency are unreliable because of differences between studies in the definition used, diagnostic coding, and documentation by obstetricians. Maternal request cesareans in the era predating the current high rates of cesarean section were estimated to account for 4% to 18% of all cesarean deliveries.
To address this issue, the investigators estimated the rate of cesarean section by maternal request in Australia using 2 anonymous 1-page postal surveys, one for all 1239 specialist obstetricians and the other for all 317 registered obstetric trainees (residents) in Australia. The specialists were asked whether they perform cesarean delivery by maternal request and if so, how many maternal request cesareans they performed in the previous year. Trainees were asked if they would perform such deliveries in their future practice. A reminder letter with the questionnaire enclosed was sent 6 weeks after first mailing. Measures were taken to avoid having any practitioners answer the survey more than once.
The response rate for specialists was 99% and for trainees was 81%. From the specialist responses, it was estimated that between 8553 and 12,434 maternal request cesarean sections were performed in 2006. Using the lowest estimate (8553) in calculations, maternal request accounted for 17.3% of all elective cesarean sections and 3.2% of all births in that year. The likelihood of agreeing to perform maternal request cesarean deliveries was higher among specialists who were 10 or less years from qualification. Two-third of trainees expressed the intention of doing such cesareans in their future practice.
These findings support the hypothesis that maternal request cesareans make a significant contribution to the overall rate of cesarean deliveries in Australia."
Thursday, April 22, 2010
€4.5m settlement - delayed cesarean cited in case
RTE has reported on the €4.5 settlement for a 14-year-old boy who sustained injuries that left him severely disabled during his birth in Sligo General Hospital, Ireland.
It was made "without admission of liability by the Health Service Executive", but the report outlines issues during the birth that included "too high a dose of a labour-inducing drug being given to his mother, the detachment of a monitor during the labour process, too long a delay before the decision was taken to carry out a Caesarian section and the delay in a consultant arriving to carry out the delivery."
Evan Doyle has cerebral palsy and is quadriplegic.
14 years
What I notice most about this all-too-frequent story is the number of years that this poor family have had to wait to receive compensation (or rather, announcement of a settlement amount).
14 years of fighting, waiting, suffering...
It was made "without admission of liability by the Health Service Executive", but the report outlines issues during the birth that included "too high a dose of a labour-inducing drug being given to his mother, the detachment of a monitor during the labour process, too long a delay before the decision was taken to carry out a Caesarian section and the delay in a consultant arriving to carry out the delivery."
Evan Doyle has cerebral palsy and is quadriplegic.
14 years
What I notice most about this all-too-frequent story is the number of years that this poor family have had to wait to receive compensation (or rather, announcement of a settlement amount).
14 years of fighting, waiting, suffering...
Saturday, April 17, 2010
Multiple childbirth is linked to risk of stroke
A study published in March, Parity and risk of hemorrhagic strokes (Jung et al), has reported that: "Increased number of childbirths may be related to an increased risk of both intracerebral hemorrhage and subarachnoid hemorrhage."
An article on the study, Multiple childbirth linked to stroke risk, in the March issue of Neurology, explains this finding in more detail:
"Pregnancy and delivery are known to raise stroke risk. To further look into the association between multiple births and stroke risk, researchers compared 459 women who had stroke and 918 who did not. The women were about 56 years old on average at the time of the study.
Among women who had a stroke, 38 had zero or one childbirth, 143 had given birth twice, 107 had given birth three times, and 171 had four or more deliveries. After allowing for many other factors associated with stroke risk such as age, family history of stroke, high blood pressure, diabetes, cigarette and alcohol use, as well as oral contraceptive and hormone replacement use, each additional birth was associated with 27 percent greater risk for stroke. Women reporting four or more childbirths had nearly a threefold higher risk of stroke as women with no childbirths or childbirth.
The findings could be attributed to the speculation that multiple births might further strain and stress blood vessels and other body systems, and the stress of raising children may also raise stroke risk."
An article on the study, Multiple childbirth linked to stroke risk, in the March issue of Neurology, explains this finding in more detail:
"Pregnancy and delivery are known to raise stroke risk. To further look into the association between multiple births and stroke risk, researchers compared 459 women who had stroke and 918 who did not. The women were about 56 years old on average at the time of the study.
Among women who had a stroke, 38 had zero or one childbirth, 143 had given birth twice, 107 had given birth three times, and 171 had four or more deliveries. After allowing for many other factors associated with stroke risk such as age, family history of stroke, high blood pressure, diabetes, cigarette and alcohol use, as well as oral contraceptive and hormone replacement use, each additional birth was associated with 27 percent greater risk for stroke. Women reporting four or more childbirths had nearly a threefold higher risk of stroke as women with no childbirths or childbirth.
The findings could be attributed to the speculation that multiple births might further strain and stress blood vessels and other body systems, and the stress of raising children may also raise stroke risk."
Malta: Safe birth outcomes, not fewer cesareans should be goal
Juan Ameen's article in The Times of Malta, Fewer caesarean section births but top obstetrician has reservations, reports on a reduction in cesarean births in Malta, but includes a warning from the head of the Obstetrics Department at Mater Dei Hospital, Mark Brincat, who believes that cutting the numbers should not be the ultimate goal.
He is described as still welcoming the decline, but with an insistence that the drop "is not a goal in itself as the primary aim should be the safe outcome for the mother and the baby".
The article states that the number of cesareans "increased steadily between 1999 and 2006 but started dropping from 2006 when 35% of deliveries were by [cesarean], further declining to 31%, or 1,321 births, in 2008."
He is described as still welcoming the decline, but with an insistence that the drop "is not a goal in itself as the primary aim should be the safe outcome for the mother and the baby".
The article states that the number of cesareans "increased steadily between 1999 and 2006 but started dropping from 2006 when 35% of deliveries were by [cesarean], further declining to 31%, or 1,321 births, in 2008."
Misleading facts about cesarean rates
Writing in the Times Union a few weeks ago, A. Garry Finkell, President of Perinatal Data Solutions Inc. in New York, made a very interesting contribution to the debate over rising cesarean rates, and one that I hope might help women in the U.S. in particular - but also elsewhere - when making their decision about where to give birth.
While I don't necessarily agree with his choice of words in the last paragraph, "undesirable increase in C-sections" (after all, some of the cesareans contributing to the increase - mine included - was very much desired - by me, at least...), I thought his points were worthy of posting here.
Here's an extract of what he says:
"One common feature of almost all articles on this topic is the inclusion of C-section rates for individual hospitals, implying that hospitals can be compared on this basis. There is some validity to this, but it can also be misleading.
As Dr. Camille Kanaan of Albany Medical Center pointed out, for example, AMC's rate is highly influenced by its role as the Northeastern New York Regional Perinatal Center. As such, AMC has women with high risk pregnancies transported into its birthing center from other hospitals in the region. These women have a much higher than average likelihood of needing C-sections, and this raises AMC's rate.
Further, it is the individual provider who makes the decision to perform a C-section. In any hospital with more than one obstetrical provider, the hospital's average is really the average of all the providers. In my experience, providers in a single hospital can vary widely in their C-section rates.
At the same time, an individual provider may deliver babies at more than one hospital, presumably bringing their same likelihood to do a C-section to each hospital.
An expectant mother should look to her obstetrical provider rather than to the birthing hospital in order to determine her chances of ending up with a C-section. The same is true for analysts who want to understand the dynamics involved in the undesirable increase in C-sections."
While I don't necessarily agree with his choice of words in the last paragraph, "undesirable increase in C-sections" (after all, some of the cesareans contributing to the increase - mine included - was very much desired - by me, at least...), I thought his points were worthy of posting here.
Here's an extract of what he says:
"One common feature of almost all articles on this topic is the inclusion of C-section rates for individual hospitals, implying that hospitals can be compared on this basis. There is some validity to this, but it can also be misleading.
As Dr. Camille Kanaan of Albany Medical Center pointed out, for example, AMC's rate is highly influenced by its role as the Northeastern New York Regional Perinatal Center. As such, AMC has women with high risk pregnancies transported into its birthing center from other hospitals in the region. These women have a much higher than average likelihood of needing C-sections, and this raises AMC's rate.
Further, it is the individual provider who makes the decision to perform a C-section. In any hospital with more than one obstetrical provider, the hospital's average is really the average of all the providers. In my experience, providers in a single hospital can vary widely in their C-section rates.
At the same time, an individual provider may deliver babies at more than one hospital, presumably bringing their same likelihood to do a C-section to each hospital.
An expectant mother should look to her obstetrical provider rather than to the birthing hospital in order to determine her chances of ending up with a C-section. The same is true for analysts who want to understand the dynamics involved in the undesirable increase in C-sections."
Saturday, March 27, 2010
U.S. cesarean rates increase to 32.3% in 2008
The latest CDC figures (preliminary data for 2007 and 2008) show another U.S. rise in cesarean rates to 32.3%, although as usual, there is unfortunately no breakdown in the figures between how many of those were emergency and how many were elective.
Numerous media outlets reported on the rate rise, such as Business Week's Cesarean rates Reach Record High, in which the five states with the highest cesarean rates were named as "New Jersey (38%), Florida (37%), Mississippi (36%), and Louisiana and West Virginia (35%).
On a personal note, the birth of our daughter was in New Jersey in 2007, so we're included in these numbers!
Numerous media outlets reported on the rate rise, such as Business Week's Cesarean rates Reach Record High, in which the five states with the highest cesarean rates were named as "New Jersey (38%), Florida (37%), Mississippi (36%), and Louisiana and West Virginia (35%).
On a personal note, the birth of our daughter was in New Jersey in 2007, so we're included in these numbers!
62% cesarean rate in private Hong Kong hospitals
An article in the Gulf Times on the 22nd March reported that while 40% of women in Hong Kong give birth by cesarean, in private hospitals, the rate is 62%.
It reports that Hong Kong women opt for cesarean births "because of convenience, fear of pain and the desire to give birth on an “auspicious” date".
You might want to listen to a recent radio programme from Beijing that I was invited to speak on, which discusses China's high cesarean rate.
It reports that Hong Kong women opt for cesarean births "because of convenience, fear of pain and the desire to give birth on an “auspicious” date".
You might want to listen to a recent radio programme from Beijing that I was invited to speak on, which discusses China's high cesarean rate.
Tuesday, March 16, 2010
Recent data sheds light on elective c-section debate
I've just read and posted comments on this article by Cassie Piercey, on the San Diego News Network website. This is what I've said:
There is so much that I could write in response to this article but unfortunately, time does not allow this evening. What I would like to simply point out though, is this: you provide case studies of two women's birth experiences – one, a planned cesarean birth and the other, a planned vaginal birth - and their outcomes reflect a common phenomenon.
Mo Davis-White says, "I never once wavered on my decision to have a C-section", and by all accounts was very satisfied with her birth experience. In contrast, Rose says, "My delivery experience was traumatic… It was upsetting to know my baby was suffering."
Greater levels of satisfaction following a maternal request cesarean birth have been confirmed in medical studies too. For example, this one from Sweden: After PCD "women reported a better birth experience compared to PVD women." (Wiklund et al, 2007) I am not suggesting that all women would be wise to choose a cesarean, but rather, I am defending the perfectly legitimate decision by some women to plan a cesarean in preference to a trial of labor.
There is so much that I could write in response to this article but unfortunately, time does not allow this evening. What I would like to simply point out though, is this: you provide case studies of two women's birth experiences – one, a planned cesarean birth and the other, a planned vaginal birth - and their outcomes reflect a common phenomenon.
Mo Davis-White says, "I never once wavered on my decision to have a C-section", and by all accounts was very satisfied with her birth experience. In contrast, Rose says, "My delivery experience was traumatic… It was upsetting to know my baby was suffering."
Greater levels of satisfaction following a maternal request cesarean birth have been confirmed in medical studies too. For example, this one from Sweden: After PCD "women reported a better birth experience compared to PVD women." (Wiklund et al, 2007) I am not suggesting that all women would be wise to choose a cesarean, but rather, I am defending the perfectly legitimate decision by some women to plan a cesarean in preference to a trial of labor.
Science should guide decisions on your health
I've just read and posted comments on this online article by Roger W. Harms, M.D. of the Mayo Clinic. This is what I've said:
I am a firm advocate of women 'looking to scientific information to inform their decisions', but I think it's also important to be aware of flaws that exist in the presentation of some cesarean data, and I would offer the following reports as evidence of a recent example where this has occurred:
*30 Jan 10 Nigel Hawkes: A bad case of bias against Caesareans, Independent
*26 Jan 10 Funny Figures from WHO on Caesareans, Straight Statistics
*12 Jan 10 Study advises against non-medial cesareans but how accurate is the advice?
When bias against surgery is removed, and studies containing mixed cesarean data are excluded, there is evidence that maternal request cesareans can result in better outcomes than planned vaginal deliveries. Read the stories posted on any birth trauma website (physical and psychological trauma) and you will struggle to find a single complaint from a woman who’s had a maternal request cesarean, yet there are thousands from women who planned vaginal deliveries (this is also backed up by research such as a 2007 Swedish study involving 357 women; those with maternal request cesareans ‘reported a better birth experience compared to those with planned vaginal deliveries.’). Women are simply not being informed about the whole truth. Just two examples: 1. The latest CEMACH report in the UK showed that women were less likely to die following a planned cesarean than any other birth type. 2. A 2009 Canadian study of 40,000 deliveries concluded that ‘elective pre-labour caesarean section…at full term decreased the risk of life-threatening neonatal morbidity compared with spontaneous labour with anticipated vaginal delivery’.
I would also like to pick up on the issue of cost and resources. Firstly, current cost comparisons are flawed in terms of maternal request, as they contain medical and/or emergency surgical costs, but more crucially, vaginal delivery costs repeatedly fail to include the financial impact of: 1. all planned vaginal delivery outcomes, including spontaneous, instrumental and emergency cesareans. 2. short and long-term perineal and pelvic floor repair (e.g. prolapse) and counseling when trauma occurs. 3. huge litigation bills when vaginal delivery goes wrong and a baby/mother is injured or dies. In fact, the UK’s 2004 NICE guideline discusses one cost model in which ‘maternal request would lead to savings’ (not that I’m suggesting this as a motivation), but promptly dismisses the finding as ‘not a realistic conclusion’. The bottom line is: there are risks and benefits with both birth plans - vaginal and cesarean - and women should be allowed to make their own informed decision.
I am a firm advocate of women 'looking to scientific information to inform their decisions', but I think it's also important to be aware of flaws that exist in the presentation of some cesarean data, and I would offer the following reports as evidence of a recent example where this has occurred:
*30 Jan 10 Nigel Hawkes: A bad case of bias against Caesareans, Independent
*26 Jan 10 Funny Figures from WHO on Caesareans, Straight Statistics
*12 Jan 10 Study advises against non-medial cesareans but how accurate is the advice?
When bias against surgery is removed, and studies containing mixed cesarean data are excluded, there is evidence that maternal request cesareans can result in better outcomes than planned vaginal deliveries. Read the stories posted on any birth trauma website (physical and psychological trauma) and you will struggle to find a single complaint from a woman who’s had a maternal request cesarean, yet there are thousands from women who planned vaginal deliveries (this is also backed up by research such as a 2007 Swedish study involving 357 women; those with maternal request cesareans ‘reported a better birth experience compared to those with planned vaginal deliveries.’). Women are simply not being informed about the whole truth. Just two examples: 1. The latest CEMACH report in the UK showed that women were less likely to die following a planned cesarean than any other birth type. 2. A 2009 Canadian study of 40,000 deliveries concluded that ‘elective pre-labour caesarean section…at full term decreased the risk of life-threatening neonatal morbidity compared with spontaneous labour with anticipated vaginal delivery’.
I would also like to pick up on the issue of cost and resources. Firstly, current cost comparisons are flawed in terms of maternal request, as they contain medical and/or emergency surgical costs, but more crucially, vaginal delivery costs repeatedly fail to include the financial impact of: 1. all planned vaginal delivery outcomes, including spontaneous, instrumental and emergency cesareans. 2. short and long-term perineal and pelvic floor repair (e.g. prolapse) and counseling when trauma occurs. 3. huge litigation bills when vaginal delivery goes wrong and a baby/mother is injured or dies. In fact, the UK’s 2004 NICE guideline discusses one cost model in which ‘maternal request would lead to savings’ (not that I’m suggesting this as a motivation), but promptly dismisses the finding as ‘not a realistic conclusion’. The bottom line is: there are risks and benefits with both birth plans - vaginal and cesarean - and women should be allowed to make their own informed decision.
Let's be honest about childbirth
This article in The Guardian on Saturday is a must-read for any pregnant women, and I don't say that because I want to scare women into choosing a cesarean birth (before I'm accused of doing just that). I say it because I truly believe that women are not being properly informed about the potential risks involved with a trial of labor; rather, their heads are filled with the evils that await them if they end up with a cesarean.
Certainly, there are planned vaginal births that result in positive outcomes - a healthy baby and a happy, healthy mother - but there are also those that end like this one. That's Mother Nature for you. In case you missed reading it at the weekend, Emily Woof's description of her traumatic birth - 'Let's be honest about childbirth' - dares to reveal what every pregnant woman deserves to know.
Certainly, there are planned vaginal births that result in positive outcomes - a healthy baby and a happy, healthy mother - but there are also those that end like this one. That's Mother Nature for you. In case you missed reading it at the weekend, Emily Woof's description of her traumatic birth - 'Let's be honest about childbirth' - dares to reveal what every pregnant woman deserves to know.
I had a c-section - does that make me less of a mother?
Of course not, but I came across this article yesterday, and while I don't agree with everything the writer says, I just felt that I wanted to draw attention to one particular paragraph. The poetry of it really touched a nerve for me - the nice, tingly kind:
"I had surgery. I had an epidural. I had stitches and pain medication for weeks afterward. Does that make my birth experience unnatural? Does it make me less of a woman or a mother? What do people get out of vaginal birth that I didn't experience? I had a baby, I saw her face and nearly broke from the love of it."
Amy's description of how she felt about her baby completely encapsulates how I felt when presented with my children for the first time. The happiest births are the healthiest ones, and I have never regretted for one minute that mine were surgical.
"I had surgery. I had an epidural. I had stitches and pain medication for weeks afterward. Does that make my birth experience unnatural? Does it make me less of a woman or a mother? What do people get out of vaginal birth that I didn't experience? I had a baby, I saw her face and nearly broke from the love of it."
Amy's description of how she felt about her baby completely encapsulates how I felt when presented with my children for the first time. The happiest births are the healthiest ones, and I have never regretted for one minute that mine were surgical.
VBAC versus cesarean statement from the NIH
There have been a number of media reports following the latest statement on cesarean delivery from the National Institutes of Health, and I have been concerned by the number of headlines that imply that the NIH has said "VBAC is safe". Now, while I am completely in support of low risk women making an informed decision to have a VBAC birth, and sympathize with those who have been refused their birth choice in some hospitals, it is dangerous to start describing a VBAC as 'safe'. There are indisputable risks involved, as there are with a repeat cesarean, and it's a case of choosing which set of risks and benefits (as they apply to your particular medical history) you are most comfortable with.
Therefore, I think it's useful to present the NIH's actual summary here (known as an 'Abstract') for women to read for themselves, and if you are considering a VBAC, I would suggest you read the whole statement in full as part of your birth research. Through my work, I am rarely contacted by women who are trying to plan a VBAC; on the contrary, I hear mainly from women who are trying to plan a cesarean for their first birth. And of course personally, I didn't choose a vaginal birth first time round, much less consider having one after a cesarean. But that was my personal decision, and I think it's important that every woman's personal decision is respected. Respected and informed.
Vaginal Birth After Cesarean: New Insights
Objective: To provide health care providers, patients, and the general public with a responsible assessment of currently available data on vaginal birth after cesarean (VBAC).
Participants: A non-DHHS, nonadvocate 15-member panel representing the fields of TEXT, and a public representative. In addition, 21 experts from pertinent fields presented data to the panel and conference audience.
Evidence: Presentations by experts and a systematic review of the literature prepared by the Oregon Evidence-based Practice Center, through the Agency for Healthcare Research and Quality. Scientific evidence was given precedence over anecdotal experience.
Conference Process: The panel drafted its statement based on scientific evidence presented in open forum and on published scientific literature. The draft statement was presented on the final day of the conference and circulated to the audience for comment. The panel released a revised statement later that day at http://consensus.nih.gov. This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government.
Conclusions: Given the available evidence, TOL is a reasonable option for many pregnant women with a prior low transverse uterine incision. The data reviewed in this report show that both TOL and ERCD for a pregnant woman with a prior transverse uterine incision have important risks and benefits and that these risks and benefits differ for the woman and her fetus. This poses a profound ethical dilemma for the woman as well as her caregivers, because benefit for the woman may come at the price of increased risk for the fetus and vice versa. This conundrum is worsened by the general paucity of high-level evidence about both medical and nonmedical factors, which prevents the precise quantification of risks and benefits that might help to make an informed decision about TOL versus ERCD. We are mindful of these clinical and ethical uncertainties in making the following conclusions and recommendations.
One of our major goals is to support pregnant women with a prior transverse uterine incision to make informed decisions about TOL versus ERCD. We urge clinicians and other maternity care providers to use the responses to the six questions, especially questions 3 and 4, to incorporate an evidence-based approach into the decisionmaking process. Information, including risk assessment, should be shared with the woman at a level and pace that she can understand. When both TOL and ERCD are medically equivalent options, a shared decisionmaking process should be adopted and, whenever possible, the woman’s preference should be honored.
We are concerned about the barriers that women face in accessing clinicians and facilities that are able and willing to offer TOL. Given the level of evidence for the requirement for “immediately available” surgical and anesthesia personnel in current guidelines, we recommend that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement relative to other obstetrical complications of comparable risk, risk stratification, and in light of limited physician and nursing resources. Healthcare organizations, physicians, and other clinicians should consider making public their TOL policy and VBAC rates, as well as their plans for responding to obstetric emergencies. We recommend that hospitals, maternity care providers, healthcare and professional liability insurers, consumers, and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to TOL.
We are concerned that medico-legal considerations add to, as well as exacerbate, these barriers. Policymakers, providers, and other stakeholders must collaborate in the development and implementation of appropriate strategies to mitigate the chilling effect of the medico-legal environment on access to care.
High-quality research is needed in many areas. We have identified areas that need attention in response to question 6. Research in these areas should be prioritized and appropriately funded, especially to characterize more precisely the short-term and long-term maternal, fetal, and neonatal outcomes of TOL and ERCD.
Therefore, I think it's useful to present the NIH's actual summary here (known as an 'Abstract') for women to read for themselves, and if you are considering a VBAC, I would suggest you read the whole statement in full as part of your birth research. Through my work, I am rarely contacted by women who are trying to plan a VBAC; on the contrary, I hear mainly from women who are trying to plan a cesarean for their first birth. And of course personally, I didn't choose a vaginal birth first time round, much less consider having one after a cesarean. But that was my personal decision, and I think it's important that every woman's personal decision is respected. Respected and informed.
Vaginal Birth After Cesarean: New Insights
Objective: To provide health care providers, patients, and the general public with a responsible assessment of currently available data on vaginal birth after cesarean (VBAC).
Participants: A non-DHHS, nonadvocate 15-member panel representing the fields of TEXT, and a public representative. In addition, 21 experts from pertinent fields presented data to the panel and conference audience.
Evidence: Presentations by experts and a systematic review of the literature prepared by the Oregon Evidence-based Practice Center, through the Agency for Healthcare Research and Quality. Scientific evidence was given precedence over anecdotal experience.
Conference Process: The panel drafted its statement based on scientific evidence presented in open forum and on published scientific literature. The draft statement was presented on the final day of the conference and circulated to the audience for comment. The panel released a revised statement later that day at http://consensus.nih.gov. This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government.
Conclusions: Given the available evidence, TOL is a reasonable option for many pregnant women with a prior low transverse uterine incision. The data reviewed in this report show that both TOL and ERCD for a pregnant woman with a prior transverse uterine incision have important risks and benefits and that these risks and benefits differ for the woman and her fetus. This poses a profound ethical dilemma for the woman as well as her caregivers, because benefit for the woman may come at the price of increased risk for the fetus and vice versa. This conundrum is worsened by the general paucity of high-level evidence about both medical and nonmedical factors, which prevents the precise quantification of risks and benefits that might help to make an informed decision about TOL versus ERCD. We are mindful of these clinical and ethical uncertainties in making the following conclusions and recommendations.
One of our major goals is to support pregnant women with a prior transverse uterine incision to make informed decisions about TOL versus ERCD. We urge clinicians and other maternity care providers to use the responses to the six questions, especially questions 3 and 4, to incorporate an evidence-based approach into the decisionmaking process. Information, including risk assessment, should be shared with the woman at a level and pace that she can understand. When both TOL and ERCD are medically equivalent options, a shared decisionmaking process should be adopted and, whenever possible, the woman’s preference should be honored.
We are concerned about the barriers that women face in accessing clinicians and facilities that are able and willing to offer TOL. Given the level of evidence for the requirement for “immediately available” surgical and anesthesia personnel in current guidelines, we recommend that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement relative to other obstetrical complications of comparable risk, risk stratification, and in light of limited physician and nursing resources. Healthcare organizations, physicians, and other clinicians should consider making public their TOL policy and VBAC rates, as well as their plans for responding to obstetric emergencies. We recommend that hospitals, maternity care providers, healthcare and professional liability insurers, consumers, and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to TOL.
We are concerned that medico-legal considerations add to, as well as exacerbate, these barriers. Policymakers, providers, and other stakeholders must collaborate in the development and implementation of appropriate strategies to mitigate the chilling effect of the medico-legal environment on access to care.
High-quality research is needed in many areas. We have identified areas that need attention in response to question 6. Research in these areas should be prioritized and appropriately funded, especially to characterize more precisely the short-term and long-term maternal, fetal, and neonatal outcomes of TOL and ERCD.
Sunday, February 28, 2010
How did we let these barbaric doctors get away with it?
I wrote this to a friend today: "I thought I'd heard it all, but no, there's more...". I'd just read a story in the Irish Herald highlighting new horrors that women have been subjected to during 'normal' vaginal deliveries in hospital.
I knew what an episiotomy was, of course. I also knew I wanted to avoid one. But a symphysiotomy? That was a new one on me, and here's what I learned today:
Note: More information in this SOS (survivors of symphysiotomy) press release
What is a symphysiotomy?
*A drastic operation to widen the pelvis in obstructed labour...
*It was performed on nearly 1,500 women around the time of birth, leaving many of them incontinent, in pain and suffering from depression for the rest of their lives
*The procedure, which dates back to the 18th century, was reintroduced into Ireland in the mid-1940s at a time when it was dying out in medicine in the developed world.
Scandal
*...young and vulnerable women were put through a barbaric surgical procedure around the time of childbirth for dubious reasons."
*So far, around 110 victims of symphysiotomy have come forward, and there may be many more suffering in silence."
*Symphysiotomy was reportedly used to ensure women could continue to have several children, whereas a cesarean section might have limited the number of children they could bear.
*It was feared by some... that facing the alternative of repeated caesareans, women would turn to birth control.
*Those carrying out the procedure appeared to ignore its serious after-effects.
Remind you of anything?
I don't mean to suggest that the use of forceps, ventouse, episiotomy and other vaginal delivery interventions are as dangerous as symphysiotomy, but I do believe that comparisons can be drawn in relation to the final point above (regarding serious after-effects).
Women are simply not being warned about the true risks involved in planned vaginal delivery. Yes, if their outcome is spontaneous without morbidity for mother or baby, then I agree that (with hindsight) it has fewer risks than surgery. However, given that a spontaneous vaginal delivery outcome is neither predictable nor guaranteed, I simply cannot understand the justification for refusing a woman's request to deliver by planned cesarean surgery instead.
Improvements must come
The reporter for the Herald writes this about Ireland: "Some day, someone will properly psychoanalyse us as a nation and society to find out exactly why we put up with so much for so long."
I would make the same observation about some aspects of maternity policy and the disastrous outcomes that too many parents suffer: "Some day, someone will properly psychoanalyse expectant parents to find out exactly why we put up with so much for so long."
I knew what an episiotomy was, of course. I also knew I wanted to avoid one. But a symphysiotomy? That was a new one on me, and here's what I learned today:
Note: More information in this SOS (survivors of symphysiotomy) press release
What is a symphysiotomy?
*A drastic operation to widen the pelvis in obstructed labour...
*It was performed on nearly 1,500 women around the time of birth, leaving many of them incontinent, in pain and suffering from depression for the rest of their lives
*The procedure, which dates back to the 18th century, was reintroduced into Ireland in the mid-1940s at a time when it was dying out in medicine in the developed world.
Scandal
*...young and vulnerable women were put through a barbaric surgical procedure around the time of childbirth for dubious reasons."
*So far, around 110 victims of symphysiotomy have come forward, and there may be many more suffering in silence."
*Symphysiotomy was reportedly used to ensure women could continue to have several children, whereas a cesarean section might have limited the number of children they could bear.
*It was feared by some... that facing the alternative of repeated caesareans, women would turn to birth control.
*Those carrying out the procedure appeared to ignore its serious after-effects.
Remind you of anything?
I don't mean to suggest that the use of forceps, ventouse, episiotomy and other vaginal delivery interventions are as dangerous as symphysiotomy, but I do believe that comparisons can be drawn in relation to the final point above (regarding serious after-effects).
Women are simply not being warned about the true risks involved in planned vaginal delivery. Yes, if their outcome is spontaneous without morbidity for mother or baby, then I agree that (with hindsight) it has fewer risks than surgery. However, given that a spontaneous vaginal delivery outcome is neither predictable nor guaranteed, I simply cannot understand the justification for refusing a woman's request to deliver by planned cesarean surgery instead.
Improvements must come
The reporter for the Herald writes this about Ireland: "Some day, someone will properly psychoanalyse us as a nation and society to find out exactly why we put up with so much for so long."
I would make the same observation about some aspects of maternity policy and the disastrous outcomes that too many parents suffer: "Some day, someone will properly psychoanalyse expectant parents to find out exactly why we put up with so much for so long."
Unethical focus on reducing cesarean rates - another baby dies
This story, published in The Daily Mail on Monday this week, is a harrowing read and absolutely devastating (Why do doctors still use forceps when they killed our baby? by Jane Feinmann). It sickens me when I hear about women whose legitimate cesarean request is being ignored or refused at antenatal meetings, and the stress and trauma that they have to suffer during their pregnancy, but when I read stories like this - where there was a clear and present danger to the baby, the parents are begging for a cesarean, and medical professionals choose a riskier course of action that results in a precious baby's death - I may have tears in my eyes, but my stomach churns in anger and resolve that something must be done to stop this unethical practice.
Maggie Blott, spokeswoman for the Royal College of Obstetricians and Gynaecologists, is quoted as saying: "If we are going to have normal deliveries, we have to keep on training obstetricians to use forceps."
My view: "I planned a cesarean delivery precisely because I did not want a 'normal' or 'natural' vaginal birth. I didn't trust Mother Nature, I wanted to avoid the unpredictability of a trial of labor, and I took comfort in the growing body of research that demonstrates far safer outcomes for babies with planned cesarean delivery at 39 weeks. I wanted a safe birth - not a normal one - and hospital policy should support this choice."
I would encourage you to read this article in full, but here are some of the main details reported as the investigation continues:
The outcome
- Baby Alexandra, born weighing 9lb 4oz, died when she was just three days old
- Baby Alexandra, born weighing 9lb 4oz, died when she was just three days old
- She died as a result of severe injury to her spinal cord inflicted during a forceps delivery that went wrong - 10 hours after her parents had repeatedly begged the obstetric team to deliver the baby by cesarean
- Parents Beatrix and Craig Campbell lost the daughter they had conceived through IVF after 5 years of trying (which had involved both parents undergoing surgery)
The birth
- June 2009, at the Royal Infirmary Edinburgh’s Simpson Centre for Reproductive Health
- Beatrix, a slight 5ft 2in, was past her due date with a large baby lying sideways
- 30 hours after induction started, exhausted and barely dilated, Beatrix told the midwife she wanted a cesarean. The hospital later admitted that this would have saved Alexandra, but the request was refused.
- It took 4 doctors 75 minutes to stitch Beatrix and she had to return a month later for surgery on the wound
What the parents say
- ...they believe she was the victim of medical arrogance and a determination to reduce the rising cesarean rate
- ...they are hoping there will be an independent investigation into Alexandra’s death
- They have begun their own investigation into forceps, discovering that deaths or serious injury are far from rare. ‘We were horrified to discover this is a frequent occurrence that no one seems to be monitoring,’ says Beatrix. ‘Craig has found local newspaper reports of ten examples of babies dying or being damaged during forceps delivery, with the coroners’ reports in many cases saying that a Caesarean should have been performed earlier.’
Informing women...?
Feinmann writes: ‘NHS websites talk about “the slight risks associated with forceps delivery”, citing temporary problems such as bruising or scratches,’ says Beatrix, 32, a researcher. In fact, studies since the Eighties have reported high rates of damage to mothers and babies through forceps use. Recent research confirmed this poses a higher risk of birth injury than other interventions, including Caesareans.
Feinmann writes: ‘NHS websites talk about “the slight risks associated with forceps delivery”, citing temporary problems such as bruising or scratches,’ says Beatrix, 32, a researcher. In fact, studies since the Eighties have reported high rates of damage to mothers and babies through forceps use. Recent research confirmed this poses a higher risk of birth injury than other interventions, including Caesareans.
Over the past decade, there has been a decline in the use of forceps worldwide - the instrument is consigned to medical history in most U.S. maternity hospitals.
Using forceps safely requires a high level of skill and expertise, which ‘means that the outcome is always uncertain, even for experienced surgeons,’ says leading U.S. surgeon Atul Gawande, head of the World Health Organisation’s Safer Surgery initiative.
‘If you’re seeking the safest possible delivery of every baby, you have to take notice of the steady reports of terrible forceps injuries to babies and mothers, despite the training that clinicians have received,’ he says.
Experts are particularly concerned about a type known as Kielland’s forceps, which were used to deliver Alexandra... Unlike most forceps, which are used to speed up the delivery of a baby that has become distressed or obstructed in the final stages of delivery, Kielland’s forceps are used to rotate an infant stuck in a sideways position, usually higher in the birth passage.
The procedure is so tricky, says Professor Nick Fisk, former consultant obstetrician at Queen Charlotte’s Hospital, London, ‘that even experienced senior consultants would not attempt a Kielland’s forceps delivery’.
Should forecps be used?
Feinmann writes: Phil Steer, Professor of Obstetrics and Gynaecology at Imperial College, London, is among the many who have abandoned forceps - they are a rarity in Chelsea & Westminster, where he is a consultant obstetrician, with Kielland’s forceps all but unknown.
Yet at least 31,500 babies a year are delivered by forceps - that’s one in 20. Some hospitals continue to use Keilland’s forceps; at the Royal Infirmary, where Alexandra was born, there are 170 such deliveries a year.
Tuesday, February 9, 2010
Study suggests: Infection and early birth linked to asthma
As someone who chose to have a cesarean delivery on maternal request, and supports other women who do so, I have always been slightly skeptical of studies that suggest I might have put my children at greater risk for asthma than women who plan vaginal deliveries. This is because most of the studies that suggest an association between cesareans and asthma contain mixed cesarean delivery types (e.g. emergency cesareans and planned cesareans for medical reasons; and the latter often take place prior to the advised 39 weeks EGA for maternal request cesareans).
The study referred to in the Los Angeles Times article below also points to premature birth as a likely risk for asthma, as opposed to the cesarean delivery itself, and adds weight to some of the points I made in my December 2008 blog, "Asthma has NOT been specifically linked with non-medical cesareans".
Article by Thomas H. Maugh II, on February 2, 2010:
An infection of the uterine cavity during pregnancy combined with premature birth doubles the risk that an African American child will develop asthma, researchers have found. The combination also increases risk for some other ethnicities, though less severely.
About 8% of pregnancies are marked by such bacterial infections, called chorioamnionitis, but it is not yet clear what proportion of asthma is induced by them, said the lead author, Dr. Darios Getahun of Kaiser Permanente's Department of Research and Evaluation in Pasadena. Nor is it clear whether the duration of the infection influences the risk and why different ethnicities respond differently, he said.
But blacks have about a 25% higher incidence of asthma and the new findings could account for a significant portion of that increase. Asthma incidence is also higher in American Indian and Alaskan Native populations, but the researchers were not able to examine that association.
About 14% of American children suffer from asthma, an inflammation of the airways that is marked by wheezing, shortness of breath, chest tightening and coughing. About half of such cases are believed to be of genetic origin, but the cause of the rest has been a mystery.
Many studies have looked at the risk of asthma related to caesarean sections, exposure to antibiotics and other factors related to delivery, Getahun said. "We were thinking that it was really exposure [in the uterus] that may predispose children to asthma later in life."
Getahun and his colleagues used the extensive electronic medical records of Kaiser's Southern California Medical Group, studying 397,852 births between 1991 and 2007.
They reported Monday in the journal Archives of Pediatric and Adolescent Medicine that chorioamnionitis had no apparent effect on the rate of asthma when the fetuses were carried full term.
But when the mother suffered from the infection and gave birth prematurely, the risk of asthma developing before the age of 8 was 98% higher in black children, 70% higher in Latino children and 66% higher in whites. No increased risk was observed for children of Asian or Pacific Islander descent.
Getahun speculated that the infections -- which can be caused by a broad variety of bacteria -- cause inflammation of the fetal lungs, either injuring the lungs or predisposing them to react more severely to future environmental insults.
Chorioamnionitis is marked by a fever above 100.4 degrees and may also be manifested as increased maternal or fetal heart rate, uterine tenderness, foul-smelling amniotic fluid and increased white blood-cell counts.
The study referred to in the Los Angeles Times article below also points to premature birth as a likely risk for asthma, as opposed to the cesarean delivery itself, and adds weight to some of the points I made in my December 2008 blog, "Asthma has NOT been specifically linked with non-medical cesareans".
Article by Thomas H. Maugh II, on February 2, 2010:
An infection of the uterine cavity during pregnancy combined with premature birth doubles the risk that an African American child will develop asthma, researchers have found. The combination also increases risk for some other ethnicities, though less severely.
About 8% of pregnancies are marked by such bacterial infections, called chorioamnionitis, but it is not yet clear what proportion of asthma is induced by them, said the lead author, Dr. Darios Getahun of Kaiser Permanente's Department of Research and Evaluation in Pasadena. Nor is it clear whether the duration of the infection influences the risk and why different ethnicities respond differently, he said.
But blacks have about a 25% higher incidence of asthma and the new findings could account for a significant portion of that increase. Asthma incidence is also higher in American Indian and Alaskan Native populations, but the researchers were not able to examine that association.
About 14% of American children suffer from asthma, an inflammation of the airways that is marked by wheezing, shortness of breath, chest tightening and coughing. About half of such cases are believed to be of genetic origin, but the cause of the rest has been a mystery.
Many studies have looked at the risk of asthma related to caesarean sections, exposure to antibiotics and other factors related to delivery, Getahun said. "We were thinking that it was really exposure [in the uterus] that may predispose children to asthma later in life."
Getahun and his colleagues used the extensive electronic medical records of Kaiser's Southern California Medical Group, studying 397,852 births between 1991 and 2007.
They reported Monday in the journal Archives of Pediatric and Adolescent Medicine that chorioamnionitis had no apparent effect on the rate of asthma when the fetuses were carried full term.
But when the mother suffered from the infection and gave birth prematurely, the risk of asthma developing before the age of 8 was 98% higher in black children, 70% higher in Latino children and 66% higher in whites. No increased risk was observed for children of Asian or Pacific Islander descent.
Getahun speculated that the infections -- which can be caused by a broad variety of bacteria -- cause inflammation of the fetal lungs, either injuring the lungs or predisposing them to react more severely to future environmental insults.
Chorioamnionitis is marked by a fever above 100.4 degrees and may also be manifested as increased maternal or fetal heart rate, uterine tenderness, foul-smelling amniotic fluid and increased white blood-cell counts.
Study suggests: sutures safer than staples for cesarean
The article below appeared on the CBC News website on January 4th, and it is certainly a topic worth discussing with your OBGYN prior to your cesarean surgery.
Personally, I was given staples for both of my surgeries and was fortunate not to experience problems on either occasion; had I read about this study though, I'm sure I would have liked to discuss the risks and benefits of each beforehand.
CBC online article:
Women who had caesarean sections were less likely to suffer complications if their incisions were closed with sutures instead of staples, a U.S. study suggests.
When researchers randomly assigned more than 400 women who were having C-sections into either a staple or a suture group, they found staples were linked with a four-fold increase in risk of the wound separating compared with sutures.
Dr. Suzanne Basha, an obstetrician/gynecologist at the Lehigh Valley Health Network in Allentown, Pa., said she set out to test the difference after she noticed she was seeing more patients return with complications after staples but could not find any published research on the topic.
Wound data was available for 219 women who had sutures and 197 who received staples. They were interviewed by phone two to four weeks after delivery.
Use of staples resulted in:
•A higher rate of wound separation (16.8 per cent versus 4.6 per cent for sutures).
•Increased visits to doctors after the operation (36.0 per cent versus 10.6 per cent).
The average operating time was 49 minutes in the staple group compared with 57 minutes for those who had sutures.
The researchers concluded that sutures may be the preferred method for closing the skin for caesarean deliveries.
The findings were presented Thursday at the annual meeting of the Society for Maternal-Fetal Medicine in Chicago.
Personally, I was given staples for both of my surgeries and was fortunate not to experience problems on either occasion; had I read about this study though, I'm sure I would have liked to discuss the risks and benefits of each beforehand.
CBC online article:
Women who had caesarean sections were less likely to suffer complications if their incisions were closed with sutures instead of staples, a U.S. study suggests.
When researchers randomly assigned more than 400 women who were having C-sections into either a staple or a suture group, they found staples were linked with a four-fold increase in risk of the wound separating compared with sutures.
Dr. Suzanne Basha, an obstetrician/gynecologist at the Lehigh Valley Health Network in Allentown, Pa., said she set out to test the difference after she noticed she was seeing more patients return with complications after staples but could not find any published research on the topic.
Wound data was available for 219 women who had sutures and 197 who received staples. They were interviewed by phone two to four weeks after delivery.
Use of staples resulted in:
•A higher rate of wound separation (16.8 per cent versus 4.6 per cent for sutures).
•Increased visits to doctors after the operation (36.0 per cent versus 10.6 per cent).
The average operating time was 49 minutes in the staple group compared with 57 minutes for those who had sutures.
The researchers concluded that sutures may be the preferred method for closing the skin for caesarean deliveries.
The findings were presented Thursday at the annual meeting of the Society for Maternal-Fetal Medicine in Chicago.
Saturday, January 30, 2010
Independent: 'A bad case of bias against Caesareans'
...says Nigel Hawkes, director of Straight Statistics, writing in The Independent today. More fallout from the WHO survey, 'Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007-08'; this time published by a national newspaper, so hopefully it might reach a wider readership.
Article highlightsOn cesarean maternal mortality and morbidity
"So how many women died? None. How many suffered complications? Eight: five needed treatment in an intensive care unit (ICU), and three needed a blood transfusion. The risks for women who completed a normal birth were significantly higher. One in a thousand died, five times as many required a blood transfusion, and twice as many were admitted to an ICU.
Overall, if deaths and complications are added up to make a "Maternal mortality and morbidity index", risks to mothers in the Caesarean group were 60 per cent lower than in the normal birth group.
So how, from this, does the team conclude that risks to mothers who have Caesareans are actually 2.7 times greater? There's a hefty difference between 60 per cent smaller and 270 per cent greater, but statistical manipulation is a powerful tool."
On babies born by planned cesarean..."And what about the babies? Those born by elective Caesarean without medical indications were seven times less likely to suffer death or complications (raw data) or less than half as likely if you believe the corrected data. Understandably, the authors don't make much of this."
On the WHO's final conclusion and The Lancet's role as publisher"Did none of the 23 think this an odd conclusion to have reached? Did no one check the arithmetic in the tables, which are full of errors? The Lancet is a distinguished journal - were its referees asleep?"
Article highlightsOn cesarean maternal mortality and morbidity
"So how many women died? None. How many suffered complications? Eight: five needed treatment in an intensive care unit (ICU), and three needed a blood transfusion. The risks for women who completed a normal birth were significantly higher. One in a thousand died, five times as many required a blood transfusion, and twice as many were admitted to an ICU.
Overall, if deaths and complications are added up to make a "Maternal mortality and morbidity index", risks to mothers in the Caesarean group were 60 per cent lower than in the normal birth group.
So how, from this, does the team conclude that risks to mothers who have Caesareans are actually 2.7 times greater? There's a hefty difference between 60 per cent smaller and 270 per cent greater, but statistical manipulation is a powerful tool."
On babies born by planned cesarean..."And what about the babies? Those born by elective Caesarean without medical indications were seven times less likely to suffer death or complications (raw data) or less than half as likely if you believe the corrected data. Understandably, the authors don't make much of this."
On the WHO's final conclusion and The Lancet's role as publisher"Did none of the 23 think this an odd conclusion to have reached? Did no one check the arithmetic in the tables, which are full of errors? The Lancet is a distinguished journal - were its referees asleep?"
Friday, January 29, 2010
Three cheers for Professor Steer (BJOG Editor-in-Chief)
In May 2009, the British Journal of Obstetrics and Gynaecology editor-in-chief, Professor Philip Steer, is quoted in a wonderful article on the BBC News website, supporting a woman's decision to give birth surgically in preference to opting for a trial of labor. In it, he describes cesarean delivery as "a rational choice."
He doesn't say that all women would or should make this decision; rather, he defends their logic for doing so. Of course it is unfortunate that his views have not been taken on board by many of the NHS Trusts in England and Wales - quite the opposite according to the women who email me describing the difficulties they are having in trying to arrange a cesarean birth - but nevertheless, it takes a brave professional to speak out on this issue in the current political climate, and I for one, would like to applaud his efforts.
Below are just a few extracts from the BBC article, but you can read it in full here.
"Until as recently as the 1930s, maternal mortality around the globe was horrendous. In the early 1930s, one in 250 women in UK who became pregnant would die as a result - the same as in India today... Advances in the technology of surgery, anaesthesia, blood transfusion and antibiotics have so dramatically improved outcomes in developed countries that mortality is now one in 10,000 or fewer...
"You would think that these technological advances would be greeted with universal acclaim, but many women see childbirth as an essential "rite of passage" and exhort others of their gender to eschew technological assistance (is this "the female macho"?)...
"In BJOG (an international journal of obstetrics and gynaecology), the majority of valid science we publish goes unnoticed by the mass media. But publish something about home-birth, and we are guaranteed to get onto the national news. The discussions that ensue are repetitive, predictable and fail to distinguish emotional wish-lists from practical reality.
"Delivery by Caesarean section now accounts for almost a third of all births in many developed countries, and is remarkably safe - certainly as safe as many of the cosmetic operations that do not excite similar criticism. And yet many still argue against allowing women the autonomy to choose their mode of birth, either on spurious economic grounds or by suggesting that "birth is natural so we mustn't become dependent on technology". Without the technology of agriculture, transport, housing and energy generation, how many of the world's population would survive?"
He doesn't say that all women would or should make this decision; rather, he defends their logic for doing so. Of course it is unfortunate that his views have not been taken on board by many of the NHS Trusts in England and Wales - quite the opposite according to the women who email me describing the difficulties they are having in trying to arrange a cesarean birth - but nevertheless, it takes a brave professional to speak out on this issue in the current political climate, and I for one, would like to applaud his efforts.
Below are just a few extracts from the BBC article, but you can read it in full here.
"Until as recently as the 1930s, maternal mortality around the globe was horrendous. In the early 1930s, one in 250 women in UK who became pregnant would die as a result - the same as in India today... Advances in the technology of surgery, anaesthesia, blood transfusion and antibiotics have so dramatically improved outcomes in developed countries that mortality is now one in 10,000 or fewer...
"You would think that these technological advances would be greeted with universal acclaim, but many women see childbirth as an essential "rite of passage" and exhort others of their gender to eschew technological assistance (is this "the female macho"?)...
"In BJOG (an international journal of obstetrics and gynaecology), the majority of valid science we publish goes unnoticed by the mass media. But publish something about home-birth, and we are guaranteed to get onto the national news. The discussions that ensue are repetitive, predictable and fail to distinguish emotional wish-lists from practical reality.
"Delivery by Caesarean section now accounts for almost a third of all births in many developed countries, and is remarkably safe - certainly as safe as many of the cosmetic operations that do not excite similar criticism. And yet many still argue against allowing women the autonomy to choose their mode of birth, either on spurious economic grounds or by suggesting that "birth is natural so we mustn't become dependent on technology". Without the technology of agriculture, transport, housing and energy generation, how many of the world's population would survive?"
Mother cut 'like meat' by midwife during home birth
I usually steer clear of stories related to home birth; as far as I'm concerned, it's simply another birth method that happens to be on the opposite end of the choice spectrum to my own (planned surgery), and as long as a woman is fully informed of the risks and has not been medically advised against it for the safety of her unborn child (e.g. the pregnancy is deemed high risk), then I respect her choice.
I just had to blog about the story that appeared on the BBC News website this week though, because the outcome for mother and child were so devastating. You can read it here.
High risk, high price - physically and financially
What stands out for me is the fact that the independent midwife attending the home birth had no insurance, and it reminded me of a programme I heard on Radio 4's Woman's Hour once (I think it was last year...), which discussed how independent midwives find it difficult to arrange insurance for home birth deliveries because insurance providers consider the event too high risk.
The irony for me is that women choosing cesarean delivery on maternal request are often accused of wasting tax-payers' money, and yet when the cost of litigation and subsequent surgery for babies and mothers following planned vaginal delivery morbidity (whether the birth is in hospital or at home), the truth about which delivery plan costs the NHS more money is different to what many people might think.
I just had to blog about the story that appeared on the BBC News website this week though, because the outcome for mother and child were so devastating. You can read it here.
High risk, high price - physically and financially
What stands out for me is the fact that the independent midwife attending the home birth had no insurance, and it reminded me of a programme I heard on Radio 4's Woman's Hour once (I think it was last year...), which discussed how independent midwives find it difficult to arrange insurance for home birth deliveries because insurance providers consider the event too high risk.
The irony for me is that women choosing cesarean delivery on maternal request are often accused of wasting tax-payers' money, and yet when the cost of litigation and subsequent surgery for babies and mothers following planned vaginal delivery morbidity (whether the birth is in hospital or at home), the truth about which delivery plan costs the NHS more money is different to what many people might think.
Wednesday, January 27, 2010
British research: C-sections 'do not affect how long a mum breastfeeds'
The BBC reports today on new British research that suggests: "Having a Caesarean or instrumental birth does not appear to impact upon how long a mother breastfeeds".
In a study of 2,000 mothers who received breastfeeding support (conducted by the University of Manchester and East Lancashire Primary Care Trust), there was also "little association with how soon after birth the baby was put to the breast", but what "did have an impact was ethnicity, and the number of previous births,".
Maternal request breastfeeding study
This is good news for women planning a cesarean delivery birth, and indeed there are a number of studies that indicate positive breastfeeding experiences are more likely to follow positive birth experiences (regardless of whether the birth is vaginal or cesarean).
However, in the interests of balance, and since the above research focuses on breastfeeding longevity, I would remind readers of a Swedish study - specifically looking at women following cesarean delivery on maternal request - that found these women "were breastfeeding to a lesser extent three months after birth" when compared with a vaginal delivery group.
Voluntary end to breastfeeding?
I guess the other question to ask in these types of studies is whether the cessation of breastfeeding is voluntary or not. Anecdotally for example, I breastfed my first child for 3 months, but was not distressed by switching to 100% formula at that time, and in fact with my second child, I chose not to breastfeed; it had nothing to do with my delivery method.
Incidentally, the 2007 Swedish study I refer to, 'Cesarean section on maternal request: reasons for the request, self-estimated health, expectations, experience of birth and signs of depression among first-time mothers', by Wiklund et al, also found that:
"After planned cesarean section women in this group reported a better birth experience compared to women planning a vaginal birth ."
In a study of 2,000 mothers who received breastfeeding support (conducted by the University of Manchester and East Lancashire Primary Care Trust), there was also "little association with how soon after birth the baby was put to the breast", but what "did have an impact was ethnicity, and the number of previous births,".
Maternal request breastfeeding study
This is good news for women planning a cesarean delivery birth, and indeed there are a number of studies that indicate positive breastfeeding experiences are more likely to follow positive birth experiences (regardless of whether the birth is vaginal or cesarean).
However, in the interests of balance, and since the above research focuses on breastfeeding longevity, I would remind readers of a Swedish study - specifically looking at women following cesarean delivery on maternal request - that found these women "were breastfeeding to a lesser extent three months after birth" when compared with a vaginal delivery group.
Voluntary end to breastfeeding?
I guess the other question to ask in these types of studies is whether the cessation of breastfeeding is voluntary or not. Anecdotally for example, I breastfed my first child for 3 months, but was not distressed by switching to 100% formula at that time, and in fact with my second child, I chose not to breastfeed; it had nothing to do with my delivery method.
Incidentally, the 2007 Swedish study I refer to, 'Cesarean section on maternal request: reasons for the request, self-estimated health, expectations, experience of birth and signs of depression among first-time mothers', by Wiklund et al, also found that:
"After planned cesarean section women in this group reported a better birth experience compared to women planning a vaginal birth ."
63 surgical instruments sewn up inside New Jersey hospital patients
I came across this report by Mike Ferrara on InjuryBoard.com (21 Jan), and this is what caught my eye:
"When it comes to patient safety, it’s important to note New Jersey ’s record: doctors, nurses and other health care staff committed 9,381 preventable medical errors in 2007. Sixty-three times, a foreign object was left inside a patient’s body after surgery. (The expected number is zero.) Doctors and health care workers caused preventable injury to more than 900 women during a vaginal birth requiring forceps or other instruments."
I don't deny that medical errors occur during cesarean surgery too; of course they do - but how often do we really think about the huge number of women that suffer preventable morbidity during a vaginal delivery? How often is it reported in the media?
This is 900 women in New Jersey in 2007. How many women and how many preventable injuries have there been throughout the whole United States - not to mention the UK, Canada and Australia? These are injuries that many women who choose cesarean delivery are seeking to avoid (myself included).
"When it comes to patient safety, it’s important to note New Jersey ’s record: doctors, nurses and other health care staff committed 9,381 preventable medical errors in 2007. Sixty-three times, a foreign object was left inside a patient’s body after surgery. (The expected number is zero.) Doctors and health care workers caused preventable injury to more than 900 women during a vaginal birth requiring forceps or other instruments."
I don't deny that medical errors occur during cesarean surgery too; of course they do - but how often do we really think about the huge number of women that suffer preventable morbidity during a vaginal delivery? How often is it reported in the media?
This is 900 women in New Jersey in 2007. How many women and how many preventable injuries have there been throughout the whole United States - not to mention the UK, Canada and Australia? These are injuries that many women who choose cesarean delivery are seeking to avoid (myself included).
Inquest: death of baby occurred after difficult birth
These stories are always heart-wrenching, and one of the reasons I post them here on my blog (aside from highlighting that planned vaginal delivery is entirely unpredictable and often mismanaged) is to demonstrate that when a baby dies or is injured, it's not just a 'number' in a set of 'mortality data'.
It's the child of a real-life mother and father. The mother carried the baby inside her for nine long months, looking forward to the day she and her husband would meet their son or daughter, only to experience a personal loss and devastation only barely imaginable by anyone else.
In this case, Georgina O'Halloran writes in The Irish Times how:
"The poor condition at birth of a baby boy who died as a result of brain damage due to lack of oxygen “would be best explained” by “issues” which occurred during labour and delivery...
Baby Nathan Molyneaux of Columbas Place, Tullamore, Co Offaly, was born at Portlaoise General Hospital on July 27th, 2008 in poor condition. He never recovered and died seven days later of brain damage due to lack of oxygen to the brain, known as hypoxic ischaemic encephalopathy, at the Coombe hospital, Dublin on August 2nd, 2008. The death was not reported to the coroner’s office at the time and no postmortem was carried out...
Dublin City Coroner’s Court heard there were variable decelerations - temporary drops in the foetal heart rate - during the first stage of labour, with a prolonged second stage and a difficult delivery with a number of attempts... There was no evidence of any pre-existing abnormality of the brain or heart to explain the baby’s condition at birth..."
It's the child of a real-life mother and father. The mother carried the baby inside her for nine long months, looking forward to the day she and her husband would meet their son or daughter, only to experience a personal loss and devastation only barely imaginable by anyone else.
In this case, Georgina O'Halloran writes in The Irish Times how:
"The poor condition at birth of a baby boy who died as a result of brain damage due to lack of oxygen “would be best explained” by “issues” which occurred during labour and delivery...
Baby Nathan Molyneaux of Columbas Place, Tullamore, Co Offaly, was born at Portlaoise General Hospital on July 27th, 2008 in poor condition. He never recovered and died seven days later of brain damage due to lack of oxygen to the brain, known as hypoxic ischaemic encephalopathy, at the Coombe hospital, Dublin on August 2nd, 2008. The death was not reported to the coroner’s office at the time and no postmortem was carried out...
Dublin City Coroner’s Court heard there were variable decelerations - temporary drops in the foetal heart rate - during the first stage of labour, with a prolonged second stage and a difficult delivery with a number of attempts... There was no evidence of any pre-existing abnormality of the brain or heart to explain the baby’s condition at birth..."
Newborn's arm cut during C-section, dies
This is a terrible story from India; the article in Hindustan Times explains how:
"In an apparent case of negligence by doctors, a newborn died after his arm got cut during a C-section delivery at a government hospital in Udaipur. Ranjit Meghwal, a resident of Kelwara town in Rajsamand district, about 100 km from Udaipur, alleged that the doctors at Pannadhay Hospital accidentally cut the arm of the baby while conducting the caesarian on his wife Babli, 25, on Wednesday. The baby's condition became critical on Friday and he was put on artificial respiration. However, at 8 p.m., he was pronounced dead."
As readers of my website will know, I list 'human error' as one of the risks of cesarean delivery - even planned cesarean delivery. The competence of any medical team looking after you is vital, and while I am as horrified by the above story as anyone else, I'd like to think that the risk of something like this happening in the UK, Europe, North America or Australia (for example) is extremely low.
"In an apparent case of negligence by doctors, a newborn died after his arm got cut during a C-section delivery at a government hospital in Udaipur. Ranjit Meghwal, a resident of Kelwara town in Rajsamand district, about 100 km from Udaipur, alleged that the doctors at Pannadhay Hospital accidentally cut the arm of the baby while conducting the caesarian on his wife Babli, 25, on Wednesday. The baby's condition became critical on Friday and he was put on artificial respiration. However, at 8 p.m., he was pronounced dead."
As readers of my website will know, I list 'human error' as one of the risks of cesarean delivery - even planned cesarean delivery. The competence of any medical team looking after you is vital, and while I am as horrified by the above story as anyone else, I'd like to think that the risk of something like this happening in the UK, Europe, North America or Australia (for example) is extremely low.
Funny Figures from WHO on Caesareans
Yesterday, statistician Nigel Hawkes wrote the first journalistic article I've seen that exposes the truth about the recent WHO cesarean survey. I'm ecstatic! Writing for the website Straight Statistics, in 'Funny Figures from WHO on Caesareans', Hawkes firmly concludes:
"The findings should be ignored."
Basic premise for comparison was all wrong
Hawkes agrees with the point I made in my blog on 12 January, that (aside from the incorrect interpretation of data), using spontaneous vaginal delivery as the survey 'reference' is irrelevant. He writes:
"One final point: the comparison they make is an unfair one. The proper comparison to have made would be between women who attempt a natural birth, and women who have an elective Caesarean.
Many of those who set out to have a spontaneous birth fail, for one reason or another, and require intervention. By choosing only those who succeed and ignoring the others, the authors are failing to make their comparison on an “intention to treat” basis."
The Lancet's role in publishing the WHO's survey
Hawkes not only questions the WHO's erroneous interpretation of its own data, but also the role of the survey's reviewers. It is unclear whether he is referring to the researchers' review of their own data prior to submitting it to The Lancet, or The Lancet's review prior to accepting the text for publication, but the question he raises is valid either way:
"“The most important finding of the survey is the increased risk of maternal mortality and severe morbidity which was analysed as a composite outcome in women who undergo Caesarean section with no medical indication”, write the authors. “We conclude that Caesarean section should be done only when there is a medical indication to improve the outcome for the mother and the baby.”
Their data do not bear such a conclusion. The statistical analysis is almost certainly where the error arose. Did no referee raise the alarm?"
Undeniable BiasHawkes writes: "WHO believes too many Caesareans are done without proper cause. But in interpreting these data, the authors appear to have bent over backwards to prove the point – a classic illustration of White Hat bias."
Data actually shows that cesarean delivery is safer than vaginal delivery"The records showed just 1,515 of these deliveries were by Caesarean section chosen in advance without medical indications to justify them. The vast majority (1,356) were in China; the other countries had very low numbers.
Of these 1,515 women, none died. Five were admitted to an intensive care unit (0.3 per cent) while three (0.2 per cent, though the figure published in the paper is 0.3 per cent, presumably a mathematical error) needed a blood transfusion – a total of eight out of 1,515. None required a hysterectomy.
In mothers who had vaginal deliveries, these risks were all greater: for spontaneous vaginal delivery 0.1 per cent of mothers died, 0.6 per cent were admitted to an ICU (the paper says 0.5 per cent, another miscalculation) and 1.0 per cent required a blood transfusion. A small number, 0.04 per cent, (though I make it 0.05 per cent) required a hysterectomy."
FYI (because I didn't know about it until I read this article today):-Straight Statistics is a pressure group whose aim is to detect and expose the distortion and misuse of statistical information, and identify those responsible. It has been formed by a group of legislators, statisticians and journalists, chaired by the Labour peer Lord Lipsey.
I may be accused by some as being an advocate for cesarean delivery at the expense of vaginal delivery, but the truth is, I'm an advocate of informed birth decisions, and I believe that in order for women to have access to worthwhile information in making their birth decisions, I need to continue working hard to expose the outrageous bias that exists in much of the medical and media reporting of cesarean delivery. I'm glad to have discovered today that Straight Statistics exists, and that its statisticians have confirmed my concerns about the WHO's motives.
"The findings should be ignored."
Basic premise for comparison was all wrong
Hawkes agrees with the point I made in my blog on 12 January, that (aside from the incorrect interpretation of data), using spontaneous vaginal delivery as the survey 'reference' is irrelevant. He writes:
"One final point: the comparison they make is an unfair one. The proper comparison to have made would be between women who attempt a natural birth, and women who have an elective Caesarean.
Many of those who set out to have a spontaneous birth fail, for one reason or another, and require intervention. By choosing only those who succeed and ignoring the others, the authors are failing to make their comparison on an “intention to treat” basis."
The Lancet's role in publishing the WHO's survey
Hawkes not only questions the WHO's erroneous interpretation of its own data, but also the role of the survey's reviewers. It is unclear whether he is referring to the researchers' review of their own data prior to submitting it to The Lancet, or The Lancet's review prior to accepting the text for publication, but the question he raises is valid either way:
"“The most important finding of the survey is the increased risk of maternal mortality and severe morbidity which was analysed as a composite outcome in women who undergo Caesarean section with no medical indication”, write the authors. “We conclude that Caesarean section should be done only when there is a medical indication to improve the outcome for the mother and the baby.”
Their data do not bear such a conclusion. The statistical analysis is almost certainly where the error arose. Did no referee raise the alarm?"
Undeniable BiasHawkes writes: "WHO believes too many Caesareans are done without proper cause. But in interpreting these data, the authors appear to have bent over backwards to prove the point – a classic illustration of White Hat bias."
Data actually shows that cesarean delivery is safer than vaginal delivery"The records showed just 1,515 of these deliveries were by Caesarean section chosen in advance without medical indications to justify them. The vast majority (1,356) were in China; the other countries had very low numbers.
Of these 1,515 women, none died. Five were admitted to an intensive care unit (0.3 per cent) while three (0.2 per cent, though the figure published in the paper is 0.3 per cent, presumably a mathematical error) needed a blood transfusion – a total of eight out of 1,515. None required a hysterectomy.
In mothers who had vaginal deliveries, these risks were all greater: for spontaneous vaginal delivery 0.1 per cent of mothers died, 0.6 per cent were admitted to an ICU (the paper says 0.5 per cent, another miscalculation) and 1.0 per cent required a blood transfusion. A small number, 0.04 per cent, (though I make it 0.05 per cent) required a hysterectomy."
FYI (because I didn't know about it until I read this article today):-Straight Statistics is a pressure group whose aim is to detect and expose the distortion and misuse of statistical information, and identify those responsible. It has been formed by a group of legislators, statisticians and journalists, chaired by the Labour peer Lord Lipsey.
I may be accused by some as being an advocate for cesarean delivery at the expense of vaginal delivery, but the truth is, I'm an advocate of informed birth decisions, and I believe that in order for women to have access to worthwhile information in making their birth decisions, I need to continue working hard to expose the outrageous bias that exists in much of the medical and media reporting of cesarean delivery. I'm glad to have discovered today that Straight Statistics exists, and that its statisticians have confirmed my concerns about the WHO's motives.
Tuesday, January 19, 2010
China's cesarean rate high but birth trauma and asphyxia reducing
The media news is chock-a-block with news that China has the highest rate of cesarean deliveries in the world (46%), of which one quarter (11.7% of all births) are on maternal request without medical indication.What you may not read about however, are two very interesting studies conducted in China, published in 2007, which report on an interesting development in health outcomes for newborn babies there:
In the first, titled: 'Unexpected reduction in the incidence of birth trauma and birth asphyxia related to instrumental deliveries during the study period: was this the Hawthorne effect?' (Leung et al), researchers noticed "a significant reduction in the incidence of birth trauma and birth asphyxia related to instrumental deliveries during the study period (0.6%) when compared with that (2.8%) in the pre-study period (1998 and 1999)".
The second, titled: 'Continued reduction in the incidence of birth trauma and birth asphyxia related to instrumental deliveries after the study period: was this the Hawthorne effect?' is even more interesting.
Cesarean rate, UP, instrumental VD, DOWN, Asphyxia and trauma DOWN too
The same researchers discovered that in addition to the above reduction from 2.8% to 0.6% "this phenomenon continued into the post-study period (2001-2003) when the incidence of 1.0% was similarly lower than that in the pre-study period".
"The instrumental delivery rate decreased further in the post-study period (13.5%) compared with those in the study (16.6%) and pre-study (19.5%) periods", and there was "a marked increase in the direct second-stage Caesarean section rate in the post-study period (7.1%) compared to those in the study (0.4%) and pre-study (0.7%) periods".
They conclude that "A change in obstetric practice was identified that may explain the continued reduction in the incidence of birth trauma and birth asphyxia related to instrumental deliveries in the post-study period."
Chinese women are informed about pelvic floor disorders
Add into the mix the fact that Chinese women learn about the potential risk of pelvic floor damage with vaginal delivery (during antenatal appointments), and is it any wonder that the country has higher than average rates of maternal request cesareans?
There are scores of studies that demonstrate the protective benefit of planned cesarean delivery (even WHO admits in its 2010 survey that for 3rd- and 4th-degree perineal tears, "as expected caesarean section had a protective effect compared with vaginal delivery (data not shown)".
That WHO chose not to reveal the data is questionable in itself...
Other influential studies
Here are just five medical studies that might influence women's birth choice in China:
*2008 Beijing (120 women) concluded that pelvic organ prolapse (POP) prevalence is significantly higher after vaginal delivery than cesarean
*2008 Hong Kong (259 at 6 months postpartum) found that 24% of women changed from preferring a planned VD to an preferring an elective cesarean after their first birth
*2007 Beijing (3,750 women) concluded that selective cesarean delivery is safer than induction and spontaneous onset of labor (lower neonatal asphyxia and birth trauma) but costs the most
*2004 Beijing (548 women) concluded that cesarean delivery decreases the risk of urinary incontinence and big babies increase the risk
*2002 Taiwan (275 women) concluded that following cesarean delivery, women had a significantly higher level of positive psychosocial outcomes than after vaginal delivery - possibly due to the normalizing effect of such a high cesarean birthrate and greater social support
WHO makes wholly unsubstantiated conclusion
Despite the facts above, in the WHO's latest survey of nine Asian countries, its researchers conlcude: "To improve maternal and perinatal outcomes, caesarean section should be done only when there is a medical indication."
Yet its own findings report:
*There were no maternal deaths in this group.
*There were no cases of neonatal mortality up to hospital discharge.
*There were no cases of hysterectomy.
*Only infants delivered by antepartum cesarean had a significantly lower risk of fetal death than those born vaginally.
It also admits:
*The calculated odds ratio might overestimate the risk of caesarean section."
*"some outcomes might therefore have been underestimated, especially for women delivering vaginally”
Chinese cesarean birth date concern
Most Chinese women only have one baby (reducing the risk of future surgeries), and if you think about the fact that studies have shown an increased risk of emergency cesarean with larger maternal weight, bigger babies and smaller stature, while other studies have shown an increased risk of infant asphyxia, trauma and injuries with a trial of labor, should people really be so shocked and surprised that the country's cesarean rate is so high?
And does anyone have the right to criticize those women who make the legitimate decision to request and plan a cesarean birth?
The real concern is the reported incidences of women choosing a "lucky" date for the birth of their child. If this birth date occurs after the recommended 39th gestational week is reached (i.e. women make a choice between 3 or 4 days falling within the recommended period for lung maturity), then it is not an issue, but to risk premature birth unnecessarily is surely indefensible.
Friday, January 15, 2010
Interviewed on Beijing's 'Today' radio show on elective cesarean
At 2am this morning I was involved in a one-hour discussion on elective cesareans with CRI Beyond Beijing's Flagship News Magazine. The 'Today' news programme was exploring the reasons for such high rates of elective cesareans in China, and also talking about the risks and benefits of planned cesarean delivery versus planned vaginal delivery.
It was presented by Chris Gelken and Qinduo Xu, and I was interviewed alongside two other panelists, Dr Chen Zhe, Chief Resident Doctor and Obsterician from Renmin Hospital, and Prof Lynn Callister from the School of Nursing at Brigham Young University.
To listen to the programme, click here.
It was presented by Chris Gelken and Qinduo Xu, and I was interviewed alongside two other panelists, Dr Chen Zhe, Chief Resident Doctor and Obsterician from Renmin Hospital, and Prof Lynn Callister from the School of Nursing at Brigham Young University.
To listen to the programme, click here.
Tuesday, January 12, 2010
Study advises against non-medical cesareans but how accurate is the advice?
I am utterly perplexed by the conclusions drawn in this latest report from the World Health Organization, 'Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007-08, Lumbiganon et al', but not in the least bit surprised.[Note added 7 February 2010]
It's bad enough that the presentation of data is skewed in order to make planned vaginal delivery appear safer than it actually is, but the authors have decided to single out "the increased risk of maternal mortality and severe morbidity" in cesarean deliveries with no medical indication as the "most important finding of the survey".
Pregnant women and ALL JOURNALISTS - I urge you to please read the study in full and make up your own mind about which delivery type is the most risky.
If you don't have time, here are some extracts from the study that you won't see in today's media reports:
*The authors write: "Our study has some limitations. First, we had information about mortality and morbidities only until discharge from hospital; some outcomes might therefore have been underestimated, especially for women delivering vaginally who are usually discharged earlier than women having caesarean section."
This is important because damage to the pelvic floor (both in the short- and long-term) leads to physical and psychological trauma, financial costs and hospital readmissions that this study completely ignores. It also ignores the huge cost of litigation that can follow vaginal delivery complications.
*"The calculated odds ratio might overestimate the risk of caesarean section. Although we had adjusted for many potential confounding factors, there might be some other factors that we did not have information about and could not adjust for."
An admission of underestimating vaginal delivery risks and overestimating cesarean delivery risks - and yet this is ignored in the conclusion, perhaps because it does not suit the authors' own birth ideology.
*"Second, data were abstracted from the patients' records. We were not able to confirm the absence of some of the risk factors if they had not been recorded.
This is an issue that has been written about by doctors in the past (and indeed critics of studies such as this) because there may well have been medical indications for some of the 'without indications' cesarean group, and these were simply missing from the patients’ records. This would adversely affect the results for this group; again, potentially causing an over-estimation of its risks.
*"Third, our survey included only hospitals with caesarean facilities having 1000 or more deliveries every year. The results therefore cannot be generalised to smaller facilities."
In the UK especially, some of the highest numbers of cesarean delivery on maternal request occur in small, private hospitals. It is also worth noting here that the quality of hospital care in countries like the UK, USA, Canada and Australia (e.g. infection control through prophylactic antibiotics) may be of a higher standard than some of the regions's hositals included in this study.
*The conclusions drawn about poorer outcomes with cesarean delivery with no medical indication are "analysed as a composite outcome (the maternal mortality and morbidity index)".
This is crucial - because depending on what researchers include in such an "index", this will affect comparative results. Here is what the WHO's index includes:
"We assessed the association of each maternal outcome of death, admission to ICU, blood transfusion, hysterectomy, and mortality and morbidity index (which was defined as the presence of at least one of: maternal mortality, admission to ICU, blood transfusion, hysterectomy, or internal iliac artery ligation); and perinatal outcomes of perinatal mortality, fetal deaths, neonatal mortality up to hospital discharge, stay in neonatal ICU for 7 days or longer, and perinatal mortality and morbidity index (defined as the presence of perinatal death or stay in neonatal ICU for 7 days or longer)"
Notice what is missing: for example, pelvic floor damage; urinary and fecal incontinence; postpartum sexual health; long-term injuries to babies such as Erb's Palsy; psychological outcomes; degree of birth satisfaction. All of these potential birth outcomes are relevant in a truly 'informed' birth risk-benefit analysis, and for many women, they may have a lower tolerance for these risks than the risks associated with planned surgery.
*Referring to planned cesareans without indications, the WHO writes: “The findings for the individual outcomes that make up the composite outcome suggest that the increased risk is mainly attributable to increased admission to ICU and blood transfusion. Although we acknowledge that both ICU admission and blood transfusion depend on the availability of those services and the potentially differing thresholds for giving blood and for admission of women to ICU or referral to higher levels of care, this outcome is nevertheless important.”
This is important because effectively, it is the high occurrence of just two risks within the WHO’s “composite” and self-appointed “index” that leads to this type of cesarean delivery ending up with such a high overall negative score by the end of the study. This has occurred in previous studies too – namely, the 2006 Deneux-Tharaux et al study.
Now, PLEASE READ THE DIRECT EXTRACTS FROM THE STUDY BELOW AND ANSWER THIS QUESTION:
Which delivery type do YOU think has the most risks?
FYI, the study’s data is separated into six birth categories:
- Spontaneous vaginal delivery (reference category)
- Operative vaginal delivery
- Antepartum (before labor) cesarean delivery with indications
- Antepartum (before labor) cesarean delivery without indications
- Intrapartum (during labor) cesarean delivery with indications
- Intrapartum (during labor) cesarean delivery without indications
FOR BABIES:
“Risk of perinatal mortality was significantly increased compared with spontaneous vaginal delivery in infants born by operative vaginal delivery and intrapartum caesarean section with indications. Only infants delivered by antepartum caesarean section with indications had a significantly lower risk of fetal death than those born vaginally, whereas risk of fetal death did not differ significantly for other methods of delivery compared with spontaneous vaginal delivery. For neonatal mortality up to hospital discharge, infants born by operative vaginal delivery, antepartum caesarean section with indications, and intrapartum caesarean section with indications had significantly increased risk compared with spontaneous vaginal delivery. We recorded no cases of neonatal mortality up to hospital discharge for women delivering by caesarean section without indication, and the risk compared with spontaneous vaginal delivery could not be estimated.”
“Infants born by operative vaginal delivery and intrapartum and antepartum caesarean section with indications had significantly increased risk of stay for 7 days or longer in neonatal ICU compared with spontaneous vaginal delivery. Operative vaginal delivery and antepartum and intrapartum caesarean section with indications had significantly increased risk of perinatal mortality and morbidity index. For breech and other abnormal presentation, caesarean section with indication, either antepartum or intrapartum, significantly reduced risk of perinatal mortality but had significantly increased risk of stay in neonatal ICU for 7 days or longer.”
FOR MOTHERS:
“For maternal mortality, only operative vaginal delivery had significantly increased risk compared with spontaneous vaginal deliveries. The risk for antepartum caesarean section without indication could not be estimated because there were no maternal deaths in this group. Operative vaginal delivery and all types of caesarean section had significantly increased risk of admission to ICU compared with spontaneous vaginal delivery. Operative vaginal delivery, antepartum caesarean section with indications, and intrapartum caesarean section with and without indication had significantly increased risks of blood transfusion compared with spontaneous vaginal delivery. The risk of hysterectomy was increased in mothers who delivered by operative vaginal delivery, antepartum caesarean section with indications, and intrapartum caesarean section with indications. We recorded no cases of hysterectomy in women who delivered by antepartum caesarean section without indications and intrapartum caesarean section without indications, so the risk could not be estimated. Operative vaginal delivery and all types of caesarean section were associated with significantly increased risk of maternal mortality and morbidity index compared with spontaneous vaginal delivery. Intrapartum caesarean section (both with and without indications) had higher risk of maternal mortality and morbidity than did antepartum caesarean section. Deliveries by all types of caesarean section had significantly increased risks of maternal mortality and morbidities except for perineal tears of third and fourth degree, for which as expected caesarean section had a protective effect compared with vaginal delivery (data not shown).”
In summary:
There are NO RECORDED NEONATAL OR MATERNAL DEATHS following cesarean deliveries without medical indications – yet this is absent from the study’s conclusion. Why?
There are NO RECORDED CASES OF HYSTERECTOMY following cesarean deliveries without medical indications - yet again, this is absent from the conclusion. Why?
Cesarean delivery PROTECTS AGAINST SEVERE PERINEAL TRAUMA – yet not only is this fact absent from the conclusion, the researchers decided not to omit the data from its public report entirely. Why?
Important:
The WHO uses “spontaneous vaginal delivery” as its comparative “reference” in this study. This in itself is nonsensical. The data is going to be used to advise pregnant women about different risks during the PLANNING stage of their births - not once the birth is over. The problem is, a spontaneous delivery can never be absolutely predicted or guaranteed. Even the healthiest woman with the healthiest pregnancy can suffer a physically and psychologically traumatic labor involving instrumental assistance and ultimately surgical delivery. Therefore, the WHO should have compared birth PLANS – i.e. compared all planned vaginal deliveries (and their ultimate mortality/morbidity outcomes) with all planned cesareans (with and without indications). That said, even with the current vaginal delivery bias, I think it’s clear from the extracts above that maternal request cesareans fair better in the study than the conclusion would have us believe.
The WHO insists that “Assisted vaginal delivery represents a high-risk situation, and combination of such deliveries with spontaneous vaginal deliveries as the reference group might not be appropriate.” Firstly, we know that operative vaginal delivery does NOT always represent a high-risk situation. But even if I accept that argument, other comparative studies frequently mix the data of planned cesareans with and without medical indications, and then compare them in a negative light with vaginal delivery outcomes (and these studies are cited in WHO reports). Perhaps a fairer approach in the WHO's study (or as an additional footnote) would be to compare ALL vaginal delivery outcomes (incl. operative and emergency cesareans) with ALL planned cesarean outcomes (incl. with and without indications groups)?
MY PERSONAL THOUGHTS ON THE STUDY
**Advocates of vaginal delivery should focus their efforts on improving best practice care for women choosing vaginal delivery, and reducing the number of unwanted cesarean deliveries. They should not concern themselves with women who want a cesarean delivery. Numerous medical studies demonstrate high levels of post-birth satisfaction in women who choose a cesarean delivery and I think it’s unethical to try to stop these women enjoying a birth plan that is their legitimate choice.
Millions of women throughout the world plan to have a spontaneous delivery but you only have to look at any birth trauma website to see that many of these plans result in unhappy, traumatic stories of physical and psychological damage. From what I can see (both in studies and in emails I receive from women), those of us that choose cesareans are a generally happy bunch in terms of our birth outcome, and with the clocks turned back, would make the exact same birth decision all over again.
**The WHO is not entirely reliable in terms of making recommendations on cesarean delivery. Back in 1985 it suggested that national rates of cesarean delivery should maintain an upper limit of 15%, and then finally (after much insistence from critics, including the CCA), in its 2009 handbook it admits that "no empirical evidence for an optimum percentage" exists, an "optimum rate is unknown," and world regions may choose to "set their own standards." You can read more about this here.
**There have been a large number of media reports on this study, and what concerns me most is that if perhaps even journalists don’t have time to read a study in full (and in fairness, many don’t), then it’s unlikely that readers of their newspapers will read the study in full either. Therefore, we are in danger of effectively ‘misinforming’ whole nations of women about the true risks of different birth types. Here are a few examples:
Rebecca Smith writes for The Telegraph:
‘Perform caesarean deliveries only where medical problem: researchers’… Hospitals should only perform caesarean sections if there is medical problem and not just because women simply choose the procedure because they are 'too posh to push', experts said.
Bella Battle writes for The Sun:
‘Cesareans a ‘risk’ to mums’… MUMS dubbed 'too posh to push' were given a stark health warning on caesareans today.
Emily Cook writes for The Mirror:
‘Don't have a caesarean unless it's essential, warms news study’…Mums to be should only give birth by caesarean when strictly necessary, insists a new study.
Some of the reports do provide criticism of the WHO’s study, but this tends to come further down in the page. The Telegraph for example notes that “experts in Britain said the study was conducted in Asia and so was not as relevant to practice in Britain. They said the findings had been 'over sensationalised'.” For example, Dr Virginia Beckett, spokesman for the Royal College of Obsestricians and Gynecologists, said: "These findings are actually quite reassuring for women opting for caesarean sections. They found that three in 1,500 women who had a c-section without medical indication before labour needed a blood transfusion and I would expect elective caeseareans to be even safer in Britain… "There are some very big conclusions drawn from some very small numbers.”
**This study is relatively small; an analysis of just 107,950 deliveries throughout nine countries - Cambodia, China, India, Japan, Nepal, Philippines, Sri Lanka, Thailand and Vietnam, and is receiving maximum media exposure in the UK, Australia and North America. Yet where are the vast swathes of media reports on studies like the ones I’ve cited in this blog in the past or in the various press releases I've written (highlighting very positive health outcomes with maternal request cesareans) - many of which are conducted in countries far closer to home than Asia?
I don’t necessarily blame the media here; after all, a powerful natural birth ideology PR machine ensures its message gets reported, but isn’t it time that more journalists looked afresh at the easy target of ‘too posh to push’ mothers and consider for just one second an alternative truth – that these women are in fact making educated and informed decisions about their babies and their bodies?
And while I’m on my soapbox, could the natural birth lobby get busy making suggestions about how we deal with the extremely challenging maternal landscape that obstetrics has to deal with in the developed world – namely, mothers giving birth at increasingly older ages and with heavier body weights, and babies being born larger and heavier too. It’s all too easy to seek a reduction in cesarean rates by trying to encroach on my right to plan the birth of my choice, but what are your plans to encourage a reduction in the number of unwanted cesareans? Do they include an uncomfortable discussion on issues such as earlier parenting or pre-pregnancy weight loss? Your responsibility lies more in counseling women about vaginal delivery risks – help them achieve the delivery of their choice and allow me, and other women like me, to enjoy our own personal choice.
IN SUMMARY
The WHO reports that the “most important finding of the survey is the increased risk of maternal mortality and severe morbidity [analysed as a composite outcome using the maternal mortality and morbidity index] in women who undergo caesarean section with no medical indication.”
And it concludes that to “improve maternal and perinatal outcomes, caesarean section should be done only when there is a medical indication.”
Well, I find myself heading to bed now and still wondering, how on earth can WHO researchers conclude from the data results above that a planned cesarean delivery with no medical indication is any more risky than a planned vaginal delivery? And moreover, how can it claim that of all the data it accumulated in nine countries, that this particular finding was "the most important"?
What about the risks associated with operative vaginal delivery? What about the protective benefit of a planned cesarean with regards third and fourth degree perineal tears? What about the low number of deaths and absence of hysterectomy? What about the positive outcomes with cesarean breech deliveries? Do these areas of risk not warrant our attention?
The WHO’s goal – and that of all true birth autonomy advocates – should be POSITIVE BIRTH OUTCOMES FOR ALL WOMEN in all walks of life. Millions of women and babies continue to die in childbirth despite the WHO’s best efforts, so I would suggest that it focus more on INCREASING cesarean rates for these women and decreasing rates of UNWANTED cesareans for others, and focus less on reducing access for women that WANT cesarean surgery and don't want a trial of labor.
Friday, January 8, 2010
Induced birth research is irrelevant to maternal request cesareans
An article on the Citizens Report website yesterday, 'New Study Warns of Risks from Unnecessary Cesarean Births, and while I don't have an issue with efforts to reduce cesarean rates for women who desperately want to have a vaginal delivery (unless the surgery is needed in order to save the baby's or mother's life), I am critical of reports that make a connection between the term 'unnecessary cesarean' and women who 'choose' cesarean delivery.
My comment on the article
As far as I can ascertain, this research relates to planned vaginal deliveries that were induced (it is stated that the researchers “excluded women who had scheduled or previous cesarean deliveries”). Therefore, it is irrelevant to make a connection between this research and the legitimate decision made by women to plan a cesarean delivery and avoid a trial of labor. The research does not even include the latter type of birth in its analysis.
The advice for women considering a maternal request cesarean delivery is to ensure that they do not have surgery prior to 39 weeks (in order to ensure that the baby’s lungs have developed properly). This research reinforces the established medical opinion that risks are lower for women delivering after 39 weeks gestation.
My comment on the article
As far as I can ascertain, this research relates to planned vaginal deliveries that were induced (it is stated that the researchers “excluded women who had scheduled or previous cesarean deliveries”). Therefore, it is irrelevant to make a connection between this research and the legitimate decision made by women to plan a cesarean delivery and avoid a trial of labor. The research does not even include the latter type of birth in its analysis.
The advice for women considering a maternal request cesarean delivery is to ensure that they do not have surgery prior to 39 weeks (in order to ensure that the baby’s lungs have developed properly). This research reinforces the established medical opinion that risks are lower for women delivering after 39 weeks gestation.
Hospital readmissions after cesarean delivery - are they really higher than after vaginal delivery?
I've just posted a comment at the bottom of yesterday's Modern Medicine article 'Readmissions After Cesarean Higher Than Vaginal Delivery' because I think that the conclusions drawn - both in the media report and in the medical study itself - are not particularly helpful for women who are deciding which birth 'PLAN' to choose.
The article reports on a new U.S. study by researchers Michael Belfort et al: 'Hospital readmission after delivery: evidence for an increased incidence of nonurogenital infection in the immediate postpartum period', and here are my concerns:
The conclusion reported here (that readmission rates are higher following cesarean delivery than vaginal delivery) is a typical example of the flaws apparent in comparative medical studies – particularly in the U.S. Why? Because the research combines all cesarean outcomes (emergency and elective) together - rather than attributing health outcomes of an emergency cesarean to the planned vaginal delivery it originated as.
Actually, vaginal delivery is a risk factor for readmission
In fact, if you read this study in full, Belfort et al explain: “Potential explanations as to the reason that a primary cesarean section delivery represents a greater risk for readmission than a repeat cesarean delivery may include such factors as increased risk of infection from prolonged labor (repeated vaginal examinations, chorioamnionitis), increased blood loss with emergency surgery, and higher use of general anesthesia.”
So in effect, issues related to the trial of labor and subsequent emergency surgery are risk factors for postpartum readmission to hospital – and the risk of readmission with planned cesareans (even repeat surgeries) is lower.
My concern is that studies like this are used to deter women who request a primary elective cesarean at 39 weeks, when evidently the research has very little to do with their chosen birth plan. Rather, if the data was separated (with readmissions following emergency cesarean attributed to planned vaginal deliveries), it is likely that the reality of these readmissions in relation to the delivery method planned is different to that concluded here.
Balance of risks
In addition to the above, I think it's worth remembering that an emergency cesarean is often carried out in a life or death situation (whether it's the mother's life, the baby's life, or both, that is at risk), and while subsequent hospital readmissions are unpleasant and undesirable, they are certainly preferable to the alternative - mortality or severe morbidity if an emergency cesarean is not carried out.
The article reports on a new U.S. study by researchers Michael Belfort et al: 'Hospital readmission after delivery: evidence for an increased incidence of nonurogenital infection in the immediate postpartum period', and here are my concerns:
The conclusion reported here (that readmission rates are higher following cesarean delivery than vaginal delivery) is a typical example of the flaws apparent in comparative medical studies – particularly in the U.S. Why? Because the research combines all cesarean outcomes (emergency and elective) together - rather than attributing health outcomes of an emergency cesarean to the planned vaginal delivery it originated as.
Actually, vaginal delivery is a risk factor for readmission
In fact, if you read this study in full, Belfort et al explain: “Potential explanations as to the reason that a primary cesarean section delivery represents a greater risk for readmission than a repeat cesarean delivery may include such factors as increased risk of infection from prolonged labor (repeated vaginal examinations, chorioamnionitis), increased blood loss with emergency surgery, and higher use of general anesthesia.”
So in effect, issues related to the trial of labor and subsequent emergency surgery are risk factors for postpartum readmission to hospital – and the risk of readmission with planned cesareans (even repeat surgeries) is lower.
My concern is that studies like this are used to deter women who request a primary elective cesarean at 39 weeks, when evidently the research has very little to do with their chosen birth plan. Rather, if the data was separated (with readmissions following emergency cesarean attributed to planned vaginal deliveries), it is likely that the reality of these readmissions in relation to the delivery method planned is different to that concluded here.
Balance of risks
In addition to the above, I think it's worth remembering that an emergency cesarean is often carried out in a life or death situation (whether it's the mother's life, the baby's life, or both, that is at risk), and while subsequent hospital readmissions are unpleasant and undesirable, they are certainly preferable to the alternative - mortality or severe morbidity if an emergency cesarean is not carried out.
Thursday, January 7, 2010
Special 'cesarean wing' is opened in Utah hospital
The Standard-Examiner reports that Ogden Regional Medical Center has a new 'first of its kind' wing dedicated solely for women having caesarean-section deliveries.
I think that this is a very exciting development, and I imagine that the women having cesarean deliveries there will enjoy their postpartum surroundings. Obviously, the quality of surgical care in any hospital is of paramount importance, but these efforts to make women feel more comfortable after they've had their surgery should surely be commended.
Comfortable hospital surroundings
In the report, the hospital's marketing director Craig Bielik describes eight c-section/ postpartum suites, single-room maternity care, newborn and transitional nurseries, larger than normal hospital rooms and rooms fully equipped to handle emergencies. In addition, the new C-wing includes flat-screen televisions, Wi-Fi access, a sleeper chair and access to the new Ronald McDonald family room.
I'm sure that I will receive criticism for my interest in this area of hospital provision, but I know that from my own cesarean experiences, I really enjoyed recovering in my own private room. I also enjoyed the fact that I had access to the internet as I was able to send photos of our new children to friends and relatives via email. I could also make outgoing calls on Skype and Google any 'new mother' questions I had in the days following the birth.
I think that this is a very exciting development, and I imagine that the women having cesarean deliveries there will enjoy their postpartum surroundings. Obviously, the quality of surgical care in any hospital is of paramount importance, but these efforts to make women feel more comfortable after they've had their surgery should surely be commended.
Comfortable hospital surroundings
In the report, the hospital's marketing director Craig Bielik describes eight c-section/ postpartum suites, single-room maternity care, newborn and transitional nurseries, larger than normal hospital rooms and rooms fully equipped to handle emergencies. In addition, the new C-wing includes flat-screen televisions, Wi-Fi access, a sleeper chair and access to the new Ronald McDonald family room.
I'm sure that I will receive criticism for my interest in this area of hospital provision, but I know that from my own cesarean experiences, I really enjoyed recovering in my own private room. I also enjoyed the fact that I had access to the internet as I was able to send photos of our new children to friends and relatives via email. I could also make outgoing calls on Skype and Google any 'new mother' questions I had in the days following the birth.
Friday, January 1, 2010
Australia: 3.2% of all births are maternal request cesareans
In the first publication on the subject for 2010, researchers Robson et al in Australia have calculated that - even 'using the lowest estimate (8,553 women) in calculations, maternal request [cesareans] accounted for 17.3% of all elective cesareans and 3.2% of all births' in 2006.
'Estimating the Rate of Cesarean Section by Maternal Request: Anonymous Survey of Obstetricians in Australia' concludes that its 'findings support the hypothesis that maternal request cesareans make a significant contribution to the overall rate of cesarean deliveries in Australia.'
Rate expected to increase in future too
Of the 1,239 specialist obstetricians surveyed, it was estimated that between 8553 and 12,434 maternal request cesarean sections were performed in 2006, and the likelihood of specialists agreeing to perform maternal request cesarean deliveries was higher among those who were 10 or less years from qualification.
Of the 317 registered obstetric trainees (residents) surveyed, two-thirds expressed the intention of doing such cesareans in their future practice.
Research background
'The findings of a recent population-based study in Australia suggested that elective cesarean delivery of a singleton pregnancy at term without medical or obstetric indications (cesarean delivery by maternal request) may represent a significant proportion of cesarean births in that country... [read more here].
'Estimating the Rate of Cesarean Section by Maternal Request: Anonymous Survey of Obstetricians in Australia' concludes that its 'findings support the hypothesis that maternal request cesareans make a significant contribution to the overall rate of cesarean deliveries in Australia.'
Rate expected to increase in future too
Of the 1,239 specialist obstetricians surveyed, it was estimated that between 8553 and 12,434 maternal request cesarean sections were performed in 2006, and the likelihood of specialists agreeing to perform maternal request cesarean deliveries was higher among those who were 10 or less years from qualification.
Of the 317 registered obstetric trainees (residents) surveyed, two-thirds expressed the intention of doing such cesareans in their future practice.
Research background
'The findings of a recent population-based study in Australia suggested that elective cesarean delivery of a singleton pregnancy at term without medical or obstetric indications (cesarean delivery by maternal request) may represent a significant proportion of cesarean births in that country... [read more here].
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