Wednesday, December 24, 2008

Vitamin D deficiency may make cesarean delivery more likely

Although quite a small study, this may be of interest to women who are trying to avoid needing a cesarean delivery. Researchers discovered that women with vitamin D levels less than 37.5 nmol/L were 3.8 times as likely to have a cesarean as women with levels greater than that.

Of 253 women, 43 (17%) had a primary cesarean, and the reasons for their cesareans included failure to progress, non-reassuring fetal tracing, malpresentation such as breech, a cephalopelvic disproportion, and variable fetal heart rate.

In addition, it was reported that caucasian women and those who reported any alcohol use during pregnancy were also more likely to have a cesarean. Other studies however, have found that women of other ethnicity are more likely to have a cesarean.

Ireland's cesarean rate has risen to 24.3%

An article in the Irish Times by medical correspondent Dr Muiris Houston reports that Ireland's cesarean rate in 2006 rose to 24.3%.

Here are some of the other facts he cites from the latest
Economic and Social Research Institute (ESRI) perinatal statistics report:

*50.8% of multiple births were delivered by cesarean
*The average age of all mothers was 31 years
*The perinatal mortality rate was 7 per 1,000 live and stillbirths compared with 8.4 in 2002
*The number of stillbirths dropped from a rate of 5.6 per 1,000 to 4.7 over the same period
*An infant's length of stay in hospital decreased from an average of 3.9 days in 2002 to 3.7 days in 2006
*A mother's average total length of stay in hospital fell from 4.1 days in 2002 to 3.7 days in 2006

Tuesday, December 16, 2008

Necessary or Unnecessary cesarean - only hindsight makes the safest judgement call

My focus in these blogs is usually in relation to non-medical cesarean deliveries, and the legitimacy of informed, educated women making the decision to choose this birth plan. However, there seems to be so much negative reporting recently on the subject of unnecessary cesareans that I wanted to wanted to post my thoughts.

Firstly, I sympathize with the many angry and disappointed women for whom their preferred birth plan of vaginal delivery did not result in a vaginal delivery outcome. Unwanted cesareans are undoubtedly more difficult to recover from (at the very least from a psychological perspective) than wanted cesareans. I am also open to the possibility that there are cases of unwanted cesarean deliveries where - had early prophylactic surgery not occurred - the vaginal birth plan may well have had the outcome of a vaginal delivery without injury to the baby or mother.

But the question is - at what point precisely does an unnecessary cesarean become a necessary one? Listed below are examples of litigation cases (2008 updates to be added) in which it was concluded that a cesarean delivery should have been carried out/ sooner.

*06 Sep 07 Jury Awards Parent $13.5M In Malpractice Case ...Gardner's pregnancy was allowed to continue for 42 weeks, two weeks past her due date. Gardner and her lawyers claimed that when Nathaniel was born in 2002, the doctor failed to monitor him during the cesarean section procedure. They said Nathaniel was deprived of oxygen for up to 25 minutes, resulting in cerebral palsy... Broadlawns attorney David Brown said they will challenge the $13 million verdict.
*01 Sep 07 Doctor found guilty of misconduct A doctor has been found guilty of misconduct for trying to force a baby's delivery 12 times, as the mother begged for a caesarean. The baby boy died as Dr Avanti Patil delayed the operation and battled with forceps and suction cups. The young mother, known only as Miss A, had been in labour for 24 hours at Southend Hospital.
*31 Jul 07 MEC to pay after baby's death Gauteng MEC for Health Brian Hlongwa has agreed to pay R103 488 in damages to a Johannesburg couple who claimed their first child, a baby boy, died in his mother's womb while she was waiting for a caesarean section to be performed.
*25 Jul 07 Payout victory at last for boy A 10-year-old boy will be paid compensation running into millions of pounds after Swansea health bosses lost the right to appeal the claim. Jac Richards, who was left paralysed following a 10-minute delay in his caesarean delivery...
*18 Jul 07 Boy,14, £2.6m for injuries suffered at birth A 14-year-old boy left facing a lifetime of catastrophic disability by injuries suffered during his birth has won a £2.6m compensation deal at London's High Court. Callum Halliday, of Hunter's Chase, South Godstone, was born by caesarean section at East Surrey Hospital, Redhill, in May 1993. But oxygen starvation has left him a victim of quadriplegic cerebral palsy, confined to a wheelchair and totally dependent on others for all his care needs. His legal team argued that, had it not been for a negligent delay in his delivery, Callum would have escaped serious injury.
*06 Jul 07 Team 4: Family Awarded $23M In Malpractice Settlement ...The lawsuit said a fetal heart rate monitor showed significant abnormalities from the time Jordan was admitted to the hospital. Despite the problems, doctors allowed her to continue laboring for eight hours. Grady was delivered by cesarean section, limp and pale, with no heart rate... Grady suffers from cerebral palsy.
*30 Jun 07 Lifelong care girl sues hospital trust ...Writ: failed at 23.30 hours to proceed to emergency caesarean section... it should already have been clear that a caesarean operation was urgently needed.
*15 Jun 07 Minister sued for R5m Alleged: ignored nursing staff's requests to perform a caesarian section. The doctors and the minister have denied allegations of negligence. The case has not yet gone to court.
*11 Jun 07 Hospital accused in baby death Alleged: refused to call a doctor, agree to a caesarean delivery, administer painkillers or even a give her a glass of water... The inquest continues.
*08 Jun 07 Birth tragedy - mum ‘ignored' ...Her mother told an inquest she had not been offered a caesarian, which she would have agreed to.
*05 Jun 07 Woman in post-delivery stroke sues CHC, doctor Alleged: failing to recommend or perform a caesarian section...
*02 Jun 07 Air Force must pay $24.5M in baby delivery case ...eventually called in and performed surgery, finding the baby half extruded from Evelyn Tremain's uterus and into her abdominal cavity.
*13 Mar 07 Compensation for Caesarean delay A 10-year-old boy left disabled after a delay in his caesarean delivery has won the right to receive compensation. Jac Richards suffered oxygen starvation before his birth at Swansea's Singleton Hospital, causing brain damage. London's High Court ruled he would have escaped injury had he been delivered 10 minutes earlier, and guaranteed Jac, from Llanelli, full compensation.
*28 Feb 07 NHS Trust to pay out over birth error A Seaford mother whose child suffered devastating brain damage after the hospital refused to deliver him by caesarean is to receive massive compensation.
*27 Feb 07 Hospital sorry for blunder at birth A family whose baby suffered brain damage when doctors refused to deliver him by caesarean section is set to be paid millions of pounds in compensation. Alison Jones, 46, had asked for the caesarean for the birth of her fourth child, Ellis, after complications during her previous pregnancies. She feared a scar on her uterus could rupture and put the baby at risk. Hospital staff played down her worries and induced labour but the scar burst and Ellis received devastating brain injuries.
*19 Feb 07 £6.6m for boy, 15 injured at birth ...Ryan was starved of oxygen towards the end of his mother's labour, but the signs were not heeded and his delivery delayed. By the time he was born by emergency caesarean section, he had already suffered brain damage.
*08 Feb 07 'I'd rather have nothing and my baby boy back' Parents of a baby that died just days after being born have been given £32,000 in compensation... The tot was starved of oxygen and suffered 99% brain damage during his birth... A problem with his heartbeat had been spotted during labour - however, it was not acted upon and the baby was delivered normally about 3 hours later. The hospital has now admitted, though, that had it acted earlier - such as carrying out a Caesarian section - Jake would probably not have been brain damaged and died as a result.
*24 Jan 07 Illinois Medical Negligence Attorneys Represent Birth Injury Claim [Judge]: approved the $9,500,000 settlement of a medical negligence case... [doctors] failed to recognize the significance of changes in the fetal heart rate as evidenced on the fetal monitor strips... [The baby] was delivered by emergency caesarean section on October 24, 2001... she was diagnosed with severe cerebral palsy, spastic quadriplegia, and seizure disorder.
*13 Jan 07 Mother, child awarded $1.8 million for injuries during childbirth Virginia Beach: A child and his mother were awarded $1.8m... The lawsuit alleged that Uy failed to order a sonogram at 38 weeks of the pregnancy, failed to deliver the child by cesarean, failed to manage the mother's behavior during delivery, and failed to properly manage a problem during delivery. A problem with the shoulder obstructed Twan Johnson's birth and resulted in Uy gripping the baby's head and pulling during delivery. Defense attorney Dante Filetti said Friday that the case came down to the amount of force used by Uy during the birth.
*22 Dec 06 Couple sues doctor over baby's delivery Morgantown: A Kanawha County couple says their doctor caused injury during the birth of their child by using forceps... Complaint says: ‘As a direct result of the forceps, Plaintiff Stacy suffered permanent injuries requiring surgery which relieved but did not eliminate her injuries.'... No judge has been assigned the case yet.
*28 Nov 06 Brain-damaged girl to get £4million pay-out A girl left brain damaged after being starved of oxygen in the womb today won a compensation deal worth more than £4m and an apology from the NHS Trust who managed her birth. The Chesterfield girl, now aged 12... suffered hypoxia during her delivery at Chesterfield Royal Hospital in November 1994, and has been left with devastating cerebral palsy as a result. Through her parents, she sued Chesterfield and North Derbyshire Royal Hospital NHS Trust, claiming she should have been delivered by emergency CS and that staff negligently failed to heed warning signs that her position in the womb was irregular. The trust denied responsibility but, at London's High Court, agreed to pay damages on the basis of 96% of a full valuation of her claim.
*23 Nov 06 Why did my baby die A nurse claims a refusal by doctors to give her a cesarean in time lead to the death of her baby... She urged medical staff to give her a cesarean explaining her first child had been delivered that way because of complications. But doctors refused, told her to go home and wait for contractions. Two days... unable to feel the baby moving. She returned to the hospital and her baby girl was delivered by emergency cesarean... The child was put into a ventilator but died 2 days later.
*23 Nov 06 Why did my baby die Recent malpractice suit yielded $8m settlement: The child now lives with an intractable seizure disorder - seizures that cannot be controlled with medication... The hospital resident tasked with measuring the fetal heart rate encountered the baby's face in the birth canal. This revealed that a cesarean was indicated, as opposed to a vaginal birth. However, when she relayed this information to the attending physician, he summarily dismissed it, insisting upon delivering the baby ‘naturally.' As a result, the baby suffered facial abrasions due to his facial skin being stretched excessively while being forced down the birth canal face-first. Upon his delivery, it also became obvious that his neurological status was compromised by both the blunt force trauma of the delivery and the deprivation of oxygen.
*10 Nov 06 Couple speak of heartache During the labour hospital staff failed to act on signs of distress on a trace of Lucy's heart rate shortly after 5pm and, instead of arranging for Mrs Walker to undergo a cesarean as was appropriate, encouraged her to go to the hospital canteen... [The NHS Trust] has agreed to settle the claim out of court.
*02 Nov 06 Windsor boy, injured at birth, wins millions Hartford Superior Court jury: awarded a medical malpractice verdict of almost $2.6m to a 4-year-old Windsor boy who has permanent limitations on the use of his right arm due to injuries he suffered as he was born, according to the boy's lawyer. [In addition,] the jury awarded $108,000 to his mother... for the emotional distress she suffered... the lawsuit alleged that Anastasi made 2 mistakes during the April 2002 delivery: *He pulled on Omar's head about 6 times with a vacuum extractor. *Once Omar's head had emerged, his shoulders got stuck in the birth canal... [he] put his hand on Omar's cheekbone and pushed his head sideways in an effort to dislodge him - but used too much force... the jury found Anastasi negligent in his use of the vacuum extractor but didn't find unanimously that he should have performed a cesarean.
*15 Oct 06 Baby death mum to sue hospital Ms Rees: believes the hospital delayed the delivery and treatment of her son... ‘I was considered high-risk because of my age from the start. I believe I should have been monitored more closely and a cesarean should have been performed sooner.'
*13 Oct 06 Detroit: Monroe couple wins $15.8 million in malpractice suit Monroe couple won a $15.8m medical malpractice judgment... involving the birth of their son in 2001... Their lawyer, Brian McKeen of Detroit, said the boy suffered profound brain damage because doctors at Riverside Osteopathic Hospital in Trenton failed to perform a cesarean delivery after Julie Lowe encountered serious problems after going into labor in June 2001.
*30 Aug 06 Brain defect boy gets money, but what use is it? The NCDR forum has ordered the Cosmopolitan Hospital here and 2 doctors to pay Rs.1.1m ($24,300) to the parents of Chakkara... The first mistake took place when the senior gynecologist did not do an immediate cesarean... Geetha was left alone.
*28 Sep 06 Parents win stillborn twin case The parents of a baby boy who was stillborn after clinical negligence have won an out of court settlement... The couple maintained doctors should have performed a caesarean to help Joshua, who was a twin.
*26 Sep 06 Belleville OB sued for not performing emergency C-section
*27 Aug 06 Medical Negligence Case: Justice After 17 years A 17 year-long battle against medical negligence... hospital to pay a compensation of Rs 11.29 lakhs to a couple for causing permanent mental retardation to their son right from his birth in 1989... The commission said the doctors should have gone in for cesarean when there were clear indications of distress to foetus.
*12 Aug 06 Docs get blame for tot death Doctors were yesterday blamed by a coroner for being too slow helping a mother whose child died after she had difficulties during labour... for delaying a caesarean...
*06 Aug 06 Delhi hospital fined for death of baby in womb Finding a Delhi-based hospital guilty of ‘gross medical negligence', a city consumer court has asked it to pay Rs 75,000 as compensation to a woman whose baby died in the womb as the doctors did not opt for cesarean mode of delivery.
*24 May 06 'Breach of duty' in childbirth death Her family claimed she was not seen by a consultant obstetrician for several crucial hours. They argued the medical team should have delivered the baby by emergency caesarean once it was realised Miss Price was in danger of losing her life.
*13 Apr 06 Hospital settles childbirth case A $5m settlement was reached... a Skokie family whose 6-year-old son was born with brain damage at Evanston Hospital in July 1999... Proceeds of the settlement will pay for the care of the boy, who suffers from cerebral palsy.
*03 Apr 06 Brain damage boy, 6, awarded £3m Tzar Stevens Macmillean suffers from severe cerebral palsy caused by a lack of oxygen during his birth at St Mary's Hospital, Manchester, in June 1999.
*18 Mar 06 Award against naval hospital reduced A Fort Lauderdale federal judge...reduced his own verdict in a negligence case against a naval hospital by $20m. But at more than $40m, the judgment still could be the largest personal injury award against the federal government... The judge ruled that doctors and nurses at Jacksonville Naval Hospital waited hours too long to perform a cesarean... As a result, Kevin Rodriguez was born ‘with no heart rate, no respirations, no muscle tone and no muscle reflex.'
*13 Mar 06 Court awards mother compensation A Ballymena woman who was left acutely brain damaged after giving birth in a London hospital has been awarded £500,000 by the High Court... alleged staff were negligent because a caesarean birth was not carried out after his wife developed complications.
*02 Mar 06 Settlement Reached Over C-Section Lawsuit [The woman] was in labor for 27 hours before the decision was made to perform a cesarean.
*05 Oct 02 Mom awarded $8.5 million, Hospital botched son's birth He got stuck in the birth canal for three minutes and was deprived of oxygen. As a result, the baby, Yakeim Donald, was born with severe brain damage. Now 4, he has been diagnosed with cerebral palsy. He cannot speak or walk.

Consider this: it may indeed be possible to reduce the elective cesarean rates in many hospitals, but how many of these will become emergency cesareans instead (which are associated with greater morbidity and mortality risks), and how many will result in injury or death? In fact, the numbers may actually be very small, but for the doctor, midwife and family who are affected by severe complications, that number quickly becomes 100% - because it's happening to them.

Consider too, the implications for birth costs: Planned cesarean deliveries are often criticized for being too costly, but a UK report in 2000 illustrated just how much planned vaginal deliveries cost the NHS when litigation is taken into account: "as much as £50m a year"
*13 Jun 00 An organisation with a memory, Department of Health authored report Every year approximately 50% of the NHS litigation bill relates to claims arising from brain damaged babies. Target set: Negligent harm in obstetrics and gynaecology to be reduced 25% by 2005. It has been estimated that that this could save as much as £50m a year.

And in Los Angeles:
*26 Jan 98 Antonovich ‘shocked' at caesarian policy - calls for investigation
Los Angeles County supervisor: ‘The result of a vaginal birth theory was babies being born deformed, retarded, and in a few cases, dead. In an effort to save money by avoiding cesareans, we cost the taxpayers about $24m so far.'

Friday, December 12, 2008

Medical intervention halves incidence of brain-damaged babies

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

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

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

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

Must-see video discussing elective cesarean delivery

I was sent this link to a TV discussion on an Australian Channel Nine program titled 'The cesarean debate'. In it, Dr Kerryn Phelps discusses why women are increasingly opting for cesarean births in Australia, but what's great about it is that it touches on many of the issues I talk about in my blog.

For example, women being allowed to choose whichever birth they want, including planned cesarean delivery, and discouraging criticism of each other for the birth plans we choose. I don't agree with absolutely everything that is said, but on the whole, this is a very refreshing discussion to see being aired on TV, particularly in a country where the rate of elective cesareans is being heavily scrutinized just now. Watch it if you can.

Thursday, December 11, 2008

Non-medical cesarean delivery should wait until 39 weeks EGA

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

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

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

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

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

Wednesday, December 10, 2008

Shocking cesarean controversy in Turkey

In a December 2nd article on Today's Zaman website, reporter Ayse Karabat writes about a shocking policy on cesarean delivery in Turkey, and one that disturbingly echoes some of the calls for cesarean delivery restriction in countries like the UK, U.S. and Australia.

The report says that Turkey's Ministry of Health wants to reduce its cesarean rate from 42.5% to 25% by restricting cesarean deliveries only to those who medically need them.

In a statement issued this year, it declared that from Sept. 1, the number of cesareans at a health institution "will be taken into consideration when calculating the performance of hospitals. Pursuant to this statement, [cesareans] should be no more that 20% of all births in research and training hospitals and no more than 15% for other hospitals. If the [cesareans] in a hospital are higher than these levels, hospital funding and staff pay will be cut."

You may remember our press release back in October 2008, when the Coalition for Childbirth Autonomy warned of the dangers of forcibly or artificially reducing a nation's cesarean rate to the outdated level recommended by WHO in 1985. Well, perhaps the shocking practices now taking place in Turkey might be a lesson to other government health strategists:

Comments by doctors working in the obstetric field highlight many of the points I have made in the past about the repercussions of reducing cesarean deliveries simply in order to achieve a 'magic number' - rather than making the best decision in each individual case.

Avoidable mortality and morbidity with PVD costs more than CS
*The news report states that "
since the implementation of this program, doctors have been discussing the subject. Some are claiming that the money which is being spent to deal with complications resulting from normal births is higher than the expenditure" for cesarean deliveries.
Critical health care decisions belong in the room the birth takes place
octors are critical of the program from the Ministry of Health, claiming that decisions regarding [cesareans] can be taken only by doctors and to question it is unethical."
Litigation pressure and costs should not be ignored or underestimated
"Professor Turgay Şener, the chairman of the Turkish Perinatology Association, has said any directions from the Ministry of Health will not be useful in reducing the amount of [cesareans]. "Restrictions can lead to disagreements between doctors and patients. If there is even a small problem, the patient will ask the question if it was because of the normal birth."
Enhanced health outcomes are missed when a valid delivery route is avoided
"The doctors will feel pressured and will choose normal births in some cases where cesarean sections are better," [Professor Şener] underlined.
Financial reward (or fear of financial loss) influences doctors' decisions
*"Turkish Gynecology and Obstetric Association Chairman Bülent Tıraş has suggested that the number of [cesareans] will affect the performance of the whole of the hospital and have an impact on other doctors' pay, so this may put pressure on gynecologists to choose normal births."

Does all this really help women and their babies?
No, of course not. It's interesting to read though, that Turkey's strategy uses the
slogan: "Every pregnant woman should be given the chance to give birth naturally." I think it would make a lot more sense, save a lot more lives, and avoid a lot more birth injuries if Turkey altered its slogan to this one:

"Every pregnant woman should be given the chance to give birth in the way she chooses to."

And if the woman doesn't have a particular choice one way or the other (some don't), then it should be a case of providing the best possible health care on the day of the birth, regardless of how that birth outcome might affect a table of statistics on a desk somewhere in the hospital.

Tuesday, December 9, 2008

Study: a quarter of female OBGYNs prefer and suggest cesarean delivery

New research from Iran, 'Caesarean or normal vaginal delivery: overview of physicians' self-preference and suggestion to patients' has found a correlation between a physician's self-preferred mode of delivery and the mode of delivery they suggest to their patients.

Hantoushzadeh et al sent questionnaires to 1,000 female obstetricians and gynaecologists practicing in Tehran in the winter of 2007. They were asked their preferred mode of delivery and the mode they suggest when being consulted by parturient. 785 cases (78.5%) responded to the survey, with 60.8% in favor of suggesting normal vaginal delivery, 25.8%, cesarean section, and 13.6%, painless vaginal delivery.

The study conclusions
The authors clearly have concerns about the 25.8% figure above: "Physicians normally suggest to their patients as the safe mode of delivery what they prefer for themselves. This preference and subsequent suggestion is influenced by different factors including their age, marital status, and previous modes of delivery. As conclusion, it is inferred that informing a physician to choose the right mode of delivery for herself leads to better suggestions to the patients."

What the conclusion says, in effect, is that we not only need to educate women that planned vaginal delivery is a "better suggestion" than planned cesarean delivery, but we also need to tell obstetricians and gynecologists (who are surely sufficiently educated and 'informed' in the subject of birth risks and benefits) what's "better" for them personally too.

Please - It is one thing to argue that ordinary pregnant women are incapable of TRULY understanding the risks involved in a planned cesarean delivery or of coming to terms with the complexities of birth method comparisons (which incidentally, I disagree with), but to imply that OBGYNs are not capable of making their own informed decisions is ludicrous.

Ethical considerations
What I find most interesting about this study is the link between a health worker's personal preferred delivery method and what they suggest to others. I am sure that this element of the survey will illicit stern criticism from groups who are already concerned that physician pressure is one of the factors behind unwanted cesareans.

However, while I would agree that physicians should not coerce healthy women into choosing a birth that is not what they really want, I would also point out that this preference/suggestion behavior is not exclusive to doctors or for that matter, cesareans. I receive emails from many women who are under unwanted pressure to plan a vaginal delivery from their midwife or doctor (when their own preferred mode of delivery is a cesarean) , and this is not ethical either.

Different women want different births. Doctors and midwives should be trying to accommodate ALL women's different birth preferences rather than pressuring them into mirroring their own personal preferences.

Midwives report a 32.2% cesarean rate in Switzerland

I haven't been able to locate the official national data to confirm the data in this December 4th news story, but according to the report, the Swiss Midwives Association are calling for "more controls... to counter the rising number of caesarean births".

The Association advises that "Doctors should only recommend a caesarean for medical reasons, as the operation confers more risk than a normal birth and has an impact on the health of the baby and the mother". It says: "Twice as many children born by caesarean are transferred to intensive care with breathing problems, compared with naturally born babies." And: "Twice as many mothers also have to return to hospital for treatment after a caesarean and many have problems breastfeeding... They are also more likely to have serious complications in later pregnancies."

Of course anyone who's read my blog or website will know that the NICU transfer risk for babies is largely associated with premature or emergency cesarean deliveries - not deliveries at 39 gestational weeks. Similarly, the complications cited above for the mother are more greatly associated with emergency surgery and/or pre-existing medical conditions that led to a planned cesarean.

Asthma has NOT been specifically linked with non-medical cesareans

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

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

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

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

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

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

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

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

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

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

Wednesday, November 26, 2008

Large study reports 2.9% prevalence of severe anal sphincter tears with spontaneous VD

A Norwegian study that set out to analyze the circumstances relating to severe anal sphincter tears during spontaneous vaginal delivery at five hospitals has uncovered some interesting findings.

Firstly, Annelill Valboslash et al's study analyzed midwife-conducted non-operative vaginal deliveries only during a 12-month period..., so arguably, a best practice scenario (according to many natural birth advocates) of birth care.

Secondly, it found that 357 women sustained third and fourth grade anal sphincter tears; that's 2.9% of the 12,438 births analyzed. Remember, this number does not include women who endured less severe anal sphincter tears, which would make the overall risk of anal damage much higher.

Thirdly, the study does not include any anal tears or damage that occurred during instrumental vaginal deliveries. Other studies have documented greater prevalence of anal risk in assisted births, so again, if the outcomes of ALL planned vaginal deliveries were included, the occurrence would have been greater than 2.9%.

What made sphincter damage more/less likely to occur?
The study found that "sphincter tear incidence varied significantly between the five hospitals, from 1.3 to 4.7%", and that the "use of oxytocin in the second phase of labor and of epidural analgesia was significantly more often applied in the hospital with the lowest rate of sphincter tears." So medical intervention in this particular study was associated with better outcomes.

On the other hand, the "midwives' perception of having applied perineal support was not significantly different between the two hospitals with the highest and the lowest incidence of sphincter tear."

The authors conclude that: "The observed difference in incidence of sphincter tear between the hospitals remains unexplained, but could be due to different perineal protection handling techniques."

Planning a cesarean
What is probably of most interest to women planning an elective cesarean delivery is the fact that their risk of ANY anal sphincter damage is considerably less than if they were planning a vaginal delivery. This is surely a reasonable factor to take into consideration during an individual risk-benefit analysis of different birth types.

Study finds SUI is twice as common with PVD

This new study from Brazil is the latest in a long line of studies to show that stress urinary incontinence is more common following a vaginal delivery than it is following a cesarean delivery.

This particular study by Herrman et al assessed women's health three years after they gave birth, and found that: "Women that were asymptomatic during pregnancy and had vaginal delivery developed SUI 2.4 times more frequently than after c-section (19.2% and 8.0%, respectively)."

Difference may be greater if comparing PVD with PCD alone
I have listed other studies on my website that demonstrate a greater prevalence following emergency cesarean delivery when compared with planned cesarean delivery, so although this Brazilian study reported an 8% prevalence with cesarean delivery, it is worth remembering that the study did not separate the two types of surgery. Therefore, the difference between vaginal delivery SUI prevalence and planned cesarean delivery SUI prevalence was likely more than 2.4 times in this group of 120 women.

Monday, November 24, 2008

Natural childbirth movement 'denies women choice'

This is the title of an article in today's Independent newspaper in the UK, which quotes Maureen Treadwell, co-founder of the Birth Trauma Association (BTA):

"Childbirth has become a political football where women are often discouraged from having the sort of birth that they want in order to fulfil someone's idea of a 'normal' birth. Women don't want to have to go into childbirth and have to fight for pain relief... There is a hidden agenda here, one that will result in women being made to feel failures just for asking for pain relief or other forms of medical intervention."

Tomorrow, Monday 24th November, the BTA and other support groups are meeting with Kevin Barron MP, chair of the Commons Health Select Committee, in order to "call for urgent action to ensure women are given a real choice of treatment. The campaigners accuse the Government of having allowed childbirth to be dominated by policies which suit some groups of women to the detriment of others, and are calling on ministers to create an inclusive maternity policy."

I will be there in spirit and would have loved to be there in person as invited, but unfortunately it was not practical. I will keep readers posted on the outcome of this meeting, and invite you to demonstrate your support for autonomy in childbirth - including cesarean delivery - by signing my online petition. Signatures and comments to date are listed here.

Tuesday, November 11, 2008

Premature delivery rather than cesarean surgery itself increases respiratory illness risk

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

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

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

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

New study finds no allergy risk for cesarean born babies

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

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

Monday, November 3, 2008

The impact of planned cesarean delivery on mother and newborn

A research paper from the Department of Obstetrics and Gynecology at Weill Cornell Medical College, New York has advised that "the most concerning risks related to maternal request cesarean delivery are neonatal respiratory morbidity and those that may affect the mother's future reproductive health, including life-threatening conditions, such as placenta accreta", and advises that pregnant women should be counseled on these.

Risks for the mother are lower with PCD than with PVD
Authors YM Lee and ME D'Alton write: "The literature suggests that overall risks of maternal complications with cesarean delivery on maternal request are slightly lower than a trial of vaginal delivery and are primarily driven by the avoidance of unplanned or emergent cesarean deliveries and their associated increased rate of complications."

This is something I have been highlighting (along with many others) for many years. The risks associated with planned vaginal delivery include ALL potential outcomes of a trial of labor and should be recorded as such. Comparisons between PCD and spontaneous VD alone are ineffective and misleading.

Other issues to consider
The authors do acknowledge that cesarean delivery on maternal request is not a simple decision to make. For instance, "there are many areas on which studies are lacking", and in addition, "numerous factors can alter the risks and benefits - such as culture, maternal obesity, and provider background". This echoes the advice given by the NIH in 2006 that maternal request is only ethical following individualized consultation.

Swedish women choosing cesarean delivery

A new study from the Karolinska Institutet in Sweden set out to examine public attitudes to the act of choosing a cesarean delivery in preference to vaginal delivery. Out of the 1,066 women who responded, "two-thirds stated that a cesarean should be decided on for medical reasons and by a doctor. One-third considered that a woman, without persuasion, should decide herself about mode of delivery and should be free to choose a cesarean."

"These respondents used arguments such as women's rights, bodily integrity and childbirth fear. The results were associated with low trust in health care, women being young or middle aged, urban living and having no children. Low trust in health care was associated with experiences of insecurity, vulnerability and perceived maltreatment."

What does this mean for Sweden's future maternity care?
The study authors (Ulf Houmlgberg, Niels Lynoumle and Marianne Wulff) predict that antenatal care will encounter "more parents asking for a cesarean [in the future], and demanding that health professionals provide an ethically appropriate informed consent process."

They conclude: "Considering the risk of violating young women's trust if not respecting her wish, it seems reasonable that making decisions whether or not to perform a cesarean is part of shared decision making."

Thursday, October 30, 2008

ICAN's response to press release contains disappointing inaccuracies

The International Cesarean Awareness Network (ICAN) has published its response to our press release with a statement that disappointingly demonstrates a lack of awareness and understanding in the specific area of cesarean delivery without medical indication.

It states that "While ICAN supports both updated research on this topic and an increase in patient education and autonomy, we maintain that many women who are choosing a cesarean are making that decision without full informed consent." I would argue that certainly the women who register at my website are informed (it lists hundreds of medical studies in risk-benefit categories), and I cannot imagine a patient-doctor consultation in which the risks associated with cesarean delivery are not presented to women. IN FACT, if you read the experiences of women who set out to have a planned vaginal delivery (PVD), it becomes clear that rather it is this birth group that is not always fully informed of the risks associated with PVD.

Inaccurate citation of risks
ICAN claims (in the context of cesarean delivery with no medical indication) that research shows an increased risks of "death, hysterectomy, blood clots, increased pain & recovery time, infection, and post-partum depression." And for the infant, additional risks of "respiratory problems, breastfeeding problems, asthma in childhood and type 1 diabetes." It also cites future risks of "infertility, ectopic pregnancy, placenta abnormality, uterine rupture, preterm birth, and stillbirth."

The overwhelming majority of this list is completely untrue in relation to healthy women planning a small family and delivering via cesarean at 39 weeks confirmed gestation (as recommended by ACOG and the NIH), as demonstrated in a growing number of medical studies. Many of the risks above are associated specifically with emergency cesarean delivery (the majority of which occur as an outcome of a PVD) or planned cesareans for medical reasons. They are not specifically relevant to cesareans with no medical indication and as such, should not be used as an argument against surgical autonomy.

The truth is that in 2004, the UK's NICE found that the only directly attributable increased maternal risks associated with an elective cesarean compared with PVD are abdominal pain and a longer hospital stay. There is still some debate over the link with asthma, so yes, women need to be aware of the potential risk, and also the risk of subsequent placenta complications with multiple pregnancies (although research to date includes first cesarean births that were emergency or planned medical surgeries and this of course adversely affects the final data).

Weak references
Instead of referencing actual medical studies (as we have done in our press release and as I have done on my website), ICAN cites a 2004 book by the Maternity Center Association as its primary source of reference. Unfortunately, this does not help inform women (or indeed journalists) who are trying to better understand both sides of this argument unless they are expected to locate a copy of this book in order to examine the evidence. I think it would be more helpful if ICAN listed actual medical studies (with website links) so that women can go and read the evidence for themselves and make up their own minds about their relevance.

With regard to the risk of type 1 diabetes, ICAN does cite a specific reference, and this is very helpful because I can provide the link to it for readers to see here. You can then see that again, this study is flawed in relation to non-medical cesareans. Why? Because the study looked at all cesarean deliveries, and such a mixed body of data means that we cannot associate this risk with healthy pregnancies specifically. It is possible (as in so many other areas of reported cesarean risks) that maternal or obstetrical characteristics are more likely associated with the baby's health outcome than the delivery method itself.

It's not just an issue of 'fear of birth'
ICAN also states that it does "not believe that cesarean should be the typical solution for fear of childbirth. With appropriate counseling, most women who fear childbirth are comfortable attempting a vaginal birth. Most show long-term satisfaction with their decision to change modes of delivery, and with intensive therapy, labor times were shorter."

First of all, this statement misses the point that many women decide to have a planned cesarean in order to avoid the unpredictability of PVD and all the morbidity risks that are associated with it. For example, urinary and fecal incontinence, pelvic floor prolapse, perineal pain, instrumental delivery and emergency surgery following a prolonged labor. The prophylactic nature of cesarean delivery is often understated, largely because the risks associated with PVD are also understated.

Secondly, although ICAN cites two (2001 and 2006) studies as evidence of successful management of the fear of birth, I would also encourage women to read the studies below that report greater satisfaction in women who have a planned cesarean delivery than those who have a PVD. Remember - some women do not want their issues of 'fear' resolved; they simply prefer to accept the risks of one birth type over another.

*Elective caesarean delivery at maternal request: A preliminary study of motivations influencing women's decision-making. Robson et al, Australian and New Zealand Journal of Obstetrics and Gynaecology, Volume 48, Number 4, August 2008 , pp. 415-420(6). Australia.
*Cesarean section on maternal request: reasons for the request, self-estimated health, expectations, experience of birth and signs of depression among first-time mothers. Wiklund et al, Acta Obstet Gynecol Scand. 2007;86(4):451-6. Sweden.
*Psychologic effects of traumatic live deliveries. Pantlen and Rohde. Zentralbl Gynakol. 2001 Jan;123(1):42-7. Germany.
*An investigation of women's involvement in the decision to deliver by caesarean section. Graham et al. BJOG 1999, vol. 106, no3, pp. 213-220 (34 ref.). UK.
*Psychological Aspects of Emergency Cesarean Section. Ryding EL. Linköping University Medical Dissertations No. 576, 1998. Sweden.
*Women's involvement with the decision preceding their caesarean section and their degree of satisfaction. Mould et al. Br J Obstet Gynaecol. 1996 Nov;103(11):1074-7. UK.
*More in hope than expectation: a systematic review of women's expectations and experience of pain relief in labour. Lally et alBMC Medicine 2008, 6:7. doi:10.1186/1741-7015-6-7. UK.

Ethical and evidence-based autonomy
Finally, ICAN says it "will continue to work to improve maternal-child health and to protect a woman's right to ethical and evidence-based care during pregnancy and childbirth." As far back as 2003, an ACOG ethics committee stated that cesarean delivery on maternal request is medically ethical, and in 2006, the NIH concluded that there is sufficient evidence to support this birth decision following individualized consultation.

I have always understood ICAN's desire to reduce the number of unwanted cesareans, and I think it's important to encourage best-practice care to support women who want to deliver vaginally. However, its insistence on refusing to support wanted cesareans is extremely disappointing, and a stance I hope it is willing to review in the near future.

Wednesday, October 29, 2008

WHO's recommended 10-15% cesarean rate is outdated and unsafe

Today, the Coalition for Childbirth Autonomy (of which my website is a member) has published its first press release. We make the case that efforts to reduce national cesarean rates to a level first suggested 23 years ago are detrimental to the health and safety of mothers and babies. You can read the full release here.

Cesarean delivery protects against fecal incontinence

The latest study into whether cesarean delivery protects against fecal incontinence (FI) has reached the same conclusions as many others before it. Researchers in the U.S. (Guise et al) surveyed all women delivering between 2002 and 2003 in Oregon, and found that "vaginal delivery was associated with a greater risk of FI compared to cesarean".

The survey details
A total of 6,152 primiparous women completed the survey 3–6 months postpartum with 2,482 reporting a new onset of FI after childbirth. That's a 40% prevalence.

Although vaginal delivery was associated with a greater risk compared to cesarean, the researchers do point out that vaginal delivery without laceration or instrument assistance did not increase the risk of FI over cesarean. In addition, they report that being overweight, pushing for longer than 2 hours, and constipation were independently associated with postpartum FI regardless of route of delivery.

What the study tells us
The researchers conclude that this study "provides important data to inform counseling and management of primiparous women", and I agree. Obviously, I don't think it means that all pregnant women will or should switch their delivery plans to a cesarean, but I do think that it further supports the argument that cesarean delivery has benefits over planned vaginal delivery - and that a woman's decision to choose a cesarean is a legitimate one.

One last point. While the researchers state that vaginal delivery without laceration or instrumental assistance does not increase the risk of FI, as always, it is important to understand that these risk factors are entirely unpredictable. A spontaneous vaginal delivery without laceration or assistance cannot be guaranteed for any woman, and therefore any assessment of 'planned vaginal delivery' risks must include morbidity associated with all its potential outcomes.

Monday, October 27, 2008

Is it so shocking that fear of labor pains may be behind some cesarean deliveries?

In this Sunday's Observer newspaper, Louise Silverton, deputy general-secretary of the Royal College of Midwives (RCM) talks about the issue of rising cesarean rates, and is quoted as saying that "women under 40 are less prepared to undergo the physical trauma of childbirth than their predecessors, a trend that is pushing up the rate of surgical deliveries."

She describes England's current cesarean rate of 24.3% as an "unacceptably high and needlessly high" figure that should be brought closer to the 15% recommended by WHO. The fact that Ms Silverton criticizes cesarean rates is of no surprise to me, but what concerns me far more is some of the views she holds about pregnant women. As someone in a position of great power and influence in the world of maternity services, her attitude towards women whose birth preference she does not share is worrying, and her lack of understanding (or willingness to understand) their differing perspective on pain is equally so.

Silverton's solution to pain: 'suck it up like previous generations of women'
Let's examine what Ms Silverton says in the Observer:
"Society's tolerance of pain and illness has reduced significantly."
"Women are less tolerant of labour pains because they haven't developed tolerance of pain. For example, if they get period pain they will either take Nurofen or go to their GP."
"...women under 40 [are] more likely to have an 'epidural in a way that their predecessors wouldn't'."

Ms Silverton describes labor pain as "unbelievably painful" and yet fails to understand or accept that women may have a genuine fear of such pain or choose to avoid it altogether (whether via an epidural or a planned cesarean delivery). What right does she have to suggest that women be encouraged - or forced - to have a natural birth?

The RCM also proposed fees for unnecessary edipurals
This is not the first time that the RCM has been out of step with what contemporary pregnant women want. Back in February 2006, its education and research committee came up with the highly controversial proposal that epidurals should be "free to women who have a definite need of it [but a fee] levied for all other women who desire" one. At the time, Ms Silverton was quoted as saying: "Epidurals provide effective pain relief but, where there is no clinical indication that they are necessary, they can significantly raise the likelihood of other interventions such as caesarean section occurring. "The UK already has an extremely high Caesarean rate and, as the acknowledged experts in normal pregnancy, labour and birth we midwives need to debate ways in which we might help to bring this rate down. "This is a very serious issue and one that is likely to raise significant debate but also something that needs to be debated if we are to improve the normal birth rate."

An argument that is often used against women who choose a cesarean due to a fear of labor pain or labor itself is that they can simply have an epidural. But it is not that simple. First of all, it is clear from the opinion of the very influential midwife above that epidurals are frowned upon too, and secondly, whether it is coincidence or not, I have been contacted by women whose experience of vaginal delivery was that they were refused an epidural or an epidural was 'not available in time' for the start of their pushing. They suffered a traumatic experience and decided to seek support in trying to schedule a cesarean delivery for their next pregnancy.

Clearly, the RCM wants to reduce cesarean rates, but it must ask itself - at what cost physical and psychological cost to the women it claims to serve?

More of Ms Silverton's comments - and my responses to them
"...caesareans have become too easy to obtain"
Not according to the women I receive emails from; they cite experiences with midwives, doctors and hospitals where their cesarean requests are refused. This leads to enormous stress during their pregnancy.

"Women are trying to remove the symptoms of pregnancy as much as they can. They are seeking to control everything. Choosing to have a caesarean gives you an element of control."
Yes, a planned cesarean does provide an element of control, and this benefit is often cited by women whose birth preference is surgery. Is that such a bad thing? The unpredictability of vaginal delivery is not embraced by all women and we shouldn't expect it to be.

"A caesarean is major abdominal surgery. I don't think women realise that. They see it as just another way of giving birth. They see it as easy. And they think that if they can have an elective caesarean they will have no pain because they haven't been in labour."
Of course they realize that it is major surgery, but they have decided to accept the risks associated with that surgery in preference to the risks associated with a planned vaginal delivery. Speaking for myself, I don't view any birth type as 'easy', and I was fully aware that I would experience some abdominal pain following abdominal surgery. However, I also knew that my postpartum pain would be managed (and it was), and that I would be able to tolerate any abdominal pain far better than any perineal pain.

"Some women, tired after a long labour, were wrongly given a caesarean at 10pm to save doctors operating at 2am, when they should be left longer in case natural labour developed..."
I find this comment so reprehensible that I struggle to find the appropriate words. Is it not feasible that the doctor making this decision is making the right one? How many more hours does Ms Silverton suggest that women already "tired after a long labor" continue to labor before undergoing - in her own words - major surgery? And besides the woman, there may also be a danger to the baby in delaying cesarean delivery.

"She also accused junior doctors of approving or undertaking emergency caesareans too quickly if there were any suggestion of risk to the child's health, because they feared they might be sued if something went wrong."
Litigation fear is a reality whether we like it or not, and we might all ask ourselves what would we do in that doctor's position. But the litigation or ethical debate aside, wouldn't most women 'if there were any suggestion of risk to the child's health' also agree with the doctor's (junior or otherwise) decision to perform a cesarean delivery?

" has to question whether the women of this country are physiologically incapable of having normal births, and I don't think they are..."
Then why try to force vaginal delivery on those who don't even want one in the first place?

"She listed a caesarean's main dangers for mothers as 'the risk of infection, the effect on subsequent fertility and the effect on their ability to look after a newborn baby when they are post-operative'. There can also be respiratory complications for the baby, she added."
Yes, there is a risk of infection, and you can read more about that here. There is no association with subsequent fertility following a planned cesarean delivery; a number of studies have found that any reduction in fertility is voluntary. Women's ability to look after a newborn baby following a planned vaginal delivery can also be adversely affected; it is not necessarily any worse following planned surgery ( I personally experienced no such difficulty). Respiratory complications are largely associated with pre-term deliveries and can be mitigated by delivery at 39 weeks confirmed gestation - as advised for healthy women who choose to give birth surgically.

Friday, October 24, 2008

Sometimes it takes a celebrity to get the point across

It's funny world. In the past, I've read media articles accusing women who choose cesarean delivery of being 'celebrity copycats.' Even medical professionals have pointed towards celebrity culture as one of the reasons for the rise in cesarean on maternal request; women want surgery because they see their celebrity idols having it. This idea is also behind the name-calling trend, 'too posh to push', which refers to the specific influence of Victoria Beckham.

The fact of the matter
First of all, there is no evidence to suggest that women are merely 'copying' a celebrity culture when they choose to have a cesarean. Instead, maternal questionnaires cite fear of labor, avoidance of pelvic floor damage and a tolerance for the risks of planned, controlled surgery in preference to the more unpredictable risks associated with vaginal delivery.

In fact it is the media itself that is influenced by celebrity when it comes to reporting on childbirth. If a celebrity speaks out about a negative cesarean experience, this makes the headlines. If a celebrity describes a preference for cesarean delivery over vaginal delivery, again, their story is given center stage. Just this week, the British singer and actress Billie Piper gave birth to her son Winston by emergency cesarean after a reported 26 hours of labor. Her boyfriend is quoted as saying it was "a major thing' but it remains to be seen over the coming days whether newspapers and magazines take the stance that it's another negative cesarean story or whether it's a negative planned vaginal delivery story. My guess is that Billie Piper's first comments to the press will decide that.

Celebrity experience counts
Take for example Gwyneth Palthrow; she described how difficult she found labor with her first baby, Apple. On the flip-side, there was Davina McCall who described a very positive vaginal delivery experience. Then there was Christine Aguilera, the first celebrity to admit to planning her cesarean through her own choice due to a fear of vaginal delivery. Before that, Kate Winslet admitted that she had lied to the media about having a cesarean delivery because she was concerned about the negative press she might get.

The good thing about all these stories is that they keep the issue of childbirth in the public eye; they remind us that childbirth is not always straightforward, that there can be a whole range of experiences from good through to bad, and that we should be more tolerant of the decisions of women with different perspectives and desires than our own. And while I think it's a shame that we have to rely on celebrity news coverage to shine the spotlight on maternal autonomy, I'm also hopeful that by doing so, it acts as a catalyst for media discussion (online, in newspapers and magazines, on the radio and TV), and ultimately leads to greater access to information for women planning their births. That's the very best we can hope for.

Thursday, October 23, 2008

A step in the right direction?

As readers of this blog already know, I believe that any informed healthy pregnant woman should have her decision to give birth via cesarean delivery respected. That said, it clearly remains a highly controversial issue, and one that continues to be debated in the medical and media worlds.

One of the problems we have is that there are no short- or long-term clinical studies that specifically compare healthy women going down the planned vaginal delivery route with healthy women going down the planned cesarean delivery route. In what has become a never-ending cycle of chicken-and-egg, some medical professionals say that such a study is unethical; they claim we don't have evidence to show that planned cesarean delivery is safe enough to compare with vaginal delivery. Yet without this study, we will never have such evidence - a situation perhaps they prefer...

An ethical comparative study
Today I came across a new Australian review by Hans P. Dietz, in which he asks the question: "Elective Cesarean Section- the Right Choice for Whom?" He begins by reiterating some of the problems contemporary doctors face: "There are no scientific grounds for identifying an 'appropriate' level for Cesarean section rates, and no data to help us in counselling women who ask for elective Cesarean delivery. A 'Term Cephalic Trial' may provide such information, but poses major logistic and ethical challenges."

And here's what he proposes: "The key to a successful resolution of this issue may lie in individualized risk assessment. This has now become possible. Maternal age, a history of Cesarean Section in the parturient's mother, maternal body mass index, cervical length and/ or Bishop score, pelvic organ mobility and engagement of the fetal head are some of the factors that have recently been shown to be associated with delivery mode in nulliparous women. Individual risk assessment may soon allow us to construct intervention trials that will be ethically sound, logistically feasible and resource- neutral. Even more importantly, we may eventually be able to provide true 'informed consent' to women considering elective Cesarean delivery."

Informing women is key
This could be a very important step in the right direction. We know that women are giving birth at an increasingly older age, and we know that women's weight is often cited as an unwelcome challenge in obstetrics. Babies are getting larger and women's tolerance of risk (both maternal and fetal) is less than that of previous generations. We know that litigation (whether we like it or not) is a reality that cannot be ignored. We also know that there are other factors that can increase the likelihood of an emergency cesarean or an instrumental delivery - factors that might lead some women to opt for a planned cesarean delivery instead.

I personally feel that a comparative study of healthy pregnant women is already possible, and indeed ethical. There is no need to invite women to have a planned cesarean delivery - simply monitor and collect data on those women who have made the decision to have one themselves. Still, in the meantime, I'm happy to settle for any effort that seeks to better inform women of the risks and benefits of different delivery methods. We've been avoiding doing so for far too long already.

Wednesday, October 22, 2008

A positive birth experience aids breastfeeding more than a vaginal delivery

Cesarean delivery is frequently reported as having a negative impact on breastfeeding and bonding. However, the vast majority of problems occur following emergency surgery and also planned surgery for medical reasons that were nonetheless unwanted by the mother.

That is not to say that women who plan a cesarean delivery through their own choice are guaranteed breastfeeding success (if indeed breastfeeding is their personal choice), but as you'll see from the medical research I have listed on my website, it is erroneous to claim that these women are any less likely to have a positive breastfeeding experience.

The evidence

In answer to the question 'Is it possible to breastfeed after a cesarean birth?', La Leche League International says this: "Yes... A smooth birth contributes to a smooth breastfeeding experience, so when you take advance measures to prevent difficulties from birth complications, breastfeeding can succeed more easily."

Now a new study from New Zealand, 'Impact of Birth Trauma on Breast-feeding: A Tale of Two Pathways', reiterates this sentiment. It found that up to 34% of new mothers reported experiencing a traumatic childbirth, citing "stressful labor and delivery, unscheduled cesarean births, and psychosocial stress and pain related to childbirth". All of these traumas occurred as an outcome of a planned vaginal delivery - not a planned cesarean delivery.

The researchers continue: "Eight themes emerged about whether mothers' breast-feeding attempts were promoted or impeded. These themes included (a) proving oneself as a mother: sheer determination to succeed, (b) making up for an awful arrival: atonement to the baby, (c) helping to heal mentally: time-out from the pain in one's head, (d) just one more thing to be violated: mothers' breasts, (e) enduring the physical pain: seeming at times an insurmountable ordeal, (f) dangerous mix: birth trauma and insufficient milk supply, (g) intruding flashbacks: stealing anticipated joy, and (h) disturbing detachment: an empty affair."

Birth trauma rather than surgery leads to problems
They conclude: "The impact of birth trauma on mothers' breast-feeding experiences can lead women down two strikingly different paths. One path can propel women into persevering in breast-feeding, whereas the other path can lead to distressing impediments that curtailed women's breast-feeding attempts."

Women, midwives, doctors and journalists alike need to keep studies like this in mind before making a connection between breastfeeding problems and cesarean delivery on maternal request.

Monday, October 20, 2008

One woman's decision to have a cesarean

I came across this story last night about a woman in Australia who decided to have a planned cesarean delivery instead of a planned vaginal delivery. Snezna Stojkovski lives in Sydney, and describes her thought processes and the research she did leading up to her final decision. I thought that other women might find her story an interesting read.

Wednesday, October 15, 2008

Duration of hospital stay following birth in England

The cesarean news to come out of this year's NHS Maternity Statistics had nothing to do with England's latest national rate (it rose only slightly to 24.3% from 24.1% in 2005-06). Rather, it was the fact that "recovery time in hospital following caesarean section is lessening." The first thing to say is that this statement refers to ALL cesarean deliveries - both elective and emergency. So as usual, it is necessary to go beyond the headlines and seek the truth about the hospital stay of planned surgical procedures - in particular, to discover how this compares to planned vaginal deliveries.

What the NHS summary says
"Approximately one quarter (27,407) spent four days or more recovering in hospital in 2006-07, compared to just under a third (31,393) in 2005-06."

I found this interesting on two counts. Firstly, from the perspective of cost (the less time women spend in hospital, the lower the delivery bill), and secondly, from the perspective of postnatal care (the number of days women spend in hospital following a vaginal delivery is far fewer than that of the previous generation of mothers, but is that necessarily a good thing?).

Short versus long hospital stay
Understandably perhaps, many women dislike spending any more time than is absolutely necessary in hospital. Noisy wards, the risk of infection, hospital food and craving home comforts are just a few of the reasons often cited. Yet for some, especially those women who have just delivered their first baby, they are grateful for the opportunity to have nurses, doctors and midwives on hand to offer advice about feeding and caring for their baby. Or they want the chance to have a few hours rest while their baby is looked after in the nursery. If the luxury of a private room is available, this is an additional bonus.

The implications of cost to the NHS
In many traditional models of cost, where attempts are made to compare the cost of vaginal delivery with cesarean delivery, the duration of hospital stay for a spontaneous vaginal delivery is compared with that of all cesarean deliveries. Even when elective cesarean deliveries are separated out, researchers do not always factor in the duration of stay of all other vaginal delivery outcomes (such as instrumental or emergency cesarean). Clearly, this distorts any financial comparison that seeks to inform birth 'plans' (where the birth outcome is still unknown).

Current cost analysis is flawed
Particularly when it comes to evaluating the cost of maternal request cesarean deliveries. In NICE's 2004 Clinical Guideline, the authors admit that the "estimated cost of maternal request can change depending on the cost value entered in the model.' For example, if the lowest vaginal birth costs reported in the review and the highest CS cost estimate reported in the review are used, the additional cost for accepting 8,747 maternal requests for CS is around £21.2 million.' The report continues: ' Since the highest cost for vaginal birth in the review is higher than the lowest cost for CS, if these values were entered into the model, the model would show that increasing planned CS due to maternal request would lead to savings, which is not a realistic conclusion.' This highlights the fundamental problem in so much of existing birth comparison literature: it works backwards from a preexisting viewpoint or conclusion, and focuses on making the data fit in with it rather than being open to the data leading us to a new reality.

How long do women stay in hospital following different births?
Let's look at some of the figures contained in Table 21: "Duration of delivery episode by method of onset of labour and method of delivery". The majority of women who have a spontaneous vaginal delivery spend 1 or 2 days in hospital (67.6%). 17.6% go home on the day they deliver, and another 14.7% stay for 3 days or more. The majority of women who have a planned cesarean spend 2 or 3 days in hospital (61.2%). 2.9% go home sooner than that, and the remaining 35.9% stay for 4 days or more. But as we know, this is not the comparison that needs to be made. We also need to look at how many days women who 'planned' a spontaneous vaginal delivery, but had a different delivery 'outcome', spent in hospital.

296,058. This is the number of women whose labor began either spontaneously or was induced, and whose delivery is listed as 'spontaneous'.
53,703. This is the number of women whose labor began either spontaneously or was induced, and whose delivery is listed as 'instrumental'.
57,039. This is the number of women whose labor began either spontaneously or was induced, and whose delivery is listed as 'cesarean'.
406,800. This is the number of women who might be described in Table 21 as having 'planned' a vaginal delivery, which means 13.2% needed instrumental assistance and 14% needed an emergency cesarean delivery.

As expected, women with instrumental vaginal and emergency cesarean deliveries had longer hospital stays than women with spontaneous vaginal deliveries. With instrumental deliveries following spontaneous onset of labor, hospital stay is still mainly 1 or 2 days ( 64.7%), but 32.4% stay 3 or more days. Following labor induction, hospital stay for instrumental deliveries is mainly 2 or 3 days (51.6%), but as many as 36.7% of women stay for 4 or more days.

Similarly, with emergency cesarean delivery. Following spontaneous onset of labor, hospital stay is mainly 3 or 4 days (59.4%), with 21.2% staying 5 or more days. And following labor induction, the majority of women spend 3 or 4 days in hospital ( 48.9%), but as many as 44% stay for 5 or more days.

Future research
Only when these longer hospital stays following a planned vaginal delivery are taken into account in cost evaluations, and further - when the elective cesarean group is broken down into women who had a planned cesarean for medical reasons (i.e. the medical reason rather than the cesarean surgery itself may require longer hospital stay) and women who personally decided to have a planned cesarean - will we truly be able to discuss cost implications of cesarean delivery on maternal request.
Additional cost factors for the NHS such as long-term pelvic floor repair or litigation following injuries or death during planned vaginal deliveries is a topic I'll leave for another day...