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.


Christine Fiscer, Birthkeeper said...

The studies have not been done, because the researchers and doctors don't want to show the short and long term effects of a cesarean section on healthy women who shouldn't have undergone major abdominal surgery for childbirth to begin with.

Studies HAVE shown higher rates of long term issues such as:

Endometriosis, post cesarean.
PCOS, post cesarean.
Pelvic Adhesions, post cesarean.
Secondary Infertility, post cesarean.
Insulin resistance, post cesarean.

And that's not even listing the short and long term risks to the baby.

Or maybe you'd like pictures of babies, at term, who were perfectly healthy in utero, in the NICU with tubes coming from every possible place?

cesarean debate said...

birthkeeper - In fact the opposite is true. I have listed examples of medical professional opinion on my website that highlight a fear that planned cesarean delivery will emerge as a safer birth method than vaginal delivery in a truly comparative study.

Yes, there are risks with repeat cesarean deliveries and women need to be aware of these, but as I have always said, there are short- and long-term risks associated with every birth choice, and different women will make different decisions based on these.

Regarding risks for the baby, please read my website pages on 'Birth injuries - Risks for your baby' in order to familiarize yourself with the reality of PVD risks here. It is naive to think that respiratory illness is the only morbidity outcome that women need to consider when assessing the risk-benefit analysis of delivery method for their baby.

Christine Fiscer, Birthkeeper said...

I'm afraid my brain cannot handle another page of yours.

I can only imagine, due to the increasing prevalence of ignorance in childbirth, what your "Birth Injuries" page will hold.

I will take a stab in the dark and assume that you have never taken a look at the outcomes of out of hospital births, and the injury rates there, and compare them to hospital vaginal births.

I will agree - the injury rates in planned vaginal birth is high in the hospitals.

That's why healthy, low risk women shouldn't be giving birth in one. ;)

I'll say it again, at the risk of sounding like a broken record. It's all about the interventions. NOT the planned vaginal delivery vs. the planned cesarean.

To be accurate in your "debate" here, you need to include ALL of the possible modes of delivery. Not just American hospital planned vaginal delivery vs. Elective Cesarean. There is so much more, and the vast majority with far better outcomes than either, in between.

You might be surprised with what you find. ;)