Sunday, March 29, 2009

Caesarean beliefs 'misguided' - says misinformed article

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

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

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

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

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

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

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

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

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

Thursday, March 19, 2009

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

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

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

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

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

Monday, March 16, 2009

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

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

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

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

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

Memory of childbirth pain intensifies over time for some women

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

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

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

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

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

Maternal deaths drop by 59% in China

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

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

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

True stories behind natural birth versus caesarean debate

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

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

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

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

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