Tuesday, November 9, 2010

I am finishing writing a book on cesarean birth - hence recent blog silence

Apologies to all for my blogging absence, but please rest assured that I have been saving recent cesarean stories and medical research to blog about, which I plan to post once the book is finished.

I am writing this book together with Dr. Magnus Murphy, and our publisher is Prometheus Books. Further information to follow...

Saturday, October 9, 2010

Maternal request is not a myth

There have been a number of media reports in response to the publication this week of the study, 'Variation in rates of caesarean section among English NHS trusts after accounting for maternal and clinical risk: cross sectional study' by Bragg et al.

Below are a few examples of these stories, plus the comment I have posted in most of them:

*Who's Too Posh to Push? High Cesarean Section Rates Aren't Moms' Fault, TIME.com
*Too posh to push mums 'a myth', nhs.uk
*High caesarean rates are not down to women being 'too posh to push', The Telegraph
*Wide variation in Caesarean rates in UK, hc2d.co.uk

My comment

Aside from the fact that persistent use of the derogatory term ‘too posh to push’ is both irrelevant and unhelpful in discussions about whether women are choosing a caesarean birth plan, the idea that this study has exposed it as a myth is flawed.

The authors write: “It seems unlikely that maternal request in the absence of any clinical indication contributes substantially to the rates.” This is not the same as saying that maternal request is not contributing to the rates ‘at all’ or that women choosing caesareans is a myth. As far as I am aware, no media report as yet has actually cited the number (or percentage) of non-medically indicated caesareans found in this study, and I have contacted the authors for further clarification of this precise figure.

As it stands, the current estimate of rates of caesarean delivery on maternal request is around 5% of all births. This is clearly a very small number. However, it is more than double the number of women who request a homebirth, and yet these women and their birth choice are afforded greater support and respect by many birth support groups and the Department of Health.

As a final point, here are some other reasons why this study (which analysed routinely collected hospital episode statistics and did not involve any interviews with women or doctors) does not provide categorical proof that women are not choosing caesareans themselves or that caesareans in the absence of any clinical indication are not contributing to overall caesarean rates:

1) A medical indication and maternal request are not mutually exclusive. Anecdotally, I chose to plan a caesarean for both my births but my hospital data reads ‘breech presentation’ for the 1st (as this was discovered in the 8th month of pregnancy) and ‘repeat caesarean’ for the 2nd. I have also been contacted by other women via my website whose situation is the same.

2) It is not unknown for a medical indication to be cited by doctors on a woman’s records rather than draw attention to the more controversial indication of maternal request.

Please note that this comment is not in any way a criticism of the study itself or its authors; only the wider interpretation of maternal request caesareans that is being reported. In fact, the study itself presents extremely useful data and suggestions for NHS trusts going forward.

Saturday, August 21, 2010

WHO non-medical cesarean study under spotlight again

Nigel Hawkes has written an opinion piece in The Independent today, 'Peer-reviewed journals aren't worth the paper they're written on', in which he refers to the WHO's cesarean study that I wrote about back in January.

He writes: "A few months ago, I wrote in this column about a study in The Lancet of which I took a dim view. It claimed that Caesarean operations undertaken without medical cause were nearly three times as likely to cause death or complications to the mother as a normal birth. The evidence fell miles short of proving this claim.

Others shared my view, and one of them, Penny Christensen of Birth Trauma Canada, complained to The Lancet. Rebuffed, she sent them my analysis to support her claim. In reply, an editor wrote to her with the disparaging remark: "We are a scientific journal, and as such prefer to see the scientific debate continued by reference to other academic articles that have been peer-reviewed."

Ms Christensen's complaint has now gone to The Lancet's ombudsman, and we'll see if he shares the attitude that only the peer-reviewed are entitled to have their opinions properly considered."

I have just submitted this comment:

"I have also complained to the Lancet Ombudsman about the cesarean delivery study Nigel mentions above, and together with other references, cited his statistical analysis (and criticism) of it in my letter.

As a journalist, my confidence in the peer review process was knocked after the publication of "Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007-08, Lumbiganon et al", since I struggled to understand how such inconsistency between actual data gathered and final interpretation drawn could be accepted by reviewers for publication. I wrote about it on my blog in January this year.

I still believe peer review is a good thing, but I agree that criticism and open debate of a particular study or collection of studies should not be stifled by a requirement that all references referred to in any argument be peer reviewed first too."

Pauline McDonagh Hull
Editor, electivecesarean.com

Tuesday, August 10, 2010

It's not just an issue of Maternal Request

I probably spend most of my time writing about maternal request cesareans, and have certainly dedicated the last six years of my life to helping make the decision to request surgery a more widely respected and accepted birth plan.

However, more and more I'm just as concerned for the health and safety of women (and their babies) to whom the thought of requesting a cesarean would never occur, but who are not being properly advised of the risks and benefits of surgery versus a trial of labor as they relate to their personal circumstances.

There are numerous cases (most often highlighted in litigious court cases after the birth) when risk factors for vaginal birth problems that surface during pregnancy and/or labor are ignored or downplayed.

Birth involves risk
Stillbirth, severe injuries for the baby, debilitating pelvic floor injuries for the mother and post traumatic stress are just some of the outcomes that can result when an ideological natural birth plan is prioritized over and above timely medical intervention.

And it's one thing if the woman WANTS a natural birth plan - in other words, vaginal delivery was her maternal request - but quite another when the woman is ambivalent about the birth plan. She just wants a healthy baby and to feel satisfied at the end of it, and relies on her midwife or doctor to arrive at that outcome.

I know that I'm on record as saying that I believe a planned cesarean delivery at 39+ weeks is the safest way for a baby to enter the world, and that's the main reason I had cesareans for my two children, but as I've also said, I completely respect the choice of women who believe that a trial of labor is the best way to go.

What concerns me now is that in an attempt to protect the interests of women who WANT a vaginal delivery, the interests of women who WANT a cesarean and women whose best interest it would be to schedule one for medical reasons (and they don't mind either way) are being put at risk.

For example, we know that studies exist that show better outcomes with elective cesarean delivery in cases of breech, twin, macrosomia (big baby) and repeat cesarean versus VBAC. But there are some women who feel confident about their chances to labor naturally and who want to have that option but feel like they are being forced to have a cesarean. They feel very much wronged and campaign against what they perceive as unnecessary surgery.

Well, two wrongs don't make a right. Forcing a woman to attempt labor when she clearly wants a cesarean or advising a trial of labor in cases where a cesarean has been shown to have better outcomes (and then not reacting properly if/when things begin to go wrong) is dangerous. The law courts agree with this, and that's why usually, when serious problems arise, somebody is made to pay.

But there are thousands and thousands of cases that never even make it to litigation, where women are left physically abandoned and psychologically destroyed by a birth experience that in the event, didn't live up to its entirely unpredictable expectations.

My advice to women?


...whatever your birth plan...

Wednesday, August 4, 2010

BMJ Letter published: ACOG wants to allow, not urge, more VBACs

My letter, published in the British Medical Journal on 4th August 2010, was in response to the publication: 'Urge more women who have previously had a caesarean section to have vaginal delivery, experts say', by Bob Roehr.

It says:

The title of this article reads, ‘Urge more women who have previously had a caesarean section to have vaginal delivery, experts say’.

But this is not what the American College of Obstetricians and Gynecologists' July 2010 press release says.

Rather, ACOG says that ‘restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will’.

These two statements are entirely different, and it is important that we recognize this. Patient/maternal autonomy is not about urging a group of women to have one particular birth plan; it is about allowing them to make their own informed decision.

Also, the opening sentence of this article is not entirely accurate.

Like so many reports of ACOG’s updated VBAC guidelines, Roehr’s choice of words, ‘Doctors in the United States have emphasised the safety of vaginal delivery for women who have had one or two previous caesarean sections’, omits the crucial word ‘most’, and this dangerously changes the message intended.

In fact, ACOG says, ‘Attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans.’

That’s ‘most’ and ‘some’ women. Not by any means ‘all’.

Unfortunately, some of the confusion has arisen from ACOG's decision to talk about the ‘importance of patient autonomy’ in the same context as the desire ‘to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate’. But who and/or what will decide when this ‘reasonable’ rate has been reached?

Certainly, if ACOG's decision to change the wording in its VBAC guidelines (to reflect that ‘quickly gathered’ rather than ‘immediate’ emergency care should be available in case uterine rupture occurs) helps more women who desperately ‘want’ a VBAC, then this is a good thing.

But it's equally important to remember that many women will prefer to have a repeat cesarean, and will be completely happy with their choice. This is because although ‘approximately 60-80% of appropriate candidates who attempt VBAC will be successful’, this means that 20-40% of women with the BEST chance of success will STILL be unsuccessful.

Therefore, women’s birth plan decision to have a repeat cesarean should not be refused or disrespected in a misplaced attempt to ‘swing the pendulum back’.

Perhaps if, instead of target rates, we let patient autonomy take a greater role in maternity care... if we provide women with the risks and benefits and let them decide which birth plan they prefer... if assessment of birth outcomes includes maternal satisfaction... then the rates will fall where they will, and more women and babies will be happier and healthier for it.

Thursday, July 29, 2010

Worrying mahurat cesarean trend in India

'Are you planning a mahurat C-section?' asks Zeenia Baria in The Times of India today.

Baria reports on a worrying trend for some planned cesareans in India, and that is the decision by couples to insist on a particular time and date for the birth of their babies. It's unclear from the report whether parents are being influenced within days or weeks of their advised delivery date, but if it's the latter, this can mean serious health consequences for a newborn baby (e.g. respiratory distress).

"Obstetrician, Gynaecologist and infertility specialist Dr Faram Irani says... “Unlike the West where women request for a c-section because of the pain associated with vaginal birth or fear of damage to the pelvic floor; in India many c-sections are performed on the basis of mahurat..."

What do they hope to achieve?
"Longevity, health, marital harmony, career prospects, eclipses and domestic peace of the offspring are the biggest motivators for such couples. The astrologer formulates the most auspicious time for delivery after asking the would-be parents for the tentative delivery dates, place, time zone and DST (daylight saving time). Due to the astrological factors involved, the mahurat differs for every couple. Although they cost more than double, deliveries at sunrise are among the most auspicious."

"Gynaecologist Dr Rishma Pai Dhillon says that the trend of having mahurat babies or a planned caesarean section on an auspicious date, is getting increasingly popular among patients and is giving doctors a headache because it comes with its share of complications.

“I recently had to rush to the hospital at an unearthly hour to deliver a mahurat baby. If one refuses, one is flooded with phone calls from senior politicians and affluent bureaucrats to oblige. Mahurat babies or mahurat c-section is a controversial trend that middle and upper class women across the country are increasingly opting for. It involves planned deliveries and surgical caesarean sections in the hopes of having babies on a specific date and time predicted lucky by their astrologers. Families are so particular about the exact time of delivery that they create a ruckus if the previous surgeon is delayed in the operation theatre. This puts tremendous stress on doctors. It isn’t fair to hurry up such a delicate procedure,” she says.

“The reasons for having a mahurat baby are often credulous. One patient’s astrologer said that if her child was delivered at the right time, it would be a fair-skinned boy, who would look after his parents in their old age. How can the time of delivery change a baby’s gender, which is decided at conception itself!” asks Dr Pai.

Saturday, July 24, 2010

ACOG's motivation for new VBAC guidelines disappoints

The news that obstetricians at ACOG have published less restrictive guidelines for VBAC is good news for women that desperately want to avoid repeat cesarean surgery and who feel that their decision to plan a trial of labor is neither respected - or in many cases, and particularly in American hospitals, allowed.

But now for the not so good news...

First of all, I suggest that you read ACOG's press release for yourself, and then come back to read my thoughts on some of its contents, below.

ACOG PR: "Attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans..."

*Just a small observation I've made while perusing much of the media and blog reporting of this story - the number of headlines and bylines that have dropped the crucial word "most" from the sentence above. This is a very dangerous interpretation of what ACOG has said.

ACOG PR: "The cesarean delivery rate in the US increased dramatically over the past four decades, from 5% in 1970 to over 31% in 2007. Before 1970, the standard practice was to perform a repeat cesarean after a prior cesarean birth. During the 1970s, as women achieved successful VBACs, it became viewed as a reasonable option for some women. Over time, the VBAC rate increased from just over 5% in 1985 to 28% by 1996, but then began a steady decline. By 2006, the VBAC rate fell to 8.5%, a decrease that reflects the restrictions that some hospitals and insurers placed on trial of labor after cesarean (TOLAC) as well as decisions by patients when presented with the risks and benefits."

*It is important to remember that many women prefer to have a repeat cesarean, and are more than happy not to plan a VBAC, and their birth plan decision should not be refused or disrespected in this attempt to "swing the pendulum back".

ACOG PR: "The current cesarean rate is undeniably high and absolutely concerns us as ob-gyns," said Richard N. Waldman, MD, president of The College. "These VBAC guidelines emphasize the need for thorough counseling of benefits and risks, shared patient-doctor decision making, and the importance of patient autonomy. Moving forward, we need to work collaboratively with our patients and our colleagues, hospitals, and insurers to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate."

*I find it disappointing and indeed disconcerting that 'more reasonable rates' has even been mentioned in the context of patient autonomy here. What is a 'more reasonable' rate of VBAC? And perhaps more importantly, what is considered a reasonable rate of TOLAC? A 25-year-old argument over the optimum percentage rate of cesarean deliveries came to a head last year when the WHO admitted that there is no evidence for one, so who's got the answer to the 'right number' of VBACs and TOLACs?

I think that if, instead of target rates, we let patient autonomy (where patient autonomy is requested - remember, there are many women who are more than happy to be guided and advised by their doctor or midwife, with no personal delivery preference either way) take a greater role in maternity care... if we provide women with the risks and benefits and let them decide which birth plan they prefer... if assessment of birth outcomes includes maternal satisfaction... then the rates will fall where they will, and more women and babies will be happier and healthier for it.

ACOG PR: "In making plans for delivery, physicians and patients should consider a woman's chance of a successful VBAC as well as the risk of complications from a trial of labor, all viewed in the context of her future reproductive plans," said Dr. Ecker. Approximately 60-80% of appropriate candidates who attempt VBAC will be successful."

*This is important to understand. Approximately 60-80% of appropriate candidates will have a successful VBAC. This means that approximately 20-40% will be unsuccessful - a risk many women are not comfortable with.

And when ACOG's statement is misinterpreted by stating that VBAC might be safe for all women, it completely ignores the fact that the cited 60-80% success rate is ONLY for women firstly established as appropriate candidates. The success rate if all women with previous cesareans were included is much lower.

ACOG PR: "The risk of uterine rupture during a TOLAC is low - between 0.5% and 0.9% - but if it occurs, it is an emergency situation. A uterine rupture can cause serious injury to a mother and her baby. The College maintains that a TOLAC is most safely undertaken where staff can immediately provide an emergency cesarean, but recognizes that such resources may not be universally available.

"Given the onerous medical liability climate for ob-gyns, interpretation of The College's earlier guidelines led many hospitals to refuse allowing VBACs altogether," said Dr. Waldman. "Our primary goal is to promote the safest environment for labor and delivery, not to restrict women's access to VBAC."

Women and their physicians may still make a plan for a TOLAC in situations where there may not be "immediately available" staff to handle emergencies, but it requires a thorough discussion of the local health care system, the available resources, and the potential for incremental risk. "It is absolutely critical that a woman and her physician discuss VBAC early in the prenatal care period so that logistical plans can be made well in advance," said Dr. Grobman. And those hospitals that lack "immediately available" staff should develop a clear process for gathering them quickly and all hospitals should have a plan in place for managing emergency uterine ruptures, however rarely they may occur, Dr. Grobman added.

*In summary, it appears that the criteria for a TOLAC/VBAC birth plan has changed from requiring the availability of "immediate" emergency care for the laboring women, to that which is "quickly gathered".

The change of wording here is worthy of a blog post all of its own, but I mention it here because what happens in the inevitable cases of uterine rupture emergencies is crucial, and I think that while ACOG has done well to address the fundamental issues of insurance and litigation, questions remain.

How do we remove doctors' fears of being sued when a TOLAC fails? Do insurers now agree with ACOG that 'quickly gathered' emergency care is sufficient duty of care? Will women be asked to sign a waiver stating that they are fully aware of the risks of uterine rupture and its possible consequences? There are no easy answers to all this, and again, while helping women gain access to wanted VBACs is commendable, ACOG's statement might have provided more in the way of broadening discussion of these, and other, continuing challenges.

ACOG PR: The College says that restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC. On the other hand, if, during prenatal care, a physician is uncomfortable with a patient's desire to undergo VBAC, it is appropriate to refer her to another physician or center."

*As mentioned above, I applaud ACOG's efforts to help women who feel they are being given no choice when it comes to VBAC versus a repeat cesarean, but I just wish that this was the sole focus of its statement, with nothing said about the shared desire to swing the pendulum back on percentage rates. Has it occurred to anyone that when women are informed about the risks and benefits of VBAC, the number of women that actually choose VBAC may not swing the pendulum back as far as some may imagine? I guess only time will tell.

Thursday, July 22, 2010

BMJ Letter published: Planned Cesarean Delivery Benefit

My letter, published in the British Medical Journal on 22nd July 2010, was in response to the publication: 'Time of birth and risk of neonatal death at term: retrospective cohort study', by Dharmintra Pasupathy, Angela M Wood, Jill P Pell, Michael Fleming and Gordon C S Smith.

It says:

"The unpredictability of planned vaginal delivery or a trial of labor (i.e. the possibility of assisted delivery and/or emergency surgery) is one of the reasons often cited by women who decide to deliver their babies by planned cesarean.

This study illustrates that the unpredictable nature of the delivery outcome itself (and any associated morbidity or mortality) is not the only risk these women seek to avoid. The unpredictability of the quality of care available at different hours of the day and night when women arrive at hospital in labor is another risk they do not wish to take, especially when this might impede the safe and healthy arrival of their baby.

The 'convenience' of scheduling a time and date for maternal request cesarean delivery is sometimes criticized as an irresponsible benefit of surgery, but when looked at from the perspective of this study (and others like it), there is clearly a legitimate benefit involved in knowing exactly who will deliver your baby and when, and it has nothing whatsoever to do with convenience."

Saturday, July 10, 2010

NICE decides to review Maternal Request Cesareans

As you know, NICE (The National Institute for Health and Clinical Excellence) is currently reviewing its 2004 Clinical Guideline on Caesarean Delivery, and on Thursday 8th July, it published the Final Scope of what will be reviewed.


The NICE guideline on Maternal Request Cesareans is to be reviewed.
The draft scope, published earlier this year, had excluded Maternal Request as an area requiring review, but a number of Stakeholder organizations (including electivecesarean.com) urged NICE to reconsider at a meeting in London, and followed up with the submission of reasons and evidence to support their position.

The Final Scope reads:

"c) The original caesarean section guideline addressed issues relating to maternal request including the prevalence of request, fear of childbirth and how obstetricians should respond to such requests. In the light of new evidence and a strong concern amongst stakeholders that this area needs to be re-examined this topic will be addressed in the update."

Also now being included is a much-needed update of a table in the 2004 guideline that compared the risks of vaginal and cesarean delivery:

"d) A great deal of support has been expressed by stakeholders for the usefulness of Table 3.1 in the original guideline summarising risks and benefits of caesarean section vs. vaginal birth. Given that this table is often used as the basis of information given to women and underpins informed consent there is a need to ensure this information is as accurate and up to date as possible and therefore it will be included in the update."

Unfortunately, I was not successful in my application to be one of the Guideline Development Group (they will now review all the latest evidence and prepare the new guideline for publication), but I genuinely hope that it takes this opportunity to look at maternal request cesarean delivery with the Stakeholders' comments and concerns in mind.

Again, you can read these in detail here.

Thursday, July 1, 2010

BMJ Letter published: Homebirth versus elective caesarean risks

My letter, published in the British Medical Journal on 4th July 2010, was in response to the publication: 'Study shows higher rates of neonatal mortality with planned home births', by Susan Mayor.

It says:

The findings in this study, that planned home birth increases a baby's (albeit very small) risk of dying compared with a hospital birth plan, has received a great deal of media attention, and numerous medical professionals and birth groups have spoken out to defend home birth legitimacy and advocacy in the UK.

Surely then, particularly in light of studies such as this one published in Canada last year, 'Caesarean section on maternal request: risks and benefits in healthy nulliparous women and their infants' by LS Dahlgren et al, which found that an elective pre-labour caesarean delivery in a nulliparous woman at full term "decreased the risk of life- threatening neonatal morbidity compared with spontaneous labour with anticipated vaginal delivery", it is time to review current attitudes towards caesarean delivery on maternal request.

This Canadian study included almost 40,000 births, and even though the comparison used breech presentation as a healthy elective caesarean surrogate (which is arguably a more complicated delivery than a cephalic- presenting fetus) to compare with the healthy onset spontaneous labour group, the caesarean group's babies still had better outcomes.

Similarly an American study, also based on intent to deliver and not just actual delivery, 'Maternal Outcomes Associated with Planned Vaginal Versus Planned Primary Cesarean Delivery’ by EJ Geller et al, found that planned caesarean delivery had less chorioamnionitis (2.2% versus 17.2%), postpartum hemorrhage (1.1% versus 6.0%), uterine atony (0.6% versus 6.4%), and prolonged rupture of membranes (2.2% versus 17.5%) for the mother but a longer hospital stay (3.2 versus 2.6 days). There were no differences in transfusion rates.

If a healthy woman's maternal request to give birth at home is acceptable, then given the (two examples of) improved outcomes cited above, her request for a prophylactic caesarean delivery at 39+ weeks should be acceptable too."

News reports on the study that week included:

*01 July Home births are good for mothers but riskier for babies, says study, The Guardian
Breathing problems and failed resuscitation blamed for increased risk, with experts recommending two midwives for deliveries

*01 July Home birth risks under scrutiny, BBC News

BBC reports on the WHO's lack of cesarean rate evidence

Should there be a limit on Caesareans? asks Philippa Roxby, a BBC online Health reporter.

"The World Health Organization has dropped its recommendation that fewer births be carried out by Caesarean section, saying there was no evidence for a limit.

The WHO had previously advised that no more than 10 to 15% of babies be delivered by section, a figure often cited by those concerned about rates in the UK - where one in four babies comes into the world in this way.

But now the WHO states that "there is no empirical evidence for an optimum percentage" and stresses that "what matters most is that all women who need Caesarean sections receive them".

Yet in the NHS, doctors, hospitals and midwives have been under pressure to persuade women to give birth naturally. So should there be less pressure on women to avoid surgical intervention?" Read the full article here.

Tuesday, June 29, 2010

Finally: The news media reports on WHO's lack of evidence for a 15% cesarean rate threshold

Great news! Today in The Times, you can read the report "Pressure off to cut Caesarean births as ‘myth’ of too many demolished", written by Helen Rumbelow and David Rose.

As readers of this blog will know, ever since I first wrote an article in October 2009 about the WHO's quiet admission in its 2009 handbook that "there is no empirical evidence for an optimum percentage or range of percentages" for cesarean deliveries, I have been trying to get the information made more public.

A press release with my colleagues at the Coalition for Childbirth Autonomy in October 2009 was published on the Medical News Today website (causing great controversy at the time), as was our original official call for evidence from the WHO in October 2008, but until today, the news had really not reached a wider audience.

I hope that this Times article will be the catalyst for an open debate about the true risks and benefits of all birth plans, and an understanding that arbitrary cesarean rate targets in any country is both dangerous and unethical.

Monday, June 28, 2010

My natural birth wrecked my body - one woman's story

The story below appeared on the BBC News website last week, and I wanted to post it here in its entirety as an example of the terrible reality of childbirth that some women endure. That is not to say that this story should scare women away from giving birth vaginally if that is what they would like to do, but when informing women about the risks and benefits of ALL delivery types, I think that it is unethical if we fail to mention the possibility of pelvic floor problems such as incontinence and prolapse.

BBC News story: "It should have been the most perfect day of Nicki James-Eyer's life.

Just three hours after her first contraction the flight attendant gave birth to Jessica.

It had been the natural birth Nicki had expected, but the strain on her body had been intolerable.

Within six months she was faecally incontinent and over a decade later Nicki, from South Glamorgan, is still having problems.

Taken seriously

"As she was my first baby, I didn't really know what to expect after the birth. But a few weeks later I could hardly walk," said Nicki.

Her doctor was unsympathetic and simply put it down to the birth.

Over the next three months she saw a number of GPs who dismissed her concerns.

Finally she was diagnosed with a prolapse of the bowel and given surgery, but this left her incontinent.

"I was just 31-years old having what should have been the time of my life. I had just got married, I had a baby, and then my life just fell apart.

"It was horrendous."

Further surgery

She had further surgery in 2000 to enlarge her rectum and solve the incontinence and for a while things were better. She even managed to have a second child by caesarean.

But in 2006 she suffered a bowel infection and now needs further surgery, and her incontinence continues.

"I think childbirth is not the natural thing everyone says it is. There are problems that can happen and I think that people don't talk about them - women's bits and poo are taboo.

"My birth was very simple, so I should not really have had any problems, but nobody knows what is going to happen putting your body through that.

Up to one in every 10 new mums, like Nicki, have bowel problems as a result of childbirth.

But many do not know that they can get help, or where to go.

Common problems

Mr Charles Knowles, consultant colorectal surgeon, agreed that problems after childbirth were more common than expected.

"As many as one in 10 may have some degree of problem.

"Problems as severe as those experienced by Nicki are fortunately rare but there are few studies that have surveyed just how widespread such problems are."

He said the body was put under severe pressure.

"A number of changes occur to the pelvic floor muscles in late pregnancy due to the physical pressure of the baby. These combined with any trauma (tears or episiotomy) that may occur during delivery can result in weak sphincter muscles and laxity of the pelvic floor causing problems of incontinence."

Deborah Gilbert of the charity Bowel and Cancer Research said: "Childbirth is the commonest cause of faecal incontinence worldwide.

"The frequency of occurrence of incontinence and the problems that it causes for the thousands of women who suffer it are greatly underestimated because they are either too embarrassed to come forward or because they feel that doctors will be unable to help them.

"We are making the first steps to identifying the scope of the problem by running a survey for women on our website."

"We urge anyone who is suffering in this way to visit the site and complete the survey which we hope will lead to better service provision for women like Nicki in future."

€4.25m award over claim of birth negligence - no cesarean

This article appeared in The Irish Times last Wednesday [my bold]:

"A Severely disabled young man has secured €4.25 million in settlement of his High Court action over alleged negligence in the circumstances of his birth at a Cork hospital. The settlement is without admission of liability.

Dermot Moylan, Firville, Mallow, Co Cork, now aged 20, suffered severe mental and physical injuries as a result of his brain being deprived of oxygen shortly prior to his birth and will require lifelong care, it was claimed.

Through his mother Anna Moylan, Mr Moylan had sued the Southern Health Board; Erinville Hospital, Western Road, Cork, and two doctors – David Jenkins of Erinville Hospital and John McKiernan of the Cork Clinic, Western Road, Cork.

He claimed the defendants were negligent and breached their duty of care towards him during his birth at the hospital on the morning of August 7th 1989.

Mr Justice Iarfhlaith O’Neill said yesterday he was “more than happy” to approve the settlement offered.

In his claim, it was alleged the defendants failed to take measures including early delivery by Caesarean section which would have prevented him suffering injuries.

It was claimed that due to alleged negligence, a disruption to the child’s blood supply in the course of labour was not detected and, as a result, his brain was deprived of oxygen causing damage to his nervous system.

It was further claimed that despite the detection of an irregular heartbeat following his mother’s admission to the hospital, the defendants failed to take appropriate action.

The defendants had denied the claims.

Recommending acceptance of the settlement offer, Denis McCullough SC, for the plaintiff, said Ms Moylan was admitted to Erinville Hospital at about 3am on August 7th, 1989, and Dermot was born at approximately 7.17am.

As a result of a lack of oxygen to his brain, Dermot suffered brain damage and epilepsy, it was claimed. He has limited learning skills, mobility problems and attends a care centre five times a week, the court was told..."

Cesareans and baby immunity

You may have read about a new study that investigated the different types of bacteria found in the mouths of babies born by cesarean and vaginal delivery. I'm not going to write too much about it here, as I blogged about a similar subject earlier this year (infection and asthma), but also because I think there is a very useful website that summarizes the details very well without the need for me repeating them here.

"NHS Choices" begins:

"Children born by caesarean section are more likely to have allergies, such as asthma, because they pick up less “natural immunity” from their mother, The Daily Telegraph reported.

The story is based on a small laboratory study which investigated whether the mode of delivery affected the type of bacteria found on 10 newborn babies. Babies born by normal vaginal delivery were found to have types of bacteria that mainly resembled those found in their mothers’ vagina, while those delivered by caesarean had microbes normally found on the skin surface.

This study provides a useful contribution to our knowledge of the possible effects on babies of having a caesarean rather than vaginal delivery. However, on its own, the study is too small to offer any conclusions about the exposure of newborns to particular types of bacteria at birth, and has no implications for the long-term health of babies delivered by caesarian. Another drawback is that it did not look at any other possible differences between the mothers or their babies that may have contributed to the differences in types of bacteria, such as the use of antibiotics. As the researchers say, longer-term, larger studies are needed."

The only thing that I would add is this.

Even IF studies in the future turn out to be conclusive in establishing a link between cesarean delivery and infection and /or asthma - and even IF that link is established with maternal request cesareans at 39+ weeks' gestation too (i.e. not a link with ALL cesareans including babies born in emergency conditions or prematurely due to medical issues during pregnancy), as an expectant mother, I would still weigh this risk against other (albeit small) risks to babies that are associated with a planned vaginal delivery (e.g. stillbirth, asphyxia, shoulder dystocia), and I would personally, still choose to have a cesarean delivery.

Saturday, June 12, 2010

UK Health Secretary promises broader childbirth choice

On the 8th June 2010, the Rt Hon Andrew Lansley CBE MP, Secretary of State for Health, set out his ambition for "patient-centred care".

I really don't wish to speak too soon, but I can't help feeling very excited about the tone and content of the Health Secretary's comments on maternity care, and in particular, choice for women.

For too long, maternity groups in the UK have been obsessed with focusing on choice in terms of where a woman gives birth - at home, in hospital, in a midwifery-led unit - and women like me have been crying out to have our voices heard too.

HOW (e.g. vaginal or cesarean delivery) we give birth and WITH WHOM (e.g. midwife or obstetrician) are equally valid choices. See what you think when you read the extract from Lansley's speech below, and rest assured that I will be following this up and continuing my campaign to ensure that a woman's legitimate decision to have a planned cesarean at +39 weeks' gestation is one day supported throughout all NHS hospitals.

"And what about the relationship of information to choice? The expectation of choice has been a feature of maternity services going back to Julia Cumberlege’s 1993 report, “Changing Childbirth”. But choosing between a home delivery, a midwife-led service and an obstetric delivery is a limiting concept of choice.

Mothers-to-be should have information about the different aspects of maternity care including choices of location, but also issues like pain-relief, choice of providers as well as risk assessments – because not all choices will be appropriate or safe for all women. They should have the ability not only to compare key aspects of care, like continuity of midwifery support and one-to-one midwifery support in labour; but they should also be able to see what other mothers’ experiences have been and to hear their views of the safety and quality of care.

Mothers must have this information not only to exercise choice when originally booking their maternity care, but to be able to be in control of their childbirth, exercising safe choices at each stage.

Because, like that process of choice, listening to patients is at the heart of what we should be doing.

And listening to patients – asking, reporting, and learning from patient experience – will be of great importance in designing and improving services, including achieving greater efficiency. Just look at the high levels of patient-reported satisfaction in productive wards."

He concludes:

"Reform has stalled. Targets have trumped quality. On too many key areas our health outcomes lag behind our European neighbours.

We need change. We need to set the service free to deliver high-quality care, based on evidence of what works. Accountable for results. Answerable to informed and engaged patients. Focussed on what matters most to those patients – safe, reliable, effective care. The best care for each patient and the best outcomes for all patients.

That is my ambition, and I have been delighted today to be able to share it with you.

Thank you."

Friday, June 11, 2010

Maternal Request is Scientifically Credible and Ethically Legitimate

"At last an article that uses an 'intention to treat' type of analysis to show that primary caesarean section on maternal request is not only ethically legitimate but also has some scientific credibility. This article has demonstrated that, for healthy primiparous women, planned caesarean delivery decreases maternal morbidity whilst, not surprisingly, emergency caesarean section increases maternal risks compared with both vaginal delivery and primary elective caesarean section."

Full story:

Maternal Outcomes Associated with Planned Vaginal Versus Planned Primary Cesarean Delivery. F1000: "Changes Clinical Practice"
Geller EJ, Wu JM, Jannelli ML, Nguyen TV, Visco AG. Am J Perinatol 2010 Mar 16

Commentary from Faculty Member John Svigos
26 April 2010, Faculty of 1000 Medicine

Changes Clinical Practice: There is insufficient evidence to refuse a woman her legitimate right both ethically and now scientifically to request an elective primary caesarean section at 39 weeks gestation.

At last an article that uses an 'intention to treat' type of analysis to show that primary caesarean section on maternal request is not only ethically legitimate but also has some scientific credibility. This article has demonstrated that, for healthy primiparous women, planned caesarean delivery decreases maternal morbidity whilst, not surprisingly, emergency caesarean section increases maternal risks compared with both vaginal delivery and primary elective caesarean section.

The National Institutes of Health (NIH) statement re caesarean delivery on maternal request in 2006 that there was insufficient evidence to evaluate fully the benefits and risks of elective caesarean delivery[1] stimulated many workers to try to find this elusive evidence. Most studies before and after this statement and until the publication of this article were fundamentally flawed by including outcomes from emergency and elective surgeries in women (and babies) with pre-existing medical conditions and not including in the vaginal delivery group those that did not deliver vaginally and their respective morbidity and mortality. Additionally, there was a tendency to place more emphasis on caesarean morbidities such as haemorrhage and infection and less emphasis on the more commonly occurring post-delivery pelvic floor dysfunction and pain. The continued use of morbidity/mortality statistics from primary caesarean for breech presentation as the surrogate for caesarean section on maternal request can no longer be justified and is positively misleading if one analyses the paper by Liu et al.[2] Furthermore, the most recent paper by Lumbiganon et al.[3] after detailed analysis demonstrates the bias directed against the proposal of primary elective caesarean on maternal request. Whilst there has been considerable emphasis placed on examining maternal morbidity and mortality in this context, it would seem that the study by Hankins et al.[4] has reassured most practitioners that perinatal morbidity and mortality is not compromised and indeed may be improved in women requesting elective caesarean section at 39 weeks gestation. I believe that there is now a legitimate case for women to request elective caesarean section at 39 weeks gestation and that, as responsible obstetricians, we should be striving to reduce the number of caesarean sections in women who do not wish to have a caesarean section, particularly increasing our resolve against the flawed Term Breech Trial and the impaired retrospective studies favouring elective caesarean section for twin pregnancies and giving these women a choice to deliver vaginally!

Also see:

Maternal Outcomes Associated with Planned Vaginal Versus Planned Primary Cesarean Delivery. Geller EJ, Wu JM, Jannelli ML, Nguyen TV, Visco AG. Am J Perinatol. 2010 Mar 16. Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology.

"We compared maternal morbidity between planned vaginal and planned cesarean delivery. A university hospital's database was queried for delivery outcomes. Between 1995 and 2005, 26,356 deliveries occurred. Subjects were divided into two groups: planned vaginal and planned cesarean delivery. This was based on intent to deliver vaginally or by cesarean, despite actual route of delivery. Planned vaginal delivery included successful vaginal delivery and labored cesarean delivery intended for vaginal delivery. Planned cesarean delivery included unlabored and labored cesarean delivery and vaginal delivery intended for cesarean. Chart abstraction confirmed the delivery plan. Primary outcomes were chorioamnionitis, postpartum hemorrhage, and transfusion. Secondary outcomes were also measured. A subanalysis compared actual vaginal delivery, labored cesarean delivery, and unlabored cesarean delivery. There were 3868 planned vaginal deliveries and 180 planned cesarean deliveries. Planned cesarean delivery had less chorioamnionitis (2.2% versus 17.2%), postpartum hemorrhage (1.1% versus 6.0%), uterine atony (0.6% versus 6.4%), and prolonged rupture of membranes (2.2% versus 17.5%) but a longer hospital stay (3.2 versus 2.6 days). There were no differences in transfusion rates. For healthy primiparous women, planned cesarean delivery decreases certain morbidities. Labored cesarean delivery had increased risks compared with both vaginal delivery and unlabored cesarean delivery."

Neonatal outcomes associated with planned vaginal versus planned primary cesarean delivery. Geller EJ, Wu JM, Jannelli ML, Nguyen TV, Visco AG. J Perinatol. 2010 Apr;30(4):258-64. Epub 2009 Oct 8. Division of Urogynecology and Reconstructive Pelvic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7570, USA.

"Objective: To determine whether planned route of delivery leads to differences in neonatal morbidity. Study design: Analysis was based on planned route of delivery, not actual route of delivery. A total of 4048 subjects were divided into two groups: planned vaginal delivery and planned cesarean delivery. Primary outcomes were neonatal intensive care unit (NICU) admission, respiratory morbidity and neurologic morbidity. Result: There were 3868 planned vaginal and 180 planned cesarean deliveries. Planned vaginal delivery had decreased NICU admission... Conclusion: Planned vaginal delivery led to more meconium passage and low 1 min Apgar but less NICU admissions, oxygen resuscitation and jaundice. Multicenter trials are needed to assess rare but serious outcomes based on planned route of delivery."

Thursday, June 10, 2010

Special needs risk: 4.7% at 39 weeks and 4.4% at 40 weeks

There is a great deal of publicity in the media at the moment regarding a Scottish study that has investigated the risk of a baby developing special educational needs if it is born too early. In particular, conclusions are being drawn along the lines of how this new data should be used to inform women planning an elective cesarean.

I agree - HOWEVER - let's inform women properly and honestly.
This is the comment I submitted to Medical News Today this morning:

Difference is actually negligible

The presentation of the results of this research is very misleading, particularly in relation to the risks associated with cesarean delivery at 39 weeks’ gestation.

This is the actual percentage of children with SEN by gestation of delivery

37 weeks - 6.1%
38 weeks - 5.4%
39 weeks - 4.7%
40 weeks - 4.4%
41 weeks - 4.1%

As you can see, the difference between 39 and 40 weeks is negligible; the higher risk is present in the 37th and 38th week, which we know from other research increases other risks for babies too, such as respiratory distress.

The collective risk of all babies at 37-39 weeks is being used to disparage the legitimacy of choosing to deliver your baby at or after 39 weeks (many doctors, my own included, advise delivery at 39 and a half weeks with maternal request - i.e. during the 40th week).

Three final points worthy of note:

The authors state that while it's reported that early term births (at 37-39 weeks) account for 5.5% of SEN cases and preterm deliveries account for 3.6% of cases, this is because of the higher numbers of babies born between 37 and 39 weeks.

In the population of children studied (407,503), just 16.2% were born by cesarean delivery; therefore I would argue that the risk of SEN is just as likely, if not more, with a planned vaginal delivery (where Mother Nature decides on the gestational age or delivery is induced)
as a planned cesarean at or after 39 weeks.

The relatively small percentage of cesareans includes both planned and emergency surgeries, thereby further reducing the data pool of the very delivery type that such stark warnings are being given in reports like this one.

Wednesday, May 19, 2010

Do cesareans increase the risk of celiac disease?

In a Reuters' report this week on new cesarean research, the headline at least asks the question, 'Do c-sections increase the risk of celiac disease?', but unfortunately, many more media reports and blogs are stating that there IS a significant association between the two, and no doubt it'll soon start to appear on lists of 'reasons why women shouldn't choose a cesarean.'

Probably not
This is what I took away from the report. Firstly, as always, it's a good idea to take a look at the research yourself (click here), and if celiac disease is a particular risk that concerns you (e.g. perhaps it already affects a family member), you might want to get hold of a copy of the full text of the research.

Secondly, from what I can ascertain, the research involved children who had been delivered by ALL types of cesarean delivery - including both planned and emergency surgery - so as always, it's very difficult to make a judgment about how much women having planned cesareans need to worry.

Thirdly, the report states that Dr. Daniel Leffler, director of clinical research at the Celiac Disease Center at Boston's Beth Israel Deaconess Medical Center, said that "many of the children's mothers may have had undiagnosed celiac disease. Given that celiac disease can be inherited, and that undiagnosed celiac disease increases the risk of cesarean section, undiagnosed disease 'would be more than enough to explain the increased number of cesareans'. Enough said.

Identify celiac disease in women
It's worth reading the report yourself of course, but personally, I'm not convinced that this reported increased risk (28% versus 19%) is specifically related to planned cesareans on maternal request in otherwise healthy pregnancies, and I think the most important message we should take from Dr. Leffler's research is this:

The results "may mean we need to be looking for celiac disease in young women who want to become pregnant... He noted that when celiac disease is treated with a gluten-free diet, the risk for cesarean section is no higher than for the average woman. Untreated celiac disease, Leffler added, can have effects on the fetus as well, including slowing its growth and a higher risk of premature birth."

Wednesday, May 12, 2010

Cesareans on the rise in Iran

In this online report a member of Supreme Council of Islamic Republic of Iran Medical Council (IRIMC) warns about the risk of a rising maternal mortality rate in line with a rising national cesarean rate.

The report does not specify what the cesarean rate is or what the split is between elective and emergency.

$18.5m New Jersey payout for delayed cesarean

This story is yet another example of how much a planned vaginal delivery can cost (physically, emotionally and financially). Yet this is rarely, if ever, factored into delivery cost comparisons.

Largest in NJ's history
On April 29, 2010 an Essex County, New Jersey jury awarded a verdict of $18.5 million in a medical malpractice case against an obstetrician who delayed a C-section while the baby was in fetal distress.

This is believed to be one of the largest birth injury cerebral palsy lawsuit recoveries in New Jersey history.

Recently, I read an article that asked, "Why is the cesarean rate so high in New Jersey?".


Tuesday, May 11, 2010

Further treatment restrictions on NHS caesareans

I've just come across this outrageous news from Derbyshire - that treatment restrictions are being imposed as management looks to reduce NHS costs.

Apart from the issue of maternal request cesareans in healthy pregnancies, which continue to be a thorny (and misunderstood) issue within large parts of the NHS, this report states that cesareans "will not be routinely offered to women who have hepatitis, are pregnant with twins, have small babies or go into an early labour".

A concerned grandmother made some good points in the comments section, and this is what I've just added:

The news about caesarean delivery here is outrageous and unethical.
Why should a woman (even one with a healthy pregnancy) be forced to give birth via a TRIAL of labour?

Policy makers in the NHS constantly fail to see the obvious when they attempt cost-cutting.

Litigation following obstetric complications, the overwhelming majority of which are an outcome of a planned vaginal delivery and NOT a planned caesarean delivery (see the NHSLA website), costs the NHS more money than any other area of health litigation. Furthermore, injuries to babies and mothers during vaginal delivery (spontaneous and assisted) and emergency caesareans have to be treated, both in the short-term and the long-term (e.g. pelvic organ prolapse), yet these associated treatment costs are never included in cost comparison analysis.

Research has shown that at 39+ gestational weeks, it is safer for a baby to be born via planned caesarean delivery than to undergo a trial of labour – and while this will not be every woman's choice, for those whose choice it IS, they should not be refused on the basis of ill thought out cost-cutting efforts.

This is a disgrace, and one I continue to fight against.

Saturday, May 8, 2010

Response to Lamaze International on U.S. maternal deaths

This week, the U.S. organization Lamaze International issued a press release titled: 'Despite International Decline, Maternal Deaths a Growing Concern in U.S.'.

It states that women can reduce their risk of dying by using healthy birth practices, and lists these 'Six Healthy Birth Practices' as such:

*Let labor begin on its own
*Walk, move around and change positions throughout labor
*Bring a loved one, friend or doula for continuous support
*Avoid interventions that are not medically necessary
*Avoid giving birth on your back and follow your body's urges to push
*Keep mother and baby together; it's best for mother, baby and breastfeeding

Also in the press release, Lamaze International points to the use of cesarean surgeries or induction without a distinct medical need as increasing the risk of death and injury in childbirth.

The Reality
However, aside from one sentence in the press release that suggests women try to be 'as healthy as possible prior to getting pregnant', there is no acknowledgment of some of the biggest challenges facing maternity care in the U.S. (and indeed many other developed world countries).


As long as birth groups like Lamaze continue to ignore these elephants that are sitting squarely in the majority of antenatal rooms, we are never going to help reduce maternal mortality rates. Yes, the U.S. spends a huge amount of money on maternity care and yes, we would expect to see that translate into record low rates of maternal mortality.

Let's be honest
But the fact is that doctors across the country are battling with maternal characteristics that previous generations simply didn't have to. Women are older, women are fatter and women are less ready for LABOR (the definition of which is not always appreciated) than their ancestral and developing world counterparts.

We can have all the money in the world, but if women themselves are not healthy to start with, pregnancy and delivery is going to be more difficult - and indeed more dangerous.

We need to be HONEST with women about their chances of achieving a spontaneous vaginal delivery, and we also need to remember that if a healthy woman WANTS a cesarean delivery, she should not be dissuaded using mortality and morbidity data that is entirely unrelated to her particular circumstances.

Friday, April 30, 2010

U.S. Rate Reduction Campaigns - Frightening News

I came across news of two new campaigns in the United States that aim to reduce their local hospital cesarean rates to between 10 and 15%. I've described this as frightening news because that's exactly what it is.

Not that I believe the campaigners have any hope of achieving such low rates; I don't. But I am concerned that in their efforts to make such drastic reductions, it will be at the cost of numerous mothers' and babies' health.

20% by 2020
The first is in Sarasota, where '20% by 2020' describes itself as "an initiative to encourage elected officials, hospital staff, maternity care practitioners and consumers to reduce Sarasota's epidemic cesarean section rates to 20% by the year 2020."

Worst to First 2010
The second is in New Jersey (where both of my children were born - by elective cesarean), which is called 'Worst to First 2010'. Evidently, the State's current cesarean rate is deemed too high, and this campaign aims to reverse the situation.

It states that all but two hospitals have agreed to re-educate their staff to achieve cesarean rates of 10%-15% and episiotomy rates of 5%. But as you'll see from the figures posted, they have a long way to go...

A 10-15% cesarean rate is unachievable, undesirable and dangerous
The World Health Organization recommended this rate back in 1985, but in 2009, it finally admitted that there is no empirical evidence for such a range of numbers, and that in fact, there is no known optimum rate for cesarean delivery.

The campaign organizers above are most likely unaware of the 2009 update by the WHO, and therefore believe that they are helping women by trying to reduce cesarean rates to this level. However, they are in real danger of doing more harm that good if they're not careful; while I agree that there probably are cases where an unwanted cesarean delivery may be avoided (although I would add that hindsight is usually the most beneficial tool in deciding what was and wasn't medically necessary - obviously not available during labor), there are undeniably grave risks at stake when cesareans are delayed or avoided 'at all costs'.

Finally, I would urge these campaigners to focus on trying to reduce unwanted cesarean rates, and leaving those of us who want our cesareans well alone. After all, it should be positive, happy and healthy birth outcomes that matter - and not simply a % figure at each year end.

Mother Nature's Way versus The Easy Way

This is the title of an article (my capitalization) in the Shanghai Daily today, which you might be interested in reading here.

There's nothing particularly new to say in the article, which discusses the reasons for China's particularly high rate of cesarean births, and especially those arranged on maternal request, but I found the title itself quite interesting.

What do you think? When you read 'Mother Nature's way versus the easy way', what do you make of the words 'the easy way' in reference to a cesarean delivery?

*Is the author inferring that it is actually the easiest way to give birth? In which case, why wouldn't so many Chinese women choose to have one?

*Is it meant sarcastically/ironically (i.e. 'a cesarean is thought of as 'easy' but it is in fact the very opposite)?

*Or does it infer that women are not living up to their natural born responsibility to endure the pain of labor - an essential moral and physical rite of passage into motherhood?

I don't purport to have the answer this evening, but I wanted to write about it because it's an accusation/comment/idea I've seen written about before - that a cesarean is the 'easy' option.

A cop-out almost

Personally, I've even found at some of the mother and baby groups I attend that because I chose and enjoyed a cesarean birth, I'm ineligible for membership in the birth story 'club'. Although luckily, I make the cut for the 'my babies don't sleep through the night - ever' club, so I'm not left out in the cold completely!

It makes me wonder if perhaps there's something about women/mothers that makes us bond better when we can be joined via an empathetic shared suffering of one kind or another.

And what I find fascinating is that while in China, women are choosing cesareans to avoid the potential trauma of vaginal birth or an emergency cesarean that they've heard or read about, in Western culture, we criticize and even condemn women who make the very same decision. Here, we think its natural and normal for women to want to put themselves in the hands of Mother Nature and utilize surgery only when the likely alternative is death or serious injury.


Wednesday, April 28, 2010

Worse outcomes when fewer than expected cesareans

In a study that has echoes of the 2003 Healthgrades survey of U.S. hospitals, this month, researchers Srinivas SK et al have published: 'Evaluating risk-adjusted cesarean delivery rate as a measure of obstetric quality'.

In it, they report that when cesarean rates are lower than expected, adverse maternal or neonatal outcomes are higher.

However, as Michael Smith reports in MedPage Today, "the converse isn't true". Higher-than-expected cesareans rates "aren't associated with a protective effect".

IMPORTANT - The study was carried out in the U.S. where emergency and elective cesarean deliveries are not separated in birth records; therefore, it is highly likely, and indeed comparable with what other studies have found, that the protective effect with planned, elective cesareans is higher in these hospitals but they are being tarnished by the inclusion of emergency cesarean outcomes in the data.

MedPage Today report
In his report, Smith explains how: "the researchers constructed a population-based cohort of 845,651 patients from 401 hospitals in California and Pennsylvania. They excluded premature births and those in which C-sections were standard of care (such as for malpresentation and cord prolapse).

As well as analyzing the overall cohort, the researchers looked separately at the 274,371 primiparous patients with full-term singleton pregnancies.

For both groups, they linked birth certificate and hospital admission records to estimate the correlation between risk-adjusted cesarean delivery and a composite of adverse maternal outcomes, adverse neonatal outcomes, and four obstetric patient safety indicators from the Agency for Healthcare Research and Quality (AHRQ).

The composite maternal outcome included such events as wound infection and postdelivery hemorrhage, and the composite neonatal outcome included such things as death and birth injury. The AHRQ indicators included such things as birth trauma and injury with cesarean delivery.

The researchers used logistic regression to calculate an expected rate of C-section for each hospital and compared that with the observed rate.

In both cohorts, there was a negative correlation between the C-section rate and each of the outcomes, which was significant except for one -- AHRQ patient safety indicator 19 (injury with non-instrumented vaginal delivery).

Comparing C-section and adverse events rates showed that, in the general cohort:

•59.8% of the 107 hospitals with lower-than-expected risk-adjusted C-section rates had a higher-than-expected rate of at least one of the six adverse outcomes.
•Only 19.6% of the 102 hospitals with higher-than-expected risk-adjusted C-section rates had a higher-than-expected rate of any of the six adverse outcomes.
•The comparable figure was 36.1% for the hospitals with the as-expected risk-adjusted C-section rates, which was statistically similar to the higher-than-expected group."

£5.6 million for girl injured in ill-advised VBAC

I met a woman just the other day at a toddler group whose first baby was born by cesarean and whose second baby had arrived 7 weeks earlier via VBAC. She was happy that she had the chance to deliver vaginally. I also know there are numerous women out there who would choose a VBAC instead of a repeat cesarean, and feel that their informed decision is being unfairly denied.

However, the case below (reported by Darbys Solicitors LLP on Webwire in February) illustrates the reason why many doctors do favor repeat surgery over VBAC - because when it goes wrong, it can seriously injure a baby, distress an entire family and ensure a huge litigation bill at the end. My sympathy lies with the parents, who, like so many families, have to wait years before receiving their compensation, and who feel that they were not informed about all the risks associated with a VBAC.

Choice, not VBAC for all, is crucial
It's one thing if YOU personally want to have a VBAC and are willing to accept the risks, but I would urge caution - particularly in light of what is happening in some Trusts in the NHS currently - that VBAC is not a delivery method that should be encouraged for every woman who has had a previous cesarean. Most importantly, if a woman wants to have a repeat cesarean, she should not be forced to have a VBAC trial of labor first.

This is an extract from the report:

"A 13 year old girl who was severely injured during birth has been awarded £5.6 million in compensation, payable by South Buckinghamshire Hospitals NHS Trust.

Alice Joyce was born on 23 March 1996 at Wycombe General Hospital with breathing difficulties, and later developed fits whilst in the Special Care Baby Unit. Her development was delayed and she was later diagnosed as having spastic quadriplegic cerebral palsy. As a result Alice suffers from severely delayed mental development and learning difficulties.

Were it not for medical negligence on the part of the doctors responsible for Alice’s mother’s care, all this could have been avoided. Doctors failed to inform Mrs Joyce that, due to a previous birth which involved caesarean delivery, there was a risk of rupture of the womb should she have a subsequent labour and vaginal delivery. If she had been warned of this risk she would have chosen to have a second caesarean delivery, thus avoiding the risk of labour."

More Dutch women have epidurals - now that they can

Radio Netherlands Worldwide has reported that a growing number of Dutch women are opting to have an epidural during childbirth, according to a survey of teaching hospitals by free daily newspaper Spits.

It says that since January 2009, "All hospitals have been obliged to make the procedure available 24 hours a day – a new development in Dutch obstetrics."

Can you imagine - up until just a few months ago, in a developed European country, an epidural was not readily available as a standard of care for all laboring women?? Obviously, there are plenty of cases in other developed countries where resources are so stretched or disorganized that an epidural is not necessarily available for all women either (the anesthetist is busy with other patients for example), but in The Netherlands, an epidural has been traditionally viewed as an "unnecessary" medical intervention.

Pandora's Box
As the report states, even with a rate increase from 25% at a Maastricht teaching hospital in 2008 to 30% just one year later, "the Dutch epidural rate has a long way to go before it matches that of many other countries" (e.g. the United States, which can be as high as 85% in some hospitals).

But my guess is that the rate is only going to climb further in the coming years. Some might say that Pandora's box may well have been opened in Holland by 'allowing' women access to epidurals; after all, if more women are going to choose epidurals, it's surely a slippery slope to that other infamous medical intervention - the cesarean delivery on maternal request...

I, on the other hand, would say that access to this perfectly legitimate pain relief should be available for every laboring woman, and likewise, legitimate cesarean surgery should be available for every pregnant woman too.

Monday, April 26, 2010

April is Cesarean Awareness Month

I have some catching up to do on the blogging front as I have been unusually busy over the last six weeks, but I want to start back on the keyboard by making a plea to everyone that is involved with 'Cesarean Awareness' during the month of April.

Could you please be equally aware of these facts:

*There are women for whom a planned cesarean delivery is their number 1 preferred birth choice - we do exist, and we are capable of making independent, informed decisions about our births.

*For many women, a cesarean birth is a fulfilling, exciting and satisfying experience.

*Many cesareans are very much WANTED by mothers - so while it may be relevant to talk in terms of necessary or unnecessary cesareans for women whose cesareans are unwanted, it is entirely irrelevant to apply these labels to all cesarean births.

*There is still a great deal of confusion and misinformation about the specific risks involved with emergency cesareans, planned cesareans for medical reasons and planned cesareans on maternal request. Mixed data provides unreliable information.

*As long as a cesarean birth takes place after the start of the 39th gestational week and the mother is planning a small family, then she should not be bombarded with risks that are associated with surgery following a prolonged trial of labor or surgery carried out prematurely for medical reasons unrelated to the surgery itself. It is neither helpful nor ethical to confuse the very different degrees of risk that are applicable to each.

Australia reports maternal request cesarean rate of 3.2%

This latest survey (published in January) from Australia, 'Estimating the Rate of Cesarean Section by Maternal Request: Anonymous Survey of Obstetricians in Australia' by Stephen J Robson et al, provides us with some interesting new information - both about maternal request cesarean rates and Australian obstetricians' views on them - so I have copied the abstract text below (with my bold text).

"The findings of a recent population-based study in Australia suggested that elective cesarean delivery of a singleton pregnancy at term without medical or obstetric indications (cesarean delivery by maternal request) may represent a significant proportion of cesarean births in that country. Maternal request cesarean section has been the subject of much debate in both the lay and the medical press, but there is little useful data on this issue in the medical literature. Worldwide estimates on its frequency are unreliable because of differences between studies in the definition used, diagnostic coding, and documentation by obstetricians. Maternal request cesareans in the era predating the current high rates of cesarean section were estimated to account for 4% to 18% of all cesarean deliveries.

To address this issue, the investigators estimated the rate of cesarean section by maternal request in Australia using 2 anonymous 1-page postal surveys, one for all 1239 specialist obstetricians and the other for all 317 registered obstetric trainees (residents) in Australia. The specialists were asked whether they perform cesarean delivery by maternal request and if so, how many maternal request cesareans they performed in the previous year. Trainees were asked if they would perform such deliveries in their future practice. A reminder letter with the questionnaire enclosed was sent 6 weeks after first mailing. Measures were taken to avoid having any practitioners answer the survey more than once.

The response rate for specialists was 99% and for trainees was 81%. From the specialist responses, it was estimated that between 8553 and 12,434 maternal request cesarean sections were performed in 2006. Using the lowest estimate (8553) in calculations, maternal request accounted for 17.3% of all elective cesarean sections and 3.2% of all births in that year. The likelihood of agreeing to perform maternal request cesarean deliveries was higher among specialists who were 10 or less years from qualification. Two-third of trainees expressed the intention of doing such cesareans in their future practice.

These findings support the hypothesis that maternal request cesareans make a significant contribution to the overall rate of cesarean deliveries in Australia.

Thursday, April 22, 2010

€4.5m settlement - delayed cesarean cited in case

RTE has reported on the €4.5 settlement for a 14-year-old boy who sustained injuries that left him severely disabled during his birth in Sligo General Hospital, Ireland.

It was made "without admission of liability by the Health Service Executive", but the report outlines issues during the birth that included "too high a dose of a labour-inducing drug being given to his mother, the detachment of a monitor during the labour process, too long a delay before the decision was taken to carry out a Caesarian section and the delay in a consultant arriving to carry out the delivery."

Evan Doyle has cerebral palsy and is quadriplegic.

14 years
What I notice most about this all-too-frequent story is the number of years that this poor family have had to wait to receive compensation (or rather, announcement of a settlement amount).

14 years of fighting, waiting, suffering...

Saturday, April 17, 2010

Multiple childbirth is linked to risk of stroke

A study published in March, Parity and risk of hemorrhagic strokes (Jung et al), has reported that: "Increased number of childbirths may be related to an increased risk of both intracerebral hemorrhage and subarachnoid hemorrhage."

An article on the study, Multiple childbirth linked to stroke risk, in the March issue of Neurology, explains this finding in more detail:

"Pregnancy and delivery are known to raise stroke risk. To further look into the association between multiple births and stroke risk, researchers compared 459 women who had stroke and 918 who did not. The women were about 56 years old on average at the time of the study.

Among women who had a stroke, 38 had zero or one childbirth, 143 had given birth twice, 107 had given birth three times, and 171 had four or more deliveries. After allowing for many other factors associated with stroke risk such as age, family history of stroke, high blood pressure, diabetes, cigarette and alcohol use, as well as oral contraceptive and hormone replacement use, each additional birth was associated with 27 percent greater risk for stroke. Women reporting four or more childbirths had nearly a threefold higher risk of stroke as women with no childbirths or childbirth.

The findings could be attributed to the speculation that multiple births might further strain and stress blood vessels and other body systems, and the stress of raising children may also raise stroke risk."

Malta: Safe birth outcomes, not fewer cesareans should be goal

Juan Ameen's article in The Times of Malta, Fewer caesarean section births but top obstetrician has reservations, reports on a reduction in cesarean births in Malta, but includes a warning from the head of the Obstetrics Department at Mater Dei Hospital, Mark Brincat, who believes that cutting the numbers should not be the ultimate goal.

He is described as still welcoming the decline, but with an insistence that the drop "is not a goal in itself as the primary aim should be the safe outcome for the mother and the baby".

The article states that the number of cesareans "increased steadily between 1999 and 2006 but started dropping from 2006 when 35% of deliveries were by [cesarean], further declining to 31%, or 1,321 births, in 2008."

Misleading facts about cesarean rates

Writing in the Times Union a few weeks ago, A. Garry Finkell, President of Perinatal Data Solutions Inc. in New York, made a very interesting contribution to the debate over rising cesarean rates, and one that I hope might help women in the U.S. in particular - but also elsewhere - when making their decision about where to give birth.

While I don't necessarily agree with his choice of words in the last paragraph, "undesirable increase in C-sections" (after all, some of the cesareans contributing to the increase - mine included - was very much desired - by me, at least...), I thought his points were worthy of posting here.

Here's an extract of what he says:

"One common feature of almost all articles on this topic is the inclusion of C-section rates for individual hospitals, implying that hospitals can be compared on this basis. There is some validity to this, but it can also be misleading.

As Dr. Camille Kanaan of Albany Medical Center pointed out, for example, AMC's rate is highly influenced by its role as the Northeastern New York Regional Perinatal Center. As such, AMC has women with high risk pregnancies transported into its birthing center from other hospitals in the region. These women have a much higher than average likelihood of needing C-sections, and this raises AMC's rate.

Further, it is the individual provider who makes the decision to perform a C-section. In any hospital with more than one obstetrical provider, the hospital's average is really the average of all the providers. In my experience, providers in a single hospital can vary widely in their C-section rates.

At the same time, an individual provider may deliver babies at more than one hospital, presumably bringing their same likelihood to do a C-section to each hospital.

An expectant mother should look to her obstetrical provider rather than to the birthing hospital in order to determine her chances of ending up with a C-section. The same is true for analysts who want to understand the dynamics involved in the undesirable increase in C-sections."

Saturday, March 27, 2010

U.S. cesarean rates increase to 32.3% in 2008

The latest CDC figures (preliminary data for 2007 and 2008) show another U.S. rise in cesarean rates to 32.3%, although as usual, there is unfortunately no breakdown in the figures between how many of those were emergency and how many were elective.

Numerous media outlets reported on the rate rise, such as Business Week's Cesarean rates Reach Record High, in which the five states with the highest cesarean rates were named as "New Jersey (38%), Florida (37%), Mississippi (36%), and Louisiana and West Virginia (35%).

On a personal note, the birth of our daughter was in New Jersey in 2007, so we're included in these numbers!

62% cesarean rate in private Hong Kong hospitals

An article in the Gulf Times on the 22nd March reported that while 40% of women in Hong Kong give birth by cesarean, in private hospitals, the rate is 62%.

It reports that Hong Kong women opt for cesarean births "because of convenience, fear of pain and the desire to give birth on an “auspicious” date".

You might want to listen to a recent radio programme from Beijing that I was invited to speak on, which discusses China's high cesarean rate.

Tuesday, March 16, 2010

Recent data sheds light on elective c-section debate

I've just read and posted comments on this article by Cassie Piercey, on the San Diego News Network website. This is what I've said:

There is so much that I could write in response to this article but unfortunately, time does not allow this evening. What I would like to simply point out though, is this: you provide case studies of two women's birth experiences – one, a planned cesarean birth and the other, a planned vaginal birth - and their outcomes reflect a common phenomenon.

Mo Davis-White says, "I never once wavered on my decision to have a C-section", and by all accounts was very satisfied with her birth experience. In contrast, Rose says, "My delivery experience was traumatic… It was upsetting to know my baby was suffering."

Greater levels of satisfaction following a maternal request cesarean birth have been confirmed in medical studies too. For example, this one from Sweden: After PCD "women reported a better birth experience compared to PVD women." (Wiklund et al, 2007) I am not suggesting that all women would be wise to choose a cesarean, but rather, I am defending the perfectly legitimate decision by some women to plan a cesarean in preference to a trial of labor.

Science should guide decisions on your health

I've just read and posted comments on this online article by Roger W. Harms, M.D. of the Mayo Clinic. This is what I've said:

I am a firm advocate of women 'looking to scientific information to inform their decisions', but I think it's also important to be aware of flaws that exist in the presentation of some cesarean data, and I would offer the following reports as evidence of a recent example where this has occurred:

*30 Jan 10 Nigel Hawkes: A bad case of bias against Caesareans, Independent
*26 Jan 10 Funny Figures from WHO on Caesareans, Straight Statistics
*12 Jan 10 Study advises against non-medial cesareans but how accurate is the advice?

When bias against surgery is removed, and studies containing mixed cesarean data are excluded, there is evidence that maternal request cesareans can result in better outcomes than planned vaginal deliveries. Read the stories posted on any birth trauma website (physical and psychological trauma) and you will struggle to find a single complaint from a woman who’s had a maternal request cesarean, yet there are thousands from women who planned vaginal deliveries (this is also backed up by research such as a 2007 Swedish study involving 357 women; those with maternal request cesareans ‘reported a better birth experience compared to those with planned vaginal deliveries.’). Women are simply not being informed about the whole truth. Just two examples: 1. The latest CEMACH report in the UK showed that women were less likely to die following a planned cesarean than any other birth type. 2. A 2009 Canadian study of 40,000 deliveries concluded that ‘elective pre-labour caesarean section…at full term decreased the risk of life-threatening neonatal morbidity compared with spontaneous labour with anticipated vaginal delivery’.

I would also like to pick up on the issue of cost and resources. Firstly, current cost comparisons are flawed in terms of maternal request, as they contain medical and/or emergency surgical costs, but more crucially, vaginal delivery costs repeatedly fail to include the financial impact of: 1. all planned vaginal delivery outcomes, including spontaneous, instrumental and emergency cesareans. 2. short and long-term perineal and pelvic floor repair (e.g. prolapse) and counseling when trauma occurs. 3. huge litigation bills when vaginal delivery goes wrong and a baby/mother is injured or dies. In fact, the UK’s 2004 NICE guideline discusses one cost model in which ‘maternal request would lead to savings’ (not that I’m suggesting this as a motivation), but promptly dismisses the finding as ‘not a realistic conclusion’. The bottom line is: there are risks and benefits with both birth plans - vaginal and cesarean - and women should be allowed to make their own informed decision.

Let's be honest about childbirth

This article in The Guardian on Saturday is a must-read for any pregnant women, and I don't say that because I want to scare women into choosing a cesarean birth (before I'm accused of doing just that). I say it because I truly believe that women are not being properly informed about the potential risks involved with a trial of labor; rather, their heads are filled with the evils that await them if they end up with a cesarean.

Certainly, there are planned vaginal births that result in positive outcomes - a healthy baby and a happy, healthy mother - but there are also those that end like this one. That's Mother Nature for you. In case you missed reading it at the weekend, Emily Woof's description of her traumatic birth - 'Let's be honest about childbirth' - dares to reveal what every pregnant woman deserves to know.

I had a c-section - does that make me less of a mother?

Of course not, but I came across this article yesterday, and while I don't agree with everything the writer says, I just felt that I wanted to draw attention to one particular paragraph. The poetry of it really touched a nerve for me - the nice, tingly kind:

"I had surgery. I had an epidural. I had stitches and pain medication for weeks afterward. Does that make my birth experience unnatural? Does it make me less of a woman or a mother? What do people get out of vaginal birth that I didn't experience? I had a baby, I saw her face and nearly broke from the love of it."

Amy's description of how she felt about her baby completely encapsulates how I felt when presented with my children for the first time. The happiest births are the healthiest ones, and I have never regretted for one minute that mine were surgical.