Tuesday, January 12, 2010

Study advises against non-medical cesareans but how accurate is the advice?

I am utterly perplexed by the conclusions drawn in this latest report from the World Health Organization, 'Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007-08, Lumbiganon et al', but not in the least bit surprised.

[Note added 7 February 2010]
Further to my blog below, the following two articles have been published:Nigel Hawkes: A bad case of bias against Caesareans, The Independent, 30 Jan 2010Funny Figures from WHO on Caesareans, Straight Statistics, 26 Jan 2010

It's bad enough that the presentation of data is skewed in order to make planned vaginal delivery appear safer than it actually is, but the authors have decided to single out "the increased risk of maternal mortality and severe morbidity" in cesarean deliveries with no medical indication as the "most important finding of the survey".

Pregnant women and ALL JOURNALISTS - I urge you to please read the study in full and make up your own mind about which delivery type is the most risky.

If you don't have time, here are some extracts from the study that you won't see in today's media reports:

*The authors write: "Our study has some limitations. First, we had information about mortality and morbidities only until discharge from hospital; some outcomes might therefore have been underestimated, especially for women delivering vaginally who are usually discharged earlier than women having caesarean section."
This is important because damage to the pelvic floor (both in the short- and long-term) leads to physical and psychological trauma, financial costs and hospital readmissions that this study completely ignores. It also ignores the huge cost of litigation that can follow vaginal delivery complications.

*"The calculated odds ratio might overestimate the risk of caesarean section. Although we had adjusted for many potential confounding factors, there might be some other factors that we did not have information about and could not adjust for."
An admission of underestimating vaginal delivery risks and overestimating cesarean delivery risks - and yet this is ignored in the conclusion, perhaps because it does not suit the authors' own birth ideology.

*"Second, data were abstracted from the patients' records. We were not able to confirm the absence of some of the risk factors if they had not been recorded.
This is an issue that has been written about by doctors in the past (and indeed critics of studies such as this) because there may well have been medical indications for some of the 'without indications' cesarean group, and these were simply missing from the patients’ records. This would adversely affect the results for this group; again, potentially causing an over-estimation of its risks.

*"Third, our survey included only hospitals with caesarean facilities having 1000 or more deliveries every year. The results therefore cannot be generalised to smaller facilities."
In the UK especially, some of the highest numbers of cesarean delivery on maternal request occur in small, private hospitals. It is also worth noting here that the quality of hospital care in countries like the UK, USA, Canada and Australia (e.g. infection control through prophylactic antibiotics) may be of a higher standard than some of the regions's hositals included in this study.

*The conclusions drawn about poorer outcomes with cesarean delivery with no medical indication are "analysed as a composite outcome (the maternal mortality and morbidity index)".
This is crucial - because depending on what researchers include in such an "index", this will affect comparative results. Here is what the WHO's index includes:

"We assessed the association of each maternal outcome of death, admission to ICU, blood transfusion, hysterectomy, and mortality and morbidity index (which was defined as the presence of at least one of: maternal mortality, admission to ICU, blood transfusion, hysterectomy, or internal iliac artery ligation); and perinatal outcomes of perinatal mortality, fetal deaths, neonatal mortality up to hospital discharge, stay in neonatal ICU for 7 days or longer, and perinatal mortality and morbidity index (defined as the presence of perinatal death or stay in neonatal ICU for 7 days or longer)"
Notice what is missing: for example, pelvic floor damage; urinary and fecal incontinence; postpartum sexual health; long-term injuries to babies such as Erb's Palsy; psychological outcomes; degree of birth satisfaction. All of these potential birth outcomes are relevant in a truly 'informed' birth risk-benefit analysis, and for many women, they may have a lower tolerance for these risks than the risks associated with planned surgery.

*Referring to planned cesareans without indications, the WHO writes: “The findings for the individual outcomes that make up the composite outcome suggest that the increased risk is mainly attributable to increased admission to ICU and blood transfusion. Although we acknowledge that both ICU admission and blood transfusion depend on the availability of those services and the potentially differing thresholds for giving blood and for admission of women to ICU or referral to higher levels of care, this outcome is nevertheless important.”
This is important because effectively, it is the high occurrence of just two risks within the WHO’s “composite” and self-appointed “index” that leads to this type of cesarean delivery ending up with such a high overall negative score by the end of the study. This has occurred in previous studies too – namely, the 2006 Deneux-Tharaux et al study.

Which delivery type do YOU think has the most risks?

FYI, the study’s data is separated into six birth categories:

- Spontaneous vaginal delivery (reference category)
- Operative vaginal delivery
- Antepartum (before labor) cesarean delivery with indications
- Antepartum (before labor) cesarean delivery without indications
- Intrapartum (during labor) cesarean delivery with indications
- Intrapartum (during labor) cesarean delivery without indications

“Risk of perinatal mortality was significantly increased compared with spontaneous vaginal delivery in infants born by operative vaginal delivery and intrapartum caesarean section with indications. Only infants delivered by antepartum caesarean section with indications had a significantly lower risk of fetal death than those born vaginally, whereas risk of fetal death did not differ significantly for other methods of delivery compared with spontaneous vaginal delivery. For neonatal mortality up to hospital discharge, infants born by operative vaginal delivery, antepartum caesarean section with indications, and intrapartum caesarean section with indications had significantly increased risk compared with spontaneous vaginal delivery. We recorded no cases of neonatal mortality up to hospital discharge for women delivering by caesarean section without indication, and the risk compared with spontaneous vaginal delivery could not be estimated.”

“Infants born by operative vaginal delivery and intrapartum and antepartum caesarean section with indications had significantly increased risk of stay for 7 days or longer in neonatal ICU compared with spontaneous vaginal delivery. Operative vaginal delivery and antepartum and intrapartum caesarean section with indications had significantly increased risk of perinatal mortality and morbidity index. For breech and other abnormal presentation, caesarean section with indication, either antepartum or intrapartum, significantly reduced risk of perinatal mortality but had significantly increased risk of stay in neonatal ICU for 7 days or longer.”

“For maternal mortality, only operative vaginal delivery had significantly increased risk compared with spontaneous vaginal deliveries. The risk for antepartum caesarean section without indication could not be estimated because there were no maternal deaths in this group. Operative vaginal delivery and all types of caesarean section had significantly increased risk of admission to ICU compared with spontaneous vaginal delivery. Operative vaginal delivery, antepartum caesarean section with indications, and intrapartum caesarean section with and without indication had significantly increased risks of blood transfusion compared with spontaneous vaginal delivery. The risk of hysterectomy was increased in mothers who delivered by operative vaginal delivery, antepartum caesarean section with indications, and intrapartum caesarean section with indications. We recorded no cases of hysterectomy in women who delivered by antepartum caesarean section without indications and intrapartum caesarean section without indications, so the risk could not be estimated. Operative vaginal delivery and all types of caesarean section were associated with significantly increased risk of maternal mortality and morbidity index compared with spontaneous vaginal delivery. Intrapartum caesarean section (both with and without indications) had higher risk of maternal mortality and morbidity than did antepartum caesarean section. Deliveries by all types of caesarean section had significantly increased risks of maternal mortality and morbidities except for perineal tears of third and fourth degree, for which as expected caesarean section had a protective effect compared with vaginal delivery (data not shown).”

In summary:
There are NO RECORDED NEONATAL OR MATERNAL DEATHS following cesarean deliveries without medical indications – yet this is absent from the study’s conclusion. Why?

There are NO RECORDED CASES OF HYSTERECTOMY following cesarean deliveries without medical indications - yet again, this is absent from the conclusion. Why?

Cesarean delivery PROTECTS AGAINST SEVERE PERINEAL TRAUMA – yet not only is this fact absent from the conclusion, the researchers decided not to omit the data from its public report entirely. Why?

The WHO uses “spontaneous vaginal delivery” as its comparative “reference” in this study. This in itself is nonsensical. The data is going to be used to advise pregnant women about different risks during the PLANNING stage of their births - not once the birth is over. The problem is, a spontaneous delivery can never be absolutely predicted or guaranteed. Even the healthiest woman with the healthiest pregnancy can suffer a physically and psychologically traumatic labor involving instrumental assistance and ultimately surgical delivery. Therefore, the WHO should have compared birth PLANS – i.e. compared all planned vaginal deliveries (and their ultimate mortality/morbidity outcomes) with all planned cesareans (with and without indications). That said, even with the current vaginal delivery bias, I think it’s clear from the extracts above that maternal request cesareans fair better in the study than the conclusion would have us believe.

The WHO insists that “Assisted vaginal delivery represents a high-risk situation, and combination of such deliveries with spontaneous vaginal deliveries as the reference group might not be appropriate.” Firstly, we know that operative vaginal delivery does NOT always represent a high-risk situation. But even if I accept that argument, other comparative studies frequently mix the data of planned cesareans with and without medical indications, and then compare them in a negative light with vaginal delivery outcomes (and these studies are cited in WHO reports). Perhaps a fairer approach in the WHO's study (or as an additional footnote) would be to compare ALL vaginal delivery outcomes (incl. operative and emergency cesareans) with ALL planned cesarean outcomes (incl. with and without indications groups)?


**Advocates of vaginal delivery should focus their efforts on improving best practice care for women choosing vaginal delivery, and reducing the number of unwanted cesarean deliveries. They should not concern themselves with women who want a cesarean delivery. Numerous medical studies demonstrate high levels of post-birth satisfaction in women who choose a cesarean delivery and I think it’s unethical to try to stop these women enjoying a birth plan that is their legitimate choice.
Millions of women throughout the world plan to have a spontaneous delivery but you only have to look at any birth trauma website to see that many of these plans result in unhappy, traumatic stories of physical and psychological damage. From what I can see (both in studies and in emails I receive from women), those of us that choose cesareans are a generally happy bunch in terms of our birth outcome, and with the clocks turned back, would make the exact same birth decision all over again.

**The WHO is not entirely reliable in terms of making recommendations on cesarean delivery. Back in 1985 it suggested that national rates of cesarean delivery should maintain an upper limit of 15%, and then finally (after much insistence from critics, including the CCA), in its 2009 handbook it admits that "no empirical evidence for an optimum percentage" exists, an "optimum rate is unknown," and world regions may choose to "set their own standards." You can read more about this here.

**There have been a large number of media reports on this study, and what concerns me most is that if perhaps even journalists don’t have time to read a study in full (and in fairness, many don’t), then it’s unlikely that readers of their newspapers will read the study in full either. Therefore, we are in danger of effectively ‘misinforming’ whole nations of women about the true risks of different birth types. Here are a few examples:

Rebecca Smith writes for The Telegraph:
Perform caesarean deliveries only where medical problem: researchers’… Hospitals should only perform caesarean sections if there is medical problem and not just because women simply choose the procedure because they are 'too posh to push', experts said.

Bella Battle writes for The Sun:
Cesareans a ‘risk’ to mums’… MUMS dubbed 'too posh to push' were given a stark health warning on caesareans today.

Emily Cook writes for The Mirror:
Don't have a caesarean unless it's essential, warms news study’…Mums to be should only give birth by caesarean when strictly necessary, insists a new study.

Some of the reports do provide criticism of the WHO’s study, but this tends to come further down in the page. The Telegraph for example notes that “experts in Britain said the study was conducted in Asia and so was not as relevant to practice in Britain. They said the findings had been 'over sensationalised'.” For example, Dr Virginia Beckett, spokesman for the Royal College of Obsestricians and Gynecologists, said: "These findings are actually quite reassuring for women opting for caesarean sections. They found that three in 1,500 women who had a c-section without medical indication before labour needed a blood transfusion and I would expect elective caeseareans to be even safer in Britain… "There are some very big conclusions drawn from some very small numbers.”

**This study is relatively small; an analysis of just 107,950 deliveries throughout nine countries - Cambodia, China, India, Japan, Nepal, Philippines, Sri Lanka, Thailand and Vietnam, and is receiving maximum media exposure in the UK, Australia and North America. Yet where are the vast swathes of media reports on studies like the ones I’ve cited in this blog in the past or in the various press releases I've written (highlighting very positive health outcomes with maternal request cesareans) - many of which are conducted in countries far closer to home than Asia?

I don’t necessarily blame the media here; after all, a powerful natural birth ideology PR machine ensures its message gets reported, but isn’t it time that more journalists looked afresh at the easy target of ‘too posh to push’ mothers and consider for just one second an alternative truth – that these women are in fact making educated and informed decisions about their babies and their bodies?

And while I’m on my soapbox, could the natural birth lobby get busy making suggestions about how we deal with the extremely challenging maternal landscape that obstetrics has to deal with in the developed world – namely, mothers giving birth at increasingly older ages and with heavier body weights, and babies being born larger and heavier too. It’s all too easy to seek a reduction in cesarean rates by trying to encroach on my right to plan the birth of my choice, but what are your plans to encourage a reduction in the number of unwanted cesareans? Do they include an uncomfortable discussion on issues such as earlier parenting or pre-pregnancy weight loss? Your responsibility lies more in counseling women about vaginal delivery risks – help them achieve the delivery of their choice and allow me, and other women like me, to enjoy our own personal choice.


The WHO reports that the “most important finding of the survey is the increased risk of maternal mortality and severe morbidity [analysed as a composite outcome using the maternal mortality and morbidity index] in women who undergo caesarean section with no medical indication.

And it concludes that to “improve maternal and perinatal outcomes, caesarean section should be done only when there is a medical indication.

Well, I find myself heading to bed now and still wondering, how on earth can WHO researchers conclude from the data results above that a planned cesarean delivery with no medical indication is any more risky than a planned vaginal delivery? And moreover, how can it claim that of all the data it accumulated in nine countries, that this particular finding was "the most important"?

What about the risks associated with operative vaginal delivery? What about the protective benefit of a planned cesarean with regards third and fourth degree perineal tears? What about the low number of deaths and absence of hysterectomy? What about the positive outcomes with cesarean breech deliveries? Do these areas of risk not warrant our attention?

The WHO’s goal – and that of all true birth autonomy advocates – should be POSITIVE BIRTH OUTCOMES FOR ALL WOMEN in all walks of life. Millions of women and babies continue to die in childbirth despite the WHO’s best efforts, so I would suggest that it focus more on INCREASING cesarean rates for these women and decreasing rates of UNWANTED cesareans for others, and focus less on reducing access for women that WANT cesarean surgery and don't want a trial of labor.


Siriol Haf Griffiths said...

I wonder how they came up with the idea of 'unnecessary'? What an arbitrary term that is! Yet again, all c-section births are bundled together, whether planned or not. Why is this the case in the 21st century? And I wonder whether any correlation was made between general mortality rates in those nations and maternal mortality.... I imagine not.

Bravo Pauline for all your work in this area. Women who genuinely want to opt for a c-section delivery should be given the genuine facts, and you are doing this.

Amy Tuteur, MD said...

The study actually showed that C-section with any medical reason is the safest form of delivery. The authors tried to obscure this by creating a perinatal "index" and a maternal "index."

An index of outcomes can be useful if there are a great deal of possible complications, all of approximately the same severity. So an index might have been useful had the possible complication of surgery been for example: transfusion, ICU admission, wound infection, IV antibiotics, hospital readmission, etc.

An index is inappropriate if there are only a few outcomes (as in this paper) or if it combines outcomes of wildly different severity (as in this case). In such situations and index is often use to obscure outcomes. The WHO group desperately wanted to conclude that vaginal delivery was "safer" than C-section with no indications. The data, of course, show otherwise. There were fewer hysterectomies and maternal deaths in the C-section group, so they added in transfusions and ICU admissions to create an "index" that made vaginal delivery look better.

michele said...

What is always left out is the consequences of surgery years down the road. The long term result. Usually these studies talk about during the delivery or not far after.

I would love to see more studies on this--but they won't be available until some years down the road when the women in the midst of the c-section boom today are older.

One study that I came across recently was stating Placenta accreta has increased in the past 3 decades, along side the rise in c-sections:


I found in interesting. C/s is a surgery, and with surgery there is scar tissue.

I just read a few articles on this same study, and as you stated, it says quite the opposite. This pisses me off. As a mother, (a c/s mother) and quite possibly one in the future--I want to know the truth. I don't want biased bull.

When you go to various sites (vag/natural birth sites vs. c/s sites) and see such a discrepancy in information (esp. from the same study) obviously someone is stretching the truth. This doesn't help anybody. I wish, for the sake of all women--all mankind--that we stop trying to push agendas and speak truthfully. Only then can we benefit.

Unknown said...

The World Health Organisation has disgraced itself again but this time too outrageously to let pass. We need to get some investigative journalists on the case - this is a potentially juicy story.

cesarean debate said...

I completely agree with you that we need more studies into the long-term consequences of each birth type; evaluation of the labor, delivery and/or short-term morbidity is insufficient.

I have never tried to hide the long-term risks of cesarean delivery (although as you correctly say, it may be many more years before we get a clearer picture since the increase in cesarean deliveries is relatively recent). On my website, I list the risk of future placenta complications, adhesions and infection for example, and I believe that women should be fully informed of these risks.

One of the problems we currently face in trying to evaluate the risks of subsequent cesarean surgeries (following a planned cesarean delivery - with and without medical indication) is that the studies look at ALL repeat cesareans. That is, they do not distinguish between a repeat cesarean where the previous cesarean was planned and a repeat cesarean where the previous cesarean was an emergency.

I don't know for sure (because the study has not been done), but given that numerous studies HAVE established a greater risk with emergency cesareans than with primary planned cesareans, I wonder if the nature of the originating cesarean could have an affect on the level of risk of the subsequent cesarean?

Either way, I would reiterate that planned cesarean delivery is not risk-free and nor is it inherently 'safe'. What I try to convey in this blog is that it is safer than some medical and/or media reports would have you believe.

Coincidentally, I don't believe that enough women are informed of the long-term risks with a planned vaginal delivery either. Only when women understand the true short- and long-term risks of BOTH delivery types will they be in a position to make a truly informed birth decision.

Anonymous said...

Thank you, Pauline, for compiling this information and opening a discussion on cesarean births. I had a c-section with my son, though it was not planned and was medically necessary. There is a very long and complex history of complicated childbirth in my maternal family, so I wasn't at all surprised when the doc suggested a c-section. At that point I had been induced, was experiencing high blood pressure from pre-eclampsia, could not dilate past four, and my son's heart rate was falling with each contraction. I'd been in labor for 15 hours at that point.

I am fortunate in that I recovered very quickly and easily from my c-section - after about a week, I was pain free. I have experienced no real lasting effects from the surgery. Compared to several friends who struggled to sit down two weeks after their vaginal deliveries, I counted myself very fortunate. I was able to breastfeed immediately and was on my feet within a day. Emotionally, I felt wonderful - I had a gorgeous, healthy, 9 lb. little boy and both of us made it through healthy and happy!

Yet vaginal deliveries are still touted as the pinnicle of the childbirth experience, one that no woman is complete without. An experience that is a piece of cake that anyone can bounce back from with no ill effects. Any other way is simply believed to be "less than." And here I thought the women's movement was supposed to be about choice! Apparently, this is only the case if a woman chooses a vaginal birth. Once again, thank you for discussing the benefits of c-sections - and in making informed choices. :)

Anonymous said...

It would be just as lovely if you would do your research on the other end of the spectrum. C-sections are far more dangerous than vaginal birth.
There is nothing wrong with a medical necessarily c-section. The problem lies with women not being told that this is major surgery and being lied to that their recovery time will be just as fast as with vaginal birth.

4timeMama said...

The bottom line is that women's bodies are designed to give birth; we're not designed by nature to have major abdominal surgery. I had my first child via c/s and had a very difficult recovery that involved pain in and around the scar area for over a year, but also problems establishing breastfeeding AND a misplaced bladder that has given me difficulty ever since (it's been nine years next month).

My two subsequent births have been natural, vaginal births from which I've recovered quickly and well. I have no issues with pelvic floor problems or incontinence.

I always wonder how much interventions from hospitals and from OB staff, who seem to be trained that women's bodies are defective and cannot give birth without such interventions, affect the types of negative outcomes that are associated with vaginal births in this entry. Certainly the counted purple pushing, being forced to push while on your back or slightly reclined, being told to hold your breath and push according to a count by someone who isn't feeling the contractions, and pushing ineffectively and much too hard due to being unable to feel anything because you're numb from the waist down from your epidural... surely those things could affect the kinds of things that are asserted here ought to make c/s better?

Having had a c/s and natural vaginal birth, for me I'll trust my body and I'll do another vaginal birth before I'd ever voluntarily choose another surgical birth. And, in fact, I have chosen it: our fourth baby is due to arrive in about a month, and we're planning on having her at home in water just like we had her brother.

Anonymous said...

Why would you choose major surgery?It just doesnt make sense, on any level, unless there is underlying psychological trauma from other life events that makes one *need* to go down the path of surgery?

I'd be of the opinion that if it worked to get the baby *in there* via your vagina, that mother nature made a pretty good exit spot for the baby too?

Anonymous said...

I have to agree that women's bodies are designed to give birth... We are designed to shelter and protect our children as they grow and develop in the womb and we are designed to give them entry into this world. Unfortunately, we have scared so many women into thinking that their bodies are incapable of doing this that c/s is quickly going to become the norm.

Why anyone would choose to have MAJOR surgery is completely beyond me and trust me I'll take my two vaginal deliveries (1 unplanned, unattended homebirth and 1 hospital birth with a midwife) and my coming homebirth over allowing some doctor to slice me up and surgically remove my baby as though he or she was some sort of deadly uterine growth any day.