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.

VBAC versus cesarean statement from the NIH

There have been a number of media reports following the latest statement on cesarean delivery from the National Institutes of Health, and I have been concerned by the number of headlines that imply that the NIH has said "VBAC is safe". Now, while I am completely in support of low risk women making an informed decision to have a VBAC birth, and sympathize with those who have been refused their birth choice in some hospitals, it is dangerous to start describing a VBAC as 'safe'. There are indisputable risks involved, as there are with a repeat cesarean, and it's a case of choosing which set of risks and benefits (as they apply to your particular medical history) you are most comfortable with.

Therefore, I think it's useful to present the NIH's actual summary here (known as an 'Abstract') for women to read for themselves, and if you are considering a VBAC, I would suggest you read the whole statement in full as part of your birth research. Through my work, I am rarely contacted by women who are trying to plan a VBAC; on the contrary, I hear mainly from women who are trying to plan a cesarean for their first birth. And of course personally, I didn't choose a vaginal birth first time round, much less consider having one after a cesarean. But that was my personal decision, and I think it's important that every woman's personal decision is respected. Respected and informed.

Vaginal Birth After Cesarean: New Insights

Objective: To provide health care providers, patients, and the general public with a responsible assessment of currently available data on vaginal birth after cesarean (VBAC).

Participants: A non-DHHS, nonadvocate 15-member panel representing the fields of TEXT, and a public representative. In addition, 21 experts from pertinent fields presented data to the panel and conference audience.

Evidence: Presentations by experts and a systematic review of the literature prepared by the Oregon Evidence-based Practice Center, through the Agency for Healthcare Research and Quality. Scientific evidence was given precedence over anecdotal experience.

Conference Process: The panel drafted its statement based on scientific evidence presented in open forum and on published scientific literature. The draft statement was presented on the final day of the conference and circulated to the audience for comment. The panel released a revised statement later that day at This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government.

Conclusions: Given the available evidence, TOL is a reasonable option for many pregnant women with a prior low transverse uterine incision. The data reviewed in this report show that both TOL and ERCD for a pregnant woman with a prior transverse uterine incision have important risks and benefits and that these risks and benefits differ for the woman and her fetus. This poses a profound ethical dilemma for the woman as well as her caregivers, because benefit for the woman may come at the price of increased risk for the fetus and vice versa. This conundrum is worsened by the general paucity of high-level evidence about both medical and nonmedical factors, which prevents the precise quantification of risks and benefits that might help to make an informed decision about TOL versus ERCD. We are mindful of these clinical and ethical uncertainties in making the following conclusions and recommendations.

One of our major goals is to support pregnant women with a prior transverse uterine incision to make informed decisions about TOL versus ERCD. We urge clinicians and other maternity care providers to use the responses to the six questions, especially questions 3 and 4, to incorporate an evidence-based approach into the decisionmaking process. Information, including risk assessment, should be shared with the woman at a level and pace that she can understand. When both TOL and ERCD are medically equivalent options, a shared decisionmaking process should be adopted and, whenever possible, the woman’s preference should be honored.

We are concerned about the barriers that women face in accessing clinicians and facilities that are able and willing to offer TOL. Given the level of evidence for the requirement for “immediately available” surgical and anesthesia personnel in current guidelines, we recommend that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement relative to other obstetrical complications of comparable risk, risk stratification, and in light of limited physician and nursing resources. Healthcare organizations, physicians, and other clinicians should consider making public their TOL policy and VBAC rates, as well as their plans for responding to obstetric emergencies. We recommend that hospitals, maternity care providers, healthcare and professional liability insurers, consumers, and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to TOL.

We are concerned that medico-legal considerations add to, as well as exacerbate, these barriers. Policymakers, providers, and other stakeholders must collaborate in the development and implementation of appropriate strategies to mitigate the chilling effect of the medico-legal environment on access to care.

High-quality research is needed in many areas. We have identified areas that need attention in response to question 6. Research in these areas should be prioritized and appropriately funded, especially to characterize more precisely the short-term and long-term maternal, fetal, and neonatal outcomes of TOL and ERCD.