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."