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

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.