Sunday, July 28, 2013

The wrong debate about cesarean sections

Following a comment I left on his article this week, What Is A Normal Pregnancy?, Dr. Silvio Aladjem invited me to comment on an article he'd written in May 2012, titled, The wrong debate about cesarean sections.
Here is what I wrote:
I am always very pleased when I read criticism of the obsessive focus on caesarean rates, and of national and global efforts to reduce these rates to arbitrary levels. In 2009, the WHO admitted it had no empirical evidence (and still doesn't) for recommending a 15% threshold in 1985, and that there is no known optimum rate; yet countries and hospitals are still rated according to their overall number of caesarean surgeries as though this absolutely reflects the health outcomes of mothers and babies.
One example of the problem with these international 'league tables' can be read in my letter to the BMJ earlier this year: Reducing mortality is not as simple as low cesarean rate good, high cesarean rate bad
Another problem is that focussing on the "overall CS rate" ignores the fact that it's emergency caesareans that are associated with the greatest risks, and planned caesareans have comparatively better outcomes (and costs). Yet instead of strategies to reduce the worse types of CS, very often planned CS are refused or avoided - only to end up as an emergency CS anyway.
My instinct is that we probably agree on the above, but I am not so sure about your views on maternal request caesareans. You write that "there is no good medicine where extraneous and non medical forces intervene", so it would be interesting to read what you think about a CS that is not medically indicated (though of course someone like myself would describe such surgery as prophylactic; i.e. there is no immediate medical indication, but there is knowledge of and desire to avoid known morbidities with a trial of labour).
In this context, if I may, I'd like to highlight concerns I have with some of the statements in your article, particularly in the context of what's happening in UK maternity care (as opposed to U.S.).
Extract: "a new trend is evolving: cesarean section on demand...In the USA this is not yet a serious problem.  But in other countries, this is a problem. Cesarean sections rate has reached 90% levels, like in Brazil for example."
This is usually referred to as caesarean on maternal request, but whether demanded or requested, you refer to what I believe is a legitimate prophylactic request (given the known potential risks associated with a trial of labour - both in the intrapartum period and longer term) as "a problem". Yet there is evidence of very high maternal satisfaction following CDMR, and very good health outcomes too (for women planning small families and with delivery at 39+ weeks' gestation).
Extract: "The movement to reverse the trend is facing great obstacles."
Unfortunately, maternal request caesareans are viewed as an easy target in efforts to reduce CS rates, and I am frequently contacted by women whose legitimate request is being refused and denied. Forced trials of labour (that often end up as emergency CS or instrumental VD) for women who WANT a CS is, in my opinion, an unethical and ineffective method of 'reversing CS trends'.
Extract: "Third, there is a need for tort reform, so that medical decisions should not, even remotely, have to take into account the possibility of legal consequences of  a medical decisions."
I agree that medical liability is a factor in driving up CS rates but I disagree that tort reform should go this far. Already in the UK, we have a HUGE litigation bill for obstetrics (both current and estimated future payments), and this is a country where there is a very strong drive to reduce CS rates and increase "normal" birth rates. In countries where maternity care is cost-driven, and litigation is taken out of the equation, there ends up being too many cases where efforts to get the baby out vaginally (and avoid a CS) leads to mortality and severe morbidity. The MODE of birth should never be the driving focus, but rather health outcomes and maternal satisfaction.
Extract: "Fourth, we need to educate the public that there are going to be complications and poor outcomes, no matter who cares for the patient. The occurrence of obstetrical complications is a reality we should stop denying."
I agree with your perspective that birth is inherently risky (while accepting others' views that it is inherently safe - with intervention only as a last resort). However, this is where maternal choice is vital. Women need to be informed of the risks and benefits of BOTH birth PLANS (PVD and PCD), and allowed to choose which they prefer (e.g. some may choose VBAC, others may choose repeat CS). Maternity policies dictating one birth plan or another is a real problem.
Extract: "Neonatal morbidity was high, much of it the result of obstetrical maneuvers and manipulations intended to deliver the infant vaginally at all costs, because of fear of performing a cesarean section. Those times are gone  for ever.  Thank God."
Unfortunately, this is simply not true in countries like the UK. A quick google search (or look on my blog) will provide you with numerous examples of cases where this exact scenario has resulted in the death or injury of mothers and babies.
Extract: "“Good medicine” will take care of itself and the rate of cesarean section will find its own level. But it will not be the rate of the 50s or 60s, nor should it be."
Good medicine in the context of obstetrics is extremely subjective, and this is one of the ongoing problems in the whole caesarean debate. There are some who hold very strong ideological beliefs that vaginal delivery should always be attempted in the absence of immediate medical indications, while there are others who believe that a caesarean delivery is advisable with even the slightest risk factor. Personally, I don't propose any appropriate caesarean level, so I am not going to say that a range of 50 or 60% is either right or wrong. However, I would repeat that in some countries/hospitals with high CS rates, the rates of perinatal mortality (incl. stillbirth) and maternal mortality are very low - and also the very opposite is true. So again, I would like to see discourse moving away from the criticism of caesarean rates alone - whatever the number - and only talk about CS alongside rates such as stillbirth, perinatal mortality, maternal mortality, infant birth injuries and maternal morbidity (short- and long-term). The CS rate alone actually tells us very little.
On maternal request:
I genuinely believe that where women ARE allowed to choose CS freely, there are more women choosing it than some may be comfortable with... but this doesn't make it 'wrong', nor categorically 'unsafe'. Absolutely, surgery is not risk-free, but increasing numbers of women are realising that natural birth (or rather, a trial of labour) is not risk-free either, and the rates of CS that are seen in private hospitals - where women have greater CHOICE - demonstrate that maternal request CS is a reality; albeit one that some have chosen in turn to ignore, deny, criticise, discourage and (if all else fails) refuse.
One final comment.
This month, ACOG published the article (written by W.Lawrence Warner, MD), "Arriving at the appropriate cesarean delivery rate". Again, I'm glad that Warner is not advocating simply "lowering" the CS rate, but I have concerns about some of his comments.
He writes about an increase in maternal mortality in the U.S., linking it with a rise in the caesarean rate, but of course there are numerous other factors at play. For example, obesity levels in the U.S. and socio-economic differences in quality of health care to name just two. Also, other countries with higher CS rates than the U.S. have lower maternal mortality rates, but American women are unlikely to hear about that.
I commend Warner for seeking to reach an "appropriate" CS rate "rather than just lowering [it]", but his conclusion, that doctors "educate our patients about the immediate and future consequences of a cesarean delivery" is concerning. Surely they should be educating patients about the consequences of BOTH birth plans, and then measuring HEALTH outcomes (physical and psychological)? Perhaps this is what he means, but it's not completely clear.
Something tells me we haven't moved far enough away from the focus on caesarean rates as we need to... It's as though it's finally been agreed that yes, a 15% CS rate is unrealistic and unachievable, but if we can get down to 'let's say the mid-20s%', then that would be about right.
I disagree with this view. There is no more evidence for rates of these suggested percentages than there ever was for 15%, and with more women having (bigger) babies later in life, with very high expectations of a good outcome, obstetric challenges have never been greater.
Dr. Murphy and myself talk about this, and much more, in our book, "Choosing Cesarean: A Natural Birth Plan" (Prometheus Books, New York), and if interested, readers can browse some of the chapter pages here for more information.

1 comment:

Anonymous said...

Excellent comments. As someone very happy with the outcome of my maternal request C-section, I thank you very much for your thoughtful and persistent work on behalf of women's choices.