C-section Caps Cost Lives and Money

I was appalled to read this story in the Express this morning, "Op Cutbacks Put Mothers At Risk". 

In it, Lucy Johnston writes:  "The Sunday Express has learned a growing number of health authorities have said they will not cover the cost of caesareans if they exceed the national average of 23 per cent. They will instead pay only the rate for a normal delivery, which means hospitals could lose up to £1,300 each time."

And I couldn't agree more with some of the comments quoted in the report:

Tougher Nuts to Crack than Cesarean Rates

The irony in this article (Obesity, elective cesarean contribute to U.S. maternal mortality rate, by Robyn Carlisle, MSN, CNM, WHNP, May 9, 2011) is astonishing, and its headline does little else but feed the anti-cesarean frenzy that it is taking place amongst many birth advocates around the world. Tweet

Irony no.1:

In the developing world,

Cesareans on the rise in Iran

In this online report a member of Supreme Council of Islamic Republic of Iran Medical Council (IRIMC) warns about the risk of a rising maternal mortality rate in line with a rising national cesarean rate.

The report does not specify what the cesarean rate is or what the split is between elective and emergency.

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...

Fact:
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.

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."

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."

Australia: 3.2% of all births are maternal request cesareans

In the first publication on the subject for 2010, researchers Robson et al in Australia have calculated that - even 'using the lowest estimate (8,553 women) in calculations, maternal request [cesareans] accounted for 17.3% of all elective cesareans and 3.2% of all births' in 2006.

'Estimating the Rate of Cesarean Section by Maternal Request: Anonymous Survey of Obstetricians in Australia' concludes that its 'findings support the hypothesis that maternal request cesareans make a significant contribution to the overall rate of cesarean deliveries in Australia.'

Rate expected to increase in future too
Of the 1,239 specialist obstetricians surveyed, it was estimated that between 8553 and 12,434 maternal request cesarean sections were performed in 2006, and the likelihood of specialists agreeing to perform maternal request cesarean deliveries was higher among those who were 10 or less years from qualification.

Of the 317 registered obstetric trainees (residents) surveyed, two-thirds expressed the intention of doing such cesareans in their future practice.

Research background
'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... [read more here].

My response to WHO Press Release criticism

Henci Goer, representing Lamaze International, has criticized the CCA's latest press release, 'WHO admits: There is no evidence for recommending a 10-15% caesarean limit'. Her criticism can be read here, and this is my response.

Firstly, inside the red circle in the WHO table that Henci has highlighted, you will see a small letter 'c', and the note beneath the table reads: 'See Section 2.5 for a discussion of this range.'

Since Henci has not reproduced this discussion, I will do so here. It reads:

"Earlier editions of this handbook set a minimum (5%) and a maximum (15%) acceptable level for caesarean section. Although WHO has recommended since 1985 that the rate not exceed 10-15% (125), there is no empirical evidence for an optimum percentage or range of percentages, despite a growing body of research that shows a negative effect of high rates (126-128). It should be noted that the proposed upper limit of 15% is not a target to be achieved but rather a threshold not to be exceeded. Nevertheless, the rates in most developed countries and in many urban areas of lesser-developed countries are above that threshold. Ultimately, what matters most is that all women who need caesarean sections actually receive them."

With regard to minimum and maximum acceptable levels, it says:"Both very low and very high rates of caesarean section can be dangerous, but the optimum rate is unknown. Pending further research, users of this handbook might want to continue to use a range of 5–15% or set their own standards."

My response to Henci
1. The WHO handbook states (above) that users 'might' want to continue to use a range of 5-15% or set their own standards. Given that the WHO itself states (also above) that 'there is no empirical evidence for an optimum percentage or range of percentages', it is entirely your prerogative to choose to continue advocating a percentage threshold that has no basis in evidence.
I do not. I prefer to advocate countries setting their own standards, and in doing so, to explore a far wider body of research than the three studies that you (and the WHO) refer to in your post (more on these below).

2. This is an indisputable fact: On the subject of cesarean rates, the WHO has said in 2009 that 'the optimum rate is unknown'. This is what our press release states and while this fact may not fit in with your birth ideology, that does not make it any less factual.

3. You infer that our press release did not go far enough in terms of quoting the WHO handbook accurately, and in this context, you refer specifically to the extract 'despite a growing body of research that shows a negative effect of high rates'. Please look again - our release does include this line of text and we made no attempt to avoid or hide it.

4. I am open to debating the subject of cesarean deliveries, and in particular, my focus is on demonstrating that a planned prophylactic cesarean at 39 weeks for women planning a small family is a perfectly legitimate birth choice in preference to a trial of labor (since these women are adversely affected by strategies to reduce cesarean rates to 15%).
But what I object to strongly is your effort to censor a press release that does not agree with your point of view. Medical News Today and PRlog.org have both been contacted with the specific request to remove our press release from the internet, and to use your own words, 'shame on you' for resorting to such tactics.

5. Furthermore, in your chat with visitors to your site at the bottom of the page, you are praised for contacting Medical News Today, and you write: 'Your welcome! This is my idea of fun.' Again, I don't think there's anything funny about attempts to censor an opposing viewpoint to your own.

6. In March this year, I spoke at a seminar on the subject of cesarean rates, and my presentation included many studies to support the point of view that a 15% rate is unrealistic and unwarranted (as you know, the CCA is not the first to criticize the WHO's 1985 recommendation). I can provide you with a copy of this, and would like to note here that I received very positive feedback from many midwives and natural birth advocates in the room that day - and that the doctor with the 'opposing viewpoint' to mine in our seminar even admitted that a 15% rate is unachievable. Here is an extract on the subject of infant mortality for example:

"Since extraneous socioeconomic factors affect the U.S. infant mortality rate (deaths <1>Singh and Kogan, 2007), it is less relevant to the delivery method than the fetal mortality rate (deaths at 20-27 gestational weeks or ≥28 gestational weeks), neonatal mortality rate (deaths <28>MacDorman and Kirmeyer, 2009), (Kung et al, 2008)
Northern America, together with Australia (which has a cesarean rate of 30.8%), has the lowest regional stillbirth rate and one of the lowest regional neonatal mortality rates worldwide. The WHO says it has 'shown that one third of stillbirths take place during delivery - deaths that are largely avoidable and closely linked to the place of and care provided at delivery.' (Neonatal and perinatal mortality: country, regional and global estimates, WHO, 2006)
A UK study of 65 maternity units incl. 540,834 live births and stillbirths found that a 'higher intervention score and higher number of consultant obstetricians per 1000 births were both independently and significantly associated with lower stillbirth rates.' (Joyce et al, UK, 2004)

My criticism of WHO's 2009 handbook
1. Its recommendation on cesarean rates is now open to ambiguity. While I am glad that (after much lobbying) the WHO has finally put in print that it has no evidence for recommending an optimum cesarean rate, it is a pity that its statement remains open to this type of debate.

2. It refers to 'a growing body of research that shows a negative effect of high rates' and references three studies, '(126-128)', but there are numerous other large and contemporary studies that demonstrate very positive outcomes with cesarean deliveries, and these are not mentioned in this area of the WHO's discussion at all.

How can the WHO ignore (for example) that women in the UK (where national data on elective and emergency outcomes is separated, unlike the U.S., which only separates primary and subsequent cesareans) are less likely to die following a planned cesarean than any other birth type? Or studies from Sweden that demonstrate greater levels of satisfaction following planned cesarean births than planned vaginal deliveries? Or the latest study from Canada - of 40,000 births - that concludes: ‘elective pre-labour caesarean section… at full term decreased the risk of life-threatening neonatal morbidity compared with spontaneous labour with anticipated vaginal delivery’. And the cesarean group in this latter study were breech deliveries (understandably more complicated than cesareans with cephalic presentations) while the vaginal delivery group were cephalic presentations...

3. When I interviewed Dr Monir Islam, Director of the WHO’s ‘Making Pregnancy Safer’ program last year, he told me that he agrees with the ACOG’s 2007 and NIH’s 2006 statements on maternal request cesareans: that they are ethically justified following individualized consultation.

His exact words were: 'A woman should have the right to decide. Why should she not have the right to decide? 'It should be an informed decision; the doctor needs to give the woman all the information she needs, and then the woman should decide whether she wants a cesarean section or she doesn’t want a cesarean section.'


Clearly, maternal request cesareans add to national percentage rates of cesareans, and this is another reason why a 15% threshold is unrealistic in North America and the UK.

4. The three studies referred to as 'a growing body of evidence' are seriously flawed in the context of this debate when quoted in isolation, and particularly in any debate about maternal request cesareans with no medical indication (the notes below refer to maternal request because this is the context I first wrote about them in, but they are still relevant here because any attempt to reduce national cesarean rates to 15% would have to involve the refusal of maternal request).

*Issues with the Deneux-Tharaux et al study
If you read the research in full, it is evident that in the two causes of death where the majority of maternal mortality occurs, CD does not result in more cases of death than VD. For example, the risk of postpartum hemorrhage (the most common cause of death here, at 38.5%; n.25) is as high with VD as it is with CD. In fact, the maternal mortality risk is higher for CD in the three causes of death that occur least: Venus thromboembolism (n.7 of 10 total); Puerperal infection (n.4 of 5 total) and Complication of anesthesia (n.4 of 5 total), which equates to 15 out of 20 deaths in these areas (the total number of deaths was 65). This is the source of the 'triple the risk' headlines.

Furthermore, Deneux-Tharaux writes: 'It must be noted that 3 of the 4 deaths due to complications of anesthesia in this study occurred after general anesthesia, whereas the 4th death occurred after spinal anesthesia. This suggests that general anesthesia at cesarean delivery is associated with a much greater mortality risk than regional anesthesia.'

PMHull: General anesthesia is usually administered in an emergency CD, not an elective CD. Therefore, any deaths following the use of general anesthesia in an emergency CD should not be used to analyze the safety of an elective CD where spinal anesthesia is used.

Deneux-Tharaux: 'Cause specific mortality could not be analyzed separately for prepartum and intrapartum CD because the numbers of deaths were too small.'

PMHull: The separate analysis of prepartum and intrapartum CD is vital in any research that draws conclusions on the comparative safety of elective CD versus VD. The mix and match of analysis, results and conclusions of 'all CD' and 'elective or maternal request CD' is not an effective measure. Furthermore, maternal mortality following intrapartum CD is a measure of risk that needs to be applied to the category of 'planned vaginal delivery' and not a planned CD. This is important because risk can only be assessed at a birth 'planning' stage, and whether desired or not, the fact is that a planned spontaneous VD can have the outcome of instrumental and/or emergency cesarean delivery.

PMHull: It is also worth pointing out that the three mortality areas, where greater risk with cesarean is demonstrated, are largely preventable in quality hospitals with competent surgical personnel, using medical knowledge that has existed for many years. The data used in this study was from a period spanning 1996 to 2001. It is inadequate to make any conclusive statements using data that is over a decade old, especially when data exists in other studies from births that have occurred more recently.

*Issues with the MacDorman et al studyAlthough the researchers applied the NIH's 'intention-to-treat' recommendation, they have not accounted for one of the most important recommendations by the NIH, which is to wait until 39 weeks EGA for planned cesarean delivery with no medical indication. Instead, the study defines low-risk births as "singleton, term (37-41 weeks' gestation), vertex births, with no reported medical risk factors or placenta previa and with no prior cesarean section." This is important, because while a baby delivered at 39 weeks EGA is certainly not risk free, the neonatal mortality rate is most likely lower than the 1.73 reported here; and this is especially relevant since it is cases of 'no medical indication' that MacDorman et al are questioning.

Planned vaginal deliveries (even those for low risk women) can last beyond 41 weeks, and there is documented evidence of a 'small but significant' risk in fetal mortality beyond this point (Divon et al, 1998), and also after 40 weeks. (Caughey et al) Measuring mortality up to 41 weeks alone may have provided PVD with improved statistical outcomes in this study.

Self-reported limitations of the study include concerns about the accuracy of reporting specific data items on the birth certificate.
MacDorman et al: 'Reporting for the major variables in this study (neonatal mortality and method of delivery) is generally considered to be excellent; however, underreporting of individual medical risk factors and complications of labor and delivery on birth certificates has been documented. ...it is possible, based on either poor reporting or because the risks involved items not recorded on the birth certificate, that the group including cesarean delivery with no labor complications or procedures was still an inherently higher risk group, and those risks accounted for both the decision to perform a cesarean section and the subsequent neonatal death. It is also important to note that birth certificate data cannot be used to infer the intentions of either mothers or their practitioners, so these data do not address 'maternal request' cesareans.'

Dr Marian MacDorman said at the time of the study: ‘Even though we don't know exactly that it's elective cesarean delivery, it is probably the best approximation we can make.'...

PMHull: Critics noted in media reports that because birth records often don't accurately reflect whether a CD was medically necessary, this study could be comparing apples to oranges.

Also, again, death that occurs following an emergency CD follows an 'attempted' or 'planned' vaginal delivery (VD). Therefore, while clinicians and women are being advised to use study data to inform their birth planning, then the mortality results should be compiled in such a way that reflects original birth plans. Grouping all CD outcomes together (i.e. emergency and elective) cannot help inform the birth planning stage, and in fact grouping emergency CD outcomes with VD outcomes would be more accurate than grouping them with planned CD.

Issues with the Villar et al study
This study focused on countries in Latin America, where there are differences in standards of health care as a whole compared with North America and the UK. That is not to say the research should be dismissed; only that there are other studies in North America and the UK (that demonstrate more positive outcomes with cesarean delivery), and these should surely be included in any WHO referenced 'body of evidence'.

As a final note, readers may be interested to know that another study by Villar et al (Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study), published one year later in 2007, met with a great deal of criticism in the form of Rapid Responses on the BMJ wesbite. Headlines included:

A prospective study is still needed Maureen Treadwell (1 November 2007)
Definition of "elective" is misleading Amy B. Tuteur, Sharon, MA USA (2 November 2007)
Avoid interfering with physiology when possible David JR Hutchon (2 November 2007)
Term and preterm deliveries Gordon C S Smith (3 November 2007)
Not much help, really Robert G Buist (17 November 2007)
Somewhat misleading Zhong-Cheng Luo (19 November 2007)
Caesarean section risks and maternal choice Jonathan H West (20 November 2007)
Elective Caesarean section safest form of childbirth Michael P Wyldes (23 November 2007)
Contrary to Epidemiological Logic Dr Mudassir Azeez Khan (19 December 2007)
Anesthesia Effects Martin Dauber (27 December 2007)
New research finds lowest maternal mortality rate with elective cesarean delivery Pauline M Hull (30 July 2008)

5. To reiterate, it is not that I am suggesting that these three studies should not be used in an evidence-based assessment of cesarean outcomes; only that they should not appear as a group in isolation and defined as a 'body of research' that proves negative outcomes with high rates. They belong as part of a much larger body of evidence, which includes studies with very positive birth outcomes following cesarean delivery (including mortality and severe morbidity for both mothers and babies).

Henci, we may just have to agree to disagree on the issue of 'optimum' cesarean rates, and unfortunately, it would appear that the WHO's handbook lends itself to encouraging such an arrangement.

If you wish to engage in respectful dialogue about this issue please contact Penny Christensen at mail@birthtraumacanada.org. She has volunteered to respond to any concerns or questions regarding the CCA's release. You may wish to read BTCanada’s website at birthtraumacanada.org for background information first.

WHO admits: There is no evidence for recommending a 10-15% caesarean limit

This is the latest press release from the Coalition for Childbirth Autonomy (CCA), one year after it officially called on the World Health Organization to provide evidence for its recommended 15% limit:

WHO admits: There is no evidence for recommending a 10-15% caesarean limit

Cesarean rate in England remains the same at 24.6%

The interesting thing about this newly published data is that it shows a breakdown of all emergency and elective cesareans in various hospitals around the country.

In its coverage, the Guardian has published the byline: 'Section delivery accounts for third of Chelsea and Westminster trust babies, indicating 'too posh to push' outlook persists'.

Private patients

It continues: 'The figures, from the NHS Information Centre, show that a third of babies born at London's Chelsea and Westminster NHS trust are delivered by caesarean section, a figure more than double that in Nottingham, suggesting the rates for the procedure in England could still be influenced by well-off women dubbed "too posh to push".

The Chelsea and Westminster trust, which tops the league at 33.3% of births by caesarean, said that its numbers were swollen by women giving birth in its private delivery wing.'

Reasons behind the rates

I think that there are a number of reasons for the differences in percentages of surgery in different hospitals - particularly with elective cesareans. I already know from the women I receive emails from that it is much, much harder to arrange an elective cesarean with no medical indication outside of the London area. It has also been shown in research that it tends to be more affluent and educated women who request cesareans, so it is indeed possible that these women are affecting rates in certain hospitals.

The other reason, in my opinion, is the attitude of the doctors working in the hospitals. I don't believe that all doctors in the UK are on board with the drive to reduce cesarean rates, and I also know from conversations 'off-the-record' that some of them support cesarean delivery on maternal request, but do so quietly in order to avoid criticism from their NHS Trust.

Postcode lottery

Finally, medical reasons for cesareans aside, and again, particularly in the case of elective cesareans, the differences in rates published today highlights the fact that arranging a cesarean in the NHS is very much a postcode lottery for the women who request it.

There are those lucky enough to find the support they're looking for, and there are those who are being caught up in efforts to reduce cesarean rates - whatever the psychological or physical health costs may be.

£7.1m payout for 10-year-old boy whose cesarean delivery was delayed

A BBC article today, 'Brain damage boy gets £7m payout', reports on a '10-year-old Oxfordshire boy who suffered severe brain damage at birth... [His] lawyers said he was delivered by Caesarean section, in February 1999, four hours later than he should have been after his heart rate had slowed.'

It continues, 'Harry Snowdon, from Witney, will always need 24-hour care after being starved of oxygen at Oxford's John Radcliffe Hospital...'

How many more babies will die in the UK like this?

I find stories like this one, 'Couple compensated for baby death', published today on the BBC News website, so distressing, and they make me so angry that mistakes like this can happen in a UK hospital in 2009.

According to the report, Ms Rees, 44-years-old at the time of the birth, was '32 weeks into a "high risk" pregnancy [and] told by a doctor she was not in labour but needed a toilet.'

Previously told that her breech baby would need a cesarean delivery
'She said: "I just couldn't understand why they weren't doing anything to help me and my baby. At my last antenatal visit I was told my baby was breech and I would need a caesarean section.'

The BBC reports: 'An emergency caesarean was performed an hour-and-a-half later on a second doctor's recommendation and baby Arun was taken to the special baby care unit. The baby had been starved of oxygen during the birth and had suffered irreversible brain damage.'

Delay of an 'emergent' rather than 'emergency' cesarean led to baby's death

This report in the Bristol Evening Post today describes how an inquest heard that a 'baby girl who died within days of being born in Bristol could have lived if her birth by Caesarean section was carried out sooner...

Natasha Knowles was just four days old when she died at Southmead Hospital on February 11, 2005. When she was born on February 7 she had no heartbeat and was not breathing.'

Reducing cesarean rates at what cost to women?

Yesterday, I was browsing the website 'mybirth.tv' to see what they had to say about elective cesareans. On my first search, the video clip that came up was this one: elective caesarean

The woman being interviewed had had two vaginal deliveries and she had torn during both of them (the second birth making the first tear even worse). Fearful that her third pregnancy could result in even further damage, she requests an elective cesarean.

The Royal Sussex County Hospital however, is taking measures to reduce its cesarean section rate, and although in the end, the video shows that this woman does have a cesarean, just listen to what the hospital has to say to her during her maternal request consultation.

Vaginal reconstructive surgery versus planned cesarean surgery
It is suggested that she may want to consider operative perineal repair after the birth in order to avoid a cesarean, and the midwife says, '...if they had a terrible time last time, they haven't thought about the things they could do differently next time and still have a vaginal birth.'

What many obstetricians and midwives don't always appreciate is that the number one goal for every pregnant woman is not necessarily 'natural birth.' On the contrary, a healthy outcome for baby and mother is most likely top of the list. Efforts to reduce cesarean rates for the sake of reducing rates is of great concern to me because I genuinely believe that that in some cases, women and babies are bearing the physical and psychological cost of such arbitrary policies.

I don't believe in underestimating the risks of cesarean surgery - that would be irresponsible. But to underestimate the risks of vaginal delivery is, in my opinion, just as bad.

Finally: WHO admits there is no evidence for a 10-15% cesarean threshold

Here is an extract from my article, "WHO Finally Admits - the 'Optimum Rate [of Caesarean Section] Is Unknown' and 'There Is No Empirical Evidence' for Its 1985 Recommendation of 10-15%", published on freelibrary.com today:-

In its latest 2009 publication, 'Monitoring Emergency Obstetric Care: a handbook', the WHO states that, 'Both very low and very high rates of caesarean section can be dangerous, but the optimum rate is unknown. Pending further research, users of this handbook might want to continue to use a range of 5-15% or set their own standards.'
The statement continues, 'Earlier editions of this handbook set a minimum (5%) and a maximum (15%) acceptable level for caesarean section. Although WHO has recommended since 1985 that the rate not exceed 10-15%, there is no empirical evidence for an optimum percentage or range of percentages, despite a growing body of research that shows a negative effect of high rates.'

Evidently, there is now a degree of ambiguity in what the WHO recommends. It recommends that regions 'use a range of 10-15%' (even though there is no empirical evidence for such a range) or implement their own standards. Consequently, it is perhaps inevitable that different birth advocate groups will take a different view on what the new handbook statement actually means, and arguments over the credibility of an optimum caesarean rate (emergency and/or elective) will continue.

20% of Israeli babies born by cesarean

This is a very short report, with no details on the breakdown of emergency versus elective or planned cesareans, and no context in terms of whether there is a difference in rate in the private sector compared with public hospitals, but informs us that:

"Every fifth child in Israel is delivered by a Caesarean Section operation, according to a report published in the Hebrew-language daily Haaretz."

25.9% of births in Scotland are now cesarean deliveries

Scotland's Daily Record reports today that 15.2% of the 56,821 babies born last year were delivered by emergency surgery, while 10.7% were scheduled for surgery.

Australia: 1 in 4 caesareans by maternal request

You may read the article here - published 11th September 2009 - and the medical study here.

Cesareans in Cyprus: doctors defend high rates

In her Cyprus Mail report, 'Doctors defend C-sections figures', Alexia Saoulli writes: "Private doctors said last week they had been unfairly lambasted in the press for favouring c-sections over natural births. Recent reports of doctors “blackmailing” women into booking their delivery at convenient times prompted outpourings of outrage from women, government health authorities and lawmakers."

Dr George Leontiades, head of the Gynaecological Association: “If there is one doctor who encourages his patients to have c-sections you can’t make a generalisation that all doctors do it.” ...He said comparing Cyprus’ private c-section rate of 55% to England’s 25% was wrong... In England, in the private sector, the figures are almost as high as Cyprus,” he said.

...Leontiades said there were very many reasons why Cypriot women chose to have caesareans, starting from how affluent the country had become. “Affluence in societies affects c-section demand. Also women have a mistaken understanding of the hardship of labour. They don’t want to be put out. The way they have three cars, a big house and can buy everything in the supermarket, they think they shouldn’t suffer any hardship in bringing a child to life.”

...The doctor said there was also an increasing trend in repeat c-sections. He said most women who had a c-section for their first child wanted to follow the “tried and tested” method and “don’t want to embark on an adventure that will not guarantee they will have spontaneous vaginal delivery”.

...He said some doctors were also afraid of increased cerebral palsy risks during labour despite the fact that only one in 400 developed cerebral palsy, only 10 per cent of which accounted for events taken place during delivery. Nevertheless in a society where women only had one or two children, some doctors preferred not to chance it, he said."

Dr Gabriel Kalakoutis, a Nicosia’s Aretaeio hospital gynaecologist-obstetrician: "said although women were not encouraged to have a c-section, there was greater sensitivity to a woman’s wants. “A lot of women prefer to have a c-section because they are afraid of childbirth and the pain. I’m more prone to take the woman’s feelings into consideration and what makes her feel more psychologically comfortable. C-sections are much safer now, with very small risks and only slightly more dangerous than natural births.”

...Kalakoutis said the attitude that a c-section was a “failed” delivery no longer held true and that if there were medical indications for why one should be performed he no longer insisted on going the natural route.

...“Some women want to have a natural birth and I encourage that. If some are afraid and from the beginning think they want to have a c-section then I am more open to that. I don’t tell them from the beginning that they should have a c-section,” he said.

Numbers of women asking for cesareans in Cyprus
...The gynaecologist said in his experience four out of 10 pregnant women asked for c-sections. He also said culturally women had changed and were having fewer children. “Women have two or three children, not five or six. If they had that many caesareans it would be dangerous but up to two or three is safe,” he said."

UK study finds 3% CDMR rate

New research to be published in BJOG "suggests that ‘choice’ may not be the best way to understand women’s decision-making about birth method. The results of the study question the current focus on choice in UK maternity care policy, and challenge prevailing notions about caesarean delivery for maternal request."

You can also read more in these two news articles on the research:
'Pregnant women prioritise safety over choice' and 'Women 'do not choose Caesareans as too posh to push'.

The researchers tracked 454 women at the Liverpool Women's Foundation NHS Trust, and found that by the end of their pregnancies, the number of women still requesting cesarean delivery had fallen to 2%.