There have been a number of media reports in response to the publication this week of the study, 'Variation in rates of caesarean section among English NHS trusts after accounting for maternal and clinical risk: cross sectional study' by Bragg et al.
Below are a few examples of these stories, plus the comment I have posted in most of them:
*Who's Too Posh to Push? High Cesarean Section Rates Aren't Moms' Fault, TIME.com
*Too posh to push mums 'a myth', nhs.uk
*High caesarean rates are not down to women being 'too posh to push', The Telegraph
*Wide variation in Caesarean rates in UK, hc2d.co.uk
My comment
Aside from the fact that persistent use of the derogatory term ‘too posh to push’ is both irrelevant and unhelpful in discussions about whether women are choosing a caesarean birth plan, the idea that this study has exposed it as a myth is flawed.
The authors write: “It seems unlikely that maternal request in the absence of any clinical indication contributes substantially to the rates.” This is not the same as saying that maternal request is not contributing to the rates ‘at all’ or that women choosing caesareans is a myth. As far as I am aware, no media report as yet has actually cited the number (or percentage) of non-medically indicated caesareans found in this study, and I have contacted the authors for further clarification of this precise figure.
As it stands, the current estimate of rates of caesarean delivery on maternal request is around 5% of all births. This is clearly a very small number. However, it is more than double the number of women who request a homebirth, and yet these women and their birth choice are afforded greater support and respect by many birth support groups and the Department of Health.
As a final point, here are some other reasons why this study (which analysed routinely collected hospital episode statistics and did not involve any interviews with women or doctors) does not provide categorical proof that women are not choosing caesareans themselves or that caesareans in the absence of any clinical indication are not contributing to overall caesarean rates:
1) A medical indication and maternal request are not mutually exclusive. Anecdotally, I chose to plan a caesarean for both my births but my hospital data reads ‘breech presentation’ for the 1st (as this was discovered in the 8th month of pregnancy) and ‘repeat caesarean’ for the 2nd. I have also been contacted by other women via my website whose situation is the same.
2) It is not unknown for a medical indication to be cited by doctors on a woman’s records rather than draw attention to the more controversial indication of maternal request.
Please note that this comment is not in any way a criticism of the study itself or its authors; only the wider interpretation of maternal request caesareans that is being reported. In fact, the study itself presents extremely useful data and suggestions for NHS trusts going forward.
Showing posts with label Key Arguments. Show all posts
Showing posts with label Key Arguments. Show all posts
Saturday, October 9, 2010
Friday, April 30, 2010
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.
Easy?
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.
Mmm...
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.
Easy?
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.
Mmm...
Wednesday, November 4, 2009
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.
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.
Monday, February 2, 2009
Top 5 reasons prophylactic elective caesarean delivery with no medical indication is a legitimate decision for informed women
As a speaker at a seminar on cesarean delivery the upcoming 'Controversies in Childbirth' conference in Fort Worth, Texas (March 27, 2009), I was asked to write my 'Top 5 reasons prophylactic elective cesarean delivery with no medical indication is a legitimate decision for informed women', and here they are:
1. There are risks and benefits associated with all birth plans. A healthy spontaneous vaginal delivery (even when desired) is never guaranteed since labor, even with healthy pregnancies, is entirely unpredictable.
2. The oft-quoted risks associated with cesarean delivery frequently refer to emergency surgery or deliveries with pre-existing medical indications. These risks are not the same in healthy pregnancies with delivery at 39 weeks gestation for women planning small families.
3. Birth data compiled in the U.S. does not separate emergency and planned cesareans, only primary and repeat cesareans, which muddles the true assessment of risk as it relates to birth PLAN and the corresponding birth OUTCOME. Research from overseas demonstrates vastly reduced risks with planned surgeries, although we are yet to witness a move towards research that applies emergency cesarean outcomes to the planned vaginal delivery data set, which would be more relevant.
4. The risks (and costs) associated with planned vaginal delivery are grossly underestimated, both in the short- and long-term (in fact long-term risks and costs, financial and psychological, are rarely applied in comparative birth analysis). For example, shoulder dystocia, Erb’s palsy, fetal trauma, neonatal encephalopathy, asphyxiation, intrauterine fetal demise; damage to pelvic floor, POP, sexual health; infant and maternal severe morbidity associated with emergency cesareans; litigation trauma and cost following death or injury.
5. Research has shown high levels of birth satisfaction with planned cesarean delivery and birth trauma websites illustrate high levels of dissatisfaction with planned vaginal delivery. A ‘good birth outcome’ is not commensurate with ‘vaginal delivery for all women’ and genuine birth educators should not make this assumption. For true birth autonomy to exist, cesarean delivery must not be viewed as a second-rate outcome, and at a time in history when maternal and fetal characteristics are leading to more cesarean deliveries (e.g. increased maternal age and obesity; also birth weights), it is not only potentially dangerous to focus on drastically reducing the numbers of ‘unwanted’ surgeries, it is moreover unethical to reduce rates by discouraging or denying those surgeries that are in fact ‘wanted’.
1. There are risks and benefits associated with all birth plans. A healthy spontaneous vaginal delivery (even when desired) is never guaranteed since labor, even with healthy pregnancies, is entirely unpredictable.
2. The oft-quoted risks associated with cesarean delivery frequently refer to emergency surgery or deliveries with pre-existing medical indications. These risks are not the same in healthy pregnancies with delivery at 39 weeks gestation for women planning small families.
3. Birth data compiled in the U.S. does not separate emergency and planned cesareans, only primary and repeat cesareans, which muddles the true assessment of risk as it relates to birth PLAN and the corresponding birth OUTCOME. Research from overseas demonstrates vastly reduced risks with planned surgeries, although we are yet to witness a move towards research that applies emergency cesarean outcomes to the planned vaginal delivery data set, which would be more relevant.
4. The risks (and costs) associated with planned vaginal delivery are grossly underestimated, both in the short- and long-term (in fact long-term risks and costs, financial and psychological, are rarely applied in comparative birth analysis). For example, shoulder dystocia, Erb’s palsy, fetal trauma, neonatal encephalopathy, asphyxiation, intrauterine fetal demise; damage to pelvic floor, POP, sexual health; infant and maternal severe morbidity associated with emergency cesareans; litigation trauma and cost following death or injury.
5. Research has shown high levels of birth satisfaction with planned cesarean delivery and birth trauma websites illustrate high levels of dissatisfaction with planned vaginal delivery. A ‘good birth outcome’ is not commensurate with ‘vaginal delivery for all women’ and genuine birth educators should not make this assumption. For true birth autonomy to exist, cesarean delivery must not be viewed as a second-rate outcome, and at a time in history when maternal and fetal characteristics are leading to more cesarean deliveries (e.g. increased maternal age and obesity; also birth weights), it is not only potentially dangerous to focus on drastically reducing the numbers of ‘unwanted’ surgeries, it is moreover unethical to reduce rates by discouraging or denying those surgeries that are in fact ‘wanted’.
Thursday, December 11, 2008
Non-medical cesarean delivery should wait until 39 weeks EGA
This is not new news, but today's Science Daily report on new research into the risks of late pre-term births is a useful reminder that the safest time to deliver a baby by cesarean delivery is at confirmed 39 weeks gestation in order to ensure that the baby is fully developed.
I have no doubt that this research will be misinterpreted by some bloggers and used to criticize women who choose to have a cesarean delivery with no medical indication. But on the contrary, what it actually shows is that non-medical cesareans at 39 weeks are in fact far safer for the baby than other types of cesarean deliveries (i.e. emergency and planned medical surgeries).
What the research found
Petrini et al's research, 'Increased Risk of Adverse Neurological Development for Late Preterm Infants', "evaluated the babies’ neurological development and found that late preterm babies were more than three times as likely to be diagnosed with cerebral palsy as full term babies. They also found that late preterm babies were at an increased risk for developmental delay or mental retardation."
But commenting in the article, editorialist Dr. Michael Kramer of McGill University said that "the increased risks may not always come from early delivery itself, but from other underlying problems, such as gestational diabetes, that may lead to early delivery."
This last remark emphasizes why 'general' reported risks associated with cesarean deliveries are not always applicable to planned cesarean deliveries with no medical indication in healthy pregnancies, and should not be used as an argument to prevent birth plan autonomy.
I have no doubt that this research will be misinterpreted by some bloggers and used to criticize women who choose to have a cesarean delivery with no medical indication. But on the contrary, what it actually shows is that non-medical cesareans at 39 weeks are in fact far safer for the baby than other types of cesarean deliveries (i.e. emergency and planned medical surgeries).
What the research found
Petrini et al's research, 'Increased Risk of Adverse Neurological Development for Late Preterm Infants', "evaluated the babies’ neurological development and found that late preterm babies were more than three times as likely to be diagnosed with cerebral palsy as full term babies. They also found that late preterm babies were at an increased risk for developmental delay or mental retardation."
But commenting in the article, editorialist Dr. Michael Kramer of McGill University said that "the increased risks may not always come from early delivery itself, but from other underlying problems, such as gestational diabetes, that may lead to early delivery."
This last remark emphasizes why 'general' reported risks associated with cesarean deliveries are not always applicable to planned cesarean deliveries with no medical indication in healthy pregnancies, and should not be used as an argument to prevent birth plan autonomy.
Tuesday, December 9, 2008
Study: a quarter of female OBGYNs prefer and suggest cesarean delivery
New research from Iran, 'Caesarean or normal vaginal delivery: overview of physicians' self-preference and suggestion to patients' has found a correlation between a physician's self-preferred mode of delivery and the mode of delivery they suggest to their patients.
Hantoushzadeh et al sent questionnaires to 1,000 female obstetricians and gynaecologists practicing in Tehran in the winter of 2007. They were asked their preferred mode of delivery and the mode they suggest when being consulted by parturient. 785 cases (78.5%) responded to the survey, with 60.8% in favor of suggesting normal vaginal delivery, 25.8%, cesarean section, and 13.6%, painless vaginal delivery.
The study conclusions
The authors clearly have concerns about the 25.8% figure above: "Physicians normally suggest to their patients as the safe mode of delivery what they prefer for themselves. This preference and subsequent suggestion is influenced by different factors including their age, marital status, and previous modes of delivery. As conclusion, it is inferred that informing a physician to choose the right mode of delivery for herself leads to better suggestions to the patients."
What the conclusion says, in effect, is that we not only need to educate women that planned vaginal delivery is a "better suggestion" than planned cesarean delivery, but we also need to tell obstetricians and gynecologists (who are surely sufficiently educated and 'informed' in the subject of birth risks and benefits) what's "better" for them personally too.
Please - It is one thing to argue that ordinary pregnant women are incapable of TRULY understanding the risks involved in a planned cesarean delivery or of coming to terms with the complexities of birth method comparisons (which incidentally, I disagree with), but to imply that OBGYNs are not capable of making their own informed decisions is ludicrous.
Ethical considerations
What I find most interesting about this study is the link between a health worker's personal preferred delivery method and what they suggest to others. I am sure that this element of the survey will illicit stern criticism from groups who are already concerned that physician pressure is one of the factors behind unwanted cesareans.
However, while I would agree that physicians should not coerce healthy women into choosing a birth that is not what they really want, I would also point out that this preference/suggestion behavior is not exclusive to doctors or for that matter, cesareans. I receive emails from many women who are under unwanted pressure to plan a vaginal delivery from their midwife or doctor (when their own preferred mode of delivery is a cesarean) , and this is not ethical either.
Different women want different births. Doctors and midwives should be trying to accommodate ALL women's different birth preferences rather than pressuring them into mirroring their own personal preferences.
Hantoushzadeh et al sent questionnaires to 1,000 female obstetricians and gynaecologists practicing in Tehran in the winter of 2007. They were asked their preferred mode of delivery and the mode they suggest when being consulted by parturient. 785 cases (78.5%) responded to the survey, with 60.8% in favor of suggesting normal vaginal delivery, 25.8%, cesarean section, and 13.6%, painless vaginal delivery.
The study conclusions
The authors clearly have concerns about the 25.8% figure above: "Physicians normally suggest to their patients as the safe mode of delivery what they prefer for themselves. This preference and subsequent suggestion is influenced by different factors including their age, marital status, and previous modes of delivery. As conclusion, it is inferred that informing a physician to choose the right mode of delivery for herself leads to better suggestions to the patients."
What the conclusion says, in effect, is that we not only need to educate women that planned vaginal delivery is a "better suggestion" than planned cesarean delivery, but we also need to tell obstetricians and gynecologists (who are surely sufficiently educated and 'informed' in the subject of birth risks and benefits) what's "better" for them personally too.
Please - It is one thing to argue that ordinary pregnant women are incapable of TRULY understanding the risks involved in a planned cesarean delivery or of coming to terms with the complexities of birth method comparisons (which incidentally, I disagree with), but to imply that OBGYNs are not capable of making their own informed decisions is ludicrous.
Ethical considerations
What I find most interesting about this study is the link between a health worker's personal preferred delivery method and what they suggest to others. I am sure that this element of the survey will illicit stern criticism from groups who are already concerned that physician pressure is one of the factors behind unwanted cesareans.
However, while I would agree that physicians should not coerce healthy women into choosing a birth that is not what they really want, I would also point out that this preference/suggestion behavior is not exclusive to doctors or for that matter, cesareans. I receive emails from many women who are under unwanted pressure to plan a vaginal delivery from their midwife or doctor (when their own preferred mode of delivery is a cesarean) , and this is not ethical either.
Different women want different births. Doctors and midwives should be trying to accommodate ALL women's different birth preferences rather than pressuring them into mirroring their own personal preferences.
Wednesday, October 29, 2008
WHO's recommended 10-15% cesarean rate is outdated and unsafe
Today, the Coalition for Childbirth Autonomy (of which my website is a member) has published its first press release. We make the case that efforts to reduce national cesarean rates to a level first suggested 23 years ago are detrimental to the health and safety of mothers and babies. You can read the full release here.
Monday, October 13, 2008
Understand the facts
Vaginal delivery - GOOD
Cesarean delivery - BAD
Emergency cesarean - REALLY BAD
Elective cesarean - BETTER (BUT STILL BAD)
Broadly speaking, this is the way choice in childbirth is often portrayed - both in the media and in the majority of antenatal literature. A simple guideline to be ignored at your own peril, and more importantly, that of your unborn child. Except it's really not that simple. In fact, the truth is far more complex, and as difficult to retrieve from existing national data, hospital records and medical research as a Voldemort-encrypted horcrux.
Why? Largely because of two main problems in the collection, recording and reporting of birth data (there are actually numerous problems but let's start with the worst offenders).
1) In many hospitals (and consequently any medical research that relies on the data contained therein), little or no distinction is made between planned cesarean and emergency cesarean outcomes. This means that any risk appraisal of planned cesarean delivery is muddied by the morbidity outcomes associated with emergency surgery. Furthermore, no distinction is made between the outcomes of a planned cesarean for medical reasons and a planned cesarean with no medical indication (e.g. maternal request). This is important to recognize, as the presence of any pre-existing medical condition could lead to worse morbidity outcomes than those experienced by a healthy pregnant woman and her baby.
2) There is a huge difference between analyzing birth plans and birth outcomes, and since it is IMPOSSIBLE TO PREDICT any birth outcome, all analysis for the purposes of informing pregnant women (i.e. while they are in the birth planning stage) should compare infant and maternal morbidity and mortality outcomes as they relate to the original birth plan - rather than the eventual birth outcome. Let me explain...
A planned vaginal delivery (PVD) may have the outcome of a spontaneous vaginal delivery with no tearing, episiotomy or intervention, and no adverse health outcomes for mother and baby... or it may not. The outcome could be an assisted vaginal delivery (forceps, ventouse, episiotomy or all three), an emergency cesarean delivery (possibly following a forceps/ventouse/episiotomy attempts) or even a planned cesarean delivery decided in the very late stages of pregnancy. Similarly, a planned cesarean may have the outcome of a planned cesarean... or it could result in a spontaneous (or assisted) vaginal delivery or an emergency cesarean delivery.
What's important to note here is that planned cesarean deliveries result in the desired outcome far more often than planned vaginal deliveries. So, when comparing elective cesarean delivery with PVD for the purposes of informing healthy women of the risks and benefits of each, it is at best ineffective and at worst, misleading to only measure the successful outcome morbidity and mortality rates of each. In fact, the vast majority of emergency cesarean deliveries (which are associated with the greatest incidence of infant and maternal morbidity and mortality) are the consequence of an unsuccessful PVD attempt. Therefore, these outcome measures should be attached to PVD data prior to comparison with elective cesarean delivery - and for an even greater degree of accuracy, the elective cesarean delivery outcome measures should be separated into those with medical and non-medical indications.
In my view, research and analysis combining elective and emergency cesarean outcomes should be eliminated from all future studies that set out to compare PVD with planned cesarean delivery.
Advocates of cesarean delivery with no medical indication as a legitimate choice for pregnant women (myself included) have already looked at the data available and been able to deduce what's been suspected for a long time - that the risks and benefits associated with elective cesarean delivery are favorably comparable with those of PVD (there'll be more detail on this in future blogs, but you can check out www.electivecesarean.com if you want to read more now), and women should be advised of this during antenatal appointments.
*******
The most successful birth outcome is that of a healthy and happy mother and baby, and in survey after survey, women cite satisfaction with their birth outcome as a valued psychological benefit. For some women that outcome is vaginal delivery while for others it is cesarean delivery; arguing the case 'vaginal delivery for all' is as ignorant and damaging as suggesting 'cesarean delivery for all.' Here's why:
PREGNANCY AND BIRTH ARE INHERENTLY RISKY...
...but ultimately, it's the woman, her baby and her family who experience the birth outcome
...and they might simply fear or value one set of risks and benefits more than the other.
We're already delivering more healthy babies than at any time in human history
...DELIVERING CHOICE IS THE NEXT STEP TO FURTHER SUCCESS
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