Calculating 39 weeks for a full-term cesarean is a shared responsibility

Numerous studies have stressed the importance of planning a cesarean delivery after 39 weeks, and despite accusations to the contrary, I don't believe that obstetricians are arbritarily scheduling surgery ahead of this date unless there is an indicated medical need (either for the mother or the baby). That is - despite the risks of respiratory distress with preterm births, there is a greater risk of (for example) the baby or mother dying if it remains in utero any longer.

I also don't believe that the vast majority of women choosing a cesarean - despite accusations to the contrary - would urge their doctor to deliver their baby early for convenience, vanity reasons or to bring an end to their pregnancy.

Blame game
But now a study, reported in the media on Friday, suggests that one possible reason behind the U.S.' climbing pre-term delivery rate is that 'Many Women Miscalculate Time to Full-Term Birth'.

The report continues: 'When asked, "What is the earliest point in pregnancy that it is safe to deliver the baby, should there not be other medical complications requiring early delivery?", more than half chose 34 to 36 weeks, 41 percent chose 37 to 38 weeks and less than 8 percent chose 39 to 40 weeks.

However, experts warn that any delivery short of 39 weeks puts a baby at higher risk of respiratory distress, sepsis (blood infection) and needing to be placed in the neonatal intensive care unit, according to background information in the study. Only one-quarter of new moms realized 39 to 40 weeks was safest.'

Education, Access to Early Ultrasound and Less Confusion please
For what it's worth, here are my suggestions for improving this situation:

1) Educate women that when it comes to planning a cesarean delivery, the ideal gestational age is 39 weeks. Ideally, that means taking responsibility for recalling your last menstrual cycle date before you became pregnant - not always possible or indeed accurate, but the more information a doctor has at hand for calculating your gestational age, the better.

2) Arrange an early ultrasound. This is easier said than done sometimes - and you, your doctor, your hospital, and if applicable, your insurance company, must all take responsibility for this. With my second pregnancy, one of the hospitals I was going to go to said they didn't do the first ultrasound until 12 weeks, but my OBGYN insisted that I had it done earlier because research has shown that the most accurate calculation of gestational age can be made during an early ultrasound (read more here).

3) Stop confusing women by quoting data from medical studies with 'full-term' gestational ages described as 34 or 37 weeks one minute, and then 39-40 or 41-42 weeks the next. Women could be forgiven for not knowing the definition of 'full-term', especially in the context of planned cesarean delivery, because there is so much confusion in the presentation of planned cesarean risks and benefits in any case.

For example, when natural birth advocates want to highlight respiratory distress problems in babies born via elective cesarean, they will frequently include studies that invlude 'full-term' getational ages much earlier than 39 weeks. Equally, they are less inclined to present data from medical studies that have found greater fetal demise post-39 weeks.

Delivery at 39 weeks is optimal - for the baby's sake, we should all be working together to make sure that wherever possible, this date is reached.

And another baby dies.

Just one day after my blog on Friday of the same subject, I read again - this time in The Irish Times - how a baby boy suffered severe head injuries and died after a failed attempt at an instrumental vaginal delivery.

Georgina O'Halloranan writes that 'Parker Meredith Doyle died just one day and 10 hours after his birth by emergency Caesarean section on April 18th, 2008' at the National Maternity Hospital, Holles Street in Dublin. He was 'left severely brain damaged due to brain haemorrhage as a result of 'an attempted instrumental vaginal delivery' using a vacuum cup and forceps.'

What makes it worse
It is reported that the baby's mother, Caroline Meredith, had endured a 'failed forceps delivery 13 years earlier which had resulted in injuries to her baby'.

With the benefit of hindsight, it is evident that this baby's life would have been saved with a planned cesarean delivery, but surely in this case at least (i.e. with the mother's previous birth experience) the medical team might have made a safer delivery decision even without this benefit?

Media headline irony
It is also worthy of note that on the same day that the above article was published in The Irish Times, The Irish Independent published an article titled, 'C-section birth rate still too high', criticizing Irish hospitals for failing to reduce their cesarean rates.

Does Ireland really want to see its cesarean rates fall to dangerously low levels? Or are its obstetricians going to ignore media pressure (and other pressure from natural birth advocates), and concentrate solely on the best outcomes for mothers and their babies - regardless of where that leaves percentage rates?

I hope for the sake of babies like Parker Doyle that it is the latter...

Another delayed cesarean. Another baby dies.

In the NHS in England, as many as 14.9% of planned vaginal deliveries result in an emergency cesarean. Time and time again, we hear that this number is too high, that national cesarean rates should be lowered, and that some of the 9.7% planned cesareans are unnecessary too.

Well, reading this story in The Telegraph today, it becomes all too clear what can happen when a cesarean is delayed (or not carried out):

Tragically, 'Lewis Connolly lived for just four hours and died in the arms of his mother Eleni, 33. Mrs Connolly and her husband Steven, 29, were told at an inquest that their baby's death was avoidable.'

Prevent this happening to another child
The report explains how 'Lewis ended up lodged so firmly in the womb that a doctor at North Middlesex Hospital in Edmonton, north London, fractured his skull in a desperate bid to free him with a pair of forceps.'

'Guidelines state a baby should be delivered within three hours of the mother reaching second stage. But an emergency Caesarean section was not carried out until 2.36pm, more than five hours later.

The parents have said they 'hope that these events will prevent it from happening to anybody else', and I would completely agree with them.

Unfortunately, I'm not convinced that they will, and I remain concerned that women in antenatal classes are simply not being fully informed of the true and real risks of planning a vaginal delivery. Not that all women should or would want to choose surgery instead; only that both types of delivery have their own set of risks, and to over-exaggerate one set and under-state another is wrong.

Surrender to our birth experience? Rely on medical intervention? Or both?

I simply don’t understand the article I read in The Telegraph on Saturday. In it, Laura Donnelly writes that 'maternity guru Sheila Kitzinger says 'fairytale' expectations of childbirth end with dashed hopes for women, and warns that new mothers are often consumed by guilt when they do not experience said fairytale.

Ok, nothing new there…

But who is Mrs Kitzinger blaming for raising women’s expectations of birth in this way? Could it be herself, who has in the past described childbirth as a ‘potentially orgasmic experience’. Or natural birth advocates, who often employ language that encourages women to trust in their innate ‘empowerment’ and a body that’s ‘designed to know exactly what to do’ during the birth process?

No. It’s our ‘consumerist agenda’, our tendency to ‘test everything’ and ‘see birth as a performance’. In addition to the over-medicalization in hospitals, she says that ‘many modern women, accustomed to taking control of their careers, made a mistake in applying the same thinking to childbirth.’ Rather, they should ‘surrender to the experience’.

Yet in every other aspect of a woman’s reproductive life, control is precisely what it’s all about. Is it really feasible that on the day of our baby’s birth, we should all want to simply surrender to Mother Nature? Maybe for some women this is a desirable approach, but I doubt it’s the case for the majority. After all, Mother Nature has a nasty habit of engineering the most undesirable and traumatic experience just as easily as the orgasmic one Mrs Kitzinger suggests.

I never expected nor did I desire an orgasm during the birth of my baby, but in terms of fairytale expectations, is it really fair to blame everyone and everything else (for women’s negative feelings when their birth doesn’t go according to plan), and shoulder no responsibility yourself Mrs Kitzinger? I’m not so sure…

Why are more women pushing for Caesareans?

This is the title of an article written by Dr Mark Porter in The Times last week (2nd November). In it, I'm interviewed by journalist Peta Bee about my own two cesarean deliveries, but what I'd like to draw attention to is the comments written by readers at the bottom of the article.

I submitted two comments in response to Dr Porter's article on the 3rd November, and was very pleased to read his personal response a day later, which read:

"Pauline - I wholeheartedly agree."

Why is this important? Because I was writing about maternal request cesareans in the context of the NHS, where currently, it can be extremely difficult to find support for a cesarean birth. If more doctors in the UK could not only move towards accepting planned cesarean delivery as a legitimate birth choice, but also be willing to open up a public dialogue about it in the way that Dr Porter does here, I hope that we might see positive change in the UK sooner rather than later.

For ease of access, I have copied and pasted my comments here:

I am so glad that Dr Porter recognizes the importance of separating maternal request health outcomes to those of emergency or planned cesareans for medical reasons. When bias against surgical birth is removed, and studies containing mixed cesarean data are excluded, there is evidence that maternal request cesareans can result in better outcomes than planned vaginal deliveries. Read the stories posted on any birth trauma website (physical and psychological trauma) and you will struggle to find a single complaint from a woman who has had a maternal request cesarean, yet there are thousands from women who planned vaginal deliveries. This is also backed up by research such as the 2007 Swedish study involving 357 women; those with maternal request cesareans ‘reported a better birth experience compared to those with planned vaginal deliveries.’ Women are simply not being informed about the whole truth. Just two examples: 1. The latest CEMACH report in the UK showed that women were less likely to die following a planned cesarean than any other birth type. 2. A 2009 Canadian study of 40,000 deliveries concluded that ‘elective pre-labour caesarean section…at full term decreased the risk of life-threatening neonatal morbidity compared with spontaneous labour with anticipated vaginal delivery’.

I would also like to pick up on the issue of NHS resources, and to state that studies demonstrate that ‘convenience’ is very low down the list of reasons for maternal request - when it appears as a reason at all. Reasons are more likely to be tokophobia, concerns for their baby's safety and avoidance of pelvic floor injuries.
Firstly, current cost comparisons are flawed in terms of maternal request, as they contain medical and/or emergency surgical costs, but more crucially, vaginal delivery costs repeatedly fail to include the financial impact of: 1. all planned vaginal delivery outcomes, including spontaneous, instrumental AND emergency cesareans. 2. short and long-term perineal and pelvic floor repair (e.g. prolapse) and counseling when trauma occurs. 3. huge litigation bills when vaginal delivery goes wrong and a baby/mother is injured or dies. In fact, the 2004 NICE guideline discusses one cost model in which ‘maternal request would lead to savings’ (not that I’m suggesting this is a motivation), but promptly dismisses the finding as ‘not a realistic conclusion’. The bottom line is: there are risks and benefits with both birth plans - vaginal and cesarean - and women should be allowed to make their own informed decision.

Counseling against a cesarean delivery

For some reason, I was thinking about this today as I drove home from my daughter's toddler group, and I came up with an analogy for why counseling against a (chosen) cesarean doesn't always work - and why it would certainly never have worked for me.

To take a step back, let me explain when counseling might be used: if a woman has tokophobia - fear of childbirth - and says to her doctor that she would prefer to have a planned cesarean delivery instead of a vaginal delivery, it is often suggested that she should be given counseling (therapy) in order to help allay her fears.

Fear or simply a different choice?
I am not against this idea; if resources are available and the woman is keen to give counseling a try, then I would agree that it should do no harm. In fact, there is some evidence that women can change their minds about their cesarean birth decision and go on to plan a vaginal delivery (unfortunately, these studies don't follow up after the birth to find out if the women were happy with their decision, which might be an idea for future studies).

However, the women I'm concerned about are these: women for whom no amount of counseling will dispel their intense fear of natural birth, and women for whom counseling is viewed as a completely unnecessary - i.e. their decision to choose a cesarean is grounded in a personal health risk-benefit analysis that favors planned surgery.

It's like trying to piece together a broken marriage when one of you is in love with someone else
You see, to me, counseling can only work when the person being counseled is one hundred percent on board, and they WANT to move towards the same goal as the counselor. For example, if a couple is having problems and both of them want to make another go of things, counseling can have very positive results.

If on the other hand, one of the partners has met someone else, fallen in love, and is just itching to move out and start a whole new life elsewhere, the likelihood is that no amount of counseling is going to help.

Therapy during pregnancy
When I became pregnant with my first child, Charlotte, I already knew I wanted a planned cesarean. My decision was not based on a now suddenly impending birth day, and nor was it influenced by the hormonal changes taking place in my body. I firmly believed that a cesarean was the safest route of delivery for my baby and for me, and I would have hated to be marched off to see a counselor for weeks of therapy before a decision was finally made for me.

I was one of the lucky ones. My pregnancy was never impeded by the 'unknown' (would I be allowed to have a cesarean or would I be forced to deliver vaginally?). But this is what happens to many women around the world, in countries where 'maternal request' is a dirty word(s). In fact, one woman in England contacted me through my website, after she was made to jump through every counseling and cognitive therapy hoop available on the NHS in an attempt to cure her of a severe case of tokophobia.

And the result?

She was told at the end of it all that she would still have to endure a trial of labor - either she hadn't sufficiently convinced her therapists of her fear of childbirth or they couldn't accept that the therapy hadn't worked (I don't know) - and she made the deeply traumatic decision to terminate her pregnancy. It's time we started caring as much about women like this as we do about women who want to give birth vaginally and avoid a cesarean delivery. Their desires may be different but they are surely equal.

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.

New Canadian research: planned cesareans are safer for babies than natural birth

How much media attention has this study received? As far as I can see online, none.

Yet the conclusions of researchers Leanne S. Dahlgren et al, just published in 'Caesarean Section on Maternal Request: Risks and Benefits in Healthy Nulliparous Women and Their Infants', are of huge importance in the debate over whether women should be offered the option of planned cesarean delivery in favor of a trial of labor.

They found that, after looking at 1,046 pre-labour cesareans deliveries (with breech presentation)and 38,021 spontaneous labour with anticipated vaginal deliveries:

"An elective pre-labour Caesarean section in a nulliparous woman at term has a lower risk of life-threatening neonatal morbidity than spontaneous labour with an anticipated vaginal delivery."

Unpredictability of planned vaginal delivery is evident
The researchers point out that "the increased risk of life-threatening neonatal morbidity in the spontaneous labour group was associated with an operative vaginal delivery or emergency intrapartum Caesarean section and not a spontaneous vaginal
delivery', and this doesn't surprise me in the least.

But the fact remains that is is extremely difficult, if not indeed impossible, to predict precisely which women will have a spontaneous vaginal delivery outcome with no complications.

More than a third of PVDs did not result in spontaneous VDs
In this particular study, 63% of women with achieved a spontaneous vaginal delivery, and the researchers conclude therefore that these women "would not have benefited from delivery by Caesarean section."

But they too admit the difficulty in isolating these cases at the birth planning stage: "Further research is needed to better identify women with an increased likelihood of an operative vaginal or intrapartum Caesarean section, as this may assist maternity caregivers in decision-making about childbirth."

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

NCT choice focuses on WHERE, not HOW women give birth

This article in The Guardian reports on the latest report from the NCT about women's birth choices. The NCT is upset that women are not being given the choice about where they give birth, although its figures are disputed by the Department of Health in the article.

What concerns me though, is the NCT's focus on the word 'where' rather than 'how.' Surely 'how' a woman gives birth is just as important in terms of her access to choice??

NCT ignores many women
When will women who request cesarean deliveries (and percentage-wise, there are many more of them than there are women who request a homebirth) get the same attention (or even any attention) from the NCT?

Soon I hope, because if it truly believes in choice and access to choice, it cannot continue to ignore the women who make the valid decision to give birth via cesarean delivery.

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.

Dr Michel Odent blames fathers for cesareans now

I've never been a great fan of the opinions of Dr Michel Odent, and his particular preoccupation with the role of (the hormone) oxytocin during birth, and his latest suggestion, that men should 'stay away from childbirth' in order to help women, simply confirms my belief that he is out of touch with what pregnant women actually want.

You can read the full story in The Telegraph today, in which he is quoted as saying:

The 'tensions caused by the presence of men at birth could lead to more adrenalin, slowing the production of the hormone oxytocin, which assists effective contractions, making labour longer and more painful and increasing the chance of a caesarean section.'

'Mum dies of swine flu after her planned cesarean

The Mirror reported yesterday on the news of a 'Mum killed by swine flu after planned caesarean birth'.

It reports: 'The woman, 21, from Monmouthshire was admitted to hospital in Abergavenny for a planned caesarean but her condition deteriorated after she safely gave birth. She was transferred to intensive care and later to a specialist unit in Leicester where she died last week.

'Another women, 43, from Carmarthenshire, also succumbed to the disease but was said to have underlying health problems. The latest cases bring the number of swine flu-related deaths in Wales to three, although another death is being investigated.'

Infection risk
Infection following surgery is an undisputed risk with a planned cesarean. Other cases of infections have been reported too, such as the risk of contracting MRSA after giving birth in hospital. But the risk exists with both planned surgery and emergency surgery, and since emergency mostly occurs after a trial of labor, it means that post-surgery infection is a risk associated with a planned vaginal delivery too.

£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.'

RCM says: 'the most important thing is for women to be able to choose'

As it happens, Cathy Warwick, General Secretary of the Royal College of Midwives was talking more about homebirths in this BBC News article back on July 29th, but the language she uses could so easily have been taken from the Coalition for Childbirth Autonomy website.

Warwick concludes that, 'The bottom line here is that what women want is to be able to make a real choice, for the health service to offer them that choice, and for that choice to be based on having all the information needed to make an informed decision.'

Equality of choice
What I'd like to see now is more midwives from the Royal College of Midwives listening to and respecting the informed decision of some women to choose elective cesarean delivery as their preferred birth plan - in the same way that they listen to and respect women's decisions to homebirth.

Czech doctor: 'Vaginal delivery will disappear in evolution'

In this 18th May news article in the Prague Daily Monitor (Respekt: Cesarean section rate rising unnecessarily), Ales Roztocil, head doctor of the obstetrical ward in the Jihlava Hospital, south Moravia is reported to have told the political weekly Respekt, that: 'In my opinion, a vaginal delivery will disappear in evolution.'

For the record, this is not an opinion I share, but I thought it was interesting to record some of the views and opinions on cesarean delivery coming out of the Czech Republic, where cesarean rates are '20% on average'.

Irrational thinking is needed for natural birth

Another doctor, Helena Maslova, expressed her concerns about the increased involvement of medical technology during the birth process, coupled with issues related to women's own behaviour. She believes, ''Women have lost the ability of instinctive behaviour since they have been raised to suppress it and behave rationally for the whole life. Yet during a child delivery the irrational side must be used, which is almost impossible for many women' ...adding it was the result of the obstetrics' technical development since the 1960s.'

Wealthy women
Dr Roztocil also reveals that 'among those who demand a caesarean section unnecessarily are often well-off women, businesswomen and wives of businessmen living in cities.'

Maternal request is against the law

Interestingly, the report notes: 'Under the Czech law, a Caesarean must not be performed without medical reasons. Yet it can apparently be arranged with an obstetrician. According to Internet discussions, such women pay a couple of thousands of crowns unofficially for such 'service''.

Clearly concerned about this law, Dr Roztocil says that the 'introduction of the possibility of Caesarean at request or rather on the basis of psychological indications would prevent medical hypocrisy and frauds'.

I would add that it might also prevent a situation in which only women for whom a maternal request cesarean is financially viable are able to enjoy the birth outcome of their choice.

Financial cost of vaginal delivery is high - and unaccounted for

I've just come across this letter, published in the BMJ back in 2006, titled: 'Consider the value of a functionally intact perineum', and written in response to the study, ''Caesarean delivery in the second stage of labour'.

It's written by Michelle J Thornton, a consultant colorectal surgeon at the Wishaw General Hospital in the UK, and in it, she talks about so many of the issues I've raised with respect to the unaccounted cost of a planned spontaneous vaginal delivery - specifically, when things don't go accoring to plan and an instrumental delivery is necessary.

This is what she has to say (with references listed below):

'Spencer et al say that instrumental delivery may reduce the caesarean section rate in the second stage of labour.1 Although this may be important for the 2006 NHS budget—saving anaesthetic, operating theatre, and hospital costs in the short term—the longer term health outcomes and costs of a high forceps delivery are concerning and go unmentioned.

Recognised third and fourth degree perineal tears occur in 0.5-6% of vaginal deliveries in the western world.2 3 A further 30-44% are estimated to be unrecognised.1 One of the most significant factors, clinically and statistically, to be associated with perineal injury is an instrumental delivery.2 3

Up to a quarter of women with a tear will experience faecal incontinence.3 Although perineal injury during childbirth may not be the sole factor for faecal incontinence, perineal damage increases its likelihood.3 The economic costs of faecal incontinence are large, lifetime cost estimates ranging from £7000 to £43000, depending on treatment.4 The social implications are immeasurable. In a questionnaire of their personal birthing choices even female obstetricians chose caesarean section over an instrumentally assisted delivery.5

To advocate obstetric management that has been declined by educated colleagues is worrying, particularly when the social and economic costs are so great and the idea of gaining valid informed consent is increasing.'

1. Spencer C, Murphy D, Bewley S. Caesarean delivery in the second stage of labour. BMJ 2006;333: 613-4. (23 September.)[Free Full Text]
2. Sultan AH, Kamm MA, Hudson NH, Thomas JM, Bartram CI. Anal-sphincter disruption during vaginal delivery. N Engl J Med 1993;329: 1905-11.[Abstract/Free Full Text]
3. Abramowitz L, Sobhani I, Ganasia R, Vuagnat A, Benifla JL, Darai E, et al. Are sphincter defects the cause of anal incontinence after vaginal delivery? Results of a prospective study. Dis Colon Rectum 2000;43: 590-6.[CrossRef][ISI][Medline]
4. Adang EM, Engel GL, Rutten FF, Geerdes BP, Baeten CG. Cost-effectiveness of dynamic graciloplasty in patients with faecal incontinence. Dis Colon Rectum 1998;41: 725-34.[CrossRef][ISI][Medline]
5. Al-Mufti R, McCarthy A, Fisk NM. Obstetrician's personal choice and mode of delivery. Lancet 1996;347: 544.[Medline]

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.

Jennifer Hudson did not find cesarean recovery difficult

Just a few days after writing my blog on the fact that African American women are more likely to have a cesarean with their first baby, I've read that Jennifer Hudson has given birth to her beautiful baby David by emergency cesarean.

Fortunately, she appears to have had a very positive experience, which is great, and while I'm not suggesting for one minute that her description of recovering from surgery is every woman's experience, I feel that it remains worthy of note.

Jennifer was asked: Your son was delivered via C-section, what was your recovery like?

"Everybody told me how much it was going to hurt afterwards but I think I have a different tolerance for pain than others. By that night after I had the baby, I'm like, 'Look, I can’t sit in this bed anymore. I’ve got to get up!’ I’ve been up and about since he was born. To me, the pain is no different than when you work out a muscle you’ve never worked out before and it’s sore."

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.

Emergency cesareans more likely for older mothers

I've just been searching the internet to no avail, trying to find the actual Irish study being referred to in this Irish Times article published yesterday by Lorna Siggins. It appears in the European Journal of Obstetrics and Gynaecology and Reproductive Biology, but may not yet be available online.

I wanted to find out what age range 'older women' refers to, but in any case, the conclusion drawn in this new study (led by Professor John Morrison in Galway) should be of interest to many first-time pregnant women because they may 'run a much higher risk of emergency Caesarean section, even if pregnancies are not complicated (my italics)'.

The birth outcomes of 45,000 mothers at University College Hospital between 1989 and 2005 were analysed and advanced maternal age was found to have a 'strong bearing' on the likelihood of emergency surgery.

What does this tell us?
Prof Morrison told The Irish Times: "The findings indicate that the uterus does not work so well in older women, when one takes out the standard factors for epidurals, inductions, etc.” He continues: "There has been a lot of controversy over Caesarean sections, here and abroad, and their increasing frequency."
“The confirmation that age is a key factor in surgery is not because obstetricians are taking an ageist approach. The clear message from this is that age has an impact on ability to deliver normally."

Just as I commented in a recent post about pregnant African American women, what readers decide to do with research like this is a personal choice - and one to be discussed with your own midwife or OBGYN - but certainly for some women, in the light of research like this, the decision to avoid the risk of emergency surgery, and schedule a planned surgical birth instead, is a perfectly legitimate one.

Likelihood of a primary cesarean delivery is greatest for African Americans

Reuters reports, October 2nd, on a new Kaiser Permanente study examining the racial and ethnic disparities that occur with cesarean delivery, and notes that the study found 'disproportionately higher rate of primary c-sections among African-American women'.

The Californian study, Racial and Ethnic Disparities in the Trends in Primary Cesarean Delivery based on Indications, found that 'compared to Caucasian women, African-American women had significantly higher rates of primary CS while the increase in rates among
Hispanic women was smaller'.

What the study found
Further, it is reported that the disparity 'cannot be explained by education, smoking
during pregnancy, when prenatal care began or maternal age at delivery', and the lead author, Darios Getahun, MD, MPH, continues: 'This study underscores the importance of educating expectant women about the potential impact of CS on the outcome of future pregnancies.'

The figures published in the study's Abstract look at percentage increases in the primary cesarean rate, rather than percentage actual occurence, and it is unclear at first glance what women should do with this information. Perhaps the Full Text would prove a more useful read for African Americans - for example, it would be useful to know how many of these primary cesareans were emergency and how many were planned.

What the study tells African American women
This is the big question, and the answer is quite complex. Does the research call for better preparation for and best practice support during labor, in order to increase the likelihood of vaginal delivery? Or does it suggest that, if a women is likely to 'very likely to end up having surgery anyway', perhaps she'd be better having planned rather than emergency surgery?

Obviously, part of the answer can be found in the woman's personal birth preference, if she has one, and also, very importantly, how many children she is planning to have over the course of her life. Because however her primary cesarean occurs, through medical necessity or through choice, it is highly likely that she will go on to have further surgery in future pregnancies, and of course the health risks increase with multiple cesareans.

As a final note, the study results also note that 'Indication subtypes-specific rates of primary cesarean section varied markedly across race/ethnicity', and again, access to the study's Full Text would be useful for these women.

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.

Mother's death blamed on failures - £410,000 damages awarded

This story is so distressing to read, and evidently, the hospital have admitted that human error was at fault:

"Joanne Lockham, 45, died at Stoke Mandeville Hospital at Aylesbury in October 2007 during the birth of her first child. She was given a general anaesthetic when the baby's heart rate dropped. The oxygen supply to Mrs Lockham, of Wendover, was not put into her windpipe and she suffered cardiac arrest."

The headline of the updated story today reads: 'Payout over nurse Caesarean death', and is an example of when a caesarean delivery can be publicly associated with high risk.

However, it's important to point out that this was not a planned caesarean, and it was not spinal anaesthesia being used (both of which carry fewer risks than an emergency caesarean with general anaesthetic). This birth was a planned vaginal delivery (PVD) that ended in one of the worst birth outcomes of all.

42% of Canadian obstetricians support maternal request cesarean

A report on a nationwide survey of maternity care providers in Canada has found that 42% of obstetricians support cesarean delivery on maternal request, "even in the absence of a medical indication", "despite a push by their own professional body to "normalize" childbirth and reduce Canada's rising C-section rate."

549 obstetricians, 897 family physicians, 545 nurses, 400 midwives and 192 doulas from across Canada were surveyed in 2008-2009, and here are some of the findings reported:

*42% of obstetricians were in favour of a woman's right to choose a C-section without medical indication
*21% agreed with the statement that a C-section is as safe as a vaginal birth for women
*8% would choose C-section over vaginal delivery for themselves or their partners
*25% of obstetricians and family doctors believed sexual problems and urinary incontinence could be prevented by C-sections
*43% of obstetricians disagreed with the statement, "For a woman, having a vaginal birth is a more empowering experience than delivery by cesarean section."

The study is published in the Journal of Obstetrics and Gynaecology Canada.

Do women choose or consent to caesarean delivery?

You may read the full article here - published 11th September 2009.

Problems pasting text

I have read online that other people have been having this problem with Blogger (and if anyone has any information on how to fix it, please let me know), but currently, I am unable to copy and paste text into my Blog posts.

This makes commenting on articles and studies extremely difficult as I simply don't have time to write the text out manually. Therefore, for the time being, I am just going to post links to news articles and medical studies that I think may be of interest to you in the context of the ongoing debate over caesarean deliveries.

My apologies for this.

Australia: 1 in 4 caesareans by maternal request

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

Update on activities

In the time that has passed since my previous post, our family has moved back to the UK from the U.S., which, with a newborn baby and a toddler, has left me too busy even to Twitter!

I have managed to make some progress in my caesarean (it's a different spelling here in England!) work however. For example, as editor of my website, I've been accepted as a Stakeholder for the upcoming review of the 2004 NICE Clinical Guideline on Caesarean Delivery.

I've also contacted the All Party Parliamentary Group on Maternity to request membership to the Maternity Care Working Party, as I feel that women who choose caesarean delivery need a voice in an environment where discussions on maternity care are taking place, and more importantly, where decisions are being made.

So watch this space and I'll let you know how I get on with both of these.

The website
I've also updated my website homepage (although there is still more to do!), and have been keeping busy with email correspondence from ec members with questions, comments and concerns.

Our new baby boy!

It's been over a month since my last blog (I know - sounds more like something you'd hear in a Catholic confessional box...!), but things have been extremely hectic in our lives recently, to say the least, and my blog has had to take a back-seat for a little while.

One of the reasons though is a wonderful one. Our little boy Jack - a gorgeous baby brother for our daughter Charlotte - was born this morning at 9.04am, weighing 8lbs 15oz.

This is 'night one' in the hospital, so I'm looking forward to getting a few hours zzz's starting right about now!

Goodnight all... I'll be back soon...

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."

Cesareans in Cyprus: why women choose surgery

In her recent report, 'The big question: to cut or push', Alexia Saoulli begins: "Gynaecologists in the private sector have been accused of advocating caesarean sections at times convenient to them and without sound medical reasons, but when you talk to mothers themselves a slightly more complex picture emerges. While some doctors do actively encourage caesareans, all too often it is the mothers themselves who opt for the procedure."

It's certainly worth a read, and below, I've highlighted some of the reasons cited by women who did choose cesarean delivery:

Aileen: “I wanted to have a caesarean. I had one with my second son and it was just so easy that I decided I was going to have another one when I was pregnant with my daughter... You know exactly when your due date is. There’s none of this waiting around for your water to break. You plan it, you set a date, pack your bag and that’s it. A few hours later you’ve got a baby."

Katerina: “I was terrified of natural childbirth. I just couldn’t take the thought of the pain. I then thought that it would be more convenient to know the specific date so that I could have everything ready. I discussed it with my doctor and he agreed to perform a c-section... I don’t regret it for a minute. It was painless and harmless. They say the recovery time takes longer but a friend of mine who gave birth naturally developed an infection after they had to cut her during labour and took even longer to recuperate. I don’t think I could have handled being cut. I just couldn’t bear thinking about it."

Joanna: admitted that she’d asked for caesarean just so that she could have a Virgo baby rather than a Libra. Her doctor did nothing to dissuade her, she said. “I’d heard that Virgo boys are easier going than Libra boys and so I asked to be booked in for a c-section on September 20. My due date was September 22 which was too close to the cusp and I didn’t want to risk it.”

Maria: said her doctor encouraged her to examine her options but was very supportive when she finally decided to go ahead with the c-section. “I was so nervous about the pain. I know some cynics think the doctors are in it for the money, and maybe some are, but my doctor was definitely supportive of me and my decision. She took into account my fear, which was important... A friend of mine said this was because it would be less hassle for the doctor rather than having to talk me through my fear. I don’t know if this is true or not but I’m just glad that my doctor bothered to really listen to me and do what I wanted.”

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%.

Countries where more cesareans are needed

An IRIN news article last week asked the question, 'Can subsidised caesareans cut maternal deaths?'

It explains that some doctors in Benin have begun performing near-free caesareans, and the government is in its first week of helping women pay for caesarean operations in an effort to reduce the number of women dying during childbirth every year (estimated at 2,000).

"The government has linked the country’s high level of maternal and infant deaths in childbirth to long hospital waits for caesarean operations as underfunded hospitals scrambled to assemble the necessary equipment."

Will this be enough?
"A government health inspector who works with midwives in Cotonou, Adékambi Adjovi, told IRIN that even a steeply-subsidised caesarean operation may not be enough for some women. “The circuit [of health care costs] for women who have caesarean operations should be covered entirely because now they pay post-operative costs themselves.”

...The Ministry of Health reported 14,000 women giving birth through caesarean in 2008 and has estimated an additional 3,000 mothers will need the operation in 2009, based on population estimates."

The 'natural' cesarean

You might be interested in reading an article published in The Times this week, 'The new 'natural' caesarean', which reports on "a new movement campaigning to make [cesarean delivery] a more "natural" experience."

The delivery process has been developed by Professor Nicholas Fisk, and his two colleagues, Dr Felicity Plaat, a consultant anesthetist, and Jenny Smith, a senior midwife and author.

Readers might also be interested that both Professor Fisk and Dr Felicity Plaat have expressed their support for a woman's decision to choose a planned cesarean delivery in preference to a trial of labor, and in 2005, I interviewed Dr Plaat for my website. You can read her comments in full in the section 'Medical opinion, Exclusive interviews'.

Hysterectomy risk with multiple cesarean deliveries

The fact that risks increase with multiple cesarean deliveries is well documented, and it is important that anyone considering choosing a planned cesarean delivery in preference to a trial of labor is aware of these increased risks. In fact, this is why the NIH, ACOG and others all stress that CDMR is not recommended for women planning large families.

One of the risks often cited with multiple surgeries is the chance of needing an emergency hysterectomy, and a recent Irish news article has highlighted this risk:

The Sunday Times' 'Caesarean link to surge in hysterectomies', on April 5, reports:

"The problem is caused where the placenta, or afterbirth, attaches too deeply into the wall of the womb. The risk of the condition is increased by the presence of scar tissue from previous caesareans. Doctors from the Rotunda, Holles Street and the Coombe hospitals analysed charts of all patients who had emergency hysterectomies after giving birth in the 40 years between 1966 and 2005. Of the 320 cases, 43 of them were due to placenta accreta. It accounted for only one in 20 emergency hysterectomies from 1966 to 1975 but 47% of those between 1996 and 2005 when almost half (20) the cases occurred. The caesarean rate rose from 6% to 19% over the same period and now stands at about one in four births."

It is similar to an article that appeared in January 2008 in Australia's The Age, 'Caesars raise risk of losing womb', which reported on research from the University of Oxford:

"For most women giving birth normally for the first time, a hysterectomy is rare - only one in 30,000 will need surgery to remove their womb because of bleeding complications. But the risk of having to undergo surgery to remove the womb rises in the subsequent pregnancy for those who had a caesarean. One in 1300 women who have had one previous caesarean will have a hysterectomy. If the woman has had two or more previous caesareans, the risk rises to one in 220. Researchers estimate that more than 80 women a year have been forced to have a hysterectomy in Britain as a result of having a caesarean. But with the popularity of the procedure on the rise this figure is likely to increase. The study of 775,000 women who gave birth in Britain between February 2005 and February 2006 also found that women with twin pregnancies, older mothers and those who already had three or more children were also at higher risk of needing a hysterectomy."

Limitations of the research
The main problem with the research cited above is that the nature of the primary cesarean deliveries (that occurred prior to the subsequent surgery in which the hysterectomy is required) are not specified.

In fact, all cesarean delivery types tend to be pooled together and then the health outcomes of their subsequent pregnancies are looked at together. This means that primary cesareans that may have been an emergency delivery (which has greater morbidity risks than a planned delivery) are treated the same as planned deliveries.

Therefore, healthy women choosing a planned primary cesarean delivery should not be criticized or deterred from making their valid decision on the basis of mixed data outcomes. Yes, they should be informed of the risk of subsequent placenta complications, but every effort should be made to evaluate how many hysterectomies occur in cesarean deliveries that follow primary planned surgeries - not primary emergency surgeries.

Caesarean beliefs 'misguided' - says misinformed article

Late last night, I arrived home from speaking at the Controversies in Childbirth conference in Texas, and while there is much to write about my (very positive) experience there, I must first comment on an article I came across today - 'Caesarean beliefs 'misguided'', published in The Sydney Morning Herald.

In it, Associate Professor Stephanie Brown, from the Murdoch Children's Research Institute, is quoted as saying she is "concerned that long-term protection against pelvic dysfunction had been used increasingly to justify elective caesareans by patients and obstetricians "with very limited information"."

The article continues: "Women who choose to have an elective caesarean in the belief that it will prevent incontinence and genital prolapse are "misguided" and may be putting their health, and that of their baby, at unnecessary risk. That is the view of Jenny King, a urogynaecologist at Westmead Hospital, who questions the right of women to choose surgical births to avoid pelvic floor problems.

HERE IS JUST SOME EVIDENCE that demonstrates protection against pelvic floor disorders and incontinence with planned cesarean delivery:

Pelvic organ prolapse (POP)
*Swedish study of a total 1.4million women found the ‘strong and statistically significant association’ that CD ‘is associated with a lower risk of POP than VD.’ (Larsson et al, 2009)
*Norwegian population-based study of 2,001 randomly selected women found that 118 (6%) women reported symptomatic prolapse. In multivariable analysis, the risk of prolapse was significantly increased in women with one, two, and three or more VDs compared with nulliparous women. (Rortveit et al, 2007)
*Australian study of 801 women with a mean age of 55.3 years (range 17–90) found 79% complained of SUI and 28% of symptoms of prolapse. The risk of levator trauma increased for every year of delay in child-bearing and operative VD was associated with a near-doubling of the odds of trauma. ‘The global trend towards delayed child-bearing may result in an increased prevalence of pelvic floor disorders in coming decades.’ (Dietz et al, 2007)
*London review concluded that perineal injury sustained during childbirth is a major aetiological factor in the development of perineal pain, sexual dysfunction, prolapse and disturbance in bowel and bladder function, and selective CD for high risk women can be beneficial in preventing complications. (Fernando RJ, 2007)
*Dutch study concluded that VD may stretch and or load beyond the physiological properties of the pelvic floor tissue and in this way may lead to irreversible changes in tissue properties which play an important role in the urethral support continence mechanism. (Wijma et al, 2007)
*U.S. survey on POP found that only 1 in 5 (19%) of women aged ≥21 are aware of POP, and that 68% of those diagnosed with POP were not aware of it before experiencing symptoms. Also, 81% of women who gave birth did not receive education about it from their OBGYN (only 15% did) and yet the greatest risk factor for POP is a VD at any age. (ICR, Ethicon, 2007)

Stress urinary incontinence (SUI)
*Swedish study of 220 elective CDs and 215 VDs 9 months after delivery found prevalence of SUI after VD significantly increased both at 3 and 9 months follow-up, and in the multivariable risk model, VD was the only obstetrical predictor for SUI and for urinary urgency at 9 months. ‘VD is associated with an increased risk for lower urinary tract symptoms 9 months after childbirth when compared to elective CD.’ (Ekstrom et al, 2008)
*Indian study comparing CD and spontaneous VD found that ‘definitely normal delivery has association with urinary incontinence’. (Mahajan N, 2008)
*Canadian systematic review of MEDLINE (1966-2005) and CINAHL (1982-2005) databases found that CD reduced the risk of postpartum stress urinary incontinence from 16 to 9.8% in 6 cross-sectional studies and from 22 to 10% in 12 cohort studies, and differences persisted by parity and after exclusion of instrumental delivery. (Press et al, 2007)
*Israeli study comparing 52 women aged 40+ with spontaneous VD, 42 women aged 40+ with elective CD and 92 women (mean) aged 26 with spontaneous VD interviewed 1-2 years postpartum. None had SUI before pregnancy. The prevalence of SUI 1-2 years after spontaneous VD was significantly higher in the older women (38.5% vs. 9.8%) and women with elective CD had a significantly lower prevalence of postpartum SUI than VD (16.7% vs. 38.5%). Therefore, ‘elective CD in these women has a protective effect and lowers the risk of developing postpartum SUI.’ Groutz et al, 2007)
*Swedish study of 200 spontaneous VDs and 195 CDs at 10 years postpartum. When compared with CD, VD was associated with an increased frequency of SUI and an increased use of protective pads as well as an increased frequency of fecal urgency and gas incontinence. (Altman et al, 2007)
*U.S. interview follow-up from the CAPS study, comparing 759 primiparous women with clinically recognized anal sphincter tears after VD, no recognized tears after VD or a CD before labor at 6 months postpartum. ‘Postpartum FI and UI are associated with few modifiable risk factors.’ FI at 6 months was associated with white race, antenatal UI, 4th versus 3rd degree tear, older age at delivery, and higher body mass index (BMI). No factors were associated with FI in the VD or CD control groups. Across all groups, risk factors for postpartum UI were antenatal UI, less education, and higher BMI; CD was protective. (Burgio et al, 2007)

Fecal incontinence (FI)
*Finish study of 99 nulliparous and pregnant women at 4 weeks (mean) before and 4 months (mean) after delivery, with 76% VD and 24% CD. The symptoms of mild anal incontinence, mainly gas incontinence, increased after VD more than after CD. Occult anal sphincter defects were noted in 23% of the VD women. No new sphincter defects were found in the CD group. (Pinta et al, 2004)
*UK retrospective cohort analysis of 475 elderly women found that the principal risk factor for FI was childbirth (91%), and in most cases at least one VD had met with complications such as perineal injury or the need for forceps delivery. (Lunniss et al, 2004)
*Canadian questionnaire of 949 women in 5 hospitals in Quebec, 1995/96, 3 months postpartum found that 3.1% (n.29) reported incontinence of stool and 25.5% (n.242) had involuntary escape of flatus. ‘Anal incontinence is associated with forceps delivery and anal sphincter laceration.’ The latter is strongly predicted by first VD, median episiotomy and forceps or vacuum VD. (Eason et al, 2002)
*German study of 42 women at 32 weeks EGA and 6 weeks postpartum, with a follow-up at 12 weeks postpartum for those with occult sphincter defects after VD were compared with 10 elective CD controls. VD leads to direct mechanical trauma to the anal sphincters, while stretch and distension of the pudendal nerve seem to be of minor importance. After CD there were no changes in continence, anal pressures or rectal sensibility. (Willis et al, 2002)
*German study of 71 women 6 weeks before and 52 women 4-6 weeks after delivery, plus all patients with occult sphincter lesions 3 months postpartum. The overall incidence of anal incontinence after VD was 4.8% and occult sphincter defects, 19%. ‘Elective CD should be recommended for women at increased risk for anal incontinence.’ (Faridi et al, 2002)
*Irish study of 184 women at 6 weeks, with 9% (n.16) CD. After VD, 25% (n.42) women had impairment of fecal continence and 45% (n.76) had abnormal anal physiology. None of the CD women had altered fecal continence. (Donnelly et al, 1998)
*Irish study of 234 women in Dublin with 34 CDs, and 200 spontaneous VDs. ‘No woman delivered by CD had altered fecal continence postpartum. Anorectal physiology was unaltered in women delivered by elective CD or CD in early labor. Pudendal nerve terminal motor latency was prolonged, anal squeeze pressure increment reduced, but vector symmetry index was unchanged in women delivered by CD late in labor, indicating neurologic injury to the anal sphincter mechanism.’ (Fynes et al, 1998)

Unethical
According to this same article, a "25% increase in elective caesareans from 2001 to 2005 led NSW Health to ban elective surgical birth without a medical reason in public hospitals in 2007."

Why should women with legitimate prophylactic reasons to choose a planned cesarean delivery be denied this birth plan? The evidence I've listed above is just a small selection of studies that justify a woman's decision to choose a surgical delivery, and I see no justification at all for forcing a woman to deliver vaginally against her will.

Cesarean rate in U.S. is now at 31.8%

New figures reported by Reuters today show that the 4.3 million babies born in 2007 was the most ever recorded in the United States, topping even the peak of the baby boom in 1957.

It says there was another record high in the cesarean delivery rate too; it rose for an 11th straight year - up 2%, to 31.8% of births.

I think that the figures would be more informative if the cesarean rate was broken down further into different cesarean types and reported as such - e.g. planned cesareans for medical reasons, emergency cesareans, cesareans on maternal request, repeat cesareans etc.

The debate over whether the overall 31.8% figure is too high is meaningless without first doing this.

Cesarean delivery has a lower risk of pelvic organ prolapse than vaginal delivery

Unlike studies that heavily criticize health outcomes of cesarean delivery, this new study from Sweden, on 'Cesarean section and risk of pelvic organ prolapse...', has had minimal exposure in the media.

But I think that its conclusion is important to highlight - not to encourage more women to choose cesarean delivery - but in defense of all those women who do choose planned surgery. I refer to primary planned cesarean delivery on maternal request as 'prophylactic' in my online petition, and this study is just one of many that exemplifies this particular word choice.

The authors, Christina Larsson et al, conclude that: "Cesarean section is associated with a lower risk of pelvic organ prolapse than vaginal delivery."

And it wasn't a small study either.
The Swedish Hospital Discharge Registry was used to identify women with an inpatient diagnosis of pelvic organ prolapse, and the data were linked to the Swedish Medical Birth Registry, which meant that a total of 1.4 million women were investigated.

Memory of childbirth pain intensifies over time for some women

The first thing to say about this report on new research from Sweden is that women who elected to have a cesarean section were excluded. This is a great pity, as it would be interesting to compare their long-term memory of childbirth pain (albeit post-surgery) with women who delivered vaginally.

Reuters reports how "Dr. Ulla Waldenström, from the Department of Woman and Child Health at the Karolinska Institute, Stockholm and colleagues queried 1383 mothers about their memories of labor pain at 2 months, 1 year and 5 years after giving birth.

Five years after the women had given birth, 49% remembered childbirth as less painful than when they rated it 2 months after birth, 35% rated it the same, and 16% rated it as more painful.

"A commonly held view," Waldenström noted in an email to Reuters Health, "is that women forget the intensity of labour pain. The present study...provides evidence that in modern obstetric care, this is true for about 50% of women."

However, a woman's labor experience was an influential factor. Women who reported labor as a positive experience 2 months after childbirth had the lowest pain scores, and their memory of the intensity of pain had declined by 1 year and 5 years after giving birth."

Maternal deaths drop by 59% in China

I am highlighting this article by Wang Zhuoqiong of the China Daily, because I am aware that an increasing number of women in China are now choosing planned cesarean delivery as their preferred birth plan.

The reported 59% drop in maternal deaths has occurred mainly in urban areas as opposed to rural, and while I have no evidence to prove it, I wonder aloud whether this improvement in maternal outcomes may be as a result of increased planned cesareans...?

Obviously in China, women tend to only have one baby, which reduces or even avoids the risks associated with future surgeries, and as I have written about in the past, China could make a very interesting case study of planned primary cesarean risks and benefits. Unfortunately, there is the issue of setting delivery dates due to superstitions related to lucky numbers, but aside from that, the data could be very revealing.

True stories behind natural birth versus caesarean debate

I came across this article in the The Daily Telegraph over the weekend, 'True stories behind natural birth versus caesarean debate', by Erica Watson.

She describes the experience of mother of two, Kath Leary, who had initially wanted a vaginal delivery but needed to schedule a planned cesarean for medical reasons:

"Preparing herself for what she thought would be a not-so-pleasant and clinical procedure, Leary says she was surprised at how wonderful her birthing experience was. "Within what seemed like a few seconds I had both my kids in my arms after giving birth. There wasn't this detachment or anything like that," she says. "I didn't expect to really love the whole caesarean experience but I really did. It was a bit of a shock.""

Also worthy of note in the article is a quote form obstetrician Dr Keith Hartman:

"I think women are cruel to each other in making these value judgments," he says. While a natural birth might be an innate need for some mothers, Dr Hartman says for others it can create intense feelings of fear. "(Natural birth) is a lovely thing to see and a very exhilarating experience for women but for some they just don't want to do it," he says. "I respect that and I certainly would never criticise them for it and if other women criticise them for it I don't know where they are coming from. It's about a healthy mother and a healthy baby. As long as they are aware of their choice and not pressured into it."