Thursday, October 30, 2008

ICAN's response to press release contains disappointing inaccuracies

The International Cesarean Awareness Network (ICAN) has published its response to our press release with a statement that disappointingly demonstrates a lack of awareness and understanding in the specific area of cesarean delivery without medical indication.

It states that "While ICAN supports both updated research on this topic and an increase in patient education and autonomy, we maintain that many women who are choosing a cesarean are making that decision without full informed consent." I would argue that certainly the women who register at my website are informed (it lists hundreds of medical studies in risk-benefit categories), and I cannot imagine a patient-doctor consultation in which the risks associated with cesarean delivery are not presented to women. IN FACT, if you read the experiences of women who set out to have a planned vaginal delivery (PVD), it becomes clear that rather it is this birth group that is not always fully informed of the risks associated with PVD.

Inaccurate citation of risks
ICAN claims (in the context of cesarean delivery with no medical indication) that research shows an increased risks of "death, hysterectomy, blood clots, increased pain & recovery time, infection, and post-partum depression." And for the infant, additional risks of "respiratory problems, breastfeeding problems, asthma in childhood and type 1 diabetes." It also cites future risks of "infertility, ectopic pregnancy, placenta abnormality, uterine rupture, preterm birth, and stillbirth."

The overwhelming majority of this list is completely untrue in relation to healthy women planning a small family and delivering via cesarean at 39 weeks confirmed gestation (as recommended by ACOG and the NIH), as demonstrated in a growing number of medical studies. Many of the risks above are associated specifically with emergency cesarean delivery (the majority of which occur as an outcome of a PVD) or planned cesareans for medical reasons. They are not specifically relevant to cesareans with no medical indication and as such, should not be used as an argument against surgical autonomy.

The truth is that in 2004, the UK's NICE found that the only directly attributable increased maternal risks associated with an elective cesarean compared with PVD are abdominal pain and a longer hospital stay. There is still some debate over the link with asthma, so yes, women need to be aware of the potential risk, and also the risk of subsequent placenta complications with multiple pregnancies (although research to date includes first cesarean births that were emergency or planned medical surgeries and this of course adversely affects the final data).

Weak references
Instead of referencing actual medical studies (as we have done in our press release and as I have done on my website), ICAN cites a 2004 book by the Maternity Center Association as its primary source of reference. Unfortunately, this does not help inform women (or indeed journalists) who are trying to better understand both sides of this argument unless they are expected to locate a copy of this book in order to examine the evidence. I think it would be more helpful if ICAN listed actual medical studies (with website links) so that women can go and read the evidence for themselves and make up their own minds about their relevance.

With regard to the risk of type 1 diabetes, ICAN does cite a specific reference, and this is very helpful because I can provide the link to it for readers to see here. You can then see that again, this study is flawed in relation to non-medical cesareans. Why? Because the study looked at all cesarean deliveries, and such a mixed body of data means that we cannot associate this risk with healthy pregnancies specifically. It is possible (as in so many other areas of reported cesarean risks) that maternal or obstetrical characteristics are more likely associated with the baby's health outcome than the delivery method itself.

It's not just an issue of 'fear of birth'
ICAN also states that it does "not believe that cesarean should be the typical solution for fear of childbirth. With appropriate counseling, most women who fear childbirth are comfortable attempting a vaginal birth. Most show long-term satisfaction with their decision to change modes of delivery, and with intensive therapy, labor times were shorter."

First of all, this statement misses the point that many women decide to have a planned cesarean in order to avoid the unpredictability of PVD and all the morbidity risks that are associated with it. For example, urinary and fecal incontinence, pelvic floor prolapse, perineal pain, instrumental delivery and emergency surgery following a prolonged labor. The prophylactic nature of cesarean delivery is often understated, largely because the risks associated with PVD are also understated.

Secondly, although ICAN cites two (2001 and 2006) studies as evidence of successful management of the fear of birth, I would also encourage women to read the studies below that report greater satisfaction in women who have a planned cesarean delivery than those who have a PVD. Remember - some women do not want their issues of 'fear' resolved; they simply prefer to accept the risks of one birth type over another.

*Elective caesarean delivery at maternal request: A preliminary study of motivations influencing women's decision-making. Robson et al, Australian and New Zealand Journal of Obstetrics and Gynaecology, Volume 48, Number 4, August 2008 , pp. 415-420(6). Australia.
*Cesarean section on maternal request: reasons for the request, self-estimated health, expectations, experience of birth and signs of depression among first-time mothers. Wiklund et al, Acta Obstet Gynecol Scand. 2007;86(4):451-6. Sweden.
*Psychologic effects of traumatic live deliveries. Pantlen and Rohde. Zentralbl Gynakol. 2001 Jan;123(1):42-7. Germany.
*An investigation of women's involvement in the decision to deliver by caesarean section. Graham et al. BJOG 1999, vol. 106, no3, pp. 213-220 (34 ref.). UK.
*Psychological Aspects of Emergency Cesarean Section. Ryding EL. Linköping University Medical Dissertations No. 576, 1998. Sweden.
*Women's involvement with the decision preceding their caesarean section and their degree of satisfaction. Mould et al. Br J Obstet Gynaecol. 1996 Nov;103(11):1074-7. UK.
*More in hope than expectation: a systematic review of women's expectations and experience of pain relief in labour. Lally et alBMC Medicine 2008, 6:7. doi:10.1186/1741-7015-6-7. UK.

Ethical and evidence-based autonomy
Finally, ICAN says it "will continue to work to improve maternal-child health and to protect a woman's right to ethical and evidence-based care during pregnancy and childbirth." As far back as 2003, an ACOG ethics committee stated that cesarean delivery on maternal request is medically ethical, and in 2006, the NIH concluded that there is sufficient evidence to support this birth decision following individualized consultation.

I have always understood ICAN's desire to reduce the number of unwanted cesareans, and I think it's important to encourage best-practice care to support women who want to deliver vaginally. However, its insistence on refusing to support wanted cesareans is extremely disappointing, and a stance I hope it is willing to review in the near future.

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.

Cesarean delivery protects against fecal incontinence

The latest study into whether cesarean delivery protects against fecal incontinence (FI) has reached the same conclusions as many others before it. Researchers in the U.S. (Guise et al) surveyed all women delivering between 2002 and 2003 in Oregon, and found that "vaginal delivery was associated with a greater risk of FI compared to cesarean".

The survey details
A total of 6,152 primiparous women completed the survey 3–6 months postpartum with 2,482 reporting a new onset of FI after childbirth. That's a 40% prevalence.

Although vaginal delivery was associated with a greater risk compared to cesarean, the researchers do point out that vaginal delivery without laceration or instrument assistance did not increase the risk of FI over cesarean. In addition, they report that being overweight, pushing for longer than 2 hours, and constipation were independently associated with postpartum FI regardless of route of delivery.

What the study tells us
The researchers conclude that this study "provides important data to inform counseling and management of primiparous women", and I agree. Obviously, I don't think it means that all pregnant women will or should switch their delivery plans to a cesarean, but I do think that it further supports the argument that cesarean delivery has benefits over planned vaginal delivery - and that a woman's decision to choose a cesarean is a legitimate one.

One last point. While the researchers state that vaginal delivery without laceration or instrumental assistance does not increase the risk of FI, as always, it is important to understand that these risk factors are entirely unpredictable. A spontaneous vaginal delivery without laceration or assistance cannot be guaranteed for any woman, and therefore any assessment of 'planned vaginal delivery' risks must include morbidity associated with all its potential outcomes.

Monday, October 27, 2008

Is it so shocking that fear of labor pains may be behind some cesarean deliveries?

In this Sunday's Observer newspaper, Louise Silverton, deputy general-secretary of the Royal College of Midwives (RCM) talks about the issue of rising cesarean rates, and is quoted as saying that "women under 40 are less prepared to undergo the physical trauma of childbirth than their predecessors, a trend that is pushing up the rate of surgical deliveries."

She describes England's current cesarean rate of 24.3% as an "unacceptably high and needlessly high" figure that should be brought closer to the 15% recommended by WHO. The fact that Ms Silverton criticizes cesarean rates is of no surprise to me, but what concerns me far more is some of the views she holds about pregnant women. As someone in a position of great power and influence in the world of maternity services, her attitude towards women whose birth preference she does not share is worrying, and her lack of understanding (or willingness to understand) their differing perspective on pain is equally so.

Silverton's solution to pain: 'suck it up like previous generations of women'
Let's examine what Ms Silverton says in the Observer:
"Society's tolerance of pain and illness has reduced significantly."
"Women are less tolerant of labour pains because they haven't developed tolerance of pain. For example, if they get period pain they will either take Nurofen or go to their GP."
"...women under 40 [are] more likely to have an 'epidural in a way that their predecessors wouldn't'."

Ms Silverton describes labor pain as "unbelievably painful" and yet fails to understand or accept that women may have a genuine fear of such pain or choose to avoid it altogether (whether via an epidural or a planned cesarean delivery). What right does she have to suggest that women be encouraged - or forced - to have a natural birth?

The RCM also proposed fees for unnecessary edipurals
This is not the first time that the RCM has been out of step with what contemporary pregnant women want. Back in February 2006, its education and research committee came up with the highly controversial proposal that epidurals should be "free to women who have a definite need of it [but a fee] levied for all other women who desire" one. At the time, Ms Silverton was quoted as saying: "Epidurals provide effective pain relief but, where there is no clinical indication that they are necessary, they can significantly raise the likelihood of other interventions such as caesarean section occurring. "The UK already has an extremely high Caesarean rate and, as the acknowledged experts in normal pregnancy, labour and birth we midwives need to debate ways in which we might help to bring this rate down. "This is a very serious issue and one that is likely to raise significant debate but also something that needs to be debated if we are to improve the normal birth rate."

An argument that is often used against women who choose a cesarean due to a fear of labor pain or labor itself is that they can simply have an epidural. But it is not that simple. First of all, it is clear from the opinion of the very influential midwife above that epidurals are frowned upon too, and secondly, whether it is coincidence or not, I have been contacted by women whose experience of vaginal delivery was that they were refused an epidural or an epidural was 'not available in time' for the start of their pushing. They suffered a traumatic experience and decided to seek support in trying to schedule a cesarean delivery for their next pregnancy.

Clearly, the RCM wants to reduce cesarean rates, but it must ask itself - at what cost physical and psychological cost to the women it claims to serve?

More of Ms Silverton's comments - and my responses to them
"...caesareans have become too easy to obtain"
Not according to the women I receive emails from; they cite experiences with midwives, doctors and hospitals where their cesarean requests are refused. This leads to enormous stress during their pregnancy.

"Women are trying to remove the symptoms of pregnancy as much as they can. They are seeking to control everything. Choosing to have a caesarean gives you an element of control."
Yes, a planned cesarean does provide an element of control, and this benefit is often cited by women whose birth preference is surgery. Is that such a bad thing? The unpredictability of vaginal delivery is not embraced by all women and we shouldn't expect it to be.

"A caesarean is major abdominal surgery. I don't think women realise that. They see it as just another way of giving birth. They see it as easy. And they think that if they can have an elective caesarean they will have no pain because they haven't been in labour."
Of course they realize that it is major surgery, but they have decided to accept the risks associated with that surgery in preference to the risks associated with a planned vaginal delivery. Speaking for myself, I don't view any birth type as 'easy', and I was fully aware that I would experience some abdominal pain following abdominal surgery. However, I also knew that my postpartum pain would be managed (and it was), and that I would be able to tolerate any abdominal pain far better than any perineal pain.

"Some women, tired after a long labour, were wrongly given a caesarean at 10pm to save doctors operating at 2am, when they should be left longer in case natural labour developed..."
I find this comment so reprehensible that I struggle to find the appropriate words. Is it not feasible that the doctor making this decision is making the right one? How many more hours does Ms Silverton suggest that women already "tired after a long labor" continue to labor before undergoing - in her own words - major surgery? And besides the woman, there may also be a danger to the baby in delaying cesarean delivery.

"She also accused junior doctors of approving or undertaking emergency caesareans too quickly if there were any suggestion of risk to the child's health, because they feared they might be sued if something went wrong."
Litigation fear is a reality whether we like it or not, and we might all ask ourselves what would we do in that doctor's position. But the litigation or ethical debate aside, wouldn't most women 'if there were any suggestion of risk to the child's health' also agree with the doctor's (junior or otherwise) decision to perform a cesarean delivery?

" has to question whether the women of this country are physiologically incapable of having normal births, and I don't think they are..."
Then why try to force vaginal delivery on those who don't even want one in the first place?

"She listed a caesarean's main dangers for mothers as 'the risk of infection, the effect on subsequent fertility and the effect on their ability to look after a newborn baby when they are post-operative'. There can also be respiratory complications for the baby, she added."
Yes, there is a risk of infection, and you can read more about that here. There is no association with subsequent fertility following a planned cesarean delivery; a number of studies have found that any reduction in fertility is voluntary. Women's ability to look after a newborn baby following a planned vaginal delivery can also be adversely affected; it is not necessarily any worse following planned surgery ( I personally experienced no such difficulty). Respiratory complications are largely associated with pre-term deliveries and can be mitigated by delivery at 39 weeks confirmed gestation - as advised for healthy women who choose to give birth surgically.

Friday, October 24, 2008

Sometimes it takes a celebrity to get the point across

It's funny world. In the past, I've read media articles accusing women who choose cesarean delivery of being 'celebrity copycats.' Even medical professionals have pointed towards celebrity culture as one of the reasons for the rise in cesarean on maternal request; women want surgery because they see their celebrity idols having it. This idea is also behind the name-calling trend, 'too posh to push', which refers to the specific influence of Victoria Beckham.

The fact of the matter
First of all, there is no evidence to suggest that women are merely 'copying' a celebrity culture when they choose to have a cesarean. Instead, maternal questionnaires cite fear of labor, avoidance of pelvic floor damage and a tolerance for the risks of planned, controlled surgery in preference to the more unpredictable risks associated with vaginal delivery.

In fact it is the media itself that is influenced by celebrity when it comes to reporting on childbirth. If a celebrity speaks out about a negative cesarean experience, this makes the headlines. If a celebrity describes a preference for cesarean delivery over vaginal delivery, again, their story is given center stage. Just this week, the British singer and actress Billie Piper gave birth to her son Winston by emergency cesarean after a reported 26 hours of labor. Her boyfriend is quoted as saying it was "a major thing' but it remains to be seen over the coming days whether newspapers and magazines take the stance that it's another negative cesarean story or whether it's a negative planned vaginal delivery story. My guess is that Billie Piper's first comments to the press will decide that.

Celebrity experience counts
Take for example Gwyneth Palthrow; she described how difficult she found labor with her first baby, Apple. On the flip-side, there was Davina McCall who described a very positive vaginal delivery experience. Then there was Christine Aguilera, the first celebrity to admit to planning her cesarean through her own choice due to a fear of vaginal delivery. Before that, Kate Winslet admitted that she had lied to the media about having a cesarean delivery because she was concerned about the negative press she might get.

The good thing about all these stories is that they keep the issue of childbirth in the public eye; they remind us that childbirth is not always straightforward, that there can be a whole range of experiences from good through to bad, and that we should be more tolerant of the decisions of women with different perspectives and desires than our own. And while I think it's a shame that we have to rely on celebrity news coverage to shine the spotlight on maternal autonomy, I'm also hopeful that by doing so, it acts as a catalyst for media discussion (online, in newspapers and magazines, on the radio and TV), and ultimately leads to greater access to information for women planning their births. That's the very best we can hope for.

Thursday, October 23, 2008

A step in the right direction?

As readers of this blog already know, I believe that any informed healthy pregnant woman should have her decision to give birth via cesarean delivery respected. That said, it clearly remains a highly controversial issue, and one that continues to be debated in the medical and media worlds.

One of the problems we have is that there are no short- or long-term clinical studies that specifically compare healthy women going down the planned vaginal delivery route with healthy women going down the planned cesarean delivery route. In what has become a never-ending cycle of chicken-and-egg, some medical professionals say that such a study is unethical; they claim we don't have evidence to show that planned cesarean delivery is safe enough to compare with vaginal delivery. Yet without this study, we will never have such evidence - a situation perhaps they prefer...

An ethical comparative study
Today I came across a new Australian review by Hans P. Dietz, in which he asks the question: "Elective Cesarean Section- the Right Choice for Whom?" He begins by reiterating some of the problems contemporary doctors face: "There are no scientific grounds for identifying an 'appropriate' level for Cesarean section rates, and no data to help us in counselling women who ask for elective Cesarean delivery. A 'Term Cephalic Trial' may provide such information, but poses major logistic and ethical challenges."

And here's what he proposes: "The key to a successful resolution of this issue may lie in individualized risk assessment. This has now become possible. Maternal age, a history of Cesarean Section in the parturient's mother, maternal body mass index, cervical length and/ or Bishop score, pelvic organ mobility and engagement of the fetal head are some of the factors that have recently been shown to be associated with delivery mode in nulliparous women. Individual risk assessment may soon allow us to construct intervention trials that will be ethically sound, logistically feasible and resource- neutral. Even more importantly, we may eventually be able to provide true 'informed consent' to women considering elective Cesarean delivery."

Informing women is key
This could be a very important step in the right direction. We know that women are giving birth at an increasingly older age, and we know that women's weight is often cited as an unwelcome challenge in obstetrics. Babies are getting larger and women's tolerance of risk (both maternal and fetal) is less than that of previous generations. We know that litigation (whether we like it or not) is a reality that cannot be ignored. We also know that there are other factors that can increase the likelihood of an emergency cesarean or an instrumental delivery - factors that might lead some women to opt for a planned cesarean delivery instead.

I personally feel that a comparative study of healthy pregnant women is already possible, and indeed ethical. There is no need to invite women to have a planned cesarean delivery - simply monitor and collect data on those women who have made the decision to have one themselves. Still, in the meantime, I'm happy to settle for any effort that seeks to better inform women of the risks and benefits of different delivery methods. We've been avoiding doing so for far too long already.

Wednesday, October 22, 2008

A positive birth experience aids breastfeeding more than a vaginal delivery

Cesarean delivery is frequently reported as having a negative impact on breastfeeding and bonding. However, the vast majority of problems occur following emergency surgery and also planned surgery for medical reasons that were nonetheless unwanted by the mother.

That is not to say that women who plan a cesarean delivery through their own choice are guaranteed breastfeeding success (if indeed breastfeeding is their personal choice), but as you'll see from the medical research I have listed on my website, it is erroneous to claim that these women are any less likely to have a positive breastfeeding experience.

The evidence

In answer to the question 'Is it possible to breastfeed after a cesarean birth?', La Leche League International says this: "Yes... A smooth birth contributes to a smooth breastfeeding experience, so when you take advance measures to prevent difficulties from birth complications, breastfeeding can succeed more easily."

Now a new study from New Zealand, 'Impact of Birth Trauma on Breast-feeding: A Tale of Two Pathways', reiterates this sentiment. It found that up to 34% of new mothers reported experiencing a traumatic childbirth, citing "stressful labor and delivery, unscheduled cesarean births, and psychosocial stress and pain related to childbirth". All of these traumas occurred as an outcome of a planned vaginal delivery - not a planned cesarean delivery.

The researchers continue: "Eight themes emerged about whether mothers' breast-feeding attempts were promoted or impeded. These themes included (a) proving oneself as a mother: sheer determination to succeed, (b) making up for an awful arrival: atonement to the baby, (c) helping to heal mentally: time-out from the pain in one's head, (d) just one more thing to be violated: mothers' breasts, (e) enduring the physical pain: seeming at times an insurmountable ordeal, (f) dangerous mix: birth trauma and insufficient milk supply, (g) intruding flashbacks: stealing anticipated joy, and (h) disturbing detachment: an empty affair."

Birth trauma rather than surgery leads to problems
They conclude: "The impact of birth trauma on mothers' breast-feeding experiences can lead women down two strikingly different paths. One path can propel women into persevering in breast-feeding, whereas the other path can lead to distressing impediments that curtailed women's breast-feeding attempts."

Women, midwives, doctors and journalists alike need to keep studies like this in mind before making a connection between breastfeeding problems and cesarean delivery on maternal request.

Monday, October 20, 2008

One woman's decision to have a cesarean

I came across this story last night about a woman in Australia who decided to have a planned cesarean delivery instead of a planned vaginal delivery. Snezna Stojkovski lives in Sydney, and describes her thought processes and the research she did leading up to her final decision. I thought that other women might find her story an interesting read.

Wednesday, October 15, 2008

Duration of hospital stay following birth in England

The cesarean news to come out of this year's NHS Maternity Statistics had nothing to do with England's latest national rate (it rose only slightly to 24.3% from 24.1% in 2005-06). Rather, it was the fact that "recovery time in hospital following caesarean section is lessening." The first thing to say is that this statement refers to ALL cesarean deliveries - both elective and emergency. So as usual, it is necessary to go beyond the headlines and seek the truth about the hospital stay of planned surgical procedures - in particular, to discover how this compares to planned vaginal deliveries.

What the NHS summary says
"Approximately one quarter (27,407) spent four days or more recovering in hospital in 2006-07, compared to just under a third (31,393) in 2005-06."

I found this interesting on two counts. Firstly, from the perspective of cost (the less time women spend in hospital, the lower the delivery bill), and secondly, from the perspective of postnatal care (the number of days women spend in hospital following a vaginal delivery is far fewer than that of the previous generation of mothers, but is that necessarily a good thing?).

Short versus long hospital stay
Understandably perhaps, many women dislike spending any more time than is absolutely necessary in hospital. Noisy wards, the risk of infection, hospital food and craving home comforts are just a few of the reasons often cited. Yet for some, especially those women who have just delivered their first baby, they are grateful for the opportunity to have nurses, doctors and midwives on hand to offer advice about feeding and caring for their baby. Or they want the chance to have a few hours rest while their baby is looked after in the nursery. If the luxury of a private room is available, this is an additional bonus.

The implications of cost to the NHS
In many traditional models of cost, where attempts are made to compare the cost of vaginal delivery with cesarean delivery, the duration of hospital stay for a spontaneous vaginal delivery is compared with that of all cesarean deliveries. Even when elective cesarean deliveries are separated out, researchers do not always factor in the duration of stay of all other vaginal delivery outcomes (such as instrumental or emergency cesarean). Clearly, this distorts any financial comparison that seeks to inform birth 'plans' (where the birth outcome is still unknown).

Current cost analysis is flawed
Particularly when it comes to evaluating the cost of maternal request cesarean deliveries. In NICE's 2004 Clinical Guideline, the authors admit that the "estimated cost of maternal request can change depending on the cost value entered in the model.' For example, if the lowest vaginal birth costs reported in the review and the highest CS cost estimate reported in the review are used, the additional cost for accepting 8,747 maternal requests for CS is around £21.2 million.' The report continues: ' Since the highest cost for vaginal birth in the review is higher than the lowest cost for CS, if these values were entered into the model, the model would show that increasing planned CS due to maternal request would lead to savings, which is not a realistic conclusion.' This highlights the fundamental problem in so much of existing birth comparison literature: it works backwards from a preexisting viewpoint or conclusion, and focuses on making the data fit in with it rather than being open to the data leading us to a new reality.

How long do women stay in hospital following different births?
Let's look at some of the figures contained in Table 21: "Duration of delivery episode by method of onset of labour and method of delivery". The majority of women who have a spontaneous vaginal delivery spend 1 or 2 days in hospital (67.6%). 17.6% go home on the day they deliver, and another 14.7% stay for 3 days or more. The majority of women who have a planned cesarean spend 2 or 3 days in hospital (61.2%). 2.9% go home sooner than that, and the remaining 35.9% stay for 4 days or more. But as we know, this is not the comparison that needs to be made. We also need to look at how many days women who 'planned' a spontaneous vaginal delivery, but had a different delivery 'outcome', spent in hospital.

296,058. This is the number of women whose labor began either spontaneously or was induced, and whose delivery is listed as 'spontaneous'.
53,703. This is the number of women whose labor began either spontaneously or was induced, and whose delivery is listed as 'instrumental'.
57,039. This is the number of women whose labor began either spontaneously or was induced, and whose delivery is listed as 'cesarean'.
406,800. This is the number of women who might be described in Table 21 as having 'planned' a vaginal delivery, which means 13.2% needed instrumental assistance and 14% needed an emergency cesarean delivery.

As expected, women with instrumental vaginal and emergency cesarean deliveries had longer hospital stays than women with spontaneous vaginal deliveries. With instrumental deliveries following spontaneous onset of labor, hospital stay is still mainly 1 or 2 days ( 64.7%), but 32.4% stay 3 or more days. Following labor induction, hospital stay for instrumental deliveries is mainly 2 or 3 days (51.6%), but as many as 36.7% of women stay for 4 or more days.

Similarly, with emergency cesarean delivery. Following spontaneous onset of labor, hospital stay is mainly 3 or 4 days (59.4%), with 21.2% staying 5 or more days. And following labor induction, the majority of women spend 3 or 4 days in hospital ( 48.9%), but as many as 44% stay for 5 or more days.

Future research
Only when these longer hospital stays following a planned vaginal delivery are taken into account in cost evaluations, and further - when the elective cesarean group is broken down into women who had a planned cesarean for medical reasons (i.e. the medical reason rather than the cesarean surgery itself may require longer hospital stay) and women who personally decided to have a planned cesarean - will we truly be able to discuss cost implications of cesarean delivery on maternal request.
Additional cost factors for the NHS such as long-term pelvic floor repair or litigation following injuries or death during planned vaginal deliveries is a topic I'll leave for another day...

PTSD and PND are not more likely with a planned cesarean

Last night, I came across this story on postpartum depression on the West Virginia Public Broadcasting website. Referring to a recent study in the Journal of Child Psychology and Psychiatry, it cites that "women who have cesarean deliveries are more likely to suffer from post partum depression than women who deliver vaginally."

What it does not make clear however is that the majority of women who suffer as a result of a traumatic cesarean experience have had emergency surgery at the end of an attempted planned vaginal delivery. Yet unfortunately, most people read articles like this and think: 'mmm, another reason not to have a cesarean - and women who choose to have are putting themselves at great risk if PTSD and PND.'

The truth about birth experiences and how they affect women's mental health.
First of all, have a look at the stories written by women on birth trauma websites - for example, in the UK and Canada. You'll see that the overwhelming majority of cases of PTSD occur following a traumatic planned vaginal delivery (whether the outcome was vaginal or abdominal in the end) and not a planned cesarean delivery.

The medical evidence.
Secondly, look at other evidence and reviews on this subject before drawing any final conclusions. For example, a 2006 New Zealand review that found no such link has been established between cesarean delivery and postpartum depression.

That is not to say that PND or PTSD cannot occur following a planned cesarean delivery, but evidence shows that PTSD in particular is far less likely. The studies below highlight that part of the problem is the correlation between a woman's birth expectations and the actual outcome. As I've highlighted before, compared with planned vaginal delivery and its potential outcomes, a planned cesarean delivery is more likely to have the outcome of a cesarean delivery. Studies have shown that in cases where women have personally chosen to have a planned cesarean delivery, their psychological outcome in so far as it relates specifically to the birth (remember, PND has many other potential triggers) is positively enhanced.

*Elective caesarean delivery at maternal request: A preliminary study of motivations influencing women's decision-making. Robson et al, Australia.
*Cesarean section on maternal request: reasons for the request, self-estimated health, expectations, experience of birth and signs of depression among first-time mothers. Wiklund et al, Sweden.
*Psychologic effects of traumatic live deliveries. Pantlen and Rohde, Germany.
*An investigation of women's involvement in the decision to deliver by caesarean section. Graham et al, UK.
*Psychological Aspects of Emergency Cesarean Section. Ryding EL, Sweden.
*Women's involvement with the decision preceding their caesarean section and their degree of satisfaction. Mould et al, UK.
*More in hope than expectation: a systematic review of women's expectations and experience of pain relief in labour. Lally et al, UK.

Tuesday, October 14, 2008

Instrumental delivery is avoided with elective cesarean delivery

The unpredictability of a planned vaginal delivery is one of the reasons that some women prefer to arrange a planned cesarean delivery for the birth of their child. The overwhelming majority of planned cesarean deliveries result in the very same outcome, while unfortunately, planning a spontaneous vaginal delivery does not guarantee a spontaneous vaginal delivery outcome.

What's the likelihood of needing forceps, ventouse or both?
In 2006-07, the NHS in England estimates that only 52% of deliveries were 'normal deliveries' (the NHS' term, not mine), defined as those 'without surgical intervention, use of instruments, induction, epidural, spinal or general anaesthetic'. Table 12 states that, "For all deliveries with a spontaneous onset of labour just over three quarters resulted in a spontaneous delivery; approximately 12% resulted in an instrumental delivery; and nearly 12% resulted in a caesarean."
This means that 1 in 4 women planning a vaginal delivery will end up needing instrumental assistance (i.e. forceps, ventouse or both) and/or an emergency cesarean delivery.

By comparison, Table 12 reveals that where a cesarean delivery was planned (see: method of onset of labour), 0.9% ended up as a vaginal delivery outcome and 99% had the outcome of cesarean delivery. Unfortunately, the table does not detail how many of these cesarean outcomes were emergency surgeries, but other studies have shown that number to be very small.
This means that 1 in 10 women planning a cesarean delivery will have an unplanned vaginal delivery outcome, and only 0.1% will need instrumental vaginal assistance.

How is this a 'benefit' with planned cesarean delivery?
The NHS Maternity Statistics summary puts the total number of instrumental deliveries at 11.5%, but again (see blog on episiotomy occurrence below), you need to look at the data a little more closely to find out what percentage of vaginal deliveries involved this type of assistance. Table 12 shows that while 12.4% of vaginal deliveries that began spontaneously required instrumental assistance, the occurrence rate rises to 14%, 16% and 17.1% for vaginal deliveries that were induced. Compare these figures with the 0.1% occurrence with a planned cesarean delivery.

Then look at the medical research on the repercussions of instrumental delivery: increased risk for pevic floor disorders, incontinence, perineal pain and other long-term health issues (see my website for listings of medical studies). Remember, it is not my aim to put women off having a vaginal delivery or in any way to criticize women who choose this birth method - but the avoidance of an instrumental delivery and its associated risks serves as another legitimate reason why some women decide to schedule a cesarean.

Episiotomy is avoided with elective cesarean delivery

The 2006-07 NHS Maternity Statistics for England were published in September, and it is very interesting to look beyond the highlighted 'key facts and summary' and delve into the details and numbers contained in specific tables.

For example, the key facts state that 13% of women had an episiotomy, but this does not mean that there is a 13% chance of having an episiotomy during a planned vaginal delivery (PVD). In fact, the percentage risk is much higher. Take a look at Table 16. It states that "The highest proportion of Episiotomies were carried out for Instrumental deliveries. For spontaneous deliveries the highest proportion were carried out in the London Strategic Health Authority (31.9%) and the lowest proportion in the South East Coast Strategic Health Authority (20.5%)." So at least 1 in 5 women have an episiotomy with a PVD.

Why are these numbers so much higher?
Because the 13% figure is the number of times episiotomies occur in ALL deliveries, including cesarean deliveries. Since the rate of occurrence is "0.0%" during an elective cesarean and ""0.3%" during an emergency cesarean, you can see how this helps bring the overall total down to 13.3%.

So what is the risk of having an episiotomy with a planned vaginal delivery (PVD)?
Table 16 separates PVD into a number of different outcome categories, and while a woman can never predict which outcome will be her personal experience, this is what we know about episiotomy occurrence (and therefore likelihood) in England:

With a spontaneous vertex delivery, 7.8% of women had an episiotomy. For other types of spontaneous deliveries, 16.1% of women had an episiotomy. With a low forceps delivery, 84.8% of women had an episiotomy, and for other types of forceps deliveries, 82.5% of women had an episiotomy. With a ventouse delivery, 63.6% of women had an episiotomy. For breech deliveries, and breech extraction, 23.4% and 17.7% of women had an episiotomy respectively.
So with a PVD outcome of forceps, 4 out of every 5 women have an episiotomy.

Why is this an elective cesarean 'benefit'?
Because medical studies have cited the negative repercussions of episiotomies; in particular, the risk of severe perineal trauma and its related long-term health issues. Many medical professionals believe that episiotomies were overused in the past and have sought to reduce their incidence (see Table 15 to witness falling rates over the years). Clearly, women don't decide to have a planned cesarean 'only' to avoid an episiotomy, but its avoidance is certainly a legitimate factor in their risk-benefit analysis. You can read a list of medical studies on episiotomy 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 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:


...there are risks and benefits with every possible birth plan choice
...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