Thursday, February 26, 2009

Where cesareans are too few

Amidst talk about the increasing cesarean rates in the developed world, it is all too easy to forget the plight of women in other countries where access to cesarean surgery is dangerously low.

An article this week in the International Herald Tribune, 'Project works to improve lives scarred by childbirth injury', describes the devastating injury fistula that occurs as a result of obstructed labor during vaginal delivery.

Denise Grady writes: "If prolonged, obstructed labor often kills the baby, which may then soften enough to fit through the pelvis, so that the mother delivers a corpse. Obstructed labor can kill the mother, too, or crush her bladder, uterus and vagina between her pelvic bones and the baby's skull. The injured tissue dies, leaving a fistula: a hole that lets urine stream out constantly through the vagina. In some cases, the rectum is damaged and stool leaks out. Some women also have nerve damage in the legs."

She continues: "Fistulas are a scourge of the poor, affecting two million women and girls, mostly in sub-Saharan Africa and Asia - those who cannot get a Caesarean section or other medical help in time."

Tuesday, February 17, 2009

Risk of postpartum psychosis increases with age

This report appeared on the website EMax Health last week, and talks about new research led by Christina M. Hultman, PhD, of the Karolinksa Institutet, in Stockholm, Sweden.

Researchers found that half of women diagnosed with postpartum psychosis have no history of mental illness, and that the risk of postpartum psychosis is greater in women over age 35 who give birth for the first time.

Why is this important?
Other research has shown that women who achieve their preferred delivery method enjoy better psychological post-birth outcomes than women who don't. So if a woman plans a vaginal delivery and ends up needing an emergency cesarean, she may feel more negative about her birth experience than if she has a spontaneous vaginal delivery. Similarly, it has been shown that women who choose a cesarean delivery, and go on to have a cesarean delivery, have a much greater level of post-birth satisfaction than those who don't.

Women are not homogeneous creatures, and we should focus on supporting the individual's delivery preference rather than trying to enforce a 'one size fits all' approach to maternity care.

Deaths of 6 women giving birth raise concerns in the NHS

On February 11th, Madeleine Brindley's report: "Serious concerns raised at NHS trust after six women die" appeared on WalesOnline. It perfectly illustrates the unpredictability of vaginal delivery that exacerabates an already unpredictable Mother Nature. I believe that it is not unreasonable that some women (myself included) decide to opt for a planned surgical delivery with a dedicated, guaranteed-to-be-present during the birth, team of health carers.

"The review team found that there was no common link between the deaths, although in two of the cases, if the women’s deteriorating condition had been spotted earlier and better advance preparations had been in place, the outcomes may have been different... The report revealed:

*The trust had the highest proportion of women reporting that they were left alone and worried, in labour or shortly after the birth of their child;
*Staff from lower risk wards are frequently transferred on shift to the higher-risk labour areas, leaving the areas from which they were drawn under staffed;
*Community midwives are frequently required to work in the hospital throughout their on-call shifts after doing a full days work in the community;
*Low-risk labouring women are sometimes left alone while staff attended to higher risk women - the HIW inspectors heard of occasions when induced labour had been halted to allow staff to be rescheduled to other work;
*The numbers of midwives on the labour ward at the Royal Gwent Hospital appear “inadequate” for the size and activity levels on the ward."

UK hospitals restrict cesareans based on inaccurate cost calculations

The weekend's Sunday's Times article, 'Hospitals curb caesarean births' (by Health Editor, Sarah-Kate Templeton) was just one of many to report on the decision by hospitals in the Greater Manchester area to "ration" cesarean deliveries so that only "women with specific medical conditions" are eligible to deliver their babies via this method.

The Daily Mail's Daniel Martin's report, 'Caesareans rationed: Women denied procedure on safety grounds - and because it's too dear', and The Telegraph's Sarah Knapton's report, 'Caesarean births rationed by hospitals in order to cut costs' were two others.

Personally, I think that this decision is a national disgrace, and I can only hope that there are more doctors in the UK that will ignore such irresponsible guidelines and support the views of Doctor Christoph Lees, an obstetrician and gynaecologist at Addenbrooke's hospital in Cambridge, who is quoted in these stories saying:

"I strongly disagree with this prescriptive condition setting. Sometimes well-informed women, often older and very unlikely to have further children, do request caesarean sections and it is unreasonable to refuse if they are fully informed."

Some reasons why COST is not a valid reason for cesarean rationing
The main issue is the inaccurate cost comparison between PLANNED vaginal delivery (PVD) and PLANNED cesarean delivery. I highlight the word planned because it is no use in comparing spontaneous delivery outcomes with cesarean delivery outcomes alone. The fact is that a PVD can have many different outcomes for mother and baby - regardless of how much a spontaneous delivery is desired or encouraged - such as instrumental delivery and most importantly, emergency cesarean delivery. The cost of the latter in particular is rarely, if ever, factored into the cost of a PVD, yet it should be.

Worse still, traditional cost comparisons actually take these PVD emergency cesarean outcomes and add them to all planned cesarean costs in order to demonstrate 'hospital cesarean costs'. More recent studies have at least separated emergency and planned cesarean costs, but even then, in the argument against healthy women being able to choose a planned cesarean delivery, they do not recognize that the vast majority of these planned cesareans were for medical reasons and were therefore likely to have extra costs associated with them that would not be the case in a healthy pregnancy. The best example of this is studies that look at the NICU costs of babies born at 38 weeks gestation and earlier - obviously these costs are high, but in a healthy pregnancy where a woman delivers at 39 weeks gestation (repeatedly shown to reduce respiratory distress - see ACOG and NIH statements and others), these costs are not applicable.

The truth about birth costs
No one wants to do the study that needs to be done - an analysis of cost of women who plan a vaginal delivery (and all their actual outcomes - short and long-term) and women who plan a cesarean delivery. Doctors in Australia in 2003 looked into whether such a study would be a good idea and raised concerns that one of the biggest dangers would be the fact that planned cesarean delivery may be proven to be safer than PVD - "what a disaster" that would be, they said.

It's also worth looking at Appendix C of the NICE 2004 Clinical Guideline on Caesarean Delivery - they actually admit that it is possible to take current cesarean cost data and demonstrate that
planned cesarean delivery can be cheaper than vaginal delivery, but in the very next sentence, they dismiss it as being an 'unrealistic conclusion' to draw. It is not referred to again.

When vaginal deliveries go wrong
The cost of obstetrics litigation in the NHS is enormous and yet this is also not accounted for in any cost analysis of PVD. When a cesarean is not done in time or is not done at all, and the baby dies or is severely injured, there is a financial cost associated with that - as well as a psychological cost.

When women suffer severe pelvic floor injuries, there is a financial cost associated with post-birth surgical repair, and even more minor injuries can result in long-term damage such as incontinence or pelvic organ prolapse. Again, not to mention the psychological trauma and need for post-birth counselling that many women experience.

Perhaps hospitals would do better to concentrate on supporting positive birth experiences, and rationing negative ones - and believe me, research shows that this is not achieved by forcing all women to have a vaginal delivery.

Thursday, February 5, 2009

20-30% of women in Ludhiana request cesarean delivery

'For kids’ bright future, city women give thumbs up to caesarean' read the headline by Sameer Kumar Sharma earlier this week. The article reports that women in Ludhiana, "with the knowledge of medical science making caesarean deliveries much safer, more urbane women are opting for caesarean on request even though they could have a normal delivery."

Sharma writes: "For the fear of labour pains, many ‘educated’ women are thronging hospitals to deliver babies without having to go through 10 to 12 hours of labour pain. The rough estimates suggest a sizeable chunk of expecting mothers - as much as 20 per cent - want to go in for caesarean delivery rather than normal vaginal delivery."

Gynaecologists there say that in the last 5 years, "there has been a major shift in the way women respond to childbirth. “Today more women ask on request to have a caesarean rather than waiting for the normal delivery,” says Dr Promila Jindal, professor and unit head, department of gyaenocology, Dayanand Medical College and Hospital."

Requests have doubled in the last few years
"Dr Mini Ahuja, consultant gyneacologist at Iqbal Nursing Home, says about 30 per cent of the pregnant women approaching them talk about the possibility of caesarean even though there are no complications involved. “Such queries and requests have almost doubled in the last couple of years,” she adds."

But Dr Vaneet Kaur, senior consultant and head of the department of obstetrics and gynaecology at SPS Apollo Hospitals, says: “We counsel such women who are afraid of labour pains and condition them to prepare for normal deliveries. Moreover, the normal delivery can also be made a painless experience through epidural analgesia and all they need is a little bit of more knowledge than they already have. Normal deliveries are a natural way of delivery and one should always prefer that.”

My view
Naturally, I don't agree with the idea that all women should share the same delivery preference, but I decided to blog about this article largely because it illustrates that women choosing cesarean delivery is a reality. The issue is not going to go away by pretending it isn't happening and in my opinion, it is unethical to brush aside women's concerns over the unpredictability of vaginal delivery or to dismiss their informed decision to choose cesarean surgery instead.

50% cesarean rate in Canada can't be ruled out, says Dr

I recently came across a September 2008 article on the Vancouver Sun's website, 'Canada's caesarean capital' (a report by Katherine Dedyna on the country's 26% cesarean rate), in which Dr. Jerome Dansereau, chief of obstetrics at the Vancouver Island Health Authority, says he "doesn't rule out the rate going to 50 per cent, given the continuing upward swing. "There is no one who could have predicted what we see today," he says, "and there is no one who can predict when it will stop.""

In the same article, midwife Lyons Richardson says she "won't be surprised if eventually women walk in cold with their first pregnancy and demand a C-section for any reason they want. "Give it 10 years and I don't think it's going to be that unusual.""

Victoria General Hospital is reported to have the highest rate in the country at 37%, and some of the reasons cited by doctors for this are: "older, heavier mothers; increasing numbers of women who don't want to labour long; technology that shows potential fetal problems; mothers who have had previous C-sections returning for a second; and the presence of worried fathers in the labour room."

Luba Lyons Richardson, vice-chairwoman of midwifery at VGH, remarks on a "culture shift in her 30 years of practice. "Women themselves have less tolerance for longer labours, for a baby that's a little bit in distress." ...She knows of women who ask for elective caesarean sections and get them, depending on extenuating circumstances. "That's another debate that rages on. If women have choice, then shouldn't they have that choice?""

Also of interest in the article: "Surgeons in Victoria will do C-sections rather than traumatic forceps delivery. Only 10 per cent or fewer of VGH births involve instruments such as forceps, far lower than the national average of 16 per cent."

The doctors cited in this report do not necessarily agree with prophylactic cesarean delivery with no medical indication, but it is clear that they do not expect to see Canada's cesarean rate being reduced to the WHO's controversial recommendation of 10-15% any time soon.

Monday, February 2, 2009

Top 5 reasons prophylactic elective caesarean delivery with no medical indication is a legitimate decision for informed women

As a speaker at a seminar on cesarean delivery the upcoming 'Controversies in Childbirth' conference in Fort Worth, Texas (March 27, 2009), I was asked to write my 'Top 5 reasons prophylactic elective cesarean delivery with no medical indication is a legitimate decision for informed women', and here they are:

1. There are risks and benefits associated with all birth plans. A healthy spontaneous vaginal delivery (even when desired) is never guaranteed since labor, even with healthy pregnancies, is entirely unpredictable.

2. The oft-quoted risks associated with cesarean delivery frequently refer to emergency surgery or deliveries with pre-existing medical indications. These risks are not the same in healthy pregnancies with delivery at 39 weeks gestation for women planning small families.

3. Birth data compiled in the U.S. does not separate emergency and planned cesareans, only primary and repeat cesareans, which muddles the true assessment of risk as it relates to birth PLAN and the corresponding birth OUTCOME. Research from overseas demonstrates vastly reduced risks with planned surgeries, although we are yet to witness a move towards research that applies emergency cesarean outcomes to the planned vaginal delivery data set, which would be more relevant.

4. The risks (and costs) associated with planned vaginal delivery are grossly underestimated, both in the short- and long-term (in fact long-term risks and costs, financial and psychological, are rarely applied in comparative birth analysis). For example, shoulder dystocia, Erb’s palsy, fetal trauma, neonatal encephalopathy, asphyxiation, intrauterine fetal demise; damage to pelvic floor, POP, sexual health; infant and maternal severe morbidity associated with emergency cesareans; litigation trauma and cost following death or injury.

5. Research has shown high levels of birth satisfaction with planned cesarean delivery and birth trauma websites illustrate high levels of dissatisfaction with planned vaginal delivery. A ‘good birth outcome’ is not commensurate with ‘vaginal delivery for all women’ and genuine birth educators should not make this assumption. For true birth autonomy to exist, cesarean delivery must not be viewed as a second-rate outcome, and at a time in history when maternal and fetal characteristics are leading to more cesarean deliveries (e.g. increased maternal age and obesity; also birth weights), it is not only potentially dangerous to focus on drastically reducing the numbers of ‘unwanted’ surgeries, it is moreover unethical to reduce rates by discouraging or denying those surgeries that are in fact ‘wanted’.