Thursday, July 29, 2010

Worrying mahurat cesarean trend in India

'Are you planning a mahurat C-section?' asks Zeenia Baria in The Times of India today.

Baria reports on a worrying trend for some planned cesareans in India, and that is the decision by couples to insist on a particular time and date for the birth of their babies. It's unclear from the report whether parents are being influenced within days or weeks of their advised delivery date, but if it's the latter, this can mean serious health consequences for a newborn baby (e.g. respiratory distress).

"Obstetrician, Gynaecologist and infertility specialist Dr Faram Irani says... “Unlike the West where women request for a c-section because of the pain associated with vaginal birth or fear of damage to the pelvic floor; in India many c-sections are performed on the basis of mahurat..."

What do they hope to achieve?
"Longevity, health, marital harmony, career prospects, eclipses and domestic peace of the offspring are the biggest motivators for such couples. The astrologer formulates the most auspicious time for delivery after asking the would-be parents for the tentative delivery dates, place, time zone and DST (daylight saving time). Due to the astrological factors involved, the mahurat differs for every couple. Although they cost more than double, deliveries at sunrise are among the most auspicious."

"Gynaecologist Dr Rishma Pai Dhillon says that the trend of having mahurat babies or a planned caesarean section on an auspicious date, is getting increasingly popular among patients and is giving doctors a headache because it comes with its share of complications.

“I recently had to rush to the hospital at an unearthly hour to deliver a mahurat baby. If one refuses, one is flooded with phone calls from senior politicians and affluent bureaucrats to oblige. Mahurat babies or mahurat c-section is a controversial trend that middle and upper class women across the country are increasingly opting for. It involves planned deliveries and surgical caesarean sections in the hopes of having babies on a specific date and time predicted lucky by their astrologers. Families are so particular about the exact time of delivery that they create a ruckus if the previous surgeon is delayed in the operation theatre. This puts tremendous stress on doctors. It isn’t fair to hurry up such a delicate procedure,” she says.

“The reasons for having a mahurat baby are often credulous. One patient’s astrologer said that if her child was delivered at the right time, it would be a fair-skinned boy, who would look after his parents in their old age. How can the time of delivery change a baby’s gender, which is decided at conception itself!” asks Dr Pai.

Saturday, July 24, 2010

ACOG's motivation for new VBAC guidelines disappoints

The news that obstetricians at ACOG have published less restrictive guidelines for VBAC is good news for women that desperately want to avoid repeat cesarean surgery and who feel that their decision to plan a trial of labor is neither respected - or in many cases, and particularly in American hospitals, allowed.

But now for the not so good news...

First of all, I suggest that you read ACOG's press release for yourself, and then come back to read my thoughts on some of its contents, below.

ACOG PR: "Attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans..."

*Just a small observation I've made while perusing much of the media and blog reporting of this story - the number of headlines and bylines that have dropped the crucial word "most" from the sentence above. This is a very dangerous interpretation of what ACOG has said.

ACOG PR: "The cesarean delivery rate in the US increased dramatically over the past four decades, from 5% in 1970 to over 31% in 2007. Before 1970, the standard practice was to perform a repeat cesarean after a prior cesarean birth. During the 1970s, as women achieved successful VBACs, it became viewed as a reasonable option for some women. Over time, the VBAC rate increased from just over 5% in 1985 to 28% by 1996, but then began a steady decline. By 2006, the VBAC rate fell to 8.5%, a decrease that reflects the restrictions that some hospitals and insurers placed on trial of labor after cesarean (TOLAC) as well as decisions by patients when presented with the risks and benefits."

*It is important to remember that many women prefer to have a repeat cesarean, and are more than happy not to plan a VBAC, and their birth plan decision should not be refused or disrespected in this attempt to "swing the pendulum back".

ACOG PR: "The current cesarean rate is undeniably high and absolutely concerns us as ob-gyns," said Richard N. Waldman, MD, president of The College. "These VBAC guidelines emphasize the need for thorough counseling of benefits and risks, shared patient-doctor decision making, and the importance of patient autonomy. Moving forward, we need to work collaboratively with our patients and our colleagues, hospitals, and insurers to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate."

*I find it disappointing and indeed disconcerting that 'more reasonable rates' has even been mentioned in the context of patient autonomy here. What is a 'more reasonable' rate of VBAC? And perhaps more importantly, what is considered a reasonable rate of TOLAC? A 25-year-old argument over the optimum percentage rate of cesarean deliveries came to a head last year when the WHO admitted that there is no evidence for one, so who's got the answer to the 'right number' of VBACs and TOLACs?

I think that if, instead of target rates, we let patient autonomy (where patient autonomy is requested - remember, there are many women who are more than happy to be guided and advised by their doctor or midwife, with no personal delivery preference either way) take a greater role in maternity care... if we provide women with the risks and benefits and let them decide which birth plan they prefer... if assessment of birth outcomes includes maternal satisfaction... then the rates will fall where they will, and more women and babies will be happier and healthier for it.

ACOG PR: "In making plans for delivery, physicians and patients should consider a woman's chance of a successful VBAC as well as the risk of complications from a trial of labor, all viewed in the context of her future reproductive plans," said Dr. Ecker. Approximately 60-80% of appropriate candidates who attempt VBAC will be successful."

*This is important to understand. Approximately 60-80% of appropriate candidates will have a successful VBAC. This means that approximately 20-40% will be unsuccessful - a risk many women are not comfortable with.

And when ACOG's statement is misinterpreted by stating that VBAC might be safe for all women, it completely ignores the fact that the cited 60-80% success rate is ONLY for women firstly established as appropriate candidates. The success rate if all women with previous cesareans were included is much lower.

ACOG PR: "The risk of uterine rupture during a TOLAC is low - between 0.5% and 0.9% - but if it occurs, it is an emergency situation. A uterine rupture can cause serious injury to a mother and her baby. The College maintains that a TOLAC is most safely undertaken where staff can immediately provide an emergency cesarean, but recognizes that such resources may not be universally available.

"Given the onerous medical liability climate for ob-gyns, interpretation of The College's earlier guidelines led many hospitals to refuse allowing VBACs altogether," said Dr. Waldman. "Our primary goal is to promote the safest environment for labor and delivery, not to restrict women's access to VBAC."

Women and their physicians may still make a plan for a TOLAC in situations where there may not be "immediately available" staff to handle emergencies, but it requires a thorough discussion of the local health care system, the available resources, and the potential for incremental risk. "It is absolutely critical that a woman and her physician discuss VBAC early in the prenatal care period so that logistical plans can be made well in advance," said Dr. Grobman. And those hospitals that lack "immediately available" staff should develop a clear process for gathering them quickly and all hospitals should have a plan in place for managing emergency uterine ruptures, however rarely they may occur, Dr. Grobman added.

*In summary, it appears that the criteria for a TOLAC/VBAC birth plan has changed from requiring the availability of "immediate" emergency care for the laboring women, to that which is "quickly gathered".

The change of wording here is worthy of a blog post all of its own, but I mention it here because what happens in the inevitable cases of uterine rupture emergencies is crucial, and I think that while ACOG has done well to address the fundamental issues of insurance and litigation, questions remain.

How do we remove doctors' fears of being sued when a TOLAC fails? Do insurers now agree with ACOG that 'quickly gathered' emergency care is sufficient duty of care? Will women be asked to sign a waiver stating that they are fully aware of the risks of uterine rupture and its possible consequences? There are no easy answers to all this, and again, while helping women gain access to wanted VBACs is commendable, ACOG's statement might have provided more in the way of broadening discussion of these, and other, continuing challenges.

ACOG PR: The College says that restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC. On the other hand, if, during prenatal care, a physician is uncomfortable with a patient's desire to undergo VBAC, it is appropriate to refer her to another physician or center."

*As mentioned above, I applaud ACOG's efforts to help women who feel they are being given no choice when it comes to VBAC versus a repeat cesarean, but I just wish that this was the sole focus of its statement, with nothing said about the shared desire to swing the pendulum back on percentage rates. Has it occurred to anyone that when women are informed about the risks and benefits of VBAC, the number of women that actually choose VBAC may not swing the pendulum back as far as some may imagine? I guess only time will tell.

Thursday, July 22, 2010

BMJ Letter published: Planned Cesarean Delivery Benefit

My letter, published in the British Medical Journal on 22nd July 2010, was in response to the publication: 'Time of birth and risk of neonatal death at term: retrospective cohort study', by Dharmintra Pasupathy, Angela M Wood, Jill P Pell, Michael Fleming and Gordon C S Smith.

It says:

"The unpredictability of planned vaginal delivery or a trial of labor (i.e. the possibility of assisted delivery and/or emergency surgery) is one of the reasons often cited by women who decide to deliver their babies by planned cesarean.

This study illustrates that the unpredictable nature of the delivery outcome itself (and any associated morbidity or mortality) is not the only risk these women seek to avoid. The unpredictability of the quality of care available at different hours of the day and night when women arrive at hospital in labor is another risk they do not wish to take, especially when this might impede the safe and healthy arrival of their baby.

The 'convenience' of scheduling a time and date for maternal request cesarean delivery is sometimes criticized as an irresponsible benefit of surgery, but when looked at from the perspective of this study (and others like it), there is clearly a legitimate benefit involved in knowing exactly who will deliver your baby and when, and it has nothing whatsoever to do with convenience."

Saturday, July 10, 2010

NICE decides to review Maternal Request Cesareans

As you know, NICE (The National Institute for Health and Clinical Excellence) is currently reviewing its 2004 Clinical Guideline on Caesarean Delivery, and on Thursday 8th July, it published the Final Scope of what will be reviewed.


The NICE guideline on Maternal Request Cesareans is to be reviewed.
The draft scope, published earlier this year, had excluded Maternal Request as an area requiring review, but a number of Stakeholder organizations (including urged NICE to reconsider at a meeting in London, and followed up with the submission of reasons and evidence to support their position.

The Final Scope reads:

"c) The original caesarean section guideline addressed issues relating to maternal request including the prevalence of request, fear of childbirth and how obstetricians should respond to such requests. In the light of new evidence and a strong concern amongst stakeholders that this area needs to be re-examined this topic will be addressed in the update."

Also now being included is a much-needed update of a table in the 2004 guideline that compared the risks of vaginal and cesarean delivery:

"d) A great deal of support has been expressed by stakeholders for the usefulness of Table 3.1 in the original guideline summarising risks and benefits of caesarean section vs. vaginal birth. Given that this table is often used as the basis of information given to women and underpins informed consent there is a need to ensure this information is as accurate and up to date as possible and therefore it will be included in the update."

Unfortunately, I was not successful in my application to be one of the Guideline Development Group (they will now review all the latest evidence and prepare the new guideline for publication), but I genuinely hope that it takes this opportunity to look at maternal request cesarean delivery with the Stakeholders' comments and concerns in mind.

Again, you can read these in detail here.

Thursday, July 1, 2010

BMJ Letter published: Homebirth versus elective caesarean risks

My letter, published in the British Medical Journal on 4th July 2010, was in response to the publication: 'Study shows higher rates of neonatal mortality with planned home births', by Susan Mayor.

It says:

The findings in this study, that planned home birth increases a baby's (albeit very small) risk of dying compared with a hospital birth plan, has received a great deal of media attention, and numerous medical professionals and birth groups have spoken out to defend home birth legitimacy and advocacy in the UK.

Surely then, particularly in light of studies such as this one published in Canada last year, 'Caesarean section on maternal request: risks and benefits in healthy nulliparous women and their infants' by LS Dahlgren et al, which found that an elective pre-labour caesarean delivery in a nulliparous woman at full term "decreased the risk of life- threatening neonatal morbidity compared with spontaneous labour with anticipated vaginal delivery", it is time to review current attitudes towards caesarean delivery on maternal request.

This Canadian study included almost 40,000 births, and even though the comparison used breech presentation as a healthy elective caesarean surrogate (which is arguably a more complicated delivery than a cephalic- presenting fetus) to compare with the healthy onset spontaneous labour group, the caesarean group's babies still had better outcomes.

Similarly an American study, also based on intent to deliver and not just actual delivery, 'Maternal Outcomes Associated with Planned Vaginal Versus Planned Primary Cesarean Delivery’ by EJ Geller et al, found that planned caesarean delivery had less chorioamnionitis (2.2% versus 17.2%), postpartum hemorrhage (1.1% versus 6.0%), uterine atony (0.6% versus 6.4%), and prolonged rupture of membranes (2.2% versus 17.5%) for the mother but a longer hospital stay (3.2 versus 2.6 days). There were no differences in transfusion rates.

If a healthy woman's maternal request to give birth at home is acceptable, then given the (two examples of) improved outcomes cited above, her request for a prophylactic caesarean delivery at 39+ weeks should be acceptable too."

News reports on the study that week included:

*01 July Home births are good for mothers but riskier for babies, says study, The Guardian
Breathing problems and failed resuscitation blamed for increased risk, with experts recommending two midwives for deliveries

*01 July Home birth risks under scrutiny, BBC News

BBC reports on the WHO's lack of cesarean rate evidence

Should there be a limit on Caesareans? asks Philippa Roxby, a BBC online Health reporter.

"The World Health Organization has dropped its recommendation that fewer births be carried out by Caesarean section, saying there was no evidence for a limit.

The WHO had previously advised that no more than 10 to 15% of babies be delivered by section, a figure often cited by those concerned about rates in the UK - where one in four babies comes into the world in this way.

But now the WHO states that "there is no empirical evidence for an optimum percentage" and stresses that "what matters most is that all women who need Caesarean sections receive them".

Yet in the NHS, doctors, hospitals and midwives have been under pressure to persuade women to give birth naturally. So should there be less pressure on women to avoid surgical intervention?" Read the full article here.