International Cesarean Awareness Network

Education, Support, & Advocacy for Birth Justice & Healing

Misrepresenting the risks of cesarean (again)

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While MSNBC should be commended for it’s recent article on unassisted childbirth, it also joins the ranks of media  misrepresentations of the true risks of cesarean surgery. Here’s a breakdown of the article:

On the growing prevalence of unassisted birth:

The number of home births unattended by either a doctor or a midwife jumped by nearly 10 percent between 2004 and 2006, climbing from 7,607 unassisted births to 8,347 births, according to most recent figures from the National Center for Health Statistics. About 60 percent of the nearly 25,000 home births logged in 2006 were attended by midwives, a figure that experts expect will also rise.

Two women comment on their reasons for choosing unassisted birth:

After giving birth to her first baby in the hospital, Schoenborn, 31, chose to have her next four children at home — by herself. Although her husband was in the house during the births, he didn’t help with the deliveries.

“My hospital births were very managed,” says Schoenborn. “I wanted privacy and to be free of internal exams. I wanted to give birth in an upright position and they want you to lie down. I feel birth is an instinctive process and in the hospital they treat women like they’re broken and birth like an illness.”

And…

For Margulis, the biggest problem in the hospital — and even at home with a midwife — was interference with “normal” labor. When a pregnant woman enters the hospital, Margulis says, she’s signing on for a host of unnecessary interventions, including multiple internal exams, a greatly increased likelihood of receiving the drug oxytocin to speed delivery and also of a Caesarean section.

Margulis’ first baby was born in a hospital and the next two were at home with a midwife. Margulis wasn’t happy with either experience and decided she wanted more control over the process.

After researching the do-it-yourself option, she felt assured the birth process is “safer than taking a shower.”

Margulis cited a recent Canadian study that found giving birth at home with a midwife was about as safe for babies and moms as in a hospital, with the rate of newborn deaths about two per 1,000 for planned home births. The rate of C-sections was a few percentage points higher in hospitals.

The article goes on to discuss the potential risks – unarguably a very important issue. Women considering giving birth in any location with or without a provider should weigh all risks and take responsibility for their choices.

But here is where the report goes astray:

And while women like Margulis and Schoenborn may not like being put on a birthing schedule, experts say there are reasons doctors choose to intervene with oxytocin or a C-section if the labor isn’t progressing fast enough. Among them is the risk of damage to the musculature of the pelvic floor if women strain too long, says Sehdev.

When those muscles are damaged, it weakens the moorings that hold the uterus, the bladder and the bowels in place. The impact of that may not be seen till women hit their 50s and 60s, when the organs can unexpectedly drop down into the vaginal canal.

Really? This is the justification for major abdominal surgery? Hmmm…

While vaginal birth does have consequences for the pelvic floor, it is not a sufficient medical reason for a cesarean. Not only that, but having a cesarean does not ensure protection against pelvic floor damage.

Worse yet, the article also fails to mention the many serious risks associated with cesarean surgery. Here is an excerpt from ICAN’s Cesarean Fact Sheet documenting the risks of cesarean:

A cesarean poses documented medical risks to the mother’s health. These risks include infection, blood loss and hemorrhage, hysterectomy, transfusions, bladder and bowel injury, incisional endometriosis, heart and lung complications, blood clots in the legs, anesthesia complications, and rehospitalization due to surgical complications, rate of establishment and ongoing breastfeeding is reduced, and psychological well-being compromised and increased rate emotional trauma. Potential chronic complications from scar tissue adhesions include pelvic pain, bowel problems, and pain during sexual intercourse. Scar tissue makes subsequent cesareans more difficult to perform, increasing the risk of injury to other organs and the risk of chronic problems from adhesions. One-half of all women who have undergone a cesarean section suffer complications, and the mortality rate is at least two to four times that of women with vaginal births. Approximately 180 women die annually in the United States from elective repeat cesareans alone.

Not to mention…

Each successive cesarean greatly increases the risk of developing placenta previa, placenta accreta and placental abruption in subsequent pregnancies. Both of these complications pose life-threatening risks to mother and baby. Cesareans also increase the odds of secondary infertility, miscarriage and ectopic pregnancy in subsequent pregnancies.

Oh, and the risks to babies:

A cesarean poses documented medical risks to the baby’s health. These risks include respiratory distress syndrome (RDS), iatrogenic prematurity (when surgery is performed because of an error in determining the due date), persistent pulmonary hypertension (PPH), and surgery-related fetal injuries such as lacerations. Preliminary studies also have found cesarean delivery significantly alters the capability of cord blood mononuclear cells (CBMC) to produce cytokines. An elective cesarean section significantly increases the risk to the infant of premature birth and respiratory distress syndrome, both of which are associated with multiple complications, intensive care and burdensome financial cost. Even with mature babies, the absence of labor increases the risk of breathing problems and other complications. Far from doing better, even premature and at risk babies born by cesarean fare worse than those born vaginally.

No wonder more mamas are thinking twice about giving birth in hospitals where rates of intervention and cesarean are so high! Surely more families would consider the risks and benefits of any location for birth, if only the media (and providers) would accurately report them.

Guest Blog – Henci Goer: Does Elective Cesarean Surgery Improve Newborn Outcomes in Ultra-Low-Risk First-Time Moms?

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Bringing ICAN’s 25-year-plus tradition of support and education in the mother-to-mother and sister-to-sister model into the internet age, we have invited passionate bloggers to join us around our virtual circle of women. We hope to introduce you to new voices that you have not heard before, and also to respected voices that will already be well-known to you.

Today we welcome Henci Goer is an award winning medical writer and speaker. She has published two books: The Thinking Woman’s Guide to a Better Birth and Obstetric Myths Versus Research Realities (a new edition of which is in press).

Krista Cornish Scott, ICAN’s education director, asked me take a look at a study she found on one of the pro-cesarean websites, and I was happy to oblige.

Dahlgren LS, von Dadelszen P, Christilaw J, et al. Caesarean section on maternal request: risks and benefits in healthy nulliparous women and their infants. J Obstet Gynaecol Can 2009;31(9):808-17.

Abstract
Objective: To determine the risks and benefits of an elective Caesarean section (CS) at term in healthy nulliparous women. Methods: We conducted a population-based cohort study of deliveries between 1994 and 2002. Using bivariate and multivariable techniques, we compared maternal and neonatal outcomes in healthy nulliparous women who had undergone elective pre-labour CS (using breech presentation as a surrogate) with those in women who had undergone spontaneous labour with anticipated vaginal delivery (SL) at full term.

Results: There were 1046 deliveries in the pre-labour CS group and 38 021 in the SL group. Life-threatening maternal morbidity was similar in each group. Life-threatening neonatal morbidity was decreased in the CS group (RR 0.34; 99% CI 0.12 to 0.97). Subgroup analysis of the SL group by mode of delivery demonstrated the increased neonatal risk was associated with operative vaginal delivery and intrapartum CS but not spontaneous vaginal delivery.

In the discussion section the authors write of the gap in neonatal morbidity:

We do not suggest it is necessarily the mode of delivery itself causing the neonatal  morbidity. The increased morbidity observed in these groups is likely associated with the indication for the operative vaginal delivery or intrapartum CS.

and they conclude:

Further research is needed to better identify women with an increased likelihood of an operative vaginal delivery or intrapartum Caesarean section, as this may assist pregnancy caregivers in decision-making about childbirth.

This was disconcerting. Several of the authors are researchers whose work I know and respect, and, until this study, their work supported physiologic care. Why is this study not like their others? What happened here?

What happened was an illustration of how medical model thinking can unconsciously bias even good researchers. These investigators assembled an ultra-low-risk group of nulliparous women (term, singleton, head down baby, no medical complications, spontaneous labor onset), found that only 63% had a spontaneous vaginal birth (22% had an instrumental vaginal delivery and 15% had a cesarean, of which 2% also had an attempt at instrumental delivery), and assumed this appalling statistic had to be due to problems originating in the women. I beg to differ; my first thought was, “What an indictment of medical model management!”

The authors may dismiss the idea, but typical obstetric management such as epidural analgesia, continuous electronic fetal monitoring, and preset time limits for making progress are known to inflate instrumental and cesarean delivery rates or both, and serious neonatal complications can result from labor management, for instance, as Amy Romano and I will document in the new edition of Obstetric Myths Versus Research Realities, I.V. fluid overload can cause overly rapid breathing (transient tachypnea), narcotics cause need for resuscitation, high-dose oxytocin (AKA “active management of labor”) can cause seizure, instrumental vaginal delivery can cause intracranial hemorrhage. In fact, with physiologic care, maternal outcomes might have looked better too. For example, 6% of the women suffered anal sphincter lacerations, 5% with spontaneous vaginal birth and 15% with instrumental delivery. With optimal care, that number could have been 2% . Instead of looking for hidden defects in healthy first-time mothers, I say let’s look at defects in their care providers. Numerous studies of practice variation, including some done by some of these very same researchers, document that the best way to “decrease likelihood of an operative vaginal delivery or intrapartum Caesarean section” is to choose a care provider with a high spontaneous vaginal birth rate. To quote Childbirth Connection’s critique of the 2006 NIH conference on elective first cesareans, “We should not be asking healthy women to choose between vaginal birth with avoidable harms and birth by major abdominal surgery.”

The study also has another major problem: while we have 38,000 women in the spontaneous labor onset group, we have only 1050 women in the cesarean group, far too few to show differences in occurrence of severe or life-threatening morbidity. The rare, surgery-related catastrophe is a crucial consideration when performing elective surgery on a healthy woman. For example, a U.S. study of millions of babies found that elective cesarean was associated with an excess neonatal mortality rate of about 1 in 1000. Comparing 1050 planned cesareans with 38,000 planned vaginal births is like comparing 1050 smokers to 38,000 nonsmokers and deciding smoking is OK because analysis didn’t find differences in lung cancer or emphysema, when moreover, as already noted, all of the nonsmokers were exposed to second-hand smoke. And this is without considering, as the study authors themselves acknowledge, that the first cesarean increases risks in future pregnancies and births. To repeat, the no-risk strategy is not to cherry pick candidates for vaginal birth, but to institute care that supports the natural process and intervene medically only when lesser measures have failed and the benefits of intervening clearly outweigh the risks.

To give them their due, investigators have done a fine job collecting and analyzing their data, but as Hall and Menticoglou write, “One of the most influential biases in the acquisition of evidence is choice of the question, and the best evidence in answer to the wrong question is useless” (p. 488). I contend that “What are the benefits of performing major surgery on healthy women?” is the wrong question.

Finally, OT, but another example of how the medical model distorts thinking, in the process of justifying why elective cesarean for breech is a good proxy for elective cesarean at maternal request, the authors write, “Since the results of [the Term Breech Trial] were published, 87% to 97% of women throughout the world have chosen CS for delivery of a breech-presenting infant,” which they immediately follow by, “In Canada, the percentage of physicians offering vaginal breech delivery decreased from 84% before the trial to 14% after the trial.” Newsflash: you can’t be said to make a choice when you only have one option.

***

Henci and Amy Romano are in the final stages of completing the manuscript for a top-to-bottom new edition of Obstetric Myths Versus Research Realities, to be published by University of Michigan Press. Look for it late in 2010. In the meantime, you can find Henci at her “Ask Henci” forum and Amy at her blog, Science and Sensibility.

VBA2C Safe as Repeat Cesarean, Research Finds

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Most women who have had more than one cesarean are told that a repeat cesarean is the safest choice for their births. Many are not even offered the option by their doctors or hospitals.

Not so, according to recent research published in the British Journal of Obstetrics & Gynecology (BJOG). A systematic review and meta analysis of the medical research on vaginal birth after two cesareans (VBA2C) found that there is no statistically significant difference in key maternal and infant outcomes between VBA2C and repeat cesarean (RCS).

According to the study’s authors Samina Tahseen and Malcolm Griffiths, “Comparing VBAC-2 versus RCS, the hysterectomy rates were 0.40% versus 0.63% (P = 0.63), transfusion 1.68% versus 1.67% (P = 0.86) and febrile morbidity 6.03% versus 6.39%, respectively (P = 0.27). Maternal morbidity of VBAC-2 was comparable to RCS. Neonatal morbidity data were too limited to draw valid conclusions, however, no significant differences were indicated in VBAC-2, VBAC-1 and RCS groups in NNU admission rates and asphyxial injury/neonatal death rates (Mantel–Haenszel).”

Such findings should be encouraging to women who want to attempt VBA2C. For more evidence-based information on VBAC after multiple cesareans, click here.

Best of the Birth Blogs – Week Ending August 23rd

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Your weekly one-stop for highlights from the birth blogosphere. Visit weekly for the latest on childbirth, especially related to cesarean prevention, recovery, and VBAC. To nominate a blog post to be featured here, email me at blog@ican-online.org

Henci Goer (Science & Sensibility) – ACOG’s 2009 Induction Guidelines: Spin Doctoring Misoprostol (Cytotec): Award-winning medical writer Goer breaks down the facts about Cytotec in response to ACOG’s new guidelines. Bottom line: “…Cytotec’s real benefits are convenience for obstetricians and helping the hospital’s bottom line. For women and babies, though, it’s a roll of the dice. Most times things go fine, but sometimes the dice come up snake eyes.”

VBAC Facts – Lightning Strikes, Shark Bites and Uterine Rupture: Despite the appeal of statistics showing that women are more likely to be bit by sharks or struck by lightning than to have a uterine rupture, Jen shows why such comparisons are misleading and misinforming birthing women. Bottom line: If is sounds too good to be true, check the stats before you forward them on.

REBIRTH – Being Pushed: An L&D nurse/CNM reflects on how birthing women may often make choices so as not to inconvenience medical practitioners, as in one woman’s undergoing a repeat cesarean despite being an excellent candidate for VBAC.

Dr. Fischbein – Friday Meeting –  My Take: advocate of the midwifery model of care and obstetrician Stuart Fischbein, MD shares about his battle to preserve a woman’s right to VBAC in Southern California.

Patti Ramos – Pain…: Birth doula and photographer Patti Ramos provides a perfect picture of what makes it all worth it – “Pain is no longer pain when it is past.”

Are Mothers Driving Up the Cesarean Rate?

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A report on Enterprisenews.com would have us all believe that the cesarean rate in the U.S. is being driven in some significant way by mothers demanding elective cesareans with hapless obstetricians following their orders.

 

But is this true?

 

While the Enterprise article cites the experiences of medical personnel in one Massachusetts city, researchers who have looked systematically at the (little) available scientific evidence say otherwise.

 

Eugene Declercq, principal investigator on the only nationally representative study to-date that directly surveyed mothers about their birth experiences, states that “far less than one-percent of mothers who had a first cesarean had requested it.”

 

Declercq goes on to say that “although there are undoubtedly some women who do seek elective caesareans, they are hardly enough to increase the number of caesareans by 400,000 nationally since 1996.” Such assertions about maternal request may make for sensational media coverage, but they hardly reflect the reality of cesarean sections in the U.S.

 

So, what is causing the rise in the c-section rate nationwide?

 

A number of factors are contributing to the rise, not the least of which is changes in obstetrical practice. Rather than simply following the wishes of their patients, it seems that how obstetricians practice medicine is a decisive factor. Says Declercq, the advent of group OB practices, concerns for malpractice suits, and the ease of scheduling cesareans all appear to be more significant factors in the rising cesarean rate than maternal choice.

 

The stakes in this trend are high. Overall, the risks of cesarean section are higher for mothers than vaginal birth. As ICAN’s statement on patient choice cesarean states,

 

“The International Cesarean Awareness Network opposes the use of cesarean section where there is no medical need. Birth is a normal, physiological process. Cesarean section is major abdominal surgery which exposes the mother to all the risks of major surgery, including a higher maternal mortality rate, infection, hemorrhage, complications of anesthesia, damage to internal organs, scar tissue, increased incidence of secondary infertility, longer recovery periods, increase in clinical postpartum depression, and complications in maternal-infant bonding and breastfeeding, as well as risks to the infant of respiratory distress, prematurity and injuries from the surgery.”