Wednesday, August 09, 2006

How many C-sections is one baby worth?

In the last century, neonatal mortality dropped by over 90%. As expected, initially the drop in mortality was quite steep as technology such as antibiotics and blood banking were introduced. Also, as expected, in recent years, the rate of change has been much smaller. No one thinks that we have yet achieved the lowest possible number of neonatal deaths and we are still trying to lower the mortality rate further. As a consequence, more and more technology is brought to bear with progressively more modest results.

That's partly how we find ourselves in the current situation with a C-section rate that everyone agrees is too high, but without any idea what the optimal C-section rate is. In other words, there is no doubt that more C-sections are being done than necessary, but no idea which are the unnecessary ones.

Most homebirth studies tout the low intervention rates and claim that morbidity is valid measure of safety along with mortality. However, the existing homebirth studies appear to show a trade-off. The price for lower intervention rates appears to be an increase in preventably neonatal deaths. That raises the difficult question: how many excess interventions is the life of a baby worth?

Take the Janssen study, Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia, for example. The hospital group has far more C-sections than the homebirth group, and, in hindsight, many of those C-sections were probably unnecessary. Yet the hospital group has a no neonatal deaths and the homebirth group has two deaths. That result is not surprising when you consider that the hospital group had no babies that required prolonged ventilator assistance (greater than 24 hours), but the homebirth group had 5 babies that required prolonged ventilator assistance.

The authors trumpet the low C-section rate in the homebirth group (6.4%) compared with the physician group (18.2%) or the midwife comparison group (11.9%). Evidentally, though, that low C-section rate came at a high price: two dead babies. In the homebirth group, 55 women had C-sections. If the C-section rate in the homebirth group had matched that of the physician group, possibly 110 additional women would have had C-sections of which 108 would have been unnecessary in hindsight.

So here's my question: was it worth it to avoid 108 potentially unnecessary C-sections if 2 babies died as a result? How many unnecessary C-section would be acceptable to save the life of a baby?

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