Monday, December 24, 2007

Letter to the BMJ

At the end of October I wrote about a new BMJ study that inaccurately claims that elective C-section increases the risk of neonatal death (New BMJ study shockingly misleading. The authors of the article,Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study, claim:
Women undergoing caesarean deliveries, either intrapartum or elective ... had double the risk for severe maternal morbidity and mortality (including death, hysterectomy, blood transfusion, and admission to intensive care) and up to five times the risk of a postpartum infection compared with women undergoing vaginal delivery.
Based on the conclusion of the study itself, you might be forgiven for thinking that the study showed that elective C-sections resulted in higher maternal or neonatal mortality or morbidity. It doesn't show that. Why? Because the authors chose to call all non-emergency cesareans (regardless of the medical indication) "elective". They never even looked at maternal request cesareans or medically unindicated cesareans.

I wrote a rapid response to the BMJ on exactly this point. It was published on the web in the rapid response section, and it has been published in the December 15 print edition of the BMJ:
In her rapid response, Amy B Tuteur, an obstetrician from Massachusetts, argues that the definition of elective is misleading in the study by Villar et al.1 2 "The study compares women who had vaginal deliveries with women who had medically indicated caesarean sections, both non-emergency and emergency. It never investigated elective caesareans and therefore it reaches no conclusions about them."
The original rapid response elaborates:
According to Table 1, among the 13,208 "elective" cesareans: repeat C -section 46.1%; breech 14.2%; pre-existing medical conditions 9%; complication of current pregnancy 40.2%.

As the authors acknowledge:

"... [this] group had higher risk in terms of women with previous complicated pregnancies or perinatal outcomes, problems related to current pregnancy, and being referred from other institutions for delivery..."

This study show that cesarean section reduced the risk of neonatal death, particularly for breech babies. There was a slightly increased risk of maternal death in women undergoing emergency cesarean, but there was no significant difference in maternal death between vaginal delivery and non- emergent medically indicated cesarean. No conclusions can be reached about cesareans done without a medical indication.
This is yet another example of why it is important to read the study itself, not just the authors' conclusions, and certainly not the media's interpretation of the study. Sometimes the authors reach a conclusion that is not supported by the data in the study.

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