Sunday, March 30, 2008

Vaginal delivery dramatically increases risk of bladder and bowel problems

You might be suprised to learn that an article in the most recent issue of the journal Birth, a journal noted for its condemnation of C-sections and its support for homebirth, found that vaginal delivery dramatically increases the risk of both bladder and bowel problems after birth compared to C-section. Of course, you probably won't be suprised to learn that information is buried within the study and not even mentioned in the conclusion. Instead, the authors, who have repeatedly publicly denounced the rising C-section rate, chose to focus on the amount of postpartum pain.

Let's take a close look at the study Mothers’ Reports of Postpartum Pain Associated with Vaginal and Cesarean Deliveries: Results of a National Survey. The entire article is available for free. The study is a based on information collected for the Listening to Mothers Survey II. Interestingly, it suffers from the same problem as the main study, the authors fail to listen to mothers.

The authors asked women 8 questions about post delivery problems that fall into four major groups: pain, infection, bladder/bowel/sexual function, and exhaustion. In this paper, the authors chose to emphasize the differences in post delivery pain between women who had a C-section vs. those who had a vaginal delivery. Not suprisingly, the women who had a C-section experienced more post delivery pain than those who had a vaginal delivery. The authors present this as a remarkable finding that should be shared with all pregnant women to discourage them from choosing an elective primary C-section.

The authors blithely ignore a much more serious set of problems, presumably because it does not make the point that they wished to make. This more serious set of problems include bladder, bowel and sexual problems after delivery. I've extracted those results from Table 2. I've also changed the chart to show relative risk of problems as opposed to simple percentages. Below you can see the result:

Compared with women who had a C-section, women who had a spontaneous vaginal delivery had a 50-100% increase in bladder problems and painful sexual intercourse. The relative risk was even higher for women who had assisted vaginal deliveries. Compared to women who had a C-section, women who had an assisted vaginal delivery had a 100-200% increased risk of bowel problems.

Moreover, the authors make no attempt to determine how the patients perceive the relative importance of their postpartum problems. The authors emphasize the increase in incisional pain, but they do not ask the women whether they considered incisional pain to be as serious and distressing a problem as bladder or bowel dysfunction, or painful intercourse. Quoting from the abstract:
Results: The most frequently cited postpartum difficulty was among mothers with a cesarean section, 79 percent of whom reported experiencing pain at the incision in the first 2 months after birth, with 33 percent describing it as a major problem and 18 percent reporting persistence of the pain into the sixth month postpartum. Mothers with planned cesareans without labor were as likely as those with cesareans with labor to report problems with postpartum pain. Almost half (48%) of mothers with vaginal births (68% among those with instrumental delivery, 63% with episiotomy, 43% spontaneous vaginal birth with no episiotomy) reported experiencing a painful perineum, with 2 percent reporting the pain persisting for at least 6 months. Conclusions: Substantial proportions of mothers reported problems with postpartum pain. Women experiencing a cesarean section or an assisted vaginal delivery were most likely to report that the pain persisted for an extended period.
The discussion section of the paper takes up more than 2 pages and includes sections on fear of pain in vaginal birth, pain after delivery, and clinical implications of pain after delivery. The authors don't even bother to discuss bladder dysfunction, bowel dysfunction or painful intercourse as complications of vaginal delivery. These were not rare problems in the study. More than 25% of women who had a vaginal delivery had at least one of these problems, yet the authors chose to ignore them.

The authors make the assumption that women who choose elective C-section do so because of fear of pain. Since the authors strongly disapprove of elective C-section, they write:
Perhaps, with all the focus on labor pain, they simply do not consider the challenges associated with postpartum recovery from abdominal surgery. This disconnect between labor pain and postpartum pain was characterized by one mother who, in response to an open-ended question, stated the following, "I would much rather have the day of labor pain than the weeks of recovering from major surgery with a newborn to take care of. With my first daughter I labored for 21 hours of back labor and looking back that was a piece of cake compared to recovering from surgery." As the cesarean rate continues to grow, further research is needed into mothers’ perceptions of the pain of labor and postpartum pain associated with cesarean and vaginal birth. Until then, when doctors and midwives discuss alternative methods of delivery, they should listen carefully to mothers and develop an understanding of their expectations of postoperative pain and labor pain to address their specific concerns.
I do not approve of the rising C-section, and when I was practicing, I refused to perform purely elective C-sections. Nonetheless, I find papers like this extremely disturbing because of their blatant bias, transparent attempt to manipulate women, and unwillingess to address the real and serious complications that can occur after vaginal birth. Frankly, I find the high incidence of bladder, bowel and sexual difficulties after vaginal delivery reported in this paper concerning and worth of further investigation. The fact that authors never bothered demonstrates that they are not interested in "listening to mothers"; they are only interested in manipulating women with incomplete information about the risks and benefits of C-section.

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By Anonymous Anonymous, at 5:05 PM