Monday, June 02, 2008

Elective C-sections are better for babies

This is a very bad week for homebirth advocacy and "natural" childbirth advocacy. Many central (and unsubstantiated) claims are being systematically demolished by newly published scientific studies and data.

In the past week alone, I have written about the fact that obstetricians want C-sections for themselves, that many women want a C-section after having a vaginal birth, and that birth centers and homebirth don't save very much money. In addition, late prematurity is rising because of deliberate early C-section delivery for pregnancy complications, and the perinatal mortality rate has fallen at the same time. Most importantly, newly released data from the National Center for Health Statistics shows that homebirth with a direct entry midwife is the most dangerous way to have a baby in the US (short of no medical attendant at all).

Now comes new evidence that elective (maternal request) C-sections are better for babies than waiting for labor to begin spontaneously. Homebirth and "natural" childbirth advocates have pointed to the increased risk of self-limited respiratory morbidity as a reason to avoid C-section. However, when all outcome data are assembled, it seems that the trade-off for increased risk of self-limited respiratory problems is a large decline in perinatal mortality.

The article Neonatal Morbidity and Mortality After Elective Cesarean Delivery by Signore and Klebanoff appears in the June special issue of Clinics in Perinatology focussing on the epidemiology and neonatal effects of C-section. The authors conducted a decision analysis
modeling the probability of perinatal death among a hypothetical cohort of 2,000,000 women who had uncomplicated pregnancies at 39 weeks, half of whom underwent ECD and half managed expectantly. After taking multiple chance probabilities into account, the model estimated that although neonatal deaths were increased among women delivered by elective cesarean, overall perinatal mortality was increased among women managed expectantly, because of the ongoing risk for fetal death in pregnancies that continue beyond 39 weeks.

The authors found:
Elective cesarean
at 39 weeks
Expectant management
Perinatal deaths8041496
Neonatal deaths804378
Respiratory morbidity11,0002524
Intracranial hemorrhage4901007
Brachial plexus injury410787
Suspected sepsis20,00033,211
Confirmed sepsis02635

In other words, if 1 million women underwent C-section at 39 weeks instead of waiting for onset of labor and attempting vaginal delivery, 692 more babies would be saved, 517 cases of intracranial hemorrhage and 377 brachial plexus injuries would be prevented. In exchange, there would be 8476 additional cases of short term respiratory problems, 5536 neonatal lacerations, and 2212 additional cases of postpartum hemorrhage.

The authors conclude:
... Elective repeat CD rates have been increasing steadily since the late 1990s, and there may be a growing trend in CDs on maternal request... [E]xisting data suggest that ECD is associated with greater risk for neonatal respiratory morbidity and fetal laceration and potentially decreased risk for brachial plexus injury, neonatal sepsis, intracranial hemorrhage, intrapartum asphyxia, and neonatal encephalopathy. Although neonatal deaths may be increased among infants delivered via elective cesarean, overall perinatal mortality may be reduced because of prevention of antepartum stillbirths. To minimize potential neonatal risks in ECDs, these deliveries should not be undertaken before 39 weeks’ gestation. Patients considering ECD should be made aware of available data on potential risks and benefits to fetus and neonate. Further research is needed to inform these discussions.
We already know that C-section is lifesaving for babies and mothers experiencing complications. It now appears that elective C-section also saves lives.


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