Cesarean section as a narcissistic injury
Narcissistic injury is a term from psychoanalysis. A narcissist in psychoanalytic theory is different from our colloquial use of the word. Rather than being a person who is obsessed with herself, a narcissist is a person who suffers a deep sense of inferiority and masks it by projecting an air of grandiosity and excessive self regard. A narcissistic injury occurs when reality threatens the narcissist's carefully constructed facade of perfection.
In reading the work of homebirth and natural childbirth advocates, I am repeatedly struck by the assumption that a not having an uncomplicated vaginal birth is viewed as an imperfection. Hence the use of words like "failed" and "broken", the insistence on comparing birth to competitive sports, and the use of goofy birth "affirmations" that are all variants of "I can do it."
I suspect that some homebirth and natural childbirth advocates experience a C-section as a narcissistic injury. A narcissistic injury is not simply an imperfection. It is an imperfection that threatens the narcissist's protections against feelings of inferiority.
For example, many people need vision correction, but the overwhelming majority are able to accept that their eyes are not perfect without viewing it as a fundamental deficiency. Similarly, many women have C-sections and view the surgery as nothing more than one of many acceptable ways to have a baby. In contrast, a small proportion of women have such a fragile sense of self, and have constructed such elaborate defenses to protect against these feelings, that a C-section is experienced as a "failure," a sign of being "broken," and an insupportable assault on a very fragile sense of self-regard.
Experiencing C-section as a narcissistic injury can explain many confusing aspects of homebirth and natural childbirth advocacy, particularly among advocates who have already had a C-section. The refusal to see a doctor (with some women even refusing to see a midwife) can be explained as the inevitable result of regarding even the possibility of pregnancy complications as personal criticism, combined with the inability to tolerate criticism of any kind.
It can also explain the seemingly inexplicable reactions to the death of a baby at homebirth. Reacting to a baby's death by being "proud" of oneself for having a vaginal birth is extremely bizarre. However, it makes sense if the mother's overriding preoccupation is to preserve her narcissistic mask of perfection and keep feelings of inferiority at bay.
The real problem, then, for women who view C-section as "failure" is not the C-section, but the outlook of the women themselves. C-section is experienced as a narcissistic injury, not because it really is an injury, but because women with carefully constructed defenses that keep feelings of inferiority at bay feel those defenses threatened by the lack of perfection.
I don't expect homebirth and natural childbirth advocates to acknowledge this. Narcissists are notorious for their lack of introspection and their insistence on blaming everything on everyone else. They could never acknowledge that the source of their distress comes from within; they are compelled to externalize it to others who are supposedly criticizing them or disrespecting them.
Labels: C-section, philosophy
Doctors used to encourage VBAC; what changed?
Have a problem with the decreasing VBAC rate? Take it up with the women and lawyers who are responsible, and stop pretending that doctors are depriving women of choice.
When I was practicing, obstetricians encouraged VBAC. I had a high rate of patients attempting VBAC and a high success rate as well. So when I first heard that ACOG had changed their guidelines, I was stunned. Why had ACOG changed? They changed the guidelines for one and only one reason: they listened to women. Despite being counseled about the risks of VBAC, women who experienced a uterine rupture routinely sued their obstetrician and routinely won. ACOG was simply recognizing the reality that women believed that they did not and could not understand the risks of VBAC.
One of the most egregious cases involved a woman who
claimed that her doctor withheld material information about the risks of VBAC. Although the obstetrician had told the patient that not only could a uterine rupture happen, she had seen one happen, the patient asserted that she wasn't adequately informed because the doctor did not mention that the baby in that case died:
... Flagg advised the plaintiff that, statistically, there were risks associated with the procedure, including uterine rupture and even a small chance of death of the child. Flagg reassured the plaintiff that all necessary steps would be taken to minimize or eliminate the risk to either the plaintiff or the plaintiff's decedent and that the risk was "very, very small . . . ." ... [T]he plaintiff asked ... whether Flagg had had any negative outcomes. In response, Flagg stated that one of her previous patients suffered a uterine rupture as a result of a VBAC delivery. She did not mention, however, that the uterine rupture had caused the infant's death and had placed the mother’s health at risk.
When patient lost her original lawsuit against the doctor, she was appealed using a new theory.
The plaintiff's informed consent claim rested on the allegation that Flagg had given an incomplete and misleading response to the plaintiff's inquiry about prior experience with VBAC deliveries. The plaintiff maintained that Flagg told the plaintiff that, in a prior VBAC delivery, she had one complication that resulted in a uterine rupture, but failed to tell the plaintiff that the uterine rupture resulted in an infant’s death. The plaintiff asserted that this evidence supported her claim that Flagg had not provided her with adequate information required for informed consent ... The plaintiff also claimed that if Flagg had informed her that the prior VBAC delivery resulted in the death of the infant, she would not have elected the VBAC procedure.
The Appeals Court agreed with the mother and granted a new trial on the theory that the mother had not given informed consent.
It is cases like these that led to the dramatically more stringent ACOG recommendations. Obstetricians wanted to offer VBACs but women insisted, and courts agreed, that the women weren't capable of understanding the risks. A journalist writing about his wife's successful VBAC gives us
insight into the position of obstetricians:
Given his support of VBACs, I was surprised to learn that Burgee himself doesn't perform them. He did for two decades, but he stopped in 1990 when he reduced his practice to half-time while he got a law degree (so far unused). When he resumed his full-time practice, he didn't take them up again. He stopped, he says, partly because his legal education made him see his legal risks more starkly. Managing the cases thus seemed more complicated than ever: The OB in him would be pulling for the VBAC, while the surgeon, lawyer, and potential trial defendant would worry that he should wheel the mother to the O.R. Now he explains to his patients why he doesn't perform VBACs, outlines the odds as well as the arguments for and against, and offers the names of midwives and doctors who will perform the procedure...
Are doctors overreacting? It's hard to make that claim when you learn how lawyers are advising women. The title of this law firm's webpage is
VBACs Too Often Result In Injury and Death:
While the promotion of VBACs may save insurance companies money, the risks simply cannot and should not be ignored. It is known that patients who fail a trial of labor are at increased risk for infection and death. Infants born by repeat caesarian delivery after a failed trial of labor also have increased rates of infection. Recent reports indicate that major maternal complications such as uterine rupture, hysterectomy, and operative injury were more prevalent in women who attempted a VBAC than those who underwent repeat caesarians.
If the uterine scar ruptures, it can be life-threatening for both the mother and the infant. For the mother, uterine rupture can require hysterectomy and can result in death.
For the infant, uterine rupture can result in both neurological damage and death. Uterine rupture can result in a sudden disruption in the blood flow to the fetus, resulting in deprivation of oxygen to the blood and tissues. This deprivation can lead to death of brain tissues and serious harm to other vital organs within only minutes. Accordingly, it is imperative that no VBAC be attempted at a facility where emergency staff are not capable of performing an emergency caesarian in minutes in order to prevent this potential harm or death to the infant and mother.
Contrary to the ravings of VBAC activists, obstetricians did not "take away" women's option for a VBAC. That was done by women themselves. If enough women claim that they cannot possibly understand the risks of VBAC and enough lawyers encourage lawsuits based on that theory, obstetricians and hospitals have no choice but to respond to their demands.
Have a problem with the decreasing VBAC rate? Take it up with the women and lawyers who are responsible, and stop pretending that doctors are depriving women of choice.
Labels: C-section
Are C-section mothers less responsive to baby's cry?
You may have read recently about the widely publicized study by Swain and colleagues claiming that mothers who had C-sections respond to their baby’s cry differently than mothers who had vaginal deliveries (
Maternal brain response to own baby-cry is
affected by cesarean section delivery). The study shows nothing of the kind, and the authors have been utterly irresponsible in the way that they have publicized their findings.
The study itself suffers from so many serious problems that it is hard to know where to begin. At a minimum we can say: The study is too small to draw any conclusions, let alone the conclusions drawn by the authors. We don’t know if there is any validity to the image of brain activity that the authors were looking at. There is no evidence that this image is correlated in any way with maternal care taking.
These problems are easier to under stand in the following thought experiment:
Suppose I asked my children to toss coins. My son tossed a coin 6 times and got 6 heads, and my daughter tossed a coin 6 times and got 6 tails. Then suppose I wrote a study claiming that gender determines whether a coin lands heads or tails. Wait a minute, you’d say, your study doesn’t prove anything, and you’d be right. My study would prove nothing for the exact same reasons that the Swain study proves nothing.
First, my study, like the Swain study, is underpowered. I haven't included enough coin tosses for my son or my daughter. We know from probability theory that if I repeated the experiment with my son tossing the coin 6000 times and my daughter tossing the coin 6000 times, they would get the exact same proportion of heads to tails; they would both get 50:50. My results are not valid because I didn’t include enough coin tosses.
Swain and his co-authors looked at the brain imaging patterns of 6 women who had vaginal deliveries and found that they were different from the 6 women who had C-sections. Just like the heads-tails study, the results could simply reflect the fact that the study is far too small.
Second, drawing the conclusion in my coin experiment that gender determines the result of a coin toss rests on the assumption that correlation equals causation. However, we know from the rules of statistics that correlation does not demonstrate causation. Correlation means that two events appear to be related. Causation means that one event caused the other. In my coin toss experiment, gender and coin toss result appeared to be correlated, but that does not mean that gender caused the coins to land heads or tails. It was just a coincidence.
Similarly, in the Swain study, the two different modes of birth appeared to be correlated with brain image, but that does not mean that the mode of birth cause the specific brain image pattern. It could just have easily been coincidence.
Third, my study claiming that gender determines the result of a coin toss would have rest on another flawed assumption, that there is something fundamentally different, beyond appearance, between a coin landing heads and a coin landing tails. In reality, though, there is no difference; it’s just a matter of chance whether a coin lands heads or tails.
Similarly, Swain and colleagues have made a seriously flawed assumption that the two different brain image patterns they observed reflect a fundamental difference in the actual reaction of the mother, not just a matter of chance. In reality, the authors present no evidence that the brain image pattern has anything to do with the mother’s response to her baby’s cry.
This study shows nothing. It could potentially represent an interesting finding that deserves more investigation, or it could be entirely the result of chance. It is extremely irresponsible for the authors to claim that they showed that mode of delivery determines a mother’s response to an infant. It is no better than a coin toss study claiming that gender determines the result of a coin toss.
Labels: C-section
The impact of C-section on women who are not part of the NCB culture
I came across a relatively old article that discusses a number of themes that I have stressed.
Cesarean Birth Outside the Natural Childbirth Culture was published in Research in Nursing and Health in 1986. It highlights the fact that "natural" childbirth is a philosophy that is not universal, but rather the product of a particular subculture. It points out that "natural" childbirth emphasizes process over outcome, and it concludes that C-section itself is not particularly emotionally traumatic, but has the power to be traumatic among women schooled in the rhetoric of "natural" childbirth.
The authors do an excellent job of describing the philosophical underpinnings of natural childbirth:
There is a new emphasis on cesarean birth as a psychosocial rather than a surgical event. Since the mid-l970s, a small body of literature has emerged describing the negative "soft" outcomes of what is increasingly viewed as the "unkindest cut of all".
Women experience cesarean birth not only as a somatic wound, but also as a psychic one; women who have cesarean births are literally and figuratively scarred. This psychosomatic wounding of women may impact on infants, fathers, and families.
A notable feature of the literature describing the negative psychosocial consequences of cesarean birth is its emphasis on a particular group of women. Specifically, this literature emphasizes the values, expectations, and experiences of women who belong to what can loosely be termed the "natural childbirth culture". For women interested in natural childbirth, typically from the middle classes, the experience of birth is an end in itself, and cesarean birth is a devastating interference with nature.
In other words, "natural" childbirth philosophy does not represent universal truths; it is merely a reflection of the cultural pre-occupations of subset of Western, white, middle class women.
The authors are concerned that "natural" childbirth advocates spend a lot of time studying themselves, as if they are representative of women as a whole. The authors are concerned that the values, expectations and reactions of women outside the charmed circle of NCB advocates are simply being ignored. The basis of this study is open ended interviews with 50 women who were medically indigent. In contrast to NCB advocates, the interviewees were predominantly African-American, of limited economic means, and of limited educational achievement.
When discussing the births, the interviewees were very unlikely to refer to standard NCB tropes like "normal" birth or empowerment.
The women viewed cesarean birth as similar to and different from, as well as better and worse than, vaginal birth... The women described vaginal, or what they called "natural" or "regular" birth in terms of physical features and sensations, normality, and mastery... Only 4 women expressed the normality theme in such comments as: "the way other people have children," "normal," "coming out the way it’s supposed to come," and "more like a woman." Only 3 women expressed the mastery theme in such remarks as having the baby "by my own body movements" and "having it yourself."
Not surprisingly, since the women were not particularly concerned with concepts of normality or mastery, their responses to cesarean were very different from those associated with NCB advocates.
... In contrast to published reports of women agonizing over what might have been and blaming themselves for constitutional and emotional flaws, the majority of women accepted the cesarean as fate, and a few managed to display pride in themselves.
The women emphasized the outcomes of birth rather than the process of birth, and frequently rated those outcomes high despite complaints about the process... Childbirth literature, oriented to the middle class model of childbirth, increasingly emphasizes the process of birth as separate from its outcomes. Women suffer when the birth process itself is not as imagined or desired. While failed expectations concerning the birth process is a major theme in the natural childbirth culture, the women in this study had few expectations or clear imaginings concerning birth-giving, and as a consequence were less likely to be disappointed. In fact, neutrality or an "it’s OK" feeling prevailed over intense joy or intense sorrow...
The authors conclude:
Despite its limitations, the study raises key questions about ways of coping and helping in childbirth. The findings suggest a model of childbirth other than the middle class model that emphasizes choice, control, preparation, self-reliance, and nature. Indeed, for the women who equalized vaginal and cesarean birth, natural childbirth is indistinguishable from cesarean birth...
The critical finding of this study is that it is not the experience of C-section itself that leads to disappointment, feelings of failure, and psychic "wounding". Rather it is the expectations encouraged by NCB philosophy that lead to these negative outcomes.
There is nothing objectively "better" about having a vaginal delivery; only women who have been socialized to believe that vaginal delivery is best are disappointed when the baby is born by C-section instead. There is no objective reason to promote the process of birth as something separate from and equally or more important that the outcome of birth. Only women who have been socialized to believe that "choice, control, preparation, and self-reliance" are paramount actually believe that those factors are important.
All of which raise the question: who is being served by the philosophy of natural childbirth? Obviously the "natural" childbirth industry is served by maintaining a set of values that must be taught through books that must be read, and classes that must be taken, and assistants who must be hired.
How about women giving birth? How are they being served by the socially constructed expectations of "natural" childbirth? Those who managed to achieve the socially constructed aims are granted a faux "achievement" that they can point to and use to denigrate other women. However, that is realized only at the price of setting unrealistic expectations virtually guaranteed to result in feelings of disappointment, failure and psychic "wounding" in a large proportion of women. Clearly "natural" childbirth is beneficial for the natural childbirth industry. It's difficult to see, though, how it is beneficial for women.
Labels: C-section
Is there any justification for a 15% C-section rate
Homebirth advocates love to point out that the World Health Organization has recommended that the C-section rate should be 10-15%. Unfortunately, the WHO appears to have pulled those numbers out of thin air. Its own data shows that a 15% C-section rate does not result in the lowest possible levels of either neonatal mortality or maternal mortality. Indeed, Dr. Marsden Wagner, who has probably done more than anyone to promote the idea of a 15% C-section rate as ideal, is a co-author of a study that actually demonstrates the opposite.
The paper is
Rates of caesarean section: analysis of global, regional and
national estimates (Paediatric and Perinatal Epidemiology, 2007; 21:98–113.) The article explicitly acknowledges that the 15% C-section rate recommendation was made without any data to support it. This paper is actually the first paper that attempts to compare international C-section rates with maternal and neonatal mortality.
Since publication of the WHO consensus statement in 1985, debate regarding desirable levels of CS has continued; nevertheless, this paper represents the first attempt to provide a global and regional comparative analysis of national rates of caesarean delivery and their ecological correlation with other indicators of reproductive health.
The data regarding C-section rates below 10% is stark:
...[T]he majority of countries with high mortality rates have CS rates well below the recommended range of 10–15%, and in these countries there appears to be a strong ecological association between increasing CS rates and decreasing mortality.
How about the data on C-section rates above 15%? The authors claim:
Interpretation of the relationship between CS rates and mortality in countries with low mortality rates is more ambiguous; nevertheless, the sum total of the evidence presented here supports the hypothesis that, as has been argued previously, when CS rates rise substantially above 15%, risks to reproductive health outcomes may begin to outweigh benefits.
Not exactly. Indeed, not even close. The data show that low maternal mortality and low neonatal mortality are associated almost exclusively with high and very high C-section rates.
The article contains a variety of charts that make this clear. Of note, the charts are of an unusual kind. Rather than graphing C-section rates against mortality rates, the authors chose to graph the log (logarithm) of C-section rates against the log of mortality rates. A log-log graph has the advantage of exposing tiny differences when all the values are bunched close together, but all the values are not bunched together in this situation. C-section rates occur along a broad range, and mortality rates occur along a broad range. As a consequence, the log-log graph magnifies the effect of tiny differences and minimizes the effect of large differences. Therefore, you need to be very careful in interpreting the graphs.
addendum: I've added an adaptation of the chart that appears in the paper. The area representing a C-section rate of 10-15% has been highlighted in yellow. The vertical blue line represents a mortality rate of 15%. Lower mortality rates are left of the blue line and higher mortality rates are right of the blue line.
The data themselves are quite clear. There are only 2 countries in the world that have C-section rates of less than 15% AND low rates of maternal and neonatal mortality. Those countries are Croatia (14%) and Kuwait (12%). Neither country is noted for the accuracy of its health statistics. In contrast, EVERY other country in the world with a C-section rate of less than 15% has higher than acceptable levels of maternal and neonatal mortality. There nothing ambiguous about that.
The authors claim:
Although below 15% higher CS rates are unambiguously
correlated with lower maternal mortality; above this range, higher CS rates are predominantly correlated with higher maternal mortality.
No, that's not what it shows at all. It shows that all countries with high C-section rates have low levels of maternal and neonatal mortality EXCEPT Latin American countries (represented on the chart by open diamonds) with high C-section rates. The only conclusion that you can draw is that high C-section rates for medical indications are associated with low rates of maternal and neonatal mortality, and high C-section rates for social reasons (as in Latin America) do not lead to low rates of maternal and neonatal mortality.
What the data actually shows is this: The only countries with low rates of maternal and neonatal mortality have HIGH C-section rates (except Croatia and Kuwait). The average C-section rate for countries with low maternal and neonatal mortality is 22%, although rates as high as 36% are consistent with low rates of maternal and neonatal mortality.
The authors claims are not supported by their own data. There is simply no support for a C-section rate of 15%, since virtually none of the countries with low rates of maternal and neonatal mortality have a C-section rate of 15% or below, and most have rates that are far higher. There is also no support for the claim that "the sum total of the evidence presented here supports the hypothesis that ... when CS rates rise substantially above 15%, risks to reproductive health outcomes may begin to outweigh benefits". When C-sections are performed for medical indications, there is no evidence that rising C-section rates lead to rising rates of maternal or neonatal mortality.
The authors own data indicate that a C-section rate of 15% is unacceptably low, and that the average should be at least 22%, with rates as high as 36% yielding low levels of maternal and neonatal mortality.
Labels: C-section
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 deaths | 804 | 1496 |
| Stillbirths | 0 | 1118 |
| Neonatal deaths | 804 | 378 |
| Respiratory morbidity | 11,000 | 2524 | |
|
| Intracranial hemorrhage | 490 | 1007 |
| Brachial plexus injury | 410 | 787 |
| PPH | 3700 | 1488 |
| Suspected sepsis | 20,000 | 33,211 |
|
| Confirmed sepsis | 0 | 2635 |
| | Laceration | 8000 | 2464 |
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.
Labels: C-section
Late prematurity rising as a result of C-sections
Tomorrow's headline today:
C- Sections a Critical Factor in Preterm Birth Increase is the title of a press release sent out by the March of Dimes today. It will undoubtedly been the subject of articles and commentary over the next fews days. It will not be surprising if lay people misunderstand the implications of the study. The press release makes it sound like prematurity, particularly late prematurity (34-36 weeks), has been rising because of C-sections that are accidentally performed too early. That's not at all what has been happening. Late prematurity has been rising as babies are delivered earlier to prevent stillbirth from underlying medical problems, and the stillbirth rate has fallen markedly in response.
The study is published in the June issue of Clinics in Perinatology. The entire issue is devoted to the epidemiology of C-sections and neonatal outcomes of C-sections. Almost all the articles in the issue are excellent, judicious and non-ideological. The article in question is
The Relationship Between Cesarean Delivery and Gestational Age Among US Singleton Births by Bettegowda, et. al. The authors describe the scope of the problem:
The frequency of early cesarean delivery is increasing for medical/obstetric indications ... For many of these cases, this reflects optimal management, such as when attempting to prevent or manage fetal distress, maternal bleeding, infections, or severe preeclampsia. Given the state of available information, several important questions should be posed. First, can the increased proportion of medically complicated pregnancies explain most of the increases in cesarean section rates? Alternatively, are interventions (including cesarean sections) occurring earlier in gestation and substantially contributing to increases in preterm birth rates? Finally, if cesarean sections without medical or obstetric indications are being performed before term, can they be prevented?..
The authors review the current literature:
Ananth and colleagues also reported that more than 30% of singleton preterm births were medically indicated. In a separate study, maternal and fetal conditions requiring medical interventions that resulted in iatrogenic preterm birth were evaluated. Conditions associated with ischemic placental disease, such as preeclampsia, fetal distress, small for gestational age, and placental abruption, were implicated in more than half of medically indicated preterm births. Although this study was based on birth certificate data, other clinical studies have supported the observation that one of these four conditions was present in the majority of preterm births that required medical intervention...
Late prematurity carries risks and should not be chosen lightly. However, many babies delivered prematurely would otherwise be at substantial risk of stillbirth. As the authors point out:
The overall increase in the preterm birth rate and the concurrent increase in medically indicated preterm births have been accompanied by a decrease in stillbirth and perinatal mortality rates. Preterm-related obstetric intervention is undertaken for maternal indications and suspected fetal compromise...
Many high-risk pregnancies have benefited from obstetric intervention at 34 to 36 weeks, as suggested by declines in rates of fetal demise during the same gestational period. As such, the increase in medically indicated preterm birth might be positively viewed in light of the reduction of stillbirths and neonatal mortality... Taken together, obstetric interventions at preterm gestation to reduce risks for the mother and fetus need to be optimally balanced with risks associated with preterm birth...
Indeed, the most recent US statistics on
fetal mortality show a drop of 29% in late stillbirths. So when you read the headlines tomorrow, keep in mind that the increase is late prematurity is not accidental; it is deliberate. It is an attempt to lower the stillbirth rate, and it is successfully doing so.
Labels: C-section
New study shows no increase in stillbirth after C-section
A new paper in the May issue of the British Journal of Obstetrics and Gynecology was unable to replicate an important paper that claimed that C-section increases the risk of unexplained stillbirth in a subsequent pregnancy. The issue is explained by the editor of BJOG in an accompanying
editorial:
For many years, there have been calls to reduce the caesarean section rate in developed countries, and yet year on year, the rate continues to increase—while the maternal mortality continues to fall. Those who argue for a reduction have to persuade women ... to pursue more doggedly a vaginal birth. Reports of the adverse effects of caesarean section are grist to their mill, and certainly, the increased rate of percent of praevia and accreta in subsequent pregnancies (together with the increased risk of caesarean hysterectomy) appears indisputable. A paper ... in the Lancet in 2003, which reported that the risk of 'unexplained' stillbirth after 39 weeks of gestation was more than doubled following a previous caesarean section ... attracted a lot of attention and has to date been cited 64 times (which is a lot!)... Wood et al. report a study of more than 158,000 second births in Alberta Canada and found no significant difference in the rate of unexplained antepartum stillbirth by mode of first delivery after adjusting for maternal age and blood pressure. Will their findings be equally highly cited?
The paper,
The risk of unexplained antepartum stillbirth in second pregnancies following caesarean section in the first pregnancy seems to be a comprehensive study of 158,502 second births. The analysis showed:
The stillbirth rate in the group with a previous caesarean section was 4.6/1000 compared with 3.9/1000 in the previous vaginal delivery group (P = 0.10). Of the stillbirths, 21% in the previous caesarean section group and 19% in the previous vaginal delivery group were intrapartum. The antepartum stillbirth rate was 3.0/1000 in the previous caesarean section group compared with 2.7/1000 in the previous vaginal delivery group (P = 0.46)...
Our study did not demonstrate an increased risk of unexplained antepartum stillbirth in second pregnancies in women who had had a previous caesarean section. This result is in contrast to a previous similar study of Scottish women... [F]ive other studies have evaluated stillbirth risk in pregnancies following caesarean section with mixed results...
It is apparent that an increased risk of stillbirth in pregnancies after caesarean section has not been consistently observed... [D]ifferences in stillbirth definitions or uncontrolled confounding factors are the most likely explanations. The initial Scottish study that generated interest in this question restricted analysis to antepartum stillbirths, and their primary finding was an increased risk of unexplained stillbirth.
The authors address the question of why their results differ from the Scottish study:
... Our study was unable to replicate the findings of the previous Scottish study, which reported a significant increased risk of unexplained stillbirth in women who had had a previous caesarean section. One possible explanation for this variability in results is the slightly differing definitions of unexplained stillbirths between the two studies. Although this is possible, we do not believe that differences in the definition of unexplained stillbirth would have affected our results... [W]e feel that it would be highly unlikely that a change in the definition of 'unexplained' stillbirth would differentially increase the proportion of stillbirths in the previous caesarean section group to the point that a statistically significant association emerged...
... As the association between previous caesarean section and total stillbirth or unexplained stillbirth has not been consistently observed, we think it would be very premature to conclude a causal association exists. However, given the important potential public health implications, further research on this question should be undertaken with other large perinatal databases.
Labels: C-section
The high C-section rate at homebirth shows that birth is not "trustworthy"
Yes, you read that correctly. Homebirth advocates point proudly to the low rate of C-sections at homebirth, but those rates only appear low in comparison to hospital rates. In the hospital, C-section is not always a lifesaving procedure (in retrospect). However, at homebirth almost all C-sections save the life of the mother, the baby or both. Therefore, it is rather astounding that for a natural process that is supposed to be "trustworthy", women who are the lowest of low risk can anticipate that 1 in 25 will need surgery to save their lives or their babies' lives.
A 1 in 25 chance of death is utterly inconsistent with the notion that birth is inherently safe or that anyone should be "trusting" birth. Homebirth advocates like to pretend, and loudly trumpet, that childbirth is safe, despite massive amounts of contemporary and historical evidence to the contrary. Failing that, they like to pretend that high neonatal and maternal death rates are caused by iatrogenic infection. Of course, that's not true, either. The next fallback position is to pretend that lifethreatening complications of pregnancy, like eclampsia, hemorrhage or prematurity, are rare, but these complications are not rare, they are relatively common. Moreover, even AFTER these complications are excluded, even when there is no reason to expect anything other than an uncomplicated vaginal delivery, 4% of women still need lifesaving surgery.
I cannot think of anything in life that has a 1 in 25 death rate that would be called even remotely safe. If every time a mother and baby got into a car there was a 1 in 25 chance that one of them would not come back alive, driving would be considered horrifically dangerous. If a routine medical procedure was known to kill 1in 25 babies, the scandal would be immense.
So how, exactly, can childbirth be considered trustworthy when 1 in 25 homebirth mothers need to be rescued by obstetricians performing life saving surgery?
Labels: C-section
C-sections and diminishing returns
There's seems to be a great deal of confusion about my comments that a 32% C-section rate is too high. I am NOT saying that the C-section rate should be arbitrarily set at a certain point, and any neonatal deaths above that point are irrelevant. I am saying that, whether we realize it or not, the controversy over the C-section rate reflect both statistics and values, so it is critically important to explore what they are.
All treatment decisions are governed by the law of diminishing returns. This is a principle first described in economics that applies to many other areas as well. It must be taken into account when determining what C-section rate is appropriate. The following is a hypothetical example of how the law of diminishing returns works, which will help us identify the issues raised by the rising C-section rate.
Imagine a hypothetical first world country that has 1 million births per year. In this hypothetical country, we are able to analyze the number of lives saved by C-sections and we are able to analyze it in hindsight so that we know which C-sections were necessary. As the C-section rate rises, the numbers of lives saved drops off (diminishing returns). In our hypothetical country, we can chart how many lives are saved for each percentage point of the C-section rate. Each percentage point of the C-section rate represents 10,000 C-sections. Our chart might look something like this:
| C-section rate | lives saved/10,000 C-sections |
| 0-5%% | 20,000 (every mother and baby) |
| 6-10% | 10,000 (every baby) |
| 11-15% | 5,000 |
| 16-20% | 500 |
| 21-25% | 50 |
| 26-30% | 5 |
| 31-35% | 0.5 |
| 36-40% | 0.05 |
We can see the law of diminishing returns in action here. At a C-section rate from 0-5%, every C-section is necessary, and every C-section saves the life of both mother and baby. From 6-10% every C-section is necessary and saves the life of the baby. From 11-15% half the C-sections are necessary, resulting in a savings of 5000 lives. At rates higher than 15%, retrospective analysis reveals that far fewer C-sections are life saving. By the time a C-section rate of 35-40% is reached, only one additional baby will be saved every other year.
The results can be expressed another way. We can determine retrospectively how many C-sections were unnecessary. Here's that chart:
| C-section rate | unnecessary C-sections/10,000 |
| 0-5% | 0 |
| 6-10% | 0 |
| 11-15% | 5,000 |
| 16-20% | 9,500 |
| 21-25% | 9,950 |
| 26-30% | 9,995 |
| 31-35% | 9.999.5 |
| 36-40% | 9,999.05 |
That's not all we have to take into account. Though the risk of maternal death from a C-section is low, it is not zero. As greater numbers of C-sections are performed, maternal deaths will become an every greater issue. Let's assume that the maternal death rate solely attributable to C-section is 1/10,000. At low C-section rates, where almost all C-sections are lifesaving, a maternal death rate of 1/10,000 seems very small. As the C-section rate begins to rise, look what happens. For C-section rates from 11-15%, 5000 babies will be saved per 10,000 C-sections, and 1 mother will die. From 21-25%, 50 babies will be saved per 10,000 C-sections, 9,950 unnecessary C-sections will have been performed and 1 mother will die. By the time you reach 31-35%, only 1 baby will be saved every other year per 10,000 C-sections. 9,999/10,000 C-sections are unnecessary and 1 mother will die. A C-section rate of 36-40% would save only 1 baby every 10 years, almost every C-section is unnecessary, and 1 woman would die per 10,000 C-sections.
Although the decision to perform a C-section is made on a case by case basis, analysis of C-sections in the aggregate show us that the C-section rate CAN be too high. When you get to the point that you are saving 1 baby every 10 years, but killing 1 mother every year, the C-section rate is clearly too high. Why has the C-section rate risen so high in first world countries? The reason is that a tremendous premium has been placed on the life of each and every baby. That societal value is directly reflected in the rising number of lawsuits and monetary judgments for babies who die or are disabled during birth. That societal value is reflected in the fact that our judicial system operates as if we believe that if a C-section had even a remote chance of preventing the death or disability, that C-section should have been done, and because it wasn't done, the parents should be compensated.
Is that what we really believe? Is any number of unnecessary C-sections justified to save the life of one baby every decade or every century? How many maternal deaths are justified to save the life of one baby every decade or every century? Personally, I think the standard should be different. The number of unnecessary C-sections done to save one baby every decade is NOT unlimited. The number of maternal deaths is certainly not unlimited, and it is not even one to one. The standard for determining fault in an obstetric malpractice case should NOT be to show that a C-section could have prevented the baby's death or disability; the standard should be that the doctor could have reasonably foreseen (based on the evidence available) that a C-section was NECESSARY to prevent the baby's death or disability.
C-sections come with costs. We have not even talked about the financial costs, because, in my judgment, these are secondary. However, massive numbers of unnecessary C-sections cause unnecessary complications and unnecessary deaths. As the C-section rate rises, these unnecessary complications and unnecessary deaths rise from relatively trivial occurences, to occurences that far outweight the number of babies' lives saved. We, as a society, need to think about where we draw the line, because we, as a society, through our punishments and incentives, determine how high the C-section rate should be. Doctors are merely responding to society's wishes as expressed through our values and our legal system.
Labels: C-section
How to lower the C-section rate: step 1, look in the mirror.
Yesterday someone wrote in to remind me that it is C-section awareness month, asking what could be done about the C-section rate, and implying that I could do something about it.
Here's what I wrote in response:
The rising C-section rate is a direct response to what PATIENTS demand, which is a perfect outcome and massive financial compensation if the outcome is not perfect. Efforts to lower the C-section rate have to start with patient expectation and demands.
The way the legal system currently operates, there is no possible justification for not doing a C-section when there is any element of doubt, no matter how tiny. Unless and until people stop penalizing doctors for not doing C-sections, they will continue to do them in ever increasing numbers. They really have no choice.
How can we modify patient expectations and demands? The most practical response would be to institute no fault compensation for a baby who dies or is permanently impaired. No fault compensation has the added advantage of being more ethical. The current system requires that getting help caring for a profoundly impaired child is completely dependent on being able to blame a medical provider for the impairment. Parents who care for impaired children who are impaired due to genetic problems (no one's fault) are forced to struggle without any assistance, while parents whose children may be less disabled receive lottery size awards as long as they can convince a jury that someone is at fault.
The bottom line is that you cannot say to obstetricians, "Give me a perfect baby or I will try to destroy you professionally and economically" and then express shock and dismay that obstetricians will perform C-sections in order to guarantee that you will have a perfect baby.Liz 1, a long time participant on the blog, is disappointed and angry with my response, but I stand by it. Let me explain further:
Obviously I believe that every single C-section and induction with a medical indication should be done. Moreover, I am certainly well aware that what is unnecessary in hindsight is not knowable in advance. Nonetheless, a C-section rate of 32% cannot be MEDICALLY justified IF the normal parameters for medical justification are used. Unfortunately, the typical parameters are not used.
Let's look at another medical issue for comparison. Ovarian cancer is one of the most dangerous problems an OB-GYN is likely to encounter. Partly that is because early ovarian cancer does not cause symptoms. There is a way that we could prevent virtually all ovarian cancer. We could remove every woman's ovaries at the age of 40.
We don't do that, and there are many reasons why we don't do that. One reason is that it would almost certainly cause more deaths than it would prevent. Another reason is known as the law of diminishing returns. As the rate of removal gets higher, the benefits drop off. Simply put, as the rate of removal gets higher, the chance that you are actually doing some good gets smaller.
Another reason we don't remove every woman's ovaries is that women understand that ovarian cancer is generally a random occurance; that it certainly is not the doctor's fault; that women do not "naturally" live to be 80 without getting cancer; and that women are not "entitled" to a life free of ovarian cancer. That translates into the fact that the overwhelming majority of women who are diagnosed with ovarian cancer do not sue and claim that someone should have figured it out sooner.
The contrast with obstetrics could not be more glaring. Women DO NOT understand that hypoxic brain damage can be a random occurance; women DO believe that a bad obstetric outcome must be someone's fault; women Do NOT understand that bad outcomes occur "naturally; and women believe that they are entitled to have perfectly healthy children. Because of these erroneous beliefs, they will sue if there is anything wrong with a child and the ONLY effective legal defense for a doctor is to show that a C-section was performed, and was performed as soon as humanly possible.
Essentially every American obstetrician is sued for a bad baby. Most are sued several times. You MUST assume that you will be sued for every bad outcome, and therefore, you must take WHATEVER steps you can have a legal defense. As I pointed out above, the only acceptable legal defense is to have done a C-section.
Of course, obstetricians win most lawsuits. The cases were without merit to begin with. One way to look at the situation is that the system works because most doctors who did nothing wrong are found not liable. However, another way to look at the high proportion of physician victories is that it tells us the system is totally dysfunctional. Most lawsuits occur in the absence of any legal wrong, yet they are allowed to proceed anyway.
A malpractice suit is a very traumatic for a physician, win or lose. It is the suit itself that is most traumatic, not the outcome. A lawsuit represents literally YEARS of worry, since the legal system works so slowly here, not to mention lost work, lost wages, etc. etc.
Lawsuits do not file themselves; patients file them, and they are an expression of patient expectations. The large number of obstetric malpractice suits, and particularly the large number of meritless suits, are a direct expression of patient expectations. They expect a perfect baby and they believe they ought to punish any doctor who doesn't present them with a perfect baby.
As the C-section rate rises, the percentage of unnecessary C-sections rise and that is a bad thing. Logically speaking we are not going to recommend a C-section rate of 100% even though a C-section rate of 100% would guarantee that everything was done to ensure a perfect baby. So where do we draw the line?
My point is that where we draw the line is in direct response to PATIENT expectations, and is out of the control of doctors. When patients demand a perfect baby or else, THEY have essentially drawn the line at a 100% C-section rate and doctors are merely attempting to respond to that. If patients stopped filing massive numbers of meritless lawsuits, the C-section rate would drop in response to THEIR acknowledgement that a perfect baby is not guaranteed.
What is especially ironic is that women who choose homebirth and women who choose UC have an entirely different standard for midwives and for themselves than they have for doctors. Women who choose homebirth are essentially saying "I can't guarantee that I will have a healthy baby if I deliver at home, but it is worth it to me to risk my baby's life in order to avoid interventions I don't want", yet when they head to the hospital, they completely reverse that logic and essentially say, "The doctor must guarantee that I have a healthy baby if I deliver at the hospital."
The expectations of the hospital are so out of touch with reality that it beggars belief. Look at the MDC case that was the inspiration for this thread. The baby is fine, the woman is fine, and yet she wants to sue (and everyone is encouraging her to sue) because the doctor allegedly pulled on the cord and it hurt! The doctor didn't listen to her when she said no! Are these even remotely defensible reasons for a lawsuit. Absolutely not, but American women are so unreasonable that not only do they think they are entitled to a perfect baby, but they think they are entitled to a perfect "experience", even after they screw up and seek emergency attention to save their lives.
There are too many C-sections being done in the US (and other industrialized) countries because American women (and the women of other industrialized countries) DEMAND a very high C-section rate, while piously pretending that they want a low C-section rate. To all the anti C-section activists out there I say: If you want to lower the C-section rate, start by looking in the mirror!
Labels: C-section
C-section increases the risk of future hysterectomy
A study in the January 2008 issue of Obstetrics and Gynecology,
Cesarean Delivery and Peripartum Hysterectomy, shows definitely that even one C-section increases the risk of a future peripartum (around the time of delivery) hysterectomy. This is not a new finding, but the paper is extremely well done and comprehensive. It also quantifies the risks in a variety of ways that will help women make informed decisions about C-section.
The study is a case-control study. They identified over 315 women who had a peripartum hysterectomy due to hemorrhage in a 13 month period. The controls were the 2 patients that had delivered in the same hospital, under the care of the same physician, immediately prior to the hysterectomy case. The reason for peripartum hysterectomy in 75% of the cases was placenta previa, placenta accreta, or uterine rupture.
Compared with controls, women who had had a peripartum hysterectomy were over three times more likely to have had a previous cesarean delivery. This risk increased with the number of previous cesarean deliveries, such that women with a peripartum hysterectomy were over eighteen times more likely to have had two or more previous cesarean deliveries. There was some evidence of an interaction between previous cesarean delivery and age; the risk associated with previous cesarean delivery was higher in women aged less than 35 years than in those aged 35 years or older...
Other risk factors for peripartum hysterectomy were also identified including: age greater than 35, parity greater than 3, previous uterine instrumentation, twin pregnancy, previous manual placenta removal and previous myomectomy. The authors calculated that approximately 28% of peripartum hysterectomies could be attributed to previous C-section.
Two women died after hysterectomy, for a case fatality rate of 0.6%.
Tha authors calculated the risk of needing a peripartum hysterectomy in different categories of women:
| risk |
| first delivery vaginally | 1:30,000 |
| first delivery by C-section | 1:1700 |
| delivery after one previous C-section | 1:1300 |
| delivery after two or more previous C-sections | 1:220 |
Clearly, having a C-section in one pregnancy dramatically increases the risk of having a peripartum hysterectomy in a subsequent pregnancy. As the authors state:
We have also been able to identify that the risk also then extends beyond the initial cesarean delivery into subsequent deliveries; women who have had one previous cesarean delivery have more than double the risk of peripartum hysterectomy in the next pregnancy, and women who have had two or more previous cesarean deliveries have more than eighteen times the risk. This full quantification of these risks provides the evidence needed to comprehensively counsel women about the risks of primary cesarean delivery and to counsel against cesarean delivery without a specific medical indication.
Of course, in order to make an informed decision, women need to know the benefits, as well as the risks. Using the data from the paper, I did some additional calculations: Let us assume, as the authors claim, that for every 1300 women who have a C-section, one woman will ultimately require a peripartum hysterectomy. Let us make an extremely conservative assumption that of the 1300 primary C-sections, only 10% were required to save the life of the baby or mother or both. That would mean that 1300 C-sections would save at least 130 lives and probably more.
| benefits | risks |
| 1300 primary C-sections | 130 lives saved | 1 current + 1 future peripartum hysterectomy |
Most people would consider that the benefits of primary C-section would far outweigh the risks. So while the risks of future complications from C-section are real, and women should not have a C-section without a medical indication, the benefits are several orders of magnitude higher. As I have said many times in the past, it is difficult to imagine that most women would accept a substantial risk of neonatal death in an effort to avoid a very small risk of future complications.
Labels: C-section
If you are wondering why the C-section rate is rising
The C-section rate is rising precipitously throughout the industrialized world. This case illustrates the social forces at work.
According to
Almost €1m award in Erb's palsy case in the RTE news of Ireland:
The High Court has approved a settlement of almost €1m in an action brought by the parents of a nine-year-old boy who suffered shoulder and hand injuries during his birth.
The boy's mother, 45-year-old Una Byron from Upper Strand Street in Youghal, Co Cork is taking a separate action for trauma.
She claims she underwent a 'horrific childbirth' which left her son John physically disabled.
The court was told that the case brought on behalf of John had been settled for €900,000...
It is the highest award ever in the case of an Erb's palsy medical negligence damages claim.
Mrs Byron claims the obstetrician, Mr Fenton, failed in his duties by failing to carry out a caesarean section and in appropriately using a forceps to deliver her son...
The C-section rate is rising because in many cases, C-sections are safer than vaginal deliveries. Anyone who is concerned about lowering the C-section rate needs to be cognizant of this fact. C-sections really are safer.
Labels: C-section
Cesarean section protects babies from trauma
Supporters of maternal request C-section, will obtain valuable ammunition from an article in the current issue of Obstetrics and Gynecology. Baskett TF, Allen VM, O’Connell CM, et al.
Fetal trauma in term pregnancy. Am J Obstet Gynecol 2007;197:499.e1-499.e7 is a comprehensive study of over 100,000 consecutive deliveries of singleton term neonates in the vertex position with no congenital anomalies:
The potential study population in Nova Scotia for the 14-year period (1988-2001) was 153,209. Twenty-two percent of the population was excluded based on the inclusion criteria of singleton (1%), term (7%), no major anomalies (3%), no fetal deaths (0.1%), and in vertex presentation(11%) to give the actual study population of 119,432.
Deliveries were grouped as follows:
... mode of delivery was defined as vaginal or cesarean, and method of delivery was defined as spontaneous vaginal, assisted vaginal (vacuum, forceps), ... and cesarean delivery (with and without labor)...
The definitions of trauma were:
Fetal trauma was considered major trauma if 1 or more of the following were present: depressed skull fracture, intracranial hemorrhage, or brachial plexus palsy. Minor trauma was considered if 1 or more of the following were present: linear skull fracture, other fractures, facial palsy, or cephalhematoma.
The results of the study showed that the risk of major and minor trauma was dramatically reduced by Cesarean section, particularly if the Cesarean was performed before labor began. If the risk of major trauma in a vaginal delivery is described as 1.0, the relative risk of major trauma is reduced by 82% by a C-section done in labor (RR 0.18), and reduced by 88% by a C-section done before labor begins (RR 0.12). In contrast, the risk of major trauma is dramatically increased by vacuum assisted delivery (RR 2.71) and even further increased by forceps delivery (RR 4.2). The same results also apply to minor trauma. As compared to a spontaneous vaginal delivery, the risk of minor trauma is lowered most (by 89%) for a C-section without labor (RR 0.11) and raised most by vaccum delivery (RR 5.49).
Major trauma
| type of delivery | spontaneous vaginal | vacuum assisted | forceps assisted | Cesarean in labor | Cesarean before labor |
| RR | 1.0 | 2.71 | 4.2 | 0.18 | 0.12 |
Minor trauma
| type of delivery | spontaneous vaginal | vacuum assisted | forceps assisted | Cesarean in labor | Cesarean before labor |
| RR | 1.0 | 5.49 | 2.95 | 0.70 | 0.11 |
The authors conclude:
... Major trauma was most likely to be associated with labor and assisted vaginal delivery. Cesarean delivery with and without labor was associated with significant reduction in risk of both minor and major fetal trauma.
When it comes to preventing trauma in the newborn, C-section is remarkably effective and protective.
Labels: C-section
Baby dies when C-section opponent fails to perform a timely C-section
According to an article in today's Dail Mail,
Natural birth doctor accused of caesarean baby death blunder:
A leading obstetrician who is a strong advocate of natural births is accused of causing the death of a baby by failing to perform a caesarean section soon enough.
Dr Susan Bewley, who has spoken out against the rise in "unnecessary" caesareans, allegedly delayed carrying out the emergency procedure until it was too late to save the child.
The 49-year-old consultant is due to face a disciplinary hearing at the General Medical Council and could be struck off...
The mother who lost her baby had caesareans to deliver her first two children but Dr Bewley apparently felt she was capable of a normal delivery for her third.
As complications developed during labour, she performed an emergency caesarean. But the infant died soon after the birth.
This case illustrates the difficulties faced by every obstetrician. The effort to avoid these tragic preventable outcomes leads to all those "unnecessary" C-sections.
Labels: C-section
Uterine rupture
Homebirth and natural childbirth advocates appear to think that the most devastating indictment of modern obstetrics is Cytotec. Cytotec (misoprostol) is a medication used for induction of labor. It was tested extensively before being used in pregnant women, and found to be safe. However, after it was in widespread use, it was noted that in a subset of women (women who had a previous C-section), it increased the risk of uterine rupture. Uterine rupture is a devastating complication that can lead to the death of the baby, to possibly hysterectomy, and even to the death of the mother. Not surprisingly, Cytotec is no longer recommended for use in inducing labor in women who have had a previous C-section.
Cytotec is hardly the most common cause of uterine rupture, and since uterine rupture is such a devastating complication, you would think that any measures that reduce the incidence of uterine rupture would be welcomed by homebirth and natural childbirth advocates. You'd be wrong. That's because the most common cause of uterine rupture is labor itself. Women who have had a previous C-section are at increased risk of uterine rupture if they attempt a VBAC instead of having a repeat C-section. This is the reason why ACOG has recommended that VBACs should not be done unless an obstetrician is present and 24 hours anesthesia and C-section capabilities are available. Since many small hospitals cannot meet those conditions, VBAC rates have dropped precipitously, to be replace by a skyrocketing rate of scheduled repeat C-sections.
Yet homebirth and natural childbirth advocates are horrified by the decline of VBACs and believe that it is thoroughly unjustified. So here's my question:
Why is Cytotec an abomination because it increases the risk of uterine rupture, but VBAC is desirable despite the fact that it increases the risk of uterine rupture?
Labels: C-section
What if a Cesarean section costs less?
It is conventional wisdom that a C-section costs more than a vaginal delivery, but conventional wisdom may be wrong. The reason is that conventional comparisons are restricted to the costs of the procedures themselves whereas a more accurate measure of economic impact is to compare total charges (mother and baby) for vaginal deliveries vs. total charges for C-sections. Much to the surprise of many people, including the researchers, C-sections may actually cost less.
The economic analysis is done by comparing different intentions to treat. In other words, instead of comparing vaginal deliveries to C-sections, researchers compared the costs for women who intended to have a vaginal delivery with the costs for women who intended to have a C-section. The study
Does a Cesarean section delivery always cost more than a vaginal delivery? undertaken by healthcare economists was done in just this way. According to the authors:
There is evidence that average total charges per episode of child birth depend on maternal plus child length of stay, neonatal intensive care unit (NICU) utilization, maternal race and mode of delivery. In particular, when maternal and child records are linked, this study suggests that when adjusted for maternal characteristics, the cost of vaginal deliveries followed by NICU utilization may be higher than the cost of Cesarean sections and NICU utilization.
... Much of the current Cesarean section literature focuses on reporting geographic and hospital-specific variations, but little has been published about the clinical and demographic characteristics of the patients, and even less about the economic consequences of a Cesarean section delivery compared with a vaginal delivery [e.g. the total hospital charges and length of neonatal intensive care unit-NICU stay] of a birth episode. To examine these relationships further, three urban Baltimore hospitals volunteered in 2004 to participate in a retrospective chart review that linked mother and child hospital records.
The authors found that when total costs were compared, C-section actually cost less than vaginal delivery:
Average total charges for vaginal deliveries [maternal plus total baby charges that includes NICU utilization (X = $17 624.38)] may be higher than average total charges for Cesarean sections [maternal plus total baby charges that includes NICU utilization (X = $13 805.47)]. Specifically, maternal race – being African American – was indirectly associated with overall charges through its association with mode of delivery and NICU utilization patterns. The presence of maternal co-morbidities – Herpes Simplex Virus, hypertension and diabetes – most probably influenced babies’ hospital stay charges as well as NICU charges when transferred to NICU following both vaginal and Cesarean section deliveries. Thus, prenatal care targeting co-morbidities management may reduce the odds of a newborn’s transfer to NICU thus avoiding greater lengths of stay, medical care and charges. Recommendations for obstetrical practices as well as health care policy on their charges should not assume that Cesarean section deliveries are always costlier than vaginal deliveries.
Similarly, when the authors of the Term Breech Trial went back and looked at the economic data for planned vaginal deliveries vs. planned C-sections, they also found that planned C-sections were less expensive.
The estimated mean cost of a planned cesarean was significantly lower than that of a planned vaginal birth ($7165 v. $8042 per mother and infant; mean difference –$877, 95% credible interval –$1286 to –$473). The estimated mean cost of a planned cesarean was lower than that of a planned vaginal birth for both women having a first birth ($7255 v. $8440) and women having had at least one prior birth ($7071 v. $7559)...
Interpretation: Planned cesarean section was found to be less costly than planned vaginal birth for the singleton fetus in a breech presentation at term in the Term Breech Trial. From The costs of planned cesarean versus planned vaginal birth in the Term Breech Trial:
The
commentary by Henderson and Stavrou explains the apparent paradox:
The difference in costs between the 2 groups was largely related to the relatively high physician fees for carrying out a vaginal breech delivery as well as to the higher costs of epidural analgesia, in-hospital costs of labour and delivery and costs of neonatal intermediate and intensive care. It is worth noting that 43% of women allocated to vaginal delivery subsequently delivered by cesarean section, 36% after labour began. Costs incurred by this group therefore included both the higher labour costs as well as the operating theatre costs associated with a cesarean section...
Based on this research, it is possible that a maternal request C-sections could actually cost less than a planned vaginal deliveries because planned C-sections obviate the need for the most expensive option, labor followed by a C-section. This is not an argument for planned C-sections, but it does demonstrate the economic benefits of vaginal delivery may be much less than commonly supposed.
Labels: C-section
A minimum C-section rate of 10% is needed for low maternal mortality and stillbirth rates
A recent article on the quality of obstetric care in developed and developing countries demonstrates that childbirth is inherently dangerous and that C-section is the most important lifesaving intervention. This paper suggests that a minimum C-section rate of 10% is required to reduce maternal mortality and stillbirth to low levels. Indeed, the ability to perform C-sections and other high tech interventions like blood transfusions is more likely to lead to low maternal mortality and stillbirth rates than low tech interventions like skilled birth attendants and increased prenatal visits.
In
Maternal mortality, stillbirth and measures of obstetric care in developing and developed countries in the International Journal of Obstetrics and Gynecology, McClure et al. explore the relationship between maternal mortality and stillbirth rates and the relationship between obstetric care and rates of maternal mortality and stillbirth.
Of the strategies in the emergency obstetric package designed to reduce maternal death, the ability to provide a timely cesarean section is among the most important to prevent a substantial number of maternal deaths and stillbirths. While it is difficult to pinpoint the exact etiology, in developing countries, prolonged labor is frequently the event leading to the maternal death or stillbirth. Associated infections and hemorrhage kill the mother, and fetal infection, asphyxia, and trauma kill the fetus. A timely cesarean section prevents many of the maternal and fetal deaths from infection and hemorrhage as well as fetal deaths from asphyxia. In cases of eclampsia/preeclampsia, a timely cesarean section will also reduce both maternal and fetal mortality.
In developing countries, for C-section rates:
<10% an increase of 1% of births by cesarean section leads to a decrease of 116 maternal deaths per 100,000 births
≥10% an increase of 1% of births by cesarean section leads to a decrease of 1 maternal deaths per 100,000 births
<13% an increase of 1% of births by cesarean section leads to a decrease of 1.72 stillbirths per 1000 births
≥13% an increase of 1% of births by cesarean section leads to a decrease of 0.05 stillbirths per 1000 births
The authors conclude:
Although in geographic areas with very high maternal mortality and stillbirth rates, community-based strategies such as training traditional birth attendants may still have a role in reducing both mortality rates, Koblinsky et al have emphasized that no evidence exists that maternal mortality below 100 per 100,000 births can be achieved through community-based strategies without access to emergency obstetric care. Some authors have estimated that to achieve an optimal reduction in maternal mortality, cesarean section rates of 5 to 15% are necessary, with 5% likely being the lowest rate associated with a maximum reduction in maternal mortality. These analyses support the view that significant reductions in maternal mortality and stillbirth may be achieved only through access to emergency obstetrical care, including cesarean section.
The clear implication is that maternal mortality rates of more than 100/100,000 births NATURALLY occur in childbirth. So contrary to the claims of homebirth advocates, childbirth is INHERENTLY dangerous. Moreover, C-sections appear to be the most important intervention needed to lower maternal mortality and stillbirth rates to low levels.
Labels: C-section, maternal mortality, neonatal mortality
Delivering your own baby at your C-section
Here's a story of determination and persistence. A mother who had wanted a homebirth for her first birth was anticipating a C-section for placenta previa instead. She asked why she couldn't lift the baby out from her abdominal incision. No one could think of a good reason why she shouldn't do so, so that's what she did.
The
West Australian News reported:
First-time mum Kiriana said she had planned to have a natural home birth when a scan 20 weeks into her pregnancy revealed she had placenta previa, or a low-lying placenta, which put her at serious risk of haemorrhaging during childbirth.
When she was told that a caesarean section was the only safe option, the trained nurse and her midwife researched a groundbreaking new technique, believed to have been performed only once previously in Australia. It let Mrs Ruffin help deliver her own baby after her obstetrician freed the child’s head and shoulders.
"I looked down and the doctor turned Seth’s head so I could see his face and I just felt a rush of love," Mrs Ruffin said. "I got my hands underneath his armpits and pulled him straight up and on to my chest."
Unlike a normal caesarean when the procedure is carried out behind a screen and the mother might not see her child for several minutes after birth, the 33-year-old was sterilised from neck to knees so she could make immediate skin contact with her son...
"At first I was devastated because I really wanted a home birth, but I really don’t think it could have been any more bonding and special than if it had been a natural delivery. It was amazing."
Mrs Ruffin said she hoped the new procedure would not encourage more mothers to have elective caesarean sections unnecessarily because of the risks of the surgery.
But with an obstetrician, midwife, nurses and anaesthetists hovering nearby, she said she was in the best place to be if anything went wrong.
Two more women are expected to undergo the procedure at King Edward Memorial Hospital in the next month.
Labels: C-section
C-sections: How many lives do they save, how many lives do they cost?
Homebirth advocates consistently blast the high level of C-sections in this country. One of the issues that they raises again and again is the potential complications from C-section. So here's my question. How many lives do C-sections save every year and how many lives do they cost? Feel free to include mortality from C-sections that occurs long after the actual surgery (if you can find any evidence that shows that such a thing happens).
Homebirth advocates also claim that there is more to safety than mortality. I'm not sure that I agree that morbidity figures are as important to people as they assume. Nonetheless, let's take a look at that, too. How much morbidity do C-sections cause and how much morbidity do they prevent? Keep in mind that the amount of morbidity (and associated costs) is quite high if a child is brain injured at birth.
I know that homebirth advocates have a sense that the morbidity and late mortality of C-sections is much higher than convential wisdoms suggests, but is there really any evidence that this is the case? I suspect that there is a lot less than homebirth advocates assume.
Labels: C-section, neonatal mortality
