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Please click here to get involved in the cesarean debate. As most readers know, I believe that the decision to choose cesarean delivery as a preferred birth method - even without medical indication - is a legitimate one. Share your thoughts here.

England's latest cesarean rate is 24.3%

The latest NHS Maternity Statistics for England in 2006-07 have just been published, and the number on everyone's lips is the slightly increased national cesarean rate of 24.3% (it was 24.1% the year before).

Unsurprisingly, newspaper copy is filled with the usual cries from some individuals and groups of: "This rate is too high. The World Health Organization recommends only 10-15% cesarean deliveries."

I plan to write more on the details of this report (which you can read in full here) over the coming days, but one of the most important things I'd like to stress initially is my concern for the women who are CHOOSING to have a cesarean delivery, and how the outcry over this new figure might impact on their health and wellbeing.

Why? Because a number of advocates of vaginal delivery have their sights set on reducing the national cesarean rate, and as I've always said, while I fully support initiatives to help women succeed in having a vaginal delivery outcome where this is their personal preference, I object strongly to women's informed request for a cesarean delivery being discouraged or refused as another way of reducing surgeries.

We need to focus on reducing 'unwanted' cesarean deliveries, and not those that are 'wanted' by women for whom planned surgery is a legitimate birth choice.

Obesity associated with cesarean delivery - again

This time the study was conducted in England, in which a rise in the cesarean rate from 6.5% to 19% had been identified over a 15 year period (between 1992 and 2006). In order to investigate further, a second phase of the study looked at the data of 126 women - 99 of whom were non-obese and 27 of whom were obese.

"Statistical analysis compared the delivery outcomes between the two groups and showed that obese women were 5.82 times more likely to have a caesarean section compared with non-obese women. This finding was highly statistically significant."

So these women were five times more likely to need a cesarean. Other studies have shown similar results (see my website for more details), and yet still in America (where obesity has been termed an "epidemic" by many medical professionals), the finger of blame for a rising cesarean rate is pointed at obstetricians.

Of course, it could be argued that the fact that increased maternal weight (and indeed maternal age) is associated with cesarean delivery outcomes does not necessarily prove that these women 'needed' the cesarean. I accept that, but the fact that this proven link is rarely discussed by natural birth advocates in their condemnation of rising cesarean rates is (for me) somewhat questionable.

Bonding is NOT impaired with planned cesarean delivery

The publicity that Swain et al's research (in which just 12 women were analyzed following their cesarean delivery) is simply incredible. Compare it if you will to the Birth Trauma Association's research earlier this year, which discovered that women are less likely to die following a planned cesarean delivery than following any other birth type. As Maureen Treadwell said on Channel Five News last week, "We bury all the positive news about cesareans and hype the bad news ."

If you want to better understand the implications and more importantly, limitations of this research, a good place to start is the NHS' Behind the Headlines online explanation.

It concludes that:
"Mothers undergoing elective or emergency caesarean sections should not be led to believe that they will be any less able to bond with their baby or respond to their baby’s needs than a mother who has undergone a natural delivery."
Here's why:
"As this was a very small study, it is highly possible that any differences found are due to chance only. The brain responses occurred when listening to a recording of a baby crying during a nappy change, not to a real-life baby and it is unclear whether the changes seen on the brain scan would have any effect on the mother or baby's experience of bonding."
In fact:
"The researchers found that there was no difference in the emotional scores given between the women in response to either their own baby's cry, another baby's cry or control noise between vaginal delivery and caesarean delivery mothers. There was also no difference within each woman in her response to her own baby's cry or another baby's cry. In both groups of mothers, there was a greater emotional response to the baby cries than to a control noise. "

The Problem with Media Reports

As is so often the case, media coverage of studies like this end up muddying the waters even further due to an evident lack of understanding of the differences between planned and emergency cesarean outcome risks. For example, the two reputable news sources below each expand further on the story by reminding the reader of an existing link between cesareans and postpartum or postnatal depression (PND).

This connection is wholly inaccurate however, as the link with PND has been associated with emergency surgery (usually the outcome of an originally planned vaginal delivery) and unwanted cesareans. It is not relevant to planned procedures where the mother herself has 'elected' to have surgery. Once again, this illustrates the problem with reporting on a vast array of mixed cesarean delivery data. Journalists need to be careful (particularly when criticizing maternal request) that any research quoted is relevant to the story context.

11 Sep 08, HealthDayNews: Natural Childbirth Moms More Attuned to Babies' Cry Finding may help shed light on postpartum depression in those choosing Caesareans
03 Sep 08, BBC news online: Natural birth 'may aid baby bond' The procedure has been linked to an increased risk of post-natal depression

Natural birth is less safe for babies

Recent research in the U.S. has shown that babies are more likely to die if the duration of pregnancy is left in the hands of Mother Nature. This was a relatively large study, and it is not the first time that overdue births have been linked with adverse outcomes for the infant. In fact, this is one if the reasons that many hospitals choose to induce labor or schedule a cesarean delivery - to increase the chances of an infant's survival. I think that critics of cesarean delivery would do well to remember that there are grave risks involved with planned vaginal delivery too.

The research

Data from 1,815,811 liveborn infants in California from 1999 to 2003 was retrieved; multiple births, congenital anomalies and infants with a gestational age of less than 38 weeks (exactly) or greater than 42 weeks and 6 days, weeks were excluded. The results found that compared to infants born at 38, 39, or 40 weeks, those born between 41 weeks (exactly) and 42 weeks and 6 days had a greater odds of neonatal mortality.

When subdivided by gestational week, infants delivered between 41 weeks (exactly) and 41 weeks and 6 days showed elevated mortality relative to earlier term births. Additional analyses supported this increased neonatal mortality across all normal birthweight categories.

The researchers conclude that “Infants born beyond 41w0d of gestation experience greater neonatal mortality relative to term infants born between 38w0d and 40w6d.”

Increased neonatal mortality among normal-weight births beyond 41 weeks of gestation in California. Tim A. Bruckner PhDa, Yvonne W. Cheng MD, MPHa, b and Aaron B. Caughey MD, PhDb.

Diabetes risk associated with cesarean delivery

For those of you who have read the many media reports on research from the University of Belfast that has found that babies born by cesarean delivery have a 20% higher risk of developing Type 1 diabetes, you may want to read the press release in full here.

While it is important for a woman to include this diabetes risk in her birth risk and benefit evaluations, it is equally important for the risk to be placed in context, and if you read some of Dr Chris Patterson's (less reported) comments, you'll see what I mean.

For example: “The study findings are interesting, but unless a biological mechanism is established it would be unwise to read too much into this association between Caesarean section delivery and diabetes.

“Fortunately figures from the Northern Ireland Type 1 diabetes register indicate that only around five per 1,0000 children will develop diabetes by their 15th birthday so a 20 per cent increase is on quite a low baseline risk.”

These doctors view cesarean delivery as a valid choice

The issue of cesarean delivery on maternal request (CDMR) remains extremely controversial, especially when there is no medical indication at all. Fortunately, more and more doctors are willing to come forward and express views in support of women's autonomy. Below is a list I've compiled with some of their comments, and I plan to keep adding to it for two reasons. Firstly, because I know it helps women who are facing criticism or refusal of their cesarean preference to know that there are supportive doctors out there, and secondly, because these doctors deserve to be recognized historically for the open-minded and progressive approach they adopted in maternity care.

*2007 Dr Judith Reichman: ‘Ultimately, the choice for CDMR has to be made by the patient after thorough consultation with her doctor... Once they have discussed all of these issues with their physician, if they wish to have scheduled cesarean deliveries, their voice and choice should be considered.’
*2007 Farrell et Cook: Royal Australian and New Zealand College of Obstetricians and Gynaecologists WA branch acting chairwoman Louise Farrell, and Family Planning Association WA chief executive Jane Cook: ‘as long as women had been advised properly about the risks they should have the final say on caesareans.’
*2006 Dr James Alexander: It is a rare for his patients to request a CS, but he accommodates those requests because he believes scientific research shows that CS are getting safer and safer all the time. ‘I don't think we're going to minimize or cheapen the birth experience by offering women what they want. We're relying on women to know that they want. Who are we to impose our opinions on someone else's experience? ...Bottom line, it's their baby, their birth, their experience.’
*2006 Dr Jeff Kotzen: ‘The benefits of CS are that you avoid the uncertainty of labor and delivery, fetal distress, fetal injury, pelvic floor injury, uterine rupture. CS eliminates a lot of risk to the fetus. It doesn't have to go through the stress of birth, rigors of labor. Now there is this rising sense that women should have some say or input over their bodies. My recommendation, if a woman elects to have a CS, she is the final word.’
*2006 Prof Philip Steer: ‘The argument that it's more dangerous is unjustified. Excluding emergency CS, there's no good evidence to show this. And many myths perpetuate about the recovery period, but this procedure doesn't leave you completely incapacitated. I've had women go home within 24 hours... We all have a right to autonomy - so women should have the right to choose a CS over a natural birth should they so wish.’
*2006 Dr Jamal Mourad: thinks it is the mother's right to choose a CS after being cautioned about the pros and cons... Dr Harry Watters: it's rare that he advises women against an elective CS. When he does, it's usually because her sole reason is convenience.
*2006 Dr Brent Bost: 'We let women have breast augmentation and liposuction and all kinds of procedures that have much higher complication rates than elective CS... The educated patient doesn't want to labor 3 days like 'Little House on the Prairie'.'
*2006 Dr Victor Hugo Gonzalez-Quintero, assoc prof, University of Miami maternal-fetal medicine division: ‘Elective cesarean has both short-term and long-term complications... If after discussion of all these factors, the woman elects for cesarean, then her choice should be respected.'
*2006 Dr Chalil Tabsh: ‘I think if somebody can decide to step into a plastic surgeon's office and have her breasts enhanced - unindicated surgery - she can have an elective cesarean.'
*2006 Dr Michael Moretti, chairman, St. Vincent's OBGYN Dept: the increasing rate of cesareans is not inherently a negative trend. ‘I think we have to respect a patient's autonomy,' he said, adding that women should choose the method they wish after receiving all relevant information. ‘I don't necessarily feel we have to have a crusade to lower the cesarean rate... What's important to understand is that cesareans are done appropriately.'
*2006 Prof Fergal Malone, chairman, RCSI OBGYN Dept: defended women's right to pursue personal preferences. [He] said while some obstetricians would probably refuse to do a cesarean purely on grounds of convenience to the mother, most would be happy to accede to the woman's wishes, so long as there was no medical reason not to. ‘There is a growing realisation that the old-fashioned paternalistic approach to medicine, the ‘doctor knows best' approach, is no longer relevant to an educated, informed patient who is well able to make up her own mind.'
*2006 All the experts interviewed by WebMD: said individual patient need - and choice - should remain the prime considerations when deciding how to give birth.
*2006 Dr Wallace Champlain, Northeastern Oklahoma Community Health Care Women's Center: considers options on an individual basis [and] doesn't doubt that some physicians would issue an order for a cesarean by request... ‘Patient motivation is extremely important... Treatment options require the patient's input. After counseling with the patient, if they are adamant about having a cesarean and there are no risks involved we are going to respond to that request.'
*2006 Dr Thomas Stuttaford: Authorities dislike cesarean at a mother's request but there can occasionally be a good psychological or social reason why a cesarean might be the preferred option. This shouldn't be denied in an appropriate case.
*2006 Dr Sydney Spiesel: Historically they have not often been given that choice, and honestly, until now I thought the medical evidence so favored vaginal delivery (except when a cesarean is strongly indicated) that I never thought much about patient choice and autonomy in picking a childbirth method. The NIH report challenged and expanded my thinking. Though I would continue almost always to favor vaginal delivery over purely elective caesarean, the choice may be a little less obvious than I previously thought.
*2006 Dr Duncan Turner: ‘If a woman wants a cesarean she should get it, and I feel very strongly about this. Obviously I would talk through the pros and cons of surgery and the risks involved, but there are many more elective surgeries today that are much more dangerous - and far less as important as childbirth - and women are able to elect for these. So in my opinion, any reason should be ok - if the woman doesn't want to go through labor, she doesn't want labor pain, she wants to plan around a certain day or she feels that cesarean delivery is safer for her baby... I'm a strong advocate of patients doing things their way with the appropriate knowledge. There isn't one treatment that's right for everyone, so informed choices are what are most important. Doing something that a patient does not want is, in my opinion, malpractice.’
*2005 Dr Colin Birch: ‘I'm an advocate of choice... Thinking realistically, the experience surely is to get to the end of [pregnancy] healthy and with a healthy baby.’
*2005 Andrew Pesce, AMA: it's important to defend the right of women to choose what's best for them: ‘I believe that properly informed patients very rarely make bad decisions...'
*2005 Samantha Collier, M.D.: ‘I think that that we've reduced women's cesarean mortality and risks so much now that it's a viable option for women to choose.’
*2005 Dr Elma Joura: ‘I tell my patients very early in their pregnancy that they have free choice of their mode of delivery. I give them all the information and then they take a few weeks to go away and think about it. At the end, most of them know what is best for their personality.’
*2005 Prof James Drife: On the 2004 UK NICE guideline: ‘The maternal request point is then followed up with rather verbose and threatening language about the woman's concerns being ‘assessed and recorded' and a recommendation further on that the woman should be offered counselling and cognitive therapy. This attempt to medicalise a perfectly rational point of view is insulting and offensive to women and flies in the face of the evidence that exists. A woman is allowed to ask for a second opinion about her cesarean choice. This is the same kind of attitude that was taken after the Abortion Act came in. Women requesting abortion could be sent to a psychiatrist, a doctor had the right to refuse her request and she was allowed to ask for a second opinion. The desire to take control of women like this is disgraceful and demeans the whole document.’
*2005 Dr Rupert Fawdry: ‘With a clear, healthy playing field, and as long as a woman understands the increased risks, as far as my relationship with my patient is concerned, I think she should have the cesarean she wants. As far as being a government employee though, I think she should pay for that choice. You've made the decision, so you should have to pay.’
*2005 Dr Harry Gee: ‘I think most obstetricians, nowadays, on receiving a woman's request for a cesarean - even if there is no medical indication - would listen to her, go through the pros and cons of it, and give her the choice. I know some colleagues who wouldn't do that but in my experience, they're becoming a minority now.’
*2004 Prof Monika Birner: surveyed >1,000 women and found that those happiest with their birth experiences were those that had dictated their terms. ‘It sounds simple, but women like things most when they get what they want.' A positive birth experience, no matter what form it takes, helps a woman feel positive toward her baby.
*2004 Dr Mary E Hannah: if a woman without an accepted medical indication requests delivery by elective cesarean and, after a thorough discussion about the risks and benefits, continues to perceive that the benefits to her and her child of a planned elective cesarean outweigh the risks, then most likely the overall health and welfare of the woman will be promoted by supporting her request.
*2004 Dr David Walters: He actively advocates for cesareans. In 1998 he wrote the book ‘Just take it out.' He says all pregnant women should be given a choice between vaginal birth and cesarean. ‘What I've done is expressed what a lot of other OBs were thinking all along.'
*2004 Dr Benjamin Sachs: ‘The opportunity for a woman to elect to have a cesarean should be as available as the opportunity to have a safe, natural childbirth... Our responsibility as physicians is to counsel at both ends of that spectrum, explain the issues and try to provide support for women.'
*2004 Prof Elmar Joura: ‘Women are much more a part of the process now. To take decisions out of their hands is just not good medicine.'
*2004 Dr Bruce Flamm a spokesman for ACOG: ‘We used to think that a cesarean with no medical reason is a silly idea. I'm not so certain anymore.'
*2004 Dr Nicholas Fisk & Dr Sara Paterson Brown: The 'too posh to push' jibe belittles a genuine, well-considered choice for many women.
*2004 Dr Vyta Senikas: ‘5 years ago I'd get a request every year or two; now it's every month or two.’
*2003 Dr Bruce Bonn: ‘I think women have a right to chose their health care and be in control of their bodies... If they're making an informed decision, they should be allowed to do that.'
*2000 Dr W. Benson Harer, [past] president of ACOG [is personally] in favor of giving women the choice to have cesarean: ‘For the baby, the risks are far higher for vaginal delivery than for an elective cesarean at term... Until this last century, 1 out of every 100 woman who got pregnant died.'
*1999 Dr Sara Paterson-Brown: The right of a patient to refuse treatment is universally acknowledged as is the opposite right to request many interventions; why then are cesarean requests so controversial?…The risks of caesarean and labour are real but different, and if fully explained to the woman, she should be allowed to accept one set of risks over the other - after all she is the person who has to live with the consequences. An elective caesarean in a fit healthy woman is neither unsafe nor bad practice if she truly understands the risks involved and is adamant that she cannot accept the risks of labour or vaginal delivery.
*1997 Dr Paterson-Brown & Dr Fisk: Until recently, doctors and patients have been united in wanting lower caesarean rates. This is changing, and the concept of a more liberal patient-centred choice is gaining credence. Caesareans are no longer black and white decisions, but are becoming increasingly discretionary, based on maternal choice, their increasing safety for mother and baby, and recognition of the pelvic damage associated with vaginal birth.

NOTE - You can read more about research and studies that have been carried out (in various different countries) on the subject of CDMR support by medical professionals by checking out the 'Medical opinion, Support for CDMR' page of my website.

Planning your cesarean means planning your family size

There is evidence that the risks associated with planned cesarean delivery increase with subsequent deliveries. This is why the NIH and ACOG advise that planned cesarean delivery on maternal request (particularly where there is no medical indication) should only be undertaken by women who are planning a small family with only one or two children.

Now broadly speaking, if you look at national fertility rates in the majority of the developed world, women today are giving birth to fewer and fewer children; in fact, it is not unusual to find fertility rates of less than two in many countries.

That said, new research out this month has demonstrated that 'planning' a small family is not always synonymous with 'having' a small family. American researchers Keeton et al asked women via an online survey to recall the maximum number of children they planned to give birth to while pregnant with their first child. This estimate was then compared with the number of children they actually had. Out of 458 women who had planned a maximum of two or fewer children, and had now completed childbearing, 39% were found to have underestimated their final parity. The researchers conclude "This raises questions about making an estimate of parity a consideration for offering cesarean delivery on maternal request."

My thoughts on the research

I think that the research is interesting, and serves as an important reminder to women requesting cesarean delivery that they really do need to carefully consider their future family plans, and indeed evaluate their likelihood of commitment success, as part of their risk-benefit analysis.

I would like to find out whether the babies of the 458 women referred to above were born via cesarean delivery or vaginal delivery. This could be an important distinction to make, because there is the possibility that women who prefer a planned cesarean birth are more likely to plan other areas of their reproductive life too, while women who choose vaginal delivery are more open to allowing nature to take its course. I have no evidence of this of course but if it turns out that the research above surveyed mixed birth groups, it would be very useful to track the family sizes of women following "maternal request" alone.

Despite the researchers' focus on maternal request in their conclusion, I think that this research is of greater concern to the wider, general population of pregnant women who have "unrequested" cesarean deliveries. Whether their cesarean is scheduled pre-labor due to medical reasons or occurs during labor in an urgent or emergency situation , the fact remains that these women are very likely to have a repeat cesarean delivery in subsequent births, and may have never considered future family size as a maternal morbidity risk. With increasing maternal age, increasing levels of obesity, and an increasing cesarean delivery rate nationwide, I would think that it is just as important to discuss the issue of parity with ALL pregnant women, not just those requesting a cesarean.

Is cesarean delivery a media beast?

Listening to NPR/WHYY's Fresh Air program in my car this week, I heard Dave Davies interviewing the author and journalist John Darnton about his new novel 'Black and White and Dead All Over'.

They began by discussing an incident in the novel based on real events, which immediately brought to my mind, contemporary media coverage of cesarean delivery.

Davies: "We've got somebody who has a wonderful story of a priest doing good works in the slums of Boston and you have the executive editor, Skeeta Diamond, shoot the idea down. Why?"
Darnton: "Well, because, Skeeta Diamond says, 'You know, this is not the time for that kind of story. That's a positive priest story. We're in the midst of a scandal here, and to keep a scandal going, you have to feed the beast. You can't just let it die out by printing a story that goes against a scandal.'"

My thoughts on this

Largely because of birth research that included combined cesarean outcomes (emergency and elective), cesarean delivery retained its title of 'most risky' birth type for many, many years. It became if you like, the media's birth beast. As time went on, and newer studies began to separate planned and emergency outcomes, emergency cesarean delivery evolved as the new generation of beast, but this proved a rather weak specimen and was all too soon defeated. In its place, an even greater, bloodcurdling creature than ever imagined before reared its ugly head. Cesarean delivery on maternal request had arrived.

As report after report of risks for the mother and baby flowed from the media's inky pen, many cried, 'Why would anyone choose surgery over the natural alternative?' The beast roared even louder when it came to light that some of the women choosing surgery didn't even have a medical indication - no tokophobia, presumed large baby, perceived small pelvis - no, not a single one of the usual excuses. Accusatory adjectives and newly created labels literally leaped from many an editor's indignant copy: selfish, dangerous, uninformed, celebrity copycat, too posh to push.

Fortunately, some journalists realized they should begin to tame this beast and investigate its origins further. They soon discovered that if the beast was born at 39 weeks EGA to a healthy mother planning a small family, it was not necessarily any more scary that all the other birth types. In fact, they also learned that some women and medical professionals actually found it less scary than the birth beast that had been around forever - vaginal delivery. Up until very recently, this beast had been inescapable by mankind, and while many now believed they had the power to tame and even control it, not every woman was convinced. So they chose instead to cautiously befriend the new beast, with the theory that when it comes to pregnancy and birth, in the end, a beast is a beast is a beast.

Maternal mortality is lowest with planned cesarean deliveries and could also be lowered for all cesareans

New research by Clark et al at the Hospital Corporation of America, Nashville, TN has concluded that "Most maternal deaths are not preventable. Preventable deaths are equally likely to result from actions by nonmedical persons as from provider error. Given the diversity of causes of maternal death, no systematic reduction in maternal death rate in the United States can be expected unless all women undergoing cesarean delivery receive thromboembolism prophylaxis. Such a policy would be expected to eliminate any statistical difference in death rates caused by cesarean and vaginal delivery."

Importantly, the study looked at the causal relationship of [all] cesarean delivery to maternal death in a series of approximately 1.5 million deliveries between 2000 and 2006. A total of 95 maternal deaths occurred in 1,461,270 pregnancies (6.5 per 100,000 pregnancies) with the leading causes of death being "complications of preeclampsia, pulmonary thromboembolism, amniotic fluid embolism, obstetric hemorrhage, and cardiac disease. Only 1 death was seen from placenta accreta." 27 deaths (28%) were deemed preventable (17 by actions of health care personnel and 10 by actions of non-health care personnel) and the rate of maternal death causally related to mode of delivery was 0.2 per 100,000 for vaginal birth and 2.2 per 100,0000 for cesarean delivery, suggesting that the number of annual deaths resulting causally from cesarean delivery in the United States is about 20.

Unfortunately, since the U.S. does not separate birth data into emergency and planned cesarean deliveries, this study has analyzed a combination of the two. However, in the UK, where birth data is separated, research earlier this year found that the lowest rate of maternal mortality occurs following a planned cesarean delivery than other birth types.

I write this not with the intention of suggesting all women should therefore be encouraged to have planned cesarean deliveries, but rather to further add to the argument that women who choose to have a cesarean in preference to vaginal delivery are making a legitimate choice.

Cesarean delivery is a legitimate choice

This month, I've started an online petition for women, doctors and everyone else interested in or affected by this issue to sign. I recently received a number of distressing emails from women around the world who are being denied this valid birth choice - often with disastrous consequences - and felt that a petition might help draw attention to their situation.

If you agree that a planned, prophylactic cesarean delivery at confirmed 39-40 weeks gestation is a legitimate birth choice for healthy pregnant women who want to avoid the unpredictable nature of vaginal delivery with all its potential outcomes (including an emergency cesarean) and associated risks (for mother and baby), and who prefer instead to accept the risks associated with planned surgery, please sign here. Thank you for your support.

Cesarean-asthma link is only one of many theories

The latest study to report a link between being born by cesarean delivery and developing asthma has been reported in Norway this month by Tollanes et al. The researchers' discovery that "children delivered by CS had a 52% increased risk of asthma compared with spontaneously vaginally delivered children" made for many negative news headlines. However, it's important to note - in the context of healthy women who choose a planned cesarean delivery at 39 weeks gestation - that Tollanes et al's conclusion actually cites "a moderately increased risk of asthma in the children delivered by CS [and further, that the] possibly stronger association with emergency CS compared with planned CS could be worth pursuing to investigate possible causal mechanisms."

The fact is, it is currently impossible to say for sure whether a link categorically exists between asthma and cesarean delivery, and indeed other research carried out has pointed to other causal factors (see below) as opposed to the mode of delivery itself. As always, if cesarean statistics were separated, the job of researchers would be made a whole lot easier, measurements would be more precise, and as a consequence, women would be provided with a much clearer picture of risk.

In the meantime, if you are concerned about the risk of asthma for your child, you might be interested in reading some of the research links and media reports listed below:

RELATED RESEARCH

*2008 A meta-analysis of the association between Caesarean section and childhood asthma, Thavagnanam et al
Conclusion: In this meta-analysis, we found a 20% increase in the subsequent risk of asthma in children who had been delivered by caesarean section.
*2008 Continued Exposure to Maternal Distress in Early Life Is Associated with an Increased Risk of Childhood Asthma, Kozyrskyj et al
Conclusions: Maternal distress in early life plays a role in the development of childhood asthma, especially if it continues beyond the postpartum period.
*2006 Mode of delivery is associated with asthma and allergy occurrences in children, Salam et al
Children born by c-section were at increased risk for asthma, hay fever, and allergy compared with those born vaginally. Risk associated with c-section was the same for children regardless of family history of asthma or allergy. Conclusion: We conclude that birth by c-section or processes associated with it may increase the risk for atopic disease in childhood.
*2005 Mode of delivery at birth and development of asthma: a population-based cohort study, Juhn et al
Conclusion: Mode of delivery is not associated with subsequent risk of developing childhood asthma or wheezing episodes. Because the effect of mode of delivery on a risk of developing asthma or wheezing episodes varies over time (ie, age), selection of the study subjects according to their ages may have influenced the findings of previous studies with a shorter follow-up period.
*2005 Perinatal characteristics and obstetric complications as risk factors for asthma, allergy and eczema at the age of 6 years, Bernsen et al
Conclusions: Prematurity is a risk factor for asthma reported at 6 years. A high ratio of head circumference to birth weight is a risk factor for any atopic disorder. Vacuum extraction was associated with a higher risk of allergy, and induced labour is a risk factor for inhalant allergy. All results should be viewed with the possibility of residual confounding.
*2005 Caesarean section delivery and the risk of allergic disorders in childhood, Renz-Polster et al
Conclusion: Caesarean sections may be associated with an increased risk of developing AR [allergic rhinoconjunctivitis] in childhood.
*2005 Childhood asthma hospitalization risk after cesarean delivery in former term and premature infants, Debley et al
Conclusions: Cesarean delivery was associated with subsequent asthma hospitalization only in premature infants. Because mothers with asthma are reported to have increased rates of cesarean delivery and premature delivery, other factors in addition to the hygiene hypothesis, including genetic and in utero influences associated with maternal asthma, may contribute to the increased risk of asthma in premature infants.
*2005 Childhood asthma hospitalization risk after cesarean delivery in former term and premature infants, Debley et al
Cesarean delivery was associated with subsequent asthma hospitalization only in premature infants. Because mothers with asthma are reported to have increased rates of cesarean delivery and premature delivery, other factors in addition to the hygiene hypothesis, including genetic and in utero influences associated with maternal asthma, may contribute to the increased risk of asthma in premature infants.
*2004 Mode of delivery is not associated with asthma or atopy in childhood, Maitra et al
Conclusion: Delivery by caesarean section was not associated with the subsequent development of asthma, wheezing or atopy in later childhood in this population.
*2003 Mode of delivery and risk of allergic rhinitis and asthma, Bager et al
Conclusions: Our findings do not support the hypothesis that cesarean section or other complicated modes of delivery are associated with the development of allergic rhinitis. However, there might be a positive association with development of asthma - in particular, for cesarean section - that was not explained by gestational age, birth weight, ponderal index, smallness for gestational age, parity, maternal age, or occupation.
*2003 Caesarean section increases the risk of hospital care in childhood for asthma and gastroenteritis, Håkansson et Källén
Conclusion: There is a significant increase of the risk for developing symptoms of asthma and/or gastroenteritis that motivates admission for hospital care in cesarean children older than 1 year. It is speculated that a disturbed intestinal colonization pattern in cesarean children may be a common pathogenic factor.
*2002 Mode of delivery and asthma -- is there a connection? Kero et al
The register study showed the cumulative incidence of asthma at the age of seven to be significantly higher in children born by caesarean section (4.2%) than in those vaginally delivered (3.3%)... In the second study, significantly more positive allergy tests were reported in questionnaires in the caesarean (22%) than in the vaginal delivery group (11%), and a trend toward more positive skin prick reactions was documented at clinical examination; 41% versus 29%. In conclusion, these results suggest that caesarean section delivery may be associated with an increased prevalence of atopic asthma.
*2001 Caesarean section and risk of asthma and allergy in adulthood, Xu et al
Prospective birth cohort born in northern Finland in 1966: Cesarean had a strong effect on current doctor-diagnosed asthma in adulthood [in 1997, aged 31]... However, no substantial effects were observed for atopy, hay fever, and atopic eczema.
*2001 Gaps in Primal Research, Odent M
...looked at the incidence of asthma in 1,953 people aged 31 who were born in 1966. Those born by caesarean were 3 times more at risk of being diagnosed with asthma but the study did not separate emergency from planned operations [and] one can assume that in 1966 most caesareans were born during labour.
*1998 Infant and maternal outcomes in the pregnancies of asthmatic women, Demissie et al
After controlling for the effects of important confounding variables, maternal asthma was associated with the following adverse infant outcomes: preterm infant, low birth weight, small-for-gestational age, congenital anomalies, and increased infant hospital length of stay. The adverse maternal outcomes associated with maternal asthma were: pre-eclampsia, placenta previa, cesarean delivery, and increased maternal hospital length of stay. The results emphasize the need for maternal asthma to be added to the list of conditions that increase the risk of adverse pregnancy outcomes.

PREVIOUS NEWS REPORTS

*15 Jul 08 Asthma risk from pregnancy nuts, BBC news online
*04 Mar 07 Damp homes 'could cause asthma', BBC news online
*20 Nov 06 Milk allergy in babies 'missed', BBC news online
*11 Nov 06 Diet may help prevent allergies and asthma, Scientist Live
*09 Sep 06 Food allergies 'gone in 10 years', BBC news online
*25 Aug 06 Childhood allergies 'more widespread', Guardian (PA)
*07 Dec 01 Vitamin link to asthma, BBC news online
*15 Nov 01 Firstborn 'more prone to allergies', BBC news online
*27 May 01 Keeping pets 'prevents allergies', BBC news online
*06 Mar 01 Allergy hope for asthmatic children, BBC news online
*12 May 00 Dust 'protects against asthma', BBC news online
*09 May 00 Your bedding could make you ill, BBC news online
*11 Feb 00 Dirt could be good for you, BBC news online
*17 Dec 99 Allergy warning over processed food, BBC news online
*08 Jun 99 Childhood asthma soars, BBC news online
*05 Feb 99 Nursery may protect against allergies, BBC news online

U.S. prepregnancy obesity rates of 25% reported

It is well established that a strong link between maternal weight and birth outcomes (both maternal and neonatal) exists. In particular, women who are overweight or obese are more likely to have adverse outcomes, and this includes the likelihood of a medical (planned or emergency) cesarean delivery.

A study published this week has highlighted the prevalence of this situation in the USA, and this is important in light of efforts being made to reduce the national cesarean rate. In 'Prepregnancy Obesity Prevalence in the United States, 2004–2005', Chu et al studied 75,403 women and found that "about one in five women who delivered were obese [and] in some state, race/ethnicity, and Medicaid status subgroups, the prevalence was as high as one-third. State-specific prevalence varied widely and ranged from 13.9 to 25.1%. Black women had an obesity prevalence about 70% higher than white and Hispanic women (black: 29.1%; white: 17.4%; Hispanic: 17.4%); however, these race-specific rates varied notably by location. Obesity prevalence was 50% higher among women whose delivery was paid for by Medicaid than by other means (e.g., private insurance, cash, HMO)." They concluded: "This prevalence makes maternal obesity and its resulting maternal morbidities (e.g., gestational diabetes mellitus) a common risk factor for a complicated pregnancy."

Why is this important?
Because if advocates of vaginal delivery want to address the escalating national cesarean rate in the U.S. (and indeed other countries), which currently stands at 31.1%, it is vital that they first address this very modern health care issue (women may have been giving birth for centuries, but they weren't the same shape and size as we see in today's society). It is not a simple fix, that is true, but these women need help and support long before they go into labor if they are to succeed in delivering their babies safely. Targeting healthy women for whom cesarean delivery is their personal preference not only ignores the problem at hand, but is grossly unfair too.

Obstetricians choose cesarean delivery too

If you've been reading my website over the past few years or seen my article in February 2008, you'll already know that many medical professionals (particularly those involved with traumatic vaginal deliveries or the post-birth health care of women and babies adversely affected) choose cesarean delivery when it comes to their own children's births. This week, the Guardian published an article on the subject ('We know the reality of childbirth'), which highlights some of their personal reasons and experiences. You might also be interested in viewing readers' comments in response to the article.

Comments that caught my attention
BettyM

Betty questions whether there really is any evidence to support this claim: "The only studies I could find in the UK are old (1996 and 1997), small (only asked London OBs) and showed 31% in favour of elective c-section from the women... A study of German OBs showed 90% would choose vaginal for a low risk pregnancy for themselves, a Danish one only 1% would choose a c-section and an Irish one 7% would choose a c-section."

For the purposes of brevity (other reports have been published since), here is an extract from my February article, which highlights a number of studies measuring doctors' preferences for planned cesarean delivery over planned vaginal delivery, plus the reasons behind their choices.

"reports exist of 46.2%, (161, USA, 2001) 22.5%, (165, Denmark, 2004) 22%, (494, USA, 2003) 21.1%, (164, USA, 2005) "one fifth", (253, USA, 2007) 17%, (158, UK, 1997) 15.5%, (474, Scotland, 2002) 15.5%; increasing to 60% in preference to trial of instrumental delivery and 72% if they could choose the obstetrician performing the delivery, (170, UK, 2001) 15%; increasing to 40-65% for higher birth weights, (167, UK, 2002) 11%; increasing to 26-55% for higher birth weights, (498, Australia, 2001) 9% (151, Israel, 2002) and 7%; increasing to 38% for higher birth weights. (169, Ireland, 2001) When asked why they support maternal request or would personally choose it for their own delivery, physicians cite a number of concerns with PVD risks; for example, fecal (78%) (159, UK, 2001) (498, Australia, 2001) or anal (35%) (164, USA, 2005) (165, Denmark, 2004) incontinence, bladder and bowel problems (44%), (163, Canada, 2005) urinary incontinence (68%), (159, UK, 2001) (165, Denmark, 2004) (498, Australia, 2001) baby's safety (165, Denmark, 2004) (250, USA, 2004) (322, USA, 1999) (51%), (159, UK, 2001) (33.3%), (164, USA, 2005) future sexual function (250, USA, 2004) (50%), (159, UK, 2001) (26.7%), (164, USA, 2005) damage to pelvic floor (165, Denmark, 2004) (250, USA, 2004) (322, USA, 1999) (88%), (158, UK, 1997) (26.7%), (164, USA, 2005) fear of labor (153, Italy, 2006) (26.7%), (164, USA, 2005) ultrasonography, (153, Italy, 2006) pain (11.7%), (164, USA, 2005) provider availability (10%), (164, USA, 2005) convenience (164, USA, 2005) (8.3%), (250, USA, 2004) autonomy... litigation, and unfounded, but understandable fear. (491, Netherlands, 2004) Notably, "convenience" is ranked as least important, and yet accusations abound that this is one of the main reasons that both doctors and women choose cesarean delivery."

Mary Newburn

Mary writes: "Midwives, obstetricians and managers should work together to facilitate normal birth."

The reality is that for many women (and indeed medical professionals), planned cesarean delivery at 39-40 weeks gestation is considered perfectly 'normal' too. Surely it is as unfair to work towards facilitating unwanted vaginal deliveries as it is to encourage unwanted cesarean deliveries? I rather think that working towards facilitating all preferred birth plans and outcomes is a far more healthy goal - for women and their babies.

DebbieCD

Debbie writes: "What I find particularly worrying about this article is that the assumption that caesareans are safer for babies is being taken as fact. There is no evidence to support this and the only research that has look at this in depth came to the conclusion that more than 1.7 times as many babies die if they were born by elective caesarean and this was not women who had pregnancy problem putting their babies at additional risk. (ref: BIRTH 33:3 September 2006 "Infant and Neonatal Mortality for Primary Cesarean and Vaginal Births to Women with "No Indicated Risk," United States, 1998-2001 Birth Cohorts - authors Marian F. MacDorman, PhD, Eugene Declercq, PhD, Fay Menacker, DrPH, CPNP, and Michael H. Malloy, MD, MS)"

I wrote about this research in some depth in my April 2008 ec Blog as I feel that it was gravely misinterpreted in some media reports (and consequently, by women like Debbie). These are just two of the observations I make, but you can click on the link above to read more:

*Although the researchers have applied the NIH's "intention-to-treat" recommendation, they have not accounted for one of the most important CDMR recommendations by the NIH, which is to wait until 39 weeks EGA for planned cesarean delivery with no medical indication. Instead, the study defines low-risk births as "singleton, term (37-41 weeks' gestation), vertex births, with no reported medical risk factors or placenta previa and with no prior cesarean section." This is important, because while a baby delivered at 39 weeks EGA is certainly not risk free, the neonatal mortality rate is most likely lower than the 1.73 reported here, and it is cases of "no medical indication" that MacDorman et al are questioning.

*Planned vaginal deliveries (even those for low risk women) can last beyond 41 weeks, and there is documented evidence of a "small but significant" risk in fetal mortality beyond this point (Divon et al, 1998), and also after 40 weeks. (Caughey et al) Measuring mortality up to 41 weeks alone may have provided PVD with improved statistical outcomes in MacDorman et al's study.

OTHER RELATED RESEARCH

2008 Cesarean section: Norwegian women do as obstetricians do-not as obstetricians say, Finsen et al
In the general public with children, 12% reported that one or more of them were born by cesarean section. The average was 8% among those with only basic schooling compared with 16% among those who had been to university for more than 4 years. This figure was 19% among physicians in general, 26% among surgeons, and 27% among the 189 specialists in obstetrics and gynecology. Conclusion: The rate of cesarean section in the general population is unlikely to fall as long as so many obstetricians have their own children delivered by cesarean section.

Choosing c-section - It's horses for courses

FACT

Up until very recently in human evolution, babies arrived into the world through just one door (or rather corridor), and that is, the vagina.

MYTH

Natural birth is a process that is desired and enjoyed by all women.

FACT

Although originally designed as a life-saving procedure (and indeed successfully so if you look at historical national mortality rates), cesarean delivery now offers babies an alternative route into the world; an alternative that is gradually gaining favor with increasing numbers of women.

MYTH

Mothers whose children are born by cesarean (where the cesarean was wanted as opposed to not wanted) are less likely to bond with them, and will miss out on the greatest experience life has to offer. As a consequence, they are not real women, and should be sympathized for their vaginal failure or chastised for daring to avoid a natural rite of passage that is the long established prerequisite to motherhood.

High horses

Let me say first, that thankfully, I think there are a number of women and health professionals involved in maternity care who agree with equal access to the full spectrum of birth choices. However, some really do need to get off their high horse when it comes to giving birth; parading vaginal delivery as the superior thoroughbred of births, immune to the possibility of false starts or of falling at the first hurdle simply ignores what can be a very stressful reality for many in the human race.

Picking a winner

True, the birth of a child (especially your own) is an amazing, wonderful, beautiful thing, but it is also an unpredictable, risky and often frightening process. This is because unfortunately, it's impossible to guarantee how any birth plan will turn out, and all you can hope to do is put in place the best preparations for the delivery of your choice. It's a personal decision whether those preparations are for vaginal delivery or cesarean surgery, and after careful deliberation and research, and with the right support and expertise (...a visit from Lady Luck wouldn't go amiss too), you'll give yourself (and your baby) the very best chance of entering the final winner's enclosure.

A finish line with starting blocks

This has been said before I know, but in the end, what most of us would describe as a successful birth outcome is the safe arrival of our healthy baby (or babies). What I would add, is that while pregnancy can sometimes make us feel as though the birth is the ultimate finish line, in fact it's only really the starting line. Raising a child is (hopefully) a long journey and there will be so many more decisions to make regarding their health and wellbeing besides their delivery route into the world.

Horses for courses

Me, I would choose a cesarean delivery every time. One of my best friends would choose a vaginal delivery every time, albeit with the further decision-making layer of whether to opt for home, hospital, water, epidural, gas and air (etc.) to consider. We have so many other things in common in life but not our method of delivery, and that's fine. She respects my choice; I respect hers. Why other women waste time and effort chastising each other for their personal birth preference, particularly when it has nothing to do with their own, utterly perplexes me.

Analogy disclaimer

I've taken the liberty of employing a rather equestrian theme in my blog today, but I'd just like to clarify that the analogies above are not designed for further expansion. That is, I am not implying that childbirth is like a day at the races, akin to irresponsible gambling or any other negative connotation. No offense is intended and I hope that none is taken.

Minimize the risk of breathing difficulties

For your baby, the biggest concern with an elective cesarean is that their lungs may not have fully developed prior to delivery, leading to respiratory distress and possibly NICU treatment when they're born. When studies such as last December's Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study from Denmark warn of increased risks with elective cesarean delivery compared with vaginal delivery, cesarean choice is labeled by many medical professionals, journalists and women as a selfish and dangerous road to travel.

NOT SO...
In fact, if you follow the advice given by numerous medical professionals and national health institutions (listed with live links below), and wait until your baby's gestational age has reached 39 weeks, the risk of respiratory is significantly reduced. For example, the Danish study above found that the risk of serious respiratory morbidity was 0.1% for PVD and 0.2% for elective cesarean at 39 weeks - a negligible difference, and you can read a full explanation of this in my March 2008 British Medical Journal Rapid Response: Further evidence of reduced infant morbidity with cesarean delivery on maternal request at 39 weeks EGA.

REMEMBER...
Even at 39 weeks, cesarean delivery is not 100% risk-free (but then no birth choice is), but next time you read a highly publicized media report on research into adverse respiratory outcomes with elective cesareans, read the small print. Does the study analyze a large pool of babies born as early as 36 or 37 weeks (or even earlier)? If so, it's likely that many of those babies were delivered early due to medical reasons or the onset of early labor. If you choose cesarean delivery with no medical indication, your doctor will advise you to wait until lung maturity is established before they begin surgery.

RELATED RESEARCH

*2008 Neonatal Mortality and Morbidity Rates in Late Preterm Births Compared With Births at Term, McIntire D et Leveno K
Late preterm births are common and associated with significantly increased neonatal mortality and morbidity compared with births at 39 weeks. Preterm labor was the most common cause (45%) for late preterm births.
*2008 Elective Cesarean Delivery, Neonatal Intensive Care Unit Admission, and Neonatal Respiratory Distress, Yee et al
Elective cesarean delivery beyond 270 days of gestational age (384/7 weeks) significantly reduced the risk for NICU admission or respiratory distress.
*2008 Is 38 weeks late enough for elective cesarean delivery? Matsuo et al
The incidence of IRDS following elective cesarean delivery at term was found to range between 7.4% and 8.4% for 37 weeks, 4.2% and 4.4% for 38 weeks, and 1.2% and 1.8% for 39 weeks in previous studies, but ultrasound was not routinely used for the dating in these studies. In our study, scheduling elective cesarean delivery at 38 weeks was not found to be associated with an increased risk of severe neonatal complications. This is most likely due to routine ultrasound dating early in the first trimester of pregnancy.
*2007 Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study, Hansen et al
Our results also suggest that a significant reduction in neonatal respiratory morbidity may be obtained if elective caesarean section is postponed to 39 weeks' gestation.
*2007 Respiratory stress syndrome (RDS) in newborn in 35-38 gestational weeks, delivered by cesarean section, Ginekol A
*2007 Timing of planned repeated caesarean section: An enigma, Abouzeid et al
The percentage of consultants who preferred to do caesarean section at 39 weeks or more gestational age in patients with previous one, two, three or more and a classical caesarean section were 93.6%, 87.3%, 71.3% and 35.9%, respectively.
*2006 NIH statement, USA
The severity of breathing difficulties can be reduced by waiting at least 39 weeks before having a cesarean.
*2005 Antenatal betamethasone and incidence of neonatal respiratory distress after elective caesarean section: pragmatic randomised trial, Stutchfield et al
Antenatal betamethasone and delaying delivery until 39 weeks both reduce admissions to special care baby units with respiratory distress after elective caesarean section at term.
*2004 NICE guideline, UK
Timing of planned CS: CS should be carried out after 39 weeks’ gestation to decrease the risk of respiratory morbidity.
*2004 Neonatal respiratory morbidity risk and mode of delivery at term: influence of timing of elective caesarean delivery, Zanardo et al
A significant reduction in neonatal RDS would be obtained if elective caesarean delivery were performed after 39 + 0 gestational weeks of pregnancy... After 39+0 wk, there was no significant difference in RDS (respiratory distress syndrome) risk [between elective caesarean delivery and vaginal delivery].
*2004 An audit of neonatal respiratory morbidity following elective caesarean section at term, Nicoll et al
A reduction in neonatal respiratory morbidity can be achieved by delaying elective caesarean section until 39 weeks gestation.
*2003 Neonatal clinical outcome after electivecesarean section before the onset of labor at the 37th and 38thweek of gestation, Yamazaki H et al, Pediatrics International
The incidence of breathing difficulty was significantly higher in the infant group born in the first half of the 37th week of gestation than in the latter group... An elective cesarean before the onset of labor early in the 37th week of gestation should not be routinely undertaken.
*2001 Life-table analysis of the risk of perinatal death at term and post term in singleton pregnancies, Smith GC
Delivery at 38 weeks' gestation was associated with the lowest risk of perinatal death.
*1999 Delaying planned caesarean delivery until 39 completed weeks of gestation: the experience of a district general hospital, Ojidu JI
It has become clear that delaying elective cesarean delivery until 39 completed weeks of pregnancy decreases neonatal respiratory morbidity...
*1998 Elective cesarean section is preferred after the completion of a minimum of 38 weeks of pregnancy, Graziosi et al
Most of neonatal respiratory morbidity could have been avoided by postponement of the at-term elective caesarean section until a certain gestational age of at least 38 complete weeks. An elective caesarean section should not be performed before that period.
*1995 Neonatal respiratory morbidity and mode of delivery at term: influence of timing of elective caesarean section, Morrison et al
A significant reduction in neonatal respiratory morbidity would be obtained if elective caesarean section was performed in the week 39+0 to 39+6 of pregnancy.

First things first (read this if nothing else)

Vaginal delivery - GOOD
Cesarean delivery - BAD
Emergency cesarean - REALLY BAD
Elective cesarean - BETTER (BUT STILL BAD)

Broadly speaking, this is the way choice in childbirth is often portrayed - both in the media and in the majority of antenatal literature. A simple guideline to be ignored at your own peril, and more importantly, that of your unborn child. Except it's really not that simple. In fact, the truth is far more complex, and as difficult to retrieve from existing national data, hospital records and medical research as a Voldemort-encrypted horcrux.

Why? Largely because of two main problems in the collection, recording and reporting of birth data (there are actually numerous problems but let's start with the worst offenders).

1) In many hospitals (and consequently any medical research that relies on the data contained therein), little or no distinction is made between planned cesarean and emergency cesarean outcomes. This means that any risk appraisal of planned cesarean delivery is muddied by the morbidity outcomes associated with emergency surgery. Furthermore, no distinction is made between the outcomes of a planned cesarean for medical reasons and a planned cesarean with no medical indication (e.g. maternal request). This is important to recognize, as the presence of any pre-existing medical condition could lead to worse morbidity outcomes than those experienced by a healthy pregnant woman and her baby.

2) There is a huge difference between analyzing birth plans and birth outcomes, and since it is IMPOSSIBLE TO PREDICT any birth outcome, all analysis for the purposes of informing pregnant women (i.e. while they are in the birth planning stage) should compare infant and maternal morbidity and mortality outcomes as they relate to the original birth plan - rather than the eventual birth outcome. Let me explain...

A planned vaginal delivery (PVD) may have the outcome of a spontaneous vaginal delivery with no tearing, episiotomy or intervention, and no adverse health outcomes for mother and baby... or it may not. The outcome could be an assisted vaginal delivery (forceps, ventouse, episiotomy or all three), an emergency cesarean delivery (possibly following a forceps/ventouse/episiotomy attempts) or even a planned cesarean delivery decided in the very late stages of pregnancy. Similarly, a planned cesarean may have the outcome of a planned cesarean... or it could result in a spontaneous (or assisted) vaginal delivery or an emergency cesarean delivery.

What's important to note here is that planned cesarean deliveries result in the desired outcome far more often than planned vaginal deliveries. So, when comparing elective cesarean delivery with PVD for the purposes of informing healthy women of the risks and benefits of each, it is at best ineffective and at worst, misleading to only measure the successful outcome morbidity and mortality rates of each. In fact, the vast majority of emergency cesarean deliveries (which are associated with the greatest incidence of infant and maternal morbidity and mortality) are the consequence of an unsuccessful PVD attempt. Therefore, these outcome measures should be attached to PVD data prior to comparison with elective cesarean delivery - and for an even greater degree of accuracy, the elective cesarean delivery outcome measures should be separated into those with medical and non-medical indications.

In my view, research and analysis combining elective and emergency cesarean outcomes should be eliminated from all future studies that set out to compare PVD with planned cesarean delivery.

Advocates of cesarean delivery with no medical indication as a legitimate choice for pregnant women (myself included) have already looked at the data available and been able to deduce what's been suspected for a long time - that the risks and benefits associated with elective cesarean delivery are favorably comparable with those of PVD (there'll be more detail on this in future blogs, but you can check out www.electivecesarean.com if you want to read more now), and women should be advised of this during antenatal appointments.

*******

The most successful birth outcome is that of a healthy and happy mother and baby, and in survey after survey, women cite satisfaction with their birth outcome as a valued psychological benefit. For some women that outcome is vaginal delivery while for others it is cesarean delivery; arguing the case 'vaginal delivery for all' is as ignorant and damaging as suggesting 'cesarean delivery for all.' Here's why:

PREGNANCY AND BIRTH ARE INHERENTLY RISKY...

...there are risks and benefits with every possible birth plan choice
...but ultimately, it's the woman, her baby and her family who experience the birth outcome
...and they might simply fear or value one set of risks and benefits more than the other.

We're already delivering more healthy babies than at any time in human history
...DELIVERING CHOICE IS THE NEXT STEP TO FURTHER SUCCESS