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