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.