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.