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.