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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.