Monday, January 27, 2014

No, Dr. Maiman this might not be a cause for celebration...

I have a problem with automatically celebrating declines in rates of caesareans without understanding why the decline happened, and whether or not there was any significant repercussion from the change. I have a problem with the assumption that vaginal birth is good, and caesarean birth is bad. I have a problem with a very superficial understanding of what is a very important health issue for both women and their children.

In short, I think the focus on caesarean rates is wholly detrimental to the health of women and their children. Which is why – I get annoyed by articles like this - that trumpet the decline of first time caesareans as some kind of public health success story. It might be, but the disservice to women and their children, comes from the assumption that the road to better health and well-being goes straight through the birth canal.

The issue of birth – and the issue of planned caesarean versus planned vaginal birth, is complex, incredibly complex, and the focus on rates of caesarean over-simplifies it. The focus on the rates of caesareans, ignores many things that matter a great deal and deserve greater attention.

There are so many things that I’d like to know before considering whether or not the movement in caesarean rates is a good thing and off the top of my head here’s just a few things:

1. Was the decline in the rate of urgent/emergent caesareans or in the rate of planned caesareans?

2. Was the decline a result of a change in the demographics of women giving birth – for example were the moms younger, more likely to be a healthy weight at the start of their pregnancies, were they less likely to be gestationally diabetic, were they planning on larger families?

3. Were there more 3rd and 4th degree tears?

4. Were more moms suffering from incontinence a year after the birth?

5. Were there more low APGAR scores?

6. Were there more deaths?

7. Did more or less moms consider the births traumatic?

8. What happened to rates of post-partum depression and/or PTSD?

9. Were any moms who would choose caesarean denied access to their delivery method of choice?

It’s true that the risks of caesareans mount with the number of caesareans that are had – and for women planning large families it is important that they pursue the birth plan that gives them the best odds of success. However, I must strenuously disagree with the assertions made by Dr. Maiman in this article that “The risks to mother and baby are much higher in a caesarean birth than in a vaginal birth” and “Vaginal delivery is the preferred method for having a baby, Cesareans should only be resorted to when its absolutely necessary.”

Vaginal delivery is not the preferred method for delivering a baby for many women – particularly those who suffered adverse consequences that could have been avoided had they been delivered by caesarean. Further, it is very debateable as to whether or not the risks of caesarean are “much” higher for both mother and baby than a planned vaginal birth. There is some evidence - that looked at 40,000 term deliveries from 1994-2002 and compared planned cesarean for breech with planned vaginal for cephalic and found the maternal morbidity (life-threatening) was similar in each group but that life-threatening neonatal morbiditiy was decreased in the pre-labour cesarean group.

However, as long as we’re focused on the headline cesarean rate, and lowering it, at what might be tremendous cost – we will never get to what really matters: the health and well-being of mothers and their babies.

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