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Sunday, December 17, 2006

Part 5 ~ Ongoing critique ~ 12-17-06

THE SCORE - October 9, 2006
How childbirth went industrial

Read First Web link to THE SCORE

New Study added ~ 11/29 blog reposted on 12-17-2006

I imagine readers (including me) must be tired of my personal story and my personal opinions about the dangers associated with medically unnecessary Cesarean surgery. So I’d like to go back to the New Yorker article and revisit the actual words of Dr Gawande on the topic of Cesarean as the all-purpose cure for everything associated with pregnancy and birth.

After revisiting these assertions in THE SCORE, I have copied excerpts of several recently published studies that, strangely enough, seem to diametrically oppose the lovely fantasy that Cesarean surgery and other obstetrical excesses can lead the way to inexpensive, risk-free, pain-free childbirth.


“If obstetrics wasn’t to go the way of phrenology or trepanning, it had to come up with a different kind of ingenuity. It had to figure out how to standardize childbirth. And it did.

…. there’s also no getting around C-sections. We have reached the point that, when there’s any question of delivery risk, the Cesarean is what clinicians turn to—it’s simply the most reliable option.

Clinicians are increasingly reluctant to take a risk, however small, with natural childbirth. …… These were the rules of the factory floor.

A measure of how safe Cesareans have become is that there is ferocious but genuine debate about whether a mother in the thirty-ninth week of pregnancy with no special risks should be offered a Cesarean delivery as an alternative to waiting for labor.

The idea seems the worst kind of hubris. How could a Cesarean delivery be considered without even trying a natural one? Surgeons don’t suggest that healthy people should get their appendixes taken out or that artificial hips might be stronger than the standard-issue ones. Our complication rates for even simple procedures remain distressingly high.

Yet in the next decade or so the industrial revolution in obstetrics could make Cesarean delivery consistently safer than the birth process that evolution gave us.

Currently, one out of five hundred babies who are healthy and kicking at thirty-nine weeks dies before or during childbirth—a historically low rate, but obstetricians have reason to believe that scheduled C-sections could avert at least some of these deaths. Many argue that the results for mothers are safe, too.

Scheduled C-sections are certainly far less risky than emergency C-sections—procedures done quickly, in dire circumstances, for mothers and babies already in distress.

One recent American study has raised concerns about the safety of scheduled C-sections, but two studies, one in Britain and one in Israel, actually found scheduled C-sections to have lower maternal mortality than vaginal delivery.

Mothers who undergo planned C-sections may also (though this remains largely speculation) have fewer problems later in life with incontinence and uterine prolapse.”


Volume 61, Number 12 2006 CME REVIEW ARTICLE

CHIEF EDITOR’S NOTE: This article is part of a series of continuing education activities in this Journal through which a total of 36 AMA/PRA Category 1 Credits can be earned in 2006.

Public Health Implications of Cesarean on Demand

Lauren A. Plante, MD, MPH Assistant Professor, Obstetrics & Gynecology and Anesthesiology, Thomas Jefferson University, Philadelphia, Pennsylvania

Cesarean rates have been rising in the United States. Recently, there has been an upsurge of interest in “cesarean on maternal request” in the absence of any medical indication, a phenomenon that will further increase the cesarean rate. This trend may not be benign on a population basis, and reliable data are lacking. This article reviews reasons for the increasing cesarean rate, describes maternal and neonatal consequences likely to accrue with a policy of cesarean on demand, and explores larger implications for public health.

Target Audience: Obstetricians & Gynecologists, Family Physicians

Learning Objectives: After completion of this article, the reader should be able to state that there continues to be a rise in the cesarean delivery rate in the United States and summarize that cesarean delivery on maternal request (CDMR) is contributing to this rise without data to indicate a decrease in maternal and fetal mortality and morbidity, possibly with a large population cost.

Synopsis of conclusions of Cesarean-related mortality and morbidity associated with a 5% annual increase in patient requests for non-indicated [medically-unnecessary] Cesarean surgery in the US:

* A total of 14 to 32 more maternal deaths
* A total of 5000 to 24,0000 more surgical complications
* A total of 4000 to 6000 more postoperative infections
* A total of 2200 more postpartum readmissions to the hospital
* A total of 200 to 300 additional venous thromboses [potentially fatal blood clots]
* A total of 33,000 more neonatal intensive care unit admissions
* A total of 8000 more cases of neonatal respiratory complications
* A total of 930,000 more hospital days for women, infant length of stay not calculated
* Between $750 million and $1.7 billion in healthcare expenditures
* Higher rates of hospital occupancy
* Longer waiting times for elective operations of all kinds
* The potential for an overall increase in medical error related to higher hospital
occupancy rates.

Doesn’t this makes you want to run out and have a couple elective Cesareans?


Postpartum Maternal Mortality and Cesarean Delivery

Catherine Deneux-Tharaux, MD, MPH, Elodie Carmona, MPH, Marie-Hélene Bouvier-Colle, PhD,and Gérard Bréart, MD


OBJECTIVE: A continuous rise in the rate of cesarean delivery has been reported in many countries during the past decades. This trend has prompted the emergence of a controversial debate on the risks and benefits associated with cesarean delivery. Our objective was to provide a valid estimate of the risk of postpartum maternal death directly associated with cesarean as compared with vaginal delivery.

METHODS: A population-based case–control study was designed, with subjects selected from recent nationwide surveys in France. To control for indication bias, maternal deaths due to antenatal morbidities were excluded. For the 5-year study period 1996–2000, 65 cases were included. The control group was selected from the 1998 French National Perinatal Survey and included 10,244 women. Multivariable logistic regression analysis was used to adjust for confounders.

RESULTS: After adjustment for potential confounders, the risk of postpartum death was 3.6 times higher after cesarean than after vaginal delivery (odds ratio 3.64 95% confidence interval 2.15– 6.19).

Both prepartum and intrapartum cesarean delivery were associated with a significantly increased risk.

Cesarean delivery was associated with a significantly increased risk of maternal death from complications of anesthesia, puerperal infection, and venous thromboembolism [potentially fatal blood clots].

The risk of death from postpartum hemorrhage did not differ significantly between vaginal and cesarean deliveries.

CONCLUSION: Cesarean delivery is associated with an increased risk of postpartum maternal death. Knowledge of the causes of death associated with this excess risk informs contemporary discussion about cesarean delivery on request and should inform preventive strategies. (Obstet Gynecol 2006;108:541–8)



Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America

José Villar et al; for the WHO 2005 global survey on maternal and perinatal health research group* Published online May 23, 2006


Background Caesarean delivery rates continue to increase worldwide. Our aim was to assess the association between caesarean delivery and pregnancy outcome at the institutional level, adjusting for the pregnant population and institutional characteristics.

Methods: For the 2005 WHO global survey on maternal and perinatal health, we assessed a multistage stratified sample, comprising 24 geographic regions in eight countries in Latin America. We obtained individual data for all women admitted for delivery over 3 months to 120 institutions randomly selected from of 410 identified institutions.

Findings: We obtained data for 97 095 of 106 546 deliveries (91% coverage). The median rate of caesarean delivery was 33% (quartile range 24–43), with the highest rates of caesarean delivery noted in private hospitals (51%, 43–57). Institution-specific rates of caesarean delivery were affected by primiparity, previous caesarean delivery, and institutional complexity.

Rate of caesarean delivery was positively associated with postpartum antibiotic treatment and severe maternal morbidity and mortality, even after adjustment for risk factors. Increase in the rate of caesarean delivery was associated with an increase in fetal mortality rates and higher numbers of babies admitted to intensive care for 7 days or longer even after adjustment for preterm delivery. Rates of preterm delivery and neonatal mortality both rose at rates of caesarean delivery of between 10% and 20%.

Interpretation: High rates of caesarean delivery do not necessarily indicate better perinatal care and can be associated with harm.


Voluntary C-Sections Result in More Baby Deaths
September 5, 2006 | New York Times

Original study -- September 2006 - Birth: Issues in Perinatal Care

A recent study of nearly six million births has found that the risk of death to newborns delivered by voluntary Caesarean section is much higher than previously believed.

Researchers have found that the neonatal mortality rate for Caesarean delivery among low-risk women is 1.77 deaths per 1,000 live births, while the rate for vaginal delivery is 0.62 deaths per 1,000. Their findings were published in this month's issue of Birth: Issues in Perinatal Care.

The percentage of Caesarean births in the United States increased to 29.1percent in 2004 from 20.7 percent in 1996, according to background information in the report.

Mortality in Caesarean deliveries has consistently been about 1½ times that of vaginal delivery, but it had been assumed that the difference was due to the higher risk profile of mothers who undergo the operation.

This study, according to the authors, is the first to examine the risk of Caesarean delivery among low-risk mothers who have no known medical reason for the operation.

Congenital malformations were the leading cause of neonatal death regardless of the type of delivery. But the risk in first Caesarean deliveries persisted even when deaths from congenital malformation were excluded from the calculation.

Intrauterine hypoxia — lack of oxygen — can be both a reason for performing a Caesarean section and a cause of death, but even eliminating those deaths left a neonatal mortality rate for Caesarean deliveries in the cases studied at more than twice that for vaginal births.

"Neonatal deaths are rare for low-risk women — on the order of about one death per 1,000 live births — but even after we adjusted for socioeconomic and medical risk factors, the difference persisted," said Marian F. MacDorman, a statistician with the Centers for Disease Control and Prevention and the lead author of the study.

"This is nothing to get people really alarmed, but it is of concern given that we're seeing a rapid increase in Caesarean births to women with no risks," Dr. MacDorman said*

Part of the reason for the increased mortality may be that labor, unpleasant as it sometimes is for the mother, is beneficial to the baby in releasing hormones that promote healthy lung function. The physical compression of the baby during labor is also useful in removing fluid from the lungs and helping the baby prepare to breathe air.

The researchers suggest that other risks of Caesarean delivery, like possible cuts to the baby during the operation or delayed establishment of breast-feeding, may also contribute to the increased death rate.

The study included 5,762,037 live births and 11,897 infant deaths in the United
from 1998 through 2001, a sample large enough to draw statistically significant conclusions even though neonatal death is a rare event. There were 311,927 Caesarean deliveries among low-risk women in the

Dr. Michael H. Malloy, a co-author of the article and a professor of pediatrics at the University of Texas Medical Branch at Galveston, said that doctors might want to consider these findings in advising their patients.

"Despite attempts to control for a number of factors that might have accounted for a greater risk in mortality associated with C-sections, we continued to observe enough risk to prompt concern," he said.

"When obstetricians review this information, perhaps it will promote greater discussion within the obstetrical community about the pros and cons of offering C-sections for convenience and promote more research into understanding why this increased risk persists."

Caesarean doubles risk of stillbirth for next child
By Jeremy Laurance, Health Editor
28 November 2003 © 2003 Independent Digital (UK) Ltd

Women who give birth by Caesarean section run twice the risk of having a stillbirth at the next pregnancy, researchers reported yesterday.

Although the risk of a later stillbirth remains low, at about one in 1,100, doctors say the finding could redefine the nature of the debate about Caesareans, which have more than doubled in the past 20 years. Concern about Caesareans has previously focused on the immediate potential risks to mother and child. Problems with the development of the placenta in subsequent pregnancies have been noted but this is the first time Caesareans have been linked with an increased risk of stillbirth.

Most Caesareans are carried out to avoid the complications of a vaginal delivery, especially involving a breech baby, and the small additional risk of a stillbirth in a future pregnancy is unlikely to affect the decisions. But an increasing number are performed at the request of the mother, and not for a clinical reason. A survey in 2001 by the Royal College of Obstetricians and Gynaecologists found 7 per cent of Caesareans were at maternal request, amounting to about 2,400 a year.

Nowadays, more than 20 per cent of births are Caesarean, up from 9 per cent in 1980, and obstetricians [???] say pressure from patients for Caesareans is intensifying.

Gordon Smith, from the department of obstetrics at the University of Cambridge, and colleagues who carried out the study, said in The Lancet: "If women are being counseled about Caesarean birth with no clear obstetric advantage, such as Caesarean section for maternal request, the possible effect on the risk of unexplained stillbirth in future pregnancies should be discussed."

The authors studied data for 120,000 births in Scotland between 1992 and 1998, and found the risk of a stillbirth from 34 weeks gestation was 1.77 per 1,000 women who had had a previous Caesarean compared with 0.89 per 1,000 for other women. The risks of a breech baby dying in a vaginal birth are put at 8.9 in 1,000 and the risk of a later stillbirth are said to be less than one in 1,000. Therefore, the new findings are "unlikely to influence the decision to have a Caesarean in a breech pregnancy," they said.

But the findings could influence the choices women make in subsequent pregnancies - and increase Caesareans. If the risk of a stillbirth in a subsequent pregnancy is increased from the 34th week onwards, women may decide they want to deliver the baby early by Caesarean. Many women are advised to have a second Caesarean because of the small extra risk of the womb rupturing along the old scar, which is put at 0.45 per 1,000 deliveries.

The researchers said the risk of a stillbirth from the 39th week of pregnancy was greater than double this risk in women who had previously had a Caesarean, at 1.06 per 1,000. "The current data suggest that an additional benefit of planned repeat Caesarean delivery at 39 weeks gestation may be to reduce the risk of unexplained stillbirth." They said their results cannot be explained by any of the usual factors affecting stillbirths, such as smoking, social deprivation or the age of the mother.

Prophylactic Cesarean At Term

The following paper, published in 1985, is an example of how far the perspective and agenda of the obstetrical profession is from the expectations of the public and genuine interests of childbearing women. Below are excerpts from an article published NEW ENGLAND JOURNAL OF MEDICINE, May 1985, by George B. Feldman, MD, Jennie A. Friedman, MD entitled Prophylactic Cesarean Section at Term?

This article brings into sharp contrast how much we need unbiased investigative reporting by media to explore these conflicts of interest. It is an example of just how much the media has been asleep at the wheel for the last century. When Dr Gawande made much the case for ‘prophylactic’ Cesarean as a way to save more babies in the 2006 New Yorker article, it was not the first time the idea had been circulated.

In 1985 the Doctors Feldman & Friedman also made the “case” for Cesarean on demand and began promoting the idea that a 100% scheduled or “prophylactic” cesarean become the norm for all women. With few exceptions, nobody noticed in 1985 and surely no one with any clout publicly objected. This tested out the waters and told the powers-that-be that eventually the obstetrical agenda to eliminate normal birth will prevail. By the time the people figure out what’s happening, no one will be able to stop this steamroller.

As with the general tone of the New Yorker article, this drastic idea is presented as a ‘preemptive strike’ to protect the baby from the ‘dangers’ normal labor and birth. It changes the professional focus of obstetrics to simply determining when fetal lung maturity is achieved so that the CS can be scheduled before the mother goes into spontaneous labor (gasp!) and gives birth naturally (yuk!).

These obstetricians boldly make a statistical case for cesarean surgery as “saving” babies with only a little “excess” or “extra maternal mortality and opine that the “low cost of excess maternal mortality” may be a price worth paying.

Prophylactic Cesarean Section at Term? Excerpts

Feldman GB, Friedman JA; N Engl J Med 1985;312:1264-1276

Here is a short excerpt:

p. 1266 ….the number of extra women dying as a result of a complete shift to prophylactic cesarean section at term would be 5.3 per 100,000…. This may be the proper moment to recall that the number of fetuses expected to suffer a disaster after reaching lung maturity is between 1 in 50 to 1 in 500. … if it could save even a fraction of the babies at risk, these calculations would seem to raise the possibility that a shift toward prophylactic cesarean section at term might save a substantial number of potentially healthy infants at a relatively low cost of excess maternal mortality.

We probably would not vary our procedures if the cost of saving the baby’s life were the loss of the mother’s. But what if it were a question of 2 babies saved per mother lost, or 5 or 10 or (as our calculations roughly suggest) as many as 36 or 360? …. Is there some ratio of fetal gain to maternal loss that would unequivocally justify a wider application of this procedure? [editor note: with its increased maternal deaths?]

p. 1267….is it tenable for us to continue to fail to inform patients explicitly of the very real risks associated with the passive anticipation of vaginal delivery after fetal lung maturity has been reached? If a patient considers the procedure and decides against it, must she then be required to sign a consent form for the attempted vaginal delivery? [emphasis added]


Once again we are back to the strangely familiar words of Dr Gawande in his 2006 New Yorker article, words and ideas that track exactly with Drs Feldmen and Friedman.

“….. one out of five hundred babies who are healthy and kicking at thirty-nine weeks dies before or during childbirth—a historically low rate, but obstetricians have reason to believe that scheduled C-sections could avert at least some of these deaths. Many argue that the results for mothers are safe, too.”

Am I the only one disturbed by the idea of eliminating normal birth based on unexamined and unscientific criteria and the weakly modified verbs such as “reason to believe” “could avert at least some of these deaths”? Would you fly on an airline that claimed to “believe” that “at least some” of their planes “could” land safely?

Am I the only one that sees gender politics here reminiscent of the last century’s attempt to gloss over the right of adult, mentally-competent women to control their fertility or to terminate a pregnancy that threatened their own lives and exposed existing children to the possibility of being orphaned?

Isn’t this just another round of the dubious abstract theory of ‘buying us better babies’, no matter what the risks, who is hurt or how much it costs? This theory readily gives rise to the notion that a pregnant woman’s value is simply as fetal container. She is expected to demur without question to ‘professional advice’ and to willingly sacrifice her or suffer permanent disability on the mere possibility that obstetrical profession “believes” they “could avert at least some” of the dangers? As for idea that the maternal request Cesarean is the highest expression of reproductive “choice”, I’d have to point out that women ask for Cesareans for the same reason that smokers buy cigarettes – a huge industry has spent a ton of money to convince them that it’s desirable. Medically-unnecessary Cesareans are to healthy childbearing what cigarettes are to healthy lung function. As with cigarette smoking, some people do indeed benefit but it is not the smoker or the in this case, not the childbearing family or society.

At the risk of sounding like a broken record, can you say “physiological package” for healthy women with normal pregnancies?

Now tell me again why investigative journalists are so disinterested in this, the most important untold story of the 20th century?