For the mother, protection of the pelvic floor through cesarean delivery has long been a hotly debated topic, and you can read much of the research to date in this area on our ‘Pelvic floor damage', ‘Urinary incontinence' and ‘Fecal incontinence' pages. Many doctors insist that cesarean delivery does have a protective effect while others maintain that it is non-existent or minimal. The latter argue that pelvic floor morbidity is simply related to women growing older, regardless of how they gave birth in their youth. Yet a new study of 4,103 women aged between 25 and 84 (80% of whom had given birth), which found an overall prevalence of between 6% and 37% morbidity (stress urinary incontinence - 15%, overactive bladder - 13%, pelvic organ prolapse - 6%, anal incontinence - 25%, and one or more disorder - 37%), has concluded that "age was not a significant contributor after adjustment for confounders." One of the study co-authors, Dr Karl Luber, explained to HealthDay News: "One of the myths surrounding pelvic floor disorder is that it affects only older women, but the truth is these conditions are extremely prevalent and extremely debilitating. But because the subject matter isn't cocktail conversation, women feel isolated and don't seek support and treatment."

This undoubtedly adds further weight to the protective benefit argument, especially when you consider that a previous study in 2006 by some of the same team of researchers found that "cesarean delivery has a protective effect, similar to nulliparity, on the development of pelvic floor disorders when compared with vaginal delivery." Of 4,458 women, they found no significant differences in the prevalence of disorders between cesarean delivery and nulliparous groups, and said the "number-needed-to-treat analysis revealed that 7 women would have to deliver only by cesarean delivery to prevent one woman from having a pelvic floor disorder."

This isn't the first time cesarean delivery has been associated with a protective benefit when compared to vaginal delivery. In 2007, BBC News reported on British research by Williams et al, which found that "Nearly 1 in 3 UK women still experience painful sex a year after giving birth [and that] Painful intercourse was reported by 19% of women who had a caesarean, 34% who had a normal birth and 36% of who had an instrument-assisted birth. Sex-related health problems were highest among instrument-assisted births (77%) and lowest among caesarean births (51%). Two-thirds of women having normal births reported at least one problem related to sex." Similarly, although following research in 2000, MacLennan et al concluded that "Caesarean delivery is not associated with a significant reduction in long term pelvic floor morbidity compared with spontaneous vaginal delivery" (the latter of which can never be guaranteed), they did find that the "difference between caesarean and instrumental delivery was significant."

The financial cost of pelvic floor damage. Another study (released on April 4th) has highlighted a further area of concern for women with pelvic floor damage, and that is the ongoing financial cost of treatment. Subak et al conclude that "Urinary incontinence is associated with substantial costs. Women spent nearly $750 per year out of pocket for incontinence management, had a significant decrement in quality of life, and were willing to pay nearly $1,400 per year for cure." Unfortunately, the long-term costs associated with vaginal delivery are very rarely considered when comparing the costs of PVD and CDMR, but as the studies above highlight, the reality of financial and emotional costs associated with PVD should not be ignored.

My Irish radio interview. The last thing to mention this month is a rather interesting experience I had as an interviewee on a radio programme (Dublin's 98 FM The Inbox) when I was invited on to talk about why I chose to have a cesarean delivery in preference to vaginal delivery and why I set up this website. The first sign I had that things were not quite as they had been described to me by the producer was when I was introduced simply as 'Pauline' with no mention of my website and a line of questioning that was not so much concerned with the facts, figures and conclusions of recent medical research as it was with anecdotal and personal experience. C'est la vie - Alison, the presenter, had evidently enjoyed a vaginal delivery and was adamant that this was the best and safest delivery method for every woman listening to the programme (she said: "At the end of the day folks, it's the most natural thing in the world to give birth naturally... Nine times out of ten it all goes well. I don't know anyone that's had a complicated pregnancy, and thankfully it went well for me too. Yes, it was difficult and it was painful but it's all worth it in the end."), so I just thought to myself, 'It's her show, her prerogative, I'm just happy to have been invited on to give my point of view.'  

But what I want to mention here is something Alison said that stuck in my mind for sometime after we came off air. In the context of a question I'd been asked about recovering from my cesarean surgery, I'd said: "All through my pregnancy I worked out. I went to the gym and I tried to stay as fit and healthy as I could, and I think whether you have a vaginal delivery or a cesarean delivery, I think being in as good health as you can possibly be will always help with the recovery." A little later in the show, Alison made this comment about my answer: "I have to say when I was listening to her, you know, and I probably should have said this to her when she was on the line, but from listening to her, she was like, 'I worked out the whole time and I was constantly staying fit and I ate properly and I needed to get back into shape and I did this and I did that', and all I could hear was 'I wanted to get back into shape and I wanted to look after myself.' That's all I could hear. I could hear a vanity thing there. Correct me if you think I'm wrong but that's what I could hear."

I find this accusation of 'vanity' very interesting, and it makes me think of the whole myriad of finger-pointing and criticism that appears to go hand-in-hand with motherhood from birth pain relief through to breastfeeding choices.  

*First of all, the very fact women criticize each other for attempting to stay healthy during pregnancy and daring to care about getting their figures back after the birth (as far as possible) is astonishing - for starters, it's none of their business. Like many other women I know, my number one priority was always the health of my unborn child (and my doctor advised that a healthy maternal diet and exercise plan was in fact best for my daughter too), but the impact of pregnancy and childbirth on my body also concerned me. I am not ashamed to admit that I hoped to improve my chances of losing weight after the birth by maintaining an exercise plan during my pregnancy (for as long as I was able to do so healthily) and I am curious as to why anyone might frown upon such a goal.  

*Secondly, I wonder if there might be a suggestion in this accusation that having a cesarean delivery helps you to lose weight. It is often hinted at in reports on celebrity births that these women may have had a tummy tuck at the same time as their cesarean, but the truth is that many celebrities regain their figures after pregnancy whether they've had a cesarean or a vaginal delivery. And every doctor I've ever asked has said categorically that tummy tucks are not carried out during cesarean surgery.

*Finally, it's worth pointing out that guidelines for diet and exercise (and weight gain) during pregnancy have recently been revised. Gone is the old adage of 'eating for two'; researchers now recommend exercising and eating more healthily during pregnancy (1, 2) and advise obese women to either maintain or actually reduce their weight during pregnancy. (3, 4, 5). Why the change? Because substantial evidence indicates an associated risk for adverse perinatal outcome with increased maternal weight and obesity.

If I've said it once, I've said it a hundred times - we really need to focus on all aspects of achieving a healthy pregnancy and birth, both physical and psychological. To simply state that 'vaginal delivery is best for all women' is to ignore and misinterpret a whole wealth of maternal, infant and clinical data.