April 2008 BLOG Print E-mail
"Challenging truths: 'Life after birth' and 'Death after cesarean'"
 

I faced a very difficult personal decision this month about whether or not to go back to work full-time and place our 7-month-old daughter in daycare. The thought of leaving her when she is still so small and vulnerable just breaks my heart, yet like so many other mothers, I feel compelled to consider my career in the long-term as well as the financial implications of staying at home. My ideal scenario is to work part-time, but although the employer in this case was very receptive to the idea and indeed helpful, in the end it has proved too difficult to orchestrate. There are other issues too. I did the math and the sums didn't look good:- new salary minus infant daycare fees and commuting gas equals not a lot of pennies for the piggy bank in return for working 45 hours a week, 51 weeks of the year. In addition, the net result of calling round several daycare centers in the area and visiting two is my daughter's name on numerous waiting lists and an earliest advisory start date of ‘sometime in June'. So for now at least, my husband and I have made the decision to hold off on my return to work for another couple of months, and I find that despite the  inevitable tightening of our belts, I'm actually breathing a little easier once again.


What has this got to do with cesarean delivery? Well it got me thinking about something I've said many times before - that there is a complete imbalance in some women's focus on the day of their baby's birth compared with the rest of their baby's life. For me, cesarean delivery took nothing away from my experience as a mother, but had I had to go back to work less than 12 weeks after my baby was born (as the vast majority of working women in the U.S. have to do), I would have been devastated. I've lived in the UK for the majority of my life, where minimum statutory maternity leave rights are the norm, and perhaps I took them for granted a little. Women there are entitled to "52 weeks maternity leave, regardless of length of service or the number of hours you work, providing you give the correct notice" and depending on your employer, you may even be able to negotiate a further extension, unpaid. Not that everything in the UK is perfect - nowhere ever is - but my greatest cultural shock since moving to the U.S. is the realization that unless families can financially afford the luxury of a stay-at-home mom (i.e. for those women who don't want to return to work immediately), babies and mothers are unwillingly separated from each other at an extremely early stage in their bonding. And what's more, it's a situation that for the most part seems to have become entrenched and accepted.


There are so many strong campaign groups in the U.S., among whom advocates of vaginal delivery are some of the most vocal (or maybe that's how it sounds to my ears). But honestly, should we be more worried about the increasing numbers of women who choose to have cesarean delivery or with women's lives after their baby's birth? When I began looking into this issue a little further, I was relieved to discover that there is a campaign group dedicated to maternity rights in the U.S. called Mom's Rising and it started in May 2006, a few months after I launched this website. I would encourage all members to visit the site and support this issue, whichever country you are originally from, and if you know of any similar groups where you live, feel free to drop me a line. Interestingly, I also discovered while reading a 2005 USA Today report on this topic that some years ago, the Clinton administration sought to address maternity leave rights. Now I don't know whether it'll turn out to be Clinton or Obama in the final race against McCain, nor who will ultimately win the presidential prize, but hypothetically, if Clinton should go all the way, I will be keen to see if she reignites this issue and improves the current status quo.


As for CESAREAN NEWS this month, more research has been published leading to familiar headlines like this one in The Sydney Morning Herald: "Death twice as likely by caesarean". The report begins: "Babies born by elective caesarean are almost 2½ times more likely to die within their first month than babies born vaginally, researchers have found, adding weight to the argument that caesareans should only be carried out in emergencies."


Given the increased mortality and morbidity risks (both maternal and neonatal) with emergency surgery, this is certainly not what MacDorman et al have concluded. What they say is this: "The finding that cesarean deliveries with no labor complications or procedures remained at a 69% higher risk of neonatal mortality than planned vaginal deliveries is important, given the rapid increase in the number of primary cesarean deliveries without a reported medical indication." So it's cesarean deliveries with no medical indication that they are criticizing, not all non-emergent cesareans. The study is a follow up to their 2006 report, when they found that  "Neonatal mortality rates were higher among infants delivered by cesarean section (1.77 per 1,000 live births) than for those delivered vaginally (0.62)." This time, MacDorman et al have employed "an 'intention-to-treat' methodology, as recommended by a National Institutes of Health conference" in order to make sure that emergency cesarean outcomes (8% of PVD here, n.617,168) were included in the planned vaginal delivery (PVD) comparison group when comparing with planned cesarean deliveries. This methodology is great to see, and I would like for it to be adopted in all comparative research.


After much number crunching, MacDorman et al determined the following neonatal mortality rates:

0.75 deaths per 1,000 live births overall

0.63 for vaginal deliveries, 1.69 for primary cesarean deliveries with labor complications or procedures, resulting in 0.72 for the planned vaginal delivery group

1.73 for primary cesareans with no reported labor complications or procedures


These are my OBSERVATIONS AND REFLECTIONS on the research:


*A 2005 study on neonatal mortality in Brazil concluded the exact opposite of MacDorman et al: "Caesarean delivery was not found to be associated with neonatal mortality." This is important because we know that Brazil has some of the highest rates of cesarean delivery in the world, and its high prevalence of maternal request with no medical indication is well documented.


*The risk factor determined by MacDorman et al is still very small, especially when you compare the numbers to other neonatal risk factors associated with PVD that a woman may want to consider when choosing her method of delivery.


*Although the researchers have applied the NIH's "intention-to-treat" recommendation, they have not accounted for one of the most important CDMR recommendations by the NIH, which is to wait until 39 weeks EGA for planned cesarean delivery with no medical indication. Instead, the study defines low-risk births as "singleton, term (37-41 weeks' gestation), vertex births, with no reported medical risk factors or placenta previa and with no prior cesarean section." This is important, because while a baby delivered at 39 weeks EGA is certainly not risk free, the neonatal mortality rate is most likely lower than the 1.73 reported here, and it is cases of "no medical indication" that MacDorman et al are questioning.


*Planned vaginal deliveries (even those for low risk women) can last beyond 41 weeks, and there is documented evidence of a "small but significant" risk in fetal mortality beyond this point (Divon et al, 1998), and also after 40 weeks. (Caughey et al) Measuring mortality up to 41 weeks alone may have provided PVD with improved statistical outcomes in MacDorman et al's study.

*Self-reported limitations of the study include concerns about the accuracy of reporting specific data items on the birth certificate: "Reporting for the major variables in this study (neonatal mortality and method of delivery) is generally considered to be excellent; however, underreporting of individual medical risk factors and complications of labor and delivery on birth certificates has been documented. ...it is possible, based on either poor reporting or because the risks involved items not recorded on the birth certificate, that the group including cesarean delivery with no labor complications or procedures was still an inherently higher risk group, and those risks accounted for both the decision to perform a cesarean section and the subsequent neonatal death. It is also important to note that birth certificate data cannot be used to infer the intentions of either mothers or their practitioners, so these data do not address "maternal request" cesareans."


*In the Sydney Morning Herald report, Andrew Child, the clinical director of women's and children's health at the Sydney South West Area Health Service says the study should be treated with caution: "It's been done by statisticians, not obstetricians or midwives."


*In the same report, David Ellwood, a professor in obstetrics and gynaecology at the Australian National University medical school, says: "We have enough evidence now to know that caesareans should only be done when there is a medical indication, but when you look at the overall risk here, it is not that high." Evidently, I disagree with the first part of Professor Ellwood's statement, and I would just like to mention here that in 2003, when considering the value of a term cephalic trial of cesarean delivery, D.Ellwood and S.Robson expressed this concern: "What a disaster it would be if it was found elective caesarean was safer than vaginal birth." Somehow, I do not think that Ellwood and Robson are alone in this concern, but that is a discussion subject for another day...

 
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