| June 2008 BLOG |
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The cost of a cesarean has been on my mind a great deal this month. Primarily because I've been busy writing a review on the cost of a cesarean in England (both within the NHS and in private hospitals) but also because of news in the U.S. that some insurers are choosing to refuse insurance to women who've had a primary cesarean or to increase their premiums (read the full news report below). Now obviously, cesareans cost money, but as you will see in ec's pages on Cost , there is currently a great deal of confusion and inaccuracy in the evaluation of the various different types of cesarean - i.e. an emergency cesarean occurring at the end of a planned vaginal delivery is very different to a planned cesarean delivery for a healthy woman at 39 weeks EGA. Furthermore, the long term costs associated with vaginal delivery (e.g. pelvic floor trauma) are not accounted for when delivery cost comparisons are made, which distorts the numbers. An unbiased and complete evaluation of all costs is urgently needed if we are to move forward on this issue.
NEW CESAREAN RESEARCH
CESAREAN IS MORE LIKELY IF YOUR MOTHER HAD ONE A study of births in Norway, 1967-2005 has discovered a ‘female-to-female familial predisposition to caesarean section'. ‘A mother born by caesarean section had a 55% increased risk of having her first child by caesarean section [and a] younger sister, whose older sister had her first child by caesarean section, had a 45% increased risk.' EC VIEW The study authors say that this could be caused by ‘biologic inheritance, primarily working through maternal alleles and/or environmental factors.' Either way, it could prove to be an important piece of research; for example, for women with concerns about pursuing a trial of labor only to need an emergency cesarean at the end. MORE NORWEGIAN OBSTETRICIANS HAVE CESAREANS (compared with the general public) This questionnaire based research discovered that 19% of physicians, 26% of surgeons, and 27% of specialists in obstetrics and gynecology had had cesarean deliveries, compared with just 12% of the general public (an average 8% of those with only basic schooling compared with 16% among those who had been to university for more than 4 years). The researchers conclude that the ‘rate of cesarean section in the general population is unlikely to fall as long as so many obstetricians have their own children delivered by cesarean section.' EC VIEW This is not the first study to discover high rates of cesarean delivery occurrence or preference within the medical community, as you'll see here. OBSTETRIC HISTORY AFFECTS CESAREAN DELIVERY OUTCOMES Research on births in Norway, 1967-2003 found increased risks of preeclampsia, small for gestational age, placenta previa, placenta accreta, placental abruption, and uterine rupture in subsequent pregnancies following a cesarean, but concluded that 'excess risks were reduced after excluding women with the actual complication in any of their previous births. To obtain less biased effects of cesarean delivery on subsequent pregnancies, it is important to account for obstetric history.' EC VIEW This is a perfect example of how repeat cesareans can appear to have increased morbidity (particularly when the data includes primary emergency cesareans), and it is to the credit of these researchers that they have pointed this out. PLACENTA PERCRETA IS A GROWING CONCERN This report looks at two cases of placenta percreta that caused massive hemorrhage during a cesarean delivery. Both women had a past history of cesarean delivery and had been diagnosed with total placenta previa and suspected adhesion of the placenta. The women needed hysterectomies, and did survive, but the researchers voice concerns that the ‘incidence of adhesion of the placenta has increased' and ‘definitive, preoperative diagnosis is difficult; especially for the severe type: placenta percreta. Therefore, intensive management is necessary for the anesthesia of pregnant women with suspected adhesion of the placenta, including adequate preparation of transfused blood, since it might be difficult to save the mother's life after the onset of massive hemorrhage.' EC VIEW The risk of complications related to the placenta in subsequent cesarean deliveries is something that all women considering primary cesarean delivery (for any reason) should be aware of, and it is undoubtedly an important consideration when weighing the risks and benefits of a cesarean versus PVD. INFANT INJURIES DURING VAGINAL DELIVERY DECREASE AS CESAREAN RATES RISE U.S. research looking at 11 million births in 1997, 2000, and 2003 found 17,334 cases of documented brachial plexus injury], yielding a nationwide mean and standard error of incidence of neonatal brachial plexus palsy in the United States of at least 1.51 ± 0.02 cases per 1000 live births. Conclusions: This nationwide study of neonatal brachial plexus palsy in the United States demonstrates a decreasing incidence over time. Shoulder dystocia poses the greatest risk for brachial plexus injury, and having a twin or multiple birth mates and delivery by cesarean section are associated with a protective effect against injury. Most children with neonatal brachial plexus palsy did not have known risk factors. EC VIEW Very often, criticism of cesarean delivery choice fails to recognize the very real risk of injury for infants that is associated with planned vaginal delivery. BREASTFEEDING AFTER A CESAREAN Research in Puerto Rico (in which 36% of 1,695 women had a cesarean) has found that a cesarean was 'negatively related to breastfeeding initiation.' EC VIEW It is important to note that this research involved all cesarean delivery types (including emergency) and as you will read in other published studies (see our Cesarean and breastfeeding page), having an elective cesarean delivery does not mean that you are less likely to succeed in breastfeeding - if breastfeeding is your personal preference. SEVERE MORBIDITY IS MORE LIKELY WITH A CESAREAN Research in Finland has found that severe maternal morbidity is more frequent in cesarean than vaginal deliveries, and more frequent in non-elective than in elective operations. In 2002, the rate of severe maternal morbidity was 7.6 per 1,000 in all deliveries, 5.2 per 1,000 in spontaneous vaginal deliveries, 12.1 per 1,000 in elective cesarean sections (CSs), and 27.2 per 1,000 in non-elective CSs. EC VIEW The severe maternal morbidity refers to 'deep venous thromboembolism and amniotic fluid embolism, major puerperal infection, severe hemorrhage, events requiring operative intervention after delivery, uterine rupture and inversion, and intestinal obstruction', and it's important to note that the study looked at ALL singleton deliveries. Why? Because the elective CSs will have included repeat cesareans following a previous emergency cesarean, and elective CSs that were carried out for medical reasons. The risk of severe morbidity is undoubtedly lower (albeit still there) for healthy women with non-medical planned cesarean deliveries. Also, women choosing cesarean delivery instead of vaginal delivery may place more weight on the risk of morbidity associated with PVD (including non-severe morbidity) and the prophylactic benefits with cesarean delivery. Finally, it is important that studies like this begin to consistently factor emergency cesarean morbidity (a 27.2 per 1,000 risk here) into PVD outcome measures. The 5.2 per 1,000 risk with spontaneous VD quoted above means little without acknowledgement of the unpredictability of spontaneous VD. FURTHER EVIDENCE OF INCREASED RISKS WITH MATERNAL OBESITY Researchers found that maternal obesity is associated with an increased risk of an NTD-affected pregnancy [neural tube defects]. EC VIEW It is now established that women who are overweight or obese before and during pregnancy have increased health risks during their baby's delivery - whether vaginal or cesarean.
OTHER STORIES IN THE MEDIA
*01 Jun 08 After Caesareans, Some See Higher Insurance Cost, The New York Times, Barbara P. Fernandez EC VIEW see this month's blog intro above. *09 Jun 08 Rise of the sumo baby, guardian.co.uk The average birth weight of babies has been creeping up for the past 30 years... but the rise in babies with macrosomia (excessive birth weight) is more pronounced. EC VIEW Birth weight and maternal weight are important factors in any risk and benefit analysis. *16 Jun 08 Dramatic rise in Caesarean births, Times of Malta EC VIEW This article reports a dramatic increase in the number of cesareans in Malta; from 15.9% in 1995 to 32.3% in 2007 (34.8% in 2006), amid much criticism. However, it also states: 'There have not been any maternal deaths since 2001, when there were two; The rate of foetal deaths - death before complete expulsion or extraction from the mother - has gone down from 6.2 out of every 1,000 in 1999 to 2.8 out of every 1,000 births last year.' Food for thought perhaps... *25 Jun 08 Cesarean births hit record level, The globe and Mail (The Canadian Press), Sheryl Ubelacker EC VIEW Canada's latest (2006) national cesarean rate of XXX% has highlighted a frustrating situation. While there are numerous reasons for increased cesarean rates worldwide (e.g. increased maternal age and weight, fear of litigation, mothers' preference), rather than focus on strategies to avoid ‘unwanted' cesareans, policy makers insist on trying to reduce the (reportedly small) numbers of women who choose ‘wanted' cesareans. For example, in this article, SOGC President Dr. Guylaine Lefebvre: ‘There are some things that are beyond our control,' Dr. Lefebvre said. ‘We're not going to overnight change obesity or medical complications.' ‘But there are some things we hope we can affect, such as reassuring women that in the proper setting and barring any reason why you shouldn't try, normal childbirth in Canada can be a very safe and rewarding experience.' A planned cesarean can be a very normal, safe and rewarding experience too; I know this from personal experience, and had no desire to ‘try' a vaginal delivery. *26 Jun 08 Doctors seek to reduce growing trend to C-sections, The Star, Megan Ogilvie EC VIEW I find a comment in this article, by Dr. Donna Stewart, professor and chair of women's health at the University Health Network and University of Toronto, particularly interesting in terms of ‘birth planning' and ‘birth outcome'. [Article extract]: ‘Not only are older women more likely to have complications during labour, they also are more likely to desperately count on a healthy outcome, said Stewart. "A lot of these are premium babies," she said. "If a woman is 38 years old and is going to only have one baby, there is a lot pressing on the pregnancy for the woman, and by extension for the ob-gyn. So they are ultra-careful and that often means going by the caesarean route." Still, both Stewart and Bernstein said the safest way to have a baby is by a natural vaginal birth.' Cesarean delivery is described as the ‘ultra-careful' route, in terms of avoiding litigation in case of PVD morbidity or mortality, and yet natural vaginal birth is ‘safest'. This paradox exists because of the unpredictable nature of PVD. With hindsight, a spontaneous vaginal delivery outcome may well be ‘safest', but in reality, a planned cesarean has a far greater degree of guaranteed outcome.
THE LAST WORD...
You may recall in last month's blog, I reported on the number of claims related to absent or untimely cesarean deliveries, which can add a considerable amount to the overall cost of a planned vaginal delivery. This month also highlights the tragic personal and psychological cost that can result too: *03 Jun 08 Hove family's £300,000 brain damage claim, The Argus Lite, Ruth Lumley ...Paris Carroll was left with cerebral palsy following alleged negligence around the time of his birth. His mother Paula Carroll, of Amberley Drive, Hove, has filed a High Court writ against West Suffolk Hospital NHS Trust claiming Paris's injuries were caused by not delivering him by emergency caesarean on time. *11 Jun 08 Mum died after op complications, BBC news online ...John Charlton said his wife, 36, from Newport, had wanted a planned caesarean because of a previous difficult labour. *11 Jun 08 Mother died after emergency caesarean, icWales.co.uk A father told an inquest today how his wife died within hours of giving birth to their second baby by emergency caesarean..."We were told after the first baby it was pointless to try and have a natural birth and Charmaine wanted a caesarean, but she was persuaded out of that," he said. "It was a well known fact she didn't want a normal birth, she was very unhappy about it but accepted what she was given." EC VIEW As an example of a denied cesarean delivery on maternal request, this story elicits many emotions and raises grave questions about maternity choices. All births carry risks (vaginal and cesarean) and a woman's own evaluation and tolerance of these risks should never be discounted. |
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