Three words provoke horror in natural childbirth advocates: maternal request Cesarean!
How dare women choose to bypass the excruciating pain and terror of hours of labor and vaginal birth?
How dare women do everything possible to protect the health and brain function of their children?
How dare women take control of their own bodies to protect against future incontinence?
These prospects appall most midwives and natural childbirth advocates, hence the outsize attention paid to maternal request C-sections despite the fact that they represent less than 1% of births.
But a new study shows — yet again — that C-sections are safer for babies.
Determinants and outcomes of cesarean delivery on maternal request (CDMR): A population-based study in Ontario, Canada was published in May 2020.
Of 668,468 women, 0.7% (4,821) planned CDMR and 85.6% (569,212) planned vaginal deliveries… Older age, higher education, IVF, anxiety, nulliparity, Caucasian race and maternal level IIc hospital deliveries were associated with CDMR.
What did they find?
Women who planned CDMR had fewer adverse outcomes than women who planned vaginal deliveries (aRR:0.59 [95% CI 0.52–0.67]). The WAOS [Weighted Adverse Outcome Score] was lower for planned CDMR than planned vaginal delivery (2.6 v 3.6)…
Conclusions
CDMR rates have not increased in Ontario over the last 5 years. Planned CDMR is associated with decreased risk of short-term adverse outcomes, compared to planned vaginal delivery…
Why would C-sections be safer for babies? Because birth (vaginal birth in particular) puts them at risk for all sorts of injuries.
The paper Neonatal Morbidity and Mortality After Elective Cesarean Delivery by Signore and Klebanoff appeared in the June 2006 special issue of Clinics in Perinatology focussing on the epidemiology and neonatal effects of C-section.
The authors conducted a decision analysis:
…modeling the probability of perinatal death among a hypothetical cohort of 2,000,000 women who had uncomplicated pregnancies at 39 weeks, half of whom underwent ECD and half managed expectantly. After taking multiple chance probabilities into account, the model estimated that although neonatal deaths were increased among women delivered by elective cesarean, overall perinatal mortality was increased among women managed expectantly, because of the ongoing risk for fetal death in pregnancies that continue beyond 39 weeks.
They found that C-sections were dramatically safer for babies:
In other words, if 1 million women underwent C-section at 39 weeks instead of waiting for onset of labor and attempting vaginal delivery, 692 more babies would be saved, 517 cases of intracranial hemorrhage and 377 brachial plexus injuries would be prevented. In exchange, there would be 8476 additional cases of short term respiratory problems and 5536 neonatal lacerations.
But wait! Midwives and natural childbirth advocates insist that C-sections increase the risk of maternal death. To support that claim they present papers that show that maternal death rates for C-sections are higher than for vaginal birth. Sure, just like people who spend time in ICUs have higher death rates than those who do not. The individuals in the former group are sicker than those in the later group. They don’t die because of the C-sections; they die in spite of them for the same reasons that they had the C-section in the first place: pre-existing medical conditions and severe complications of pregnancy.
That doesn’t mean that C-section is a trivial procedure. It is major surgery with all the risks that major surgery poses to anyone. Though the Ontario paper does not show it, vaginal birth is probably safer for mothers in the short term, though it does dramatically increase the risk of future pelvic organ prolapse and urinary incontinence in the long term.
The balancing of risk to the baby and risk to the mother is best done by the mother herself. If a woman can elect to have a homebirth, then surely she has a moral right to elect to bypass labor and have a C-section. C-sections are undoubtedly safer for babies and offer mothers both short and long term advantages. Mothers — not midwives or natural childbirth advocates — are best equipped to weight the risks and benefits for themselves.
