It has long been known that C-sections are safer for babies than vaginal birth. Now a new study on maternal request C-sections shows that they may be safer for mothers.
As the Times of London explains, Cesarean section no riskier for mother or baby:
Women who plan to have a caesarean section are no more likely to suffer poor medical outcomes for mother and baby following birth than those who opt for a vaginal delivery, a study has found.
The Canadian research, which looked at more than 400,000 low-risk pregnancies, found hints that women popularly characterised as “too posh to push” might even be better off.
Why might that be? Because although a C-section is surgery, vaginal birth has many risks for mothers as well as for babies.
The right to choose a C-section should be respected not merely for ethical reasons, but because they are safer.
The paper is Birth outcomes following cesarean delivery on maternal request: a population-based cohort study just published in the Canadian Medical Association Journal.
Women may prefer CDMR [Cesarean Delivery on Maternal Request] for many reasons, including scheduling convenience, anxiety regarding labour pain, perceptions that the quality of obstetrical care is better for women who have cesarean deliveries, and concerns about possible urinary incontinence and sexual maternal care and obstetricianbased antenatal care.
It has been difficult to study outcomes of CMDR because they make up such a small proportion of births, for example less than 4% of C-sections in Ottawa. This study is especially compelling because it includes so many women.
A total of 422 210 pregnancies met our inclusion criteria, of which 1827 (0.4%) and 420 383 (99.6%) were categorized as planned CDMR and planned vaginal delivery (including unplanned cesarean deliveries), respectively.
Our cohort included 46 533 cesarean deliveries, of which 1827 (3.9%) were planned CDMR, and 44 706 (96.1%) were unplanned cesarean deliveries. The proportion of all deliveries that were planned CDMR was 0.5% in the first and last fiscal years of our study (2012/13 and 2017/18) and the proportion remained stable across all fiscal years.
Who chooses CMDR? Women who are in a higher risk category than average.
Planned CDMR was associated with late maternal age (≥ 35 yr), being White, living in a neighbourhood of a higher educational quintiles, gaining more than the recommended weight in pregnancy, nulliparity, conception by in vitro fertilization, anxiety, not attending prenatal classes, delivering at a hospital that provides maternal level IIc or III care and receiving antenatal care from obstetricians.
How did the authors evaluate outcomes?
The primary outcome was the Adverse Outcome Index (AOI), a composite of 10 adverse events related to labour and delivery. 33,34 The AOI is reported as the percentage of individual patients with at least 1 adverse event relative to the total number of deliveries. As the AOI may be influenced by dominant outcomes, it cannot be used as an exclusive measure of quality and safety. For this reason, we also measured the Weighted Adverse Outcomes Score (WAOS) and the Severity Index (SI). The WAOS reflects a combination of the frequency and severity of events, and the SI evaluates the severity of adverse events among the pregnancies with an adverse event.
What were the results?
Overall, the AOI was lower in women with planned CDMR (3.8%) than those with planned vaginal deliveries (8.3%) (Table 3). The frequencies of adverse maternal and neonatal outcomes were both lower for women with planned CDMR than those with planned vaginal deliveries. The most common maternal adverse outcomes were unanticipated operative procedures (1.2%, n = 21) for women who planned CDMR, and third-or fourth-degree perineal tear (3.3%, n = 13 686) for women who planned vaginal deliveries. Admission or transfer to the neonatal intensive care unit (NICU) was the most common neonatal outcome for both the planned CDMR and planned vaginal delivery groups…
The WAOS was lower in women with planned CDMR than in those with planned vaginal deliveries (mean difference [MD] −1.28, 95% CI −2.02 to −0.55) (Figure 2), largely because of a lower neonatal WAOS score (MD −1.35, 95% CI −2.00 to −0.69). There was no statistically significant difference in the overall severity of adverse outcomes as measured by the SI between women with planned CDMR and planned vaginal deliveries (MD 3.6, 95%CI −7.4 to 14.5). However, the severity of maternal outcomes was greater for planned CDMR than planned vaginal deliveries (MD 20.1, 95% CI 10.6 to 29.7).
These graphs illustrate the results:
The authors conclude:
…[W]e found that planned CDMR was accompanied by a decreased risk of adverse outcomes. The AOI and WAOS were lower for women with planned CDMR than women with planned vaginal deliveries, and the risk of adverse outcomes was lower after adjusting for confounding factors.
What about previous studies that claimed to show that C-sections are riskier for mothers? Most did NOT look at C-sections on maternal request but on C-sections for which the authors could not find a medical indication on the birth certificate. But it is only by checking the medical record that they could know whether there was a medical indication or not.
The results confirm what we’ve always known: childbirth is inherently dangerous. It has a natural neonatal mortality rate of approximately 7% and a natural maternal mortality rate of approximately 1%. Although modern obstetrics mitigates the risk, vaginal birth is still dangerous. For example, in this study:
– 14 women in the vaginal delivery group died compared to zero in the CMDR group.
– 100 women in the vaginal delivery group sustained a uterine rupture, but none in the CMDR group.
– And 13,686 women in the vaginal delivery group suffered a 3rd or 4th degree tear compared to zero in the CMDR group.
Does this mean that C-sections are always safer than vaginal birth? No, because this study looked only at non-emergency C-sections that were chosen in advance. C-sections done for medical indications are more dangerous than those done electively and the comparison with vaginal birth might yield different results.
But the study DOES mean that women who choose CMDR are making a request that isn’t merely consistent with their right to bodily autonomy but is certainly safer for their babies and also safer for themselves. The right to choose a C-section should be respected not merely for ethical reasons, but — as this paper demonstrates — for medical reasons as well.
I’m very happy to see this paper. Twenty years ago, I was pregnant with my first in the Netherlands. I am a research scientist and, initially out of curiosity and then later out of intensifying alarm, I spent the first 3 months of my pregnancy researching birthing options. Meanwhile I learned about the birthing system in NL, which was like from the Stone Ages. Home birth with NO painkillers was pushed on to you relentlessly. There was NO prenatal screening – when I asked for the screening blood test, I was told it was not allowed because the high false positive rate “unnecessarily agitated the mothers”. I said, “That should be my choice”, and was met with a screw you kind of shrug. It was all midwife led. My encounters with the midwives horrified me. One of them still had blood under her cuticles from the birth she had just attended. Another told me she didn’t like to use the Doppler because “it upsets the baby”. Yet another, when I asked about pain relief, pulled open a drawer and showed me a piece of black rubber. I looked at it with perplexity and she said, “we give this to our patients to bite down on, it helps with the pain. And it protects their dental work.”
Jesus Christ. At that point, my lit review indicated to me that an elective CS was definitely safest for my child, and on balance, when taking into consideration long term outcomes like pelvic floor prolapse, incontinence, and psychological trauma, safer for me (compared to attempted vaginal birth).
But I wanted to discuss it with a professional. The midwives – well, they put a note on my medical forms indicating that I am a crank (I discovered this later, when I left NL and got my medical records). I went to a Dutch Ob/gyn to discuss it. He tried to throw me out. He said, “You will not find anyone in the Netherlands who will do this.” I refused to leave until he did an ultrasound, which he did with a very sour angry face.
I wrote an Ob/gyn in Britain, who had just published an article arguing that women should be allowed to ask for an elective CS. She agreed with my analysis, but was wary: her proposal had been met with a storm from other obs. It was already clear to me from my lit review that the whole birthing field around the world was full of emotion and horribly politicized – sometimes, the conclusions of the papers being published around that time were simply not consistent with the actual data being reported!
At that point, when I was 3 months pregnant, my sister-in-law in a country neighboring NL had a CS after being in labor for 3 days. My husband and I met with that Ob/gyn, who listened to my story sympathetically. He and his head midwife agreed to perform an elective CS, but we’d have to do it secretly: they would pretend that I had been driving through and started labor, which stalled, and I had to have a CS.
It all went wonderfully well, and so did my next 2 elective CSs in another country. But the hurdles I faced with my first pregnancy were crazy. I only managed to get what I wanted because I was educated and had money. Later, I heard so many stories from women in NL about how they had been in labor for days in pain, how their kid came out with permanent Erb’s palsy, how they’d been ripped asunder and still had problems decades later…
I’m just so glad that the tide is turning. thank you for posting this paper, Dr Amy.
I refused to leave until he did an ultrasound, which he did with a very sour angry face. Thank god I did, because it dated the pregnancy, which helped the ob in the neighboring country to set me up for an elective CS.
I was very worried about a VD but was told I was low risk and a CS wasn’t an option. Ended up with a fourth degree tear and a years long recovery. I’ve been “shopping” for a sympathetic OB since we started talking about a second baby. I’ve had horrible nightmares, terrified of another delivery. Every OB has been adamant that another VD is low risk. Finally found an OB who immediately agreed that a CS would be preferable for my physical AND mental health. No more nightmares, I finally feel like I can move on from the trauma. So glad for you that you were able to access the care you wanted. Thank you for sharing, really made me feel more confident in my decision <3
I’m glad that my story helped you, and especially that you don’t have nightmares anymore. It’s awful that many Obs still do not allow women to choose elective CS. The evidence is not on their side. Even 20 years ago, when it seemed like everyone was bowing to the juggernaut of “natural childbirth”, the actual data told the truth. Elective CS is safer the child for sure – funny how people in the literature were really avoiding this question 20 years ago. And on balance, in first world countries, it is safer for the mother.
A couple of years after I had my first, my sister in law had her second. She had had a traumatic delivery and a bad tear with the first. I told her about elective CS and she went for it with the second kid, even though she faced the same sort of opposition you and I did. She said later that it saved her sanity: it was a beautiful calm birth, and it healed her somewhat from the trauma of the first.
Oh my goodness, so thankful for you sharing this. This is my secret hope: that somehow a calmer birth will help me heal somewhat. Cannot tell you how healing it is just to know that it might be possible ❤️
My second vaginal delivery was so much better than my first, no tearing and only a 3 hour induced labor. I still have problems from my first birth with 4th degree tear and he is 18 years old now. A lot of people say the second time is better.
In your case you also had a cervical tear so go for the elective section if you have a second baby.I know I would not have had another vaginal if my cervix had also been torn.
After a 2.7L post partum haemorrhage and 3a tear with my first, I am so happy to be having an elective caesar with number 2. We went for a private obstetrician with delivery in a public hospital and he has been so amazingly supportive.
So many people cite the Netherlands as a Utopia of ‘natural’, midwife-led childbirth. i’ll take obstetric care thanks.
Yes, NL was like a dystopia for me! And now home birth is rapidly becoming very much out of favor in NL – it’s dropped from 80% or so in the 50s to about 15% now. They are wising up, and quickly. I think part of the the problem in NL was that the Dutch obstetrics field in the 1950s-80s was dominated by a guy called Kloosterman at the University of Amsterdam. He believed that pregnancy and birth is a natural thing and should not be medicalized. He was kind of charismatic and well-spoken and unusually for his time, he went on radio and TV shows to propound on his views. He trained the next generation of Dutch obstetricians, who clearly adhered tightly to his views. I think it took his retirement in the 1990s and his death in the early 2000s for the field in NL to open up to more critical views of his midwife-led home birth model.
I remember when I started reading this blog (2009) how the homebirthers were holding up the NL as the poster child for how homebirth could be successful if it was being done by great trained professionals. Just look at how many homebirths there are in the Netherlands!!!!! The women there love it!
You don’t hear that any more, as Dutch women have stampeded to hospitals. Because they can.
IOW, they weren’t having homebirths because they liked the idea, but they were doing it because they didn’t have a choice. Given the choice, they don’t want homebirths.