Scientific efforts to demonize C-sections bear an ugly resemblance to scientific efforts to demonize abortion

embryo in woman hand

What’s the difference between:

We argue that a detailed assessment of these risks should be taken into account in guidelines …

And this:

… [W]e are committed to educate … patients, the general public … and our medical colleagues regarding the medical and psychological complications …

Sounds pretty similar, right? But the first comes from a new paper on the “risks” of C-sections and the second comes from the mission statement of Prolife OBGYNs. We know for a fact that anti-choice advocates start with the conclusion that abortion is “bad” and look for evidence to support it. Unfortunately, many people now writing about C-sections approach the topic in a similar way. They start from the premise that C-sections are “bad,” and then search for evidence to support the predetermined conclusions.

Why do I bring this up?

Apparently it’s Hate on C-sections Week in the scientific journals.

First we had the doctor who described C-sections as airbags that explode in women’s faces , stung when it was pointed out that he had written a journal article encouraging homebirth in the US without having read the existing scientific literature on the death rate at US homoebirth.

Now we have this piece in the BMJ, Time to consider the risks of caesarean delivery for long term child health, by Blustein and Liu. There are a lot of problems with this piece, starting with the title.

To understand my objection, try this thought experiment: what would be your first reaction to a journal article entitled “It’s time to consider the risks of abortion on long term women’s health”? I suspect it would be immediate recognition that the piece was agenda driven with the conclusion determined long before the data was analyzed. This piece bears an uncomfortable resemblance although in this case the predetermined conclusion is not that abortions are “bad” but that C-sections are “bad.”

Our knowledge of the human microbiome is in the earliest stages of infancy. We have literally no idea what constitutes the normal human microbiome. We have no idea whether differences between individuals in the microbiome reflect genetics, environment or simple chance. We have literally no idea of the relationship (if any) between the microbiome and chronic disease.

Our knowledge of epigentics is also in its infancy. We know precious little beyond the fact that information encoded outside the genes can affect the expression of those genes.

No matter. Everyone “knows” that C-sections are “bad” even though existing scientific evidence does not support that view. The microbiome and epigenetics represent new opportunities to find “risks” to support predetermined conclusions.

What about long term beneficial effects of C-sections? Be serious; what journal is going to publish a paper about the benefits of C-sections? In an age where journals send out press releases to garner favorable public attention, it is imperative to publish headline generating papers that capture the contemporary zeitgeist. And the contemporary zeitgeist is that C-sections are “bad.”

Blustein and Liu demonstrate their bias at the outset:

…[I]n cooler moments, such as repeat or maternal choice of caesarean, it makes sense to consider the risks and benefits of caesarean versus vaginal delivery, just as we would for other medical treatments. Both modes of delivery are associated with well known acute risks. For the neonate, for example, a caesarean is associated with increased risk of admission to a neonatal intensive care unit and vaginal delivery with a greater likelihood of cephalohaematoma. To date, concerns around long term child health have largely focused on neurological impairment. But recent research points to latent risks for chronic disease: children delivered by caesarean have a higher incidence of type 1 diabetes, obesity, and asthma. We argue that a detailed assessment of these risks should be taken into account in guidelines for caesarean delivery.

What are the benefits? The authors can’t be bothered to mention those.

The scientific evidence on risks is so weak as to be practically non-existent.

Much of the evidence linking caesarean delivery to chronic disease is observational…

The absolute rates derived from these relative increases depend on many assumptions, including local rates of caesarean and disease prevalence. For example, using the US caesarean rate of 32.7% and an overall childhood obesity rate of 17%, the estimated rate of obesity is 15.8% among children delivered vaginally and 19.4% among children delivered by caesarean. With an overall childhood asthma rate of 8.4%, the rate of asthma among children delivered vaginally is estimated at 7.9% compared with 9.5% in those delivered by caesarean. And an overall childhood type 1 diabetes rate of 1.9/1000 translates to rates of 1.79/1000 children delivered vaginally and 2.13/1000 children delivered by caesarean.

In other words, risks (if they exist at all) are trivial.

What does this have to do with the microbiome or epigenetics? Funny you should ask. There’s no evidence it has anything to do with either. They are merely speculative mechanisms to explain speculative risks. We may not know why or how, but we “know” that C-sections are bad.

The truth is that we know nothing about the association between C-sections and chronic disease. The authors themselves acknowledge this repeatedly using the word may:

… When a caesarean is done after labour has started it may be preceded by rupture of membranes, with exposure to maternal microflora. The risks to long term child health might then vary between caesareans done before and after labour has started. Similarly, intrapartum stress may be higher in emergency caesarean and instrumental vaginal delivery than in unassisted vaginal delivery. Comparing outcomes in various settings allows a test of the relative importance of stress versus caesarean delivery itself. These (and other) more nuanced approaches may lead to better understanding of the dynamics underlying risk. This in turn may lead to clinical approaches to mitigating risk.

Of course may implies may not, but agenda driven research does not allow for that possibility.

If someone claimed that abortions had a long term risk of chronic disease, we would rightly be suspicious of an agenda. We’d want to see proof, solid proof, of causation not merely correlation. We’d demand large population based studies, definitive data and a detailed causal mechanism. In the absence of that information, we’d have little choice but to conclude that the authors were driven by the agenda of preventing abortions and we would be angry at the attempted manipulation.

Is the C-section rate too high? Possibly.

Do C-sections lead to chronic disease? We have no idea.

Are papers speculating on long term risks of C-sections in the absence of solid data manipulative and irresponsible? Undoubtedly!