C-sections are safer for babies

Closeup of woman belly with a scar from a cesarean section. Woman with baby on hand

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:

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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.

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  • Lou

    “Available data have limitations, and do not provide conclusive evidence regarding the safety of planned ECD versus planned vaginal delivery. Some data suggest an association between ECD and increased neonatal respiratory morbidity and lacerations, and possibly decreased central and peripheral nervous system injury. ” The above quote is directly from the article you referenced. That seems to draw different conclusions than you are from the article. Have I misunderstood but the article is based on modelling not actual data.

  • Mel

    This reminds me of the time Consumers Report got themselves into a tizzy because hospitals couldn’t give a simple, single-value price for a delivery – and then got even more wound up that the range of values given by hospitals spanned 100x.

    Apparently, the editors didn’t think out that an uncomplicated vaginal delivery to an experienced parent who was able to take a baby home at 48 hours would be a whole lot cheaper than my 28 hours in high-risk L&D (with much higher staffing ratios and lots of medications) followed by a C-section with two teams in the room – one to watch me in case HELLP syndrome did something bad to me and another one to resus my 26 week gestation son.

    Similarly, a whole lot of C-sections happen because either the mom or the baby or both is not tolerating labor well or doctors have reason to expect that mom or baby will not do well with a vaginal delivery. That already sorts deliveries into two boxes – vaginal deliveries for dyads who are doing well and c-sections for dyads who are struggling. Of course the C-section group will have worse outcomes; the groups have already been sorted by warning signs of bad outcomes.

    So….not surprised at all that MRCS have better outcomes. It’s as close to a RCT of c-sections vs. vaginal deliveries.

  • Franklyn

    But; there are thousands of studies showing that surgically born children have: worse health, emotional problems, and even lower intelligence.
    Maybe the first 5 minutes of life are better with cesareans.

    • Amy Tuteur, MD

      Actually there aren’t ANY studies that show that C-sections caused the differences. It’s like claiming that people who have spent time in ICUs have more health problems than people who haven’t; it’s the result of confusing cause and effect.

    • The Bofa on the Sofa

      Do any of those studies show that the “surgically born children” would have been better off if they had not been born that way?

      As Amy implies, perhaps all the bad outcomes associated with c-sections are due to the factors that led to having a c-section in the first place?

      The interesting part about this study is that it has controlled for that aspect. Amazingly, if you look at c-sections that are do not have an underlying medical cause, the babies do better.

  • The Bofa on the Sofa

    Yep

  • Stephanie

    This also doesn’t take in later outcomes for mom and baby. As a personal example, one of my children had decels during labour and her birth, which resulted in Apgars of 5 and 5 some minor neurological conditions picked up once she started school. My other child was born via MRCS, no decels, Apgars of 9 & 10, and no signs of the same neurological conditions.

  • mythsayer

    I had one…one baby, and I knew I didn’t want a vaginal birth. My CS was one of the best decisions I ever made. It makes me so mad when people try to say I shouldn’t have had the right to ask for one.