Monday, February 02, 2009

Recent research on cesarean sections

Pre-term elective cesareans:
Elective cesarean before 39 weeks worsens neonatal outcomes. Source: Alan T.N. Tita, et al. "Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes." NEJM 360.2 (Jan 8, 2009): 111-120. Email me for full text.

There have been several news reports about this recent study in the New England Journal of Medicine.
I think Jennifer Block's response, Can We Please Stop Blaming Women for C-Sections?, is spot on.
Elective implies freely chosen, life-enhancing. Laser eye surgery is elective. Tattoos are elective. But the vast majority of so-called "elective" cesarean sections are not, and it is inappropriate and disingenuous to call them so in the medical literature, as did the recent study in this month's New England Journal of Medicine, "Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes."...

[I]n spite of the true risk, VBACs are often vehemently discouraged. In fact, many obstetricians now refuse to attend them, and hundreds of hospitals have officially banned them. And malpractice liability fears are a strong motivation to schedule the surgery early, so as to avoid the possibility of labor—and vaginal birth. The fact is that VBAC is inaccessible to most women.

So, if a woman with a scar from a previous cesarean goes to her OB and is recommended to schedule a repeat cesarean—and is told that a vaginal birth would be risky, and that anyway it won't be done by this doctor, this practice, or this hospital—can the surgery possibly be called "elective?"
ICAN is currently compiling a database of all US hospitals' VBAC policies. So far, out of more than 1,600 hospitals, close to 1/3 have an outright ban on VBACs. Several hundred more restrict the practice with de-facto bans; even though the hospital might not have a written policy forbidding VBACS, in actual practice no physicians will attend them. I feel that access to VBAC is one of the most pressing issues in US maternity care today.

Cesareans and Serious Maternal Complications:

The increase in cesarean rates also seems to be tied to a rise in severe obstetric complications. Here are a few articles discussing the recent research article Severe Obstetric Morbidity in the United States: 1998-2005 in the Feb 2009 issue of Obstetrics & Gynecology. (Email me if you'd like to see the full text).
Benefits of Maternity Leave:
Maternity leave benefits moms and babies. Maternity leave before pregnancy is connected with much lower c-section rates. And taking more leave afterwards is beneficial for breastfeeding (big surprise, right?). Email for the full text of the following two articles:
Sources: Sylvia Guendelman et al. "Maternity Leave In The Ninth Month of Pregnancy and Birth Outcomes Among Working Women." Women's Health Issues 19.1 (January-February 2009): 30-37.
Sylvia Guendelman et al. "Juggling Work and Breastfeeding: Effects of Maternity Leave and Occupational Characteristics." Pediatrics 123.1 (January 2009): e38-e46.

Canada's C-Section rate at Record High:
From The Calgary Herald:
Canada’s pregnancy specialists are calling on doctors to curb the fast-growing use of caesarean sections to deliver babies, saying the worrisome trend is exposing mothers and infants to more risk, not less. With one in four births now occurring by C-section - 92,799 babies a year - it is time to get “back to the basics,” says Dr. Vyta Senikas, associate executive vice-president of the Society of Obstetricians and Gynaecologists of Canada.

The group is urging doctors and women to choose a C-section only when there is a medical reason to justify one. “Safety of a woman and a baby should be the driving decisions here,” Senikas said. “We have to come back to the basics, and the basics are that 90 per cent of women will have a nice vaginal delivery without any problems to produce a healthy mother and baby.”


  1. Fantastic post and thanks for all the great links. What a read.

    I'm in Australia - where as far as I'm aware hospitals haven't yet taken to formally banning vbacs (yet...although I guess in small country hospitals this has probably happened) - however individual practioners certainly do, or else make the conditions for "attempting" one ridiculous. I recently had a lady tell me her OB was scheduling her a repeat c/section if her baby hadn't engaged by 37 weeks. Yet months earlier he had told her he was supportive of her having a VBAC and happily took her payment for his "care" - in my opinion under completely false pretense, since he had to know damn well she wouldn't be having a vbac with him given a condition like that. What a joke. Fortunately at 38 weeks she told him what he could do with his vbac "attempt" and found herself a midwife.

  2. Hi Rixa,
    I found your blog a while ago and really enjoy the articles you post. I am glad there are people like you out there that blog about natural birth. I had a natural waterbirth with a midwife and it was the most empowering experience in my life. I just wanted to thank you for posting all these informative topics. I love reading them! Dana

  3. Wonderful compilation of relevant information!

  4. Thanks, as always, for the info!
    I love the tummy pictures- beautiful! Thank you so much for sharing your journey with us!

  5. Interesting article about the Canadians taking notice of the alarming increase of c-sections. I recently learned that the US is taking notice too. I was recently asked by my OB during a 2nd trimester check-up if I would participate in a study conducted by the U.S. Dept of Health and Human Services. They had randomly chosen doctors from the American Board of Obstetrics and Gynecology all over the country to ask their pregnant patients to participate. I agreed and the research facilitators contacted me. Most of the questions were about my OB and her attitude and my relationship with her. Maybe, just maybe, there will be some good from this. Maybe some OB's will realize that someone is taking a good, hard look at them. Maybe.

  6. Hi,
    I find your blog VERY interesting to read and have enjoyed clicking over every few days.

    I have had two C-sections(I developed preeclampsia- very severe with my first and mild with my second, yet they were concerned with how quickly I might progress, because of my past severe preeclamptic history). I am due in July and wonder, based on your opinion, if I have any options for attempting a vaginal birth. It is an experience I would love to have; yet the midwifes and doctors I have talked to all say I am too high risk-both because of past preeclampsia occurrences and risk of uterine rupture. What is your opinion on the safety of vaginal labor for a woman with 2 past C-sections? I should also add I will be delivering my 3rd child just 15 short months after my 2nd- not sure if this also impacts things.


  7. Nicole,
    You have 2 separate issues going on here with your history of cesareans.

    The first question is: "what are the risks of a VBA2C versus a VBA1C?" There's been quite a bit of research on this, with the most recent indicating that uterine rupture rates of VBAC after 2 or more cesareans isn't significantly higher than the rate of UR of VBA1C. You can find lots of research and resources on this subject on ICAN's website.

    The second question is about pre-eclampsia, and the basic answer is: if you can keep pre-e from rearing up again, then you should be free to consider a VBAC. But if you develop the same condition severely, that might indicate a C/S is needed. You might enjoy seeking prenatal care from a midwife or physician who can really work with you on nutrition and other associated things to increase your chances of staying healthy and pre-e-free this pregnancy.

    A third issue, actually, is more political and legal: it can be extraordinarily hard to find a hospital and/or physician willing to attend a VBA2C, even though the research indicates that it's not any less safe (and there is a LOT of research showing the increased risks of multiple cesareans--each cesarean becomes successively riskier, while each successive VBAC becomes safer). This is in part because ACOG recommended against VBA2C unless the woman has had a prior vaginal birth. Like ACOG's recommendation on VBACs and the need for immediate access to anesthesia and an in-house physician, this has further restricted women's choices.


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