The Politics of Women's Health
Maternal Request for Cesarean Delivery: Myth or Reality?
Comments on the National Institutes of Health State of the Science conference “Cesarean Section by Maternal Request”
By Susan Hodges, President, Citizens for Midwifery, and NIH conference participant; March 2006
The National Institutes of Science (NIH) convened a panel for a state-of-the-science conference in March 2006, “Cesarean Section by Maternal Request” (CDMR). According to the draft report (posted 3/29/06), the panel’s overall conclusions are: “The available evidence and data comparing risks and benefits of PVD [planned vaginal delivery] and CDMR are sparse and provide few clear conclusions.” And: “There is insufficient evidence to evaluate fully the benefits and risks of CDMR as compared to PVD, and more research is needed.” On this basis, the report recommends that if the mother initiates the topic, the doctor should engage in individualized discussion with her that can result in the decision to perform a cesarean section for no medical reason, just because the mother requested it. In my opinion there were many scientific and ethical problems with this conclusion and with the draft report that has been posted.
Right from this start, the bias of the medical view of birth is evident. For example, everything is in terms of “delivery” rather than birth. So we have planned vaginal “delivery” and cesarean “delivery” on maternal request. This may seem subtle, but it is a built-in bias that suggests these two ways of having a baby come into the world are equivalent. Furthermore, the fact that the “public member” of the panel, as nice a person as she might be, was in fact a nurse totally undermines the notion that there was any “public” representation on the panel.
The conference was based on the assumption that women actually are requesting cesarean sections, even though neither the conference organizers, nor the “systematic literature review” by the Agency for Healthcare Research and Quality, nor the experts that presented at the conference, were able to provide a SINGLE piece of hard evidence that this phenomenon is even occurring.
Furthermore, both the conference literature and the panelists and presenters used terminology in confusing and misleading ways. This was partially explained in the draft report, but should have been clarified when the conference was first considered and made much clearer in the report itself. In medical terms, an “elective” cesarean section is any performed that is not an emergency procedure; this includes cesareans performed on recommendation by the doctor for a variety of risk factors and situations such as “failure to progress,” along with the very few performed at the request of the mother. Elective cesareans can include those performed for “no medical reason” or “no indicated risk.” “Patient choice” and “maternal request” cesareans comprise small subsets of “elective” cesareans. The term “maternal request” cesarean suggests that without consideration of any possible risk factors or other information from the doctor, the mother independently requested a cesarean section, especially starting early in the pregnancy. The term “patient choice” cesarean suggests that, having been provided with information about her medical risk factors and other considerations by the doctor, along with options for labor and delivery, the mother “chooses” the cesarean section option (or goes along with the doctor’s recommendation). All three of the terms, elective, patient choice and maternal request, have been used to mean the mother requesting the cesarean, even though the only data available prior to the conference were from medical records indicating that some cesareans are performed for no medical reason. However, whether any cesarean is a “patient choice” or by “maternal request” can only be determined by asking the mother, a consideration not addressed in the report. Because of the confusion in terminology and the lack of data, the conference actually looked at purported “planned cesarean deliveries” vs. purported “planned vaginal births.”
Childbirth Connection released pertinent data from their just-completed Listening to Mothers II Survey data a week prior to this conference, and made sure that all the panelists had it in hand. The results of the survey showed that extremely few mothers are actually asking for cesarean deliveries (.04% of CDs). In spite of this, the panelists omitted any mention of these findings from their report, mentioning instead confusing and irrelevant data from European countries, and US data that clearly was based merely on cesarean sections for no medical reason (4 to 18% of CDs). The report failed to clearly discredit the notion that any significant portion of the rising cesarean section rate in the US can be accounted for by “maternal request” cesarean sections, even though this was one justification for the conference as noted in the announcement. Furthermore, the report failed to mention the gap, demonstrated by the Listening to Mothers Survey II results, between women’s understanding of why they had the cesarean section and what their doctors are putting in the records. The vast majority of women believed their cesarean was for a medical reason, at the same time that the evidence shows a real and growing percentage of cesarean sections performed “for no medical reason,” as pointed out by conference participant Eugene Declerq (who was author of this research).
This was a ‘state of the science’ conference whose purpose was to identify specific future research that might be needed. Despite this mandate, the panel in their report failed to acknowledge serious issues and concerns, including those based on published research and clinical experience, for which studies were not included in the systematic review. The systematic review was restricted to studies that actually compared planned cesarean delivery (a proxy for CDMR) to planned vaginal deliveries, of which there was little and most of it of very poor quality. The panel apparently would not look at any other research, regardless of relevance. For a state of the science conference it would be logical and useful to include the issues and concerns brought by professionals based on their clinical experience (the majority of the conference audience participants) as areas where specific research is needed. In addition it would be logical, for a topic for which the panel noted there was insufficient evidence, to include these issues as areas of potential concern when discussing CDMR. However, the panel failed to include these suggestions with regard to future needed research or with regard to potential risks people might want to consider when weighing CDMR.
Aside from concerns brought by the conference participants, the panel and the review committee sought research for a number of specific outcomes, for some of which no research studies meeting the Systematic Review requirements could be found, which was noted in the report. However, the panel omitted from the conclusions and recommendations any mention of these potential adverse outcomes for which they did not have research. For example, near the beginning of the report the panel states: “A number of potential outcomes were not assessed due to a lack of data availability or clarity. Among these were hospital re-admissions, adhesions [caused by the cesarean scar], and chronic abdominal and pelvic pain syndrome.” However, none of these are mentioned again, nor are they included anywhere in the list of conclusions or recommendations, nor as considerations for decision-making. These omissions distort the report. Unless someone reads every word of the report, and remembers the two sentences above, the reader will not know that these were even possible adverse outcomes or risks that “might” be associated with cesarean section. Furthermore, in discussing “surgical and traumatic complications” the report carefully mentions 3rd and 4th degree lacerations (for planned vaginal birth), which actually can be almost eliminated by using appropriate birth practices (and not using inappropriate birth practices), but fails to make any mention at all of the cesarean cut – by comparison a huge and serious “laceration” involving the abdominal cavity, also a source of additional complications, that occurs in 100% of cesarean deliveries!
The report is almost useless for any woman who might read it in an effort to make a decision (either about “requesting” a cesarean delivery or “choosing” one in the face of “risk factors”). The report states findings from the mostly poor quality and very limited research papers in the review in vague terms such as “less than,” “more than,” “at a higher rate,” etc. No actual numbers are presented for either rates of incidence or differences between delivery methods, so it is impossible to evaluate what any of the “results” actually mean. For example, if an adverse outcome is reported at a rate of 0.01% for one delivery method, and is even twice as high for the other (0.02%), we are still talking about a very low rate. In contrast, as noted above, the cesarean scar is never really mentioned, although 100% of cesarean deliveries, whether planned or unplanned, include the abdominal/uterine scar. In addition, the panel made fairly strong statements about outcomes based on single, poor quality studies. For example, the report claims that the route of delivery makes no difference on breastfeeding, but we know from the conference itself that this conclusion was based on a single study, that may have been carried out years ago when breastfeeding rates were much lower overall than today. It is irresponsible to draw firm conclusions on single, poor quality studies, especially when experienced clinicians are pointing out that such a conclusion does not fit with their current experience, as was the case in for this topic.
The ethical issues of legal and economic influences and biases were barely mentioned, although conference participants brought these up. Specifically, the fact that obstetricians and hospitals stand to gain financially in a number of ways from performing more planned cesarean sections was pointed out. Incredibly, the report indicates that the panel apparently has absolutely no problem with more and more women being delivered by major abdominal surgery (by choice or not) simply for legal and economic considerations. Furthermore, the panelists did not address how a woman might determine if she were in fact getting honest and complete information. The fact that the Listening to Mothers Survey II showed that virtually all the sectioned women believed their cesareans were for medical reasons, when records show that a significant proportion are for no medical reason, indicates that either dishonest or ineffective communications are a real problem, though this also was not addressed by the panel.
While “planned vaginal deliveries” also included all unplanned, in-labor cesareans, the panel failed to fully acknowledge the role of typical labor and birth management practices in causing complications and the “need” for so many cesarean sections for planned vaginal births. The only place they mentioned a possible effect of clinical practices was with regard to midline episiotomies and instrumental deliveries as they relate to 3rd and 4th degree lacerations. In fact, there is ample information that standard practices and interventions typical of hospital-managed labor and deliveries increase the likelihood of many complications and additional interventions, including cesarean section. The panel failed to point out in their report or in any way acknowledge that the risks and adverse outcomes they are attributing to “planned vaginal birth” can only be attributed to “hospital-managed interventionist planned vaginal birth,” not to vaginal birth per se, because they only looked at hospital-managed planned vaginal birth. This is a serious and misleading shortcoming that undermines the entire report. Even if there were adequate high quality studies showing that maternal request cesareans are “just as safe as” planned hospital-managed vaginal deliveries (including all unplanned cesarean sections), this is comparing two problematic methods of delivery; it is kind of like claiming that using heroin is just as safe as using cocaine, and ignoring the fact that using either one is bad for your health and it is much better to use neither!
I came away from the conference with the feeling that it was an exercise in torturing the data so that the panel could pronounce that it was still fine for women to ask for and obstetricians to perform cesarean sections for no medical indication. The lack of critical thinking and common sense on the part of the panelists left me incredulous. In my opinion the conference was a waste of tax dollars in the production of a misleading and dishonest report.
For more information, see Citizens for Midwifery’s Position Statement on the Issue of “Maternal Request” Cesarean Sections.
Written by: Our Bodies Ourselves
Last revised: May 2006
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