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Editorial APRIL 2008

The Ongoing Cesarean Delivery Controversy

Vivian M. Dickerson, MD

In 1997, one of our colleagues, Bruce Flamm, MD, wrote a clinical commentary for Obstetrics and Gynecology, entitled “Once a cesarean, always a controversy.”1 That article was primarily devoted to the issue of repeat cesarean delivery vs vaginal birth after cesarean (VBAC), but many of his arguments pertain to the new controversies surrounding elective primary cesarean delivery. Dr Flamm cited the potential for a huge increase in the number of cesarean deliveries, and the fact that the definition of an “appropriate” cesarean delivery rate remained elusive and was likely to do so into the 21^st century. In 1997, the cesarean delivery rate in the US had been stable for a number of years at 22%. By 2006, it had increased to 31.1%, up from 30.2% in 2005. Furthermore, Dr Flamm’s fears have largely been realized and while the national VBAC rate is less than 9%, in many private hospitals (such as mine), it has decreased to 1% to 2%. I mention this to indicate that the trend is not only to do more sections, it is to continue to perform cesarean deliveries once that first section has been done.

In December 2007, ACOG issued a Committee Opinion on cesarean delivery based on maternal request.2 The opinion cites the NIH State of the Science Conference on Cesarean Delivery by Maternal Request held in 2006. The committee concluded that at that time, the body of evidence, based on a systematic review of more than 1400 documents, did not provide the basis to make appropriate recommendations. ACOG also concluded that the data on cesarean deliveries vs planned vaginal deliveries are mostly based on indirect comparisons and do not adequately adjust for confounding factors. The recommendations in the ACOG opinion were therefore very few and included a caution that a primary elective cesarean delivery in a woman who is planning multiple pregnancies definitely increases the risks of malplacentation and ultimate hysterectomy with each cesarean delivery. End of conversation?

Hardly! Most ObGyns recognize that the initial data on increased incontinence and prolapse with vaginal birth have not been confirmed in some of the subsequent literature, including the famous Buchsbaum article comparing parous and nulliparous postmenopausal women.3 To date, in the absence of definitive data, conflicting literature persists. Ethical issues have also been well addressed including another ACOG Committee Opinion on surgery and patient choice, issued in January of this year.4 The conclusion of this opinion is that ObGyns must look very long and hard at all of the potential consequences of surgical treatments and acknowledge the lack of definitive evidence of benefit when no such definitive evidence exists.

Benefit notwithstanding, what about harm? In December 2007, the British Medical Journal reported the results of a cohort study elaborating the risks of respiratory morbidity in term infants delivered by elective cesarean delivery.5 The authors noted an odds ratio of 1.9 (95% CI 1.2-3.0) for 39-week infants when compared to infants intended for vaginal birth. This led them to conclude that both vaginal delivery and emergency cesarean delivery provided significantly less risk of infant respiratory morbidity than did the elective surgery. As expected, the risk rose with decreasing gestational age. Is this the beginning of the end for elective primary cesarean delivery? How many of our patients would elect this procedure when told that data show an increased risk for their baby, even at term?

Catherine Spong, MD, a well known and highly respected maternal fetal medicine specialist at the National Institute of Child Health and Human Development has been quoted in the press as saying “…that the safest way for most first time mothers to give birth is via an uncomplicated vaginal delivery.” Her comments take into account the fact that we do not know which vaginal delivery is going to be uncomplicated, particularly with a first pregnancy. However, new data also show us that the recent dramatic rise in cesarean delivery rate is accompanied by an increase in maternal mortality. Is this just an increase in accurate reporting or does it represent something more sinister in which women with multiple cesarean deliveries are at risk? Should we be demanding a large scale randomized prospective trial? Is there an ethical way that such a thing could be accomplished? Are we physicians recommending to our patients that they consider this option, and should we really be doing so? Dr Eugene Declercq of Boston University is concerned and has published a study using birth certificate data and discharge records to compare elective cesarean deliveries to vaginal deliveries.6 He found that women with primary elec tive cesarean deliveries were more than 2 times as likely to be readmitted to the hospital in the month following the delivery and that the cost of their medical care, with or without readmission, was significantly higher.

It is time to take the study of these issues to a higher plane and to determine what the risks really are. The data on respiratory distress are concerning, however, and may rightly preclude such a study. In the interim, I implore physicians to look at each patient as an individual, to be detailed and specific in their conversations about options, and to honestly record in the patient’s hospital record when a cesarean delivery is truly elective. Such terms as “impending macrosomia” or “R/O PIH” (rule out pregnancy induced hypertension) have no place if we are to advance our knowledge on this most important subject. In other countries in the world, cesarean delivery rates are over 50%: is that where we want to go? I sincerely hope not; even if the maternal data on risk-benefit turn out to be equivocal, I am particularly concerned about data on the babies. We cannot just sit by and wait for judgment to come at some later time when cesarean deliveries in our own country are doled out to 1 of every 2 women.

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Vivian M. Dickerson, MD, Editor-in-Chief

References

1. Flamm BL. Once a cesarean, always a controversy. Obstet Gynecol. 1997;90(2): 312-315.
2. Cesarean delivery on maternal request. ACOG Committee Opinion No. 394. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2007; 110(6):1501-1514.
3. Buchsbaum GM, Duecy EE, Kerr LA, Huang LS, Guzick DS. Urinary incontinence in nulliparous women and their parous sisters. Obstet Gynecol. 2005; 106(6):1253-1258.
4. American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 395. Surgery and patient choice. Obstet Gynecol. 2008; 111(1):243-247.
5. Hansen AK, Wisborg K, Uldbjerg N, Henriksen TB. Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study. BMJ. 2008;336(7635):85-87.
6. Declercq E, Barger M, Cabral HJ, et al. Maternal outcomes associated with planned primary cesarean births compared with planned vaginal births. Obstet Gynecol. 2007;109(3):669-677.