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Elective cesarean sections are too risky, WHO study says

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cesarean section surgery risk mother babyDespite medical advances and increasing access to improved obstetric care across the globe, surgical childbirths are still more risky for both mother and baby, according to an ongoing international survey by the World Health Organization (WHO).

A new report from the survey, which was published online today in the medical journal The Lancet, found that in Asia—in both developed and developing nations—cesarean section births only reduced risks of major complications for mother and child if they were medically recommended. Elected surgical deliveries, on the other hand, put both at greater risk.

"Cesarean section should be done only when there is a medical indication to improve the outcome for the mother or the baby," the authors of the report concluded. Common reasons for a recommendation for cesarean delivery included a previous cesarean section, cephalopelvic disproportion (when the baby’s head cannot fit through the mother’s pelvic opening) and fetal distress.

In the nine countries studied (Cambodia, China, India, Japan, Nepal, the Philippines, Sri Lanka, Thailand and Vietnam), more than a quarter of the 107,950 births analyzed (27.3 percent) were C-sections, and in China, which had the highest rate of operations, nearly half (46.2 percent) of the births in the survey were cesarean. With these surgeries comes increased risk of maternal death, infant death, admission into an intensive care unit, blood transfusion, hysterectomy or internal iliac artery ligation (to control bleeding in the pelvis) compared to spontaneous vaginal delivery, according to the report.

But these risks have not necessarily been absorbed into popular, or even medical culture. The rates of cesarean section procedures are on the rise in many countries across the globe, the authors report, and in some countries they "have reached epidemic proportions." Among the nations studied, China had the highest rate of cesarean sections that were performed without medical indication—11.7 percent; the overall rate for the facilities studied had a rate of 1.9 percent.

Most cesarean sections (15.8 percent of births) were begun during labor, as opposed to before it starts. But these later procedures—both elected (0.5 percent) and medically required (15.3 percent)—also carry the most risks for adverse outcomes, the authors found.

In a commentary accompanying the report, Yap-Seng Chong of the National University of Medicine in Singapore and Kenneth Y C Kwek of the KK Women’s and Children’s Hospital also in Singapore call the results "surprising and chilling." The findings, they say "should help us to prioritize our strategies to reduce unnecessary interventions in childbirth," they wrote. "There is little wrong with medical interventions when indicated, but for those who are still inclined to consider caesarean delivery a harmless option, they need to take a cold hard look at the evidence against unnecessary cesarean section."

The investigators were able to analyze some 96 percent of the births reported in the 122 hospitals that participated in the survey over two to three months between 2007 and 2008. Facilities were located in the capital city of each country and two randomly chosen regions. To qualify for the survey, hospitals had to be delivering at least 1,000 babies a year and performing cesarean surgeries, so as the authors noted, "the results therefore cannot be generalized to smaller facilities" or to the countries overall.

Despite the increased risks associated with cesarean deliveries, no mothers or babies in the study died after an elected cesarean before hospital release. The most dangerous form of childbirth proved to be vaginal operative delivery, which includes using forceps or a vacuum to assist in delivery and is more rare, occurring in just 3.2 percent of the births analyzed.

The findings confirm a previous WHO report published in 2006 in The Lancet, analyzing the rates and safety of various childbirth approaches in Latin America, where the investigators found that "increasing rates of cesarean section do not necessarily lead to improved outcomes and could be associated with harm." Taking the two reports together, the authors concluded, lends "strong multiregional support for the recommendation of avoiding unnecessary cesarean sections."

Surgical childbirth also requires more resources than a natural vaginal delivery, the authors note. Especially in countries where money, medical practitioners or proper equipment is more limited, unnecessary cesarean sections can drain resources away from those cases in which it can improve the chances of a healthy mother and baby.

Image of cesarean surgery team at work courtesy of Wikimedia Commons/Bobjgaliando

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  1. 1. Quinn O 11:34 pm 01/11/2010

    So … what are the risks? I’d like to see a comparison of the rates of complications for elective C-sections (begun before labor) and non-surgical deliveries.

    I think women should have the right to choose. If a woman can choose to have a face lift or breast implants, she should be able to choose to have a C-section. There are risks inherent in any procedure – that’s what informed consent is for.

    Link to this
  2. 2. mrs 9:10 am 01/12/2010

    Hmmm…major abdominal surgery or normal birth, equal choices, I don’t think so…Yes, and the baby gets a choice too?

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  3. 3. wexworth 12:47 pm 01/12/2010

    Yes, there are two lives at risk here, not just one. Additionally, I don’t want my health insurance company paying for your vanity c-section.

    I had an "emergency" c-section with my first that was horribly traumatic for me, my husband and my baby. Labor is good for babies and moms and there is nothing better for babies than to be placed immediately on mom’s chest after birth. When you have a c-section, the baby must be kept separate, the cord must be cut right away, the initial bonding period is disrupted, nursing is delayed and mom is denied the ability to truly connect as a mother because she is doped up for the pain during recovery.

    Sure, cut open your own body as much as you like. But babies are best born through vaginas. Whether you credit Mother Nature or God with the design, how can you argue that it’s flawed and should be bypassed? Women’s bodies were created to birth babies and most of them will have no trouble with a vaginal birth if they believe in themselves and are surrounded by supportive people instead of doctors itching to grab a scalpel. 1 in 3 women in the US now has a c-section despite the WHO’s recommendation of a much lower rate.

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  4. 4. umsami 7:35 pm 01/12/2010

    QuinnO–There are studies already out there that show that women who undertake elective c-sections put themselves and their babies at increased risk.

    And I agree, I have no desire to pay for anybody’s elective c-section. Instead, let’s give every pregnant women free prenatal care and covered L&D, before we as a nation (via our health insurance) start paying for elective C-sections. There are still pregnant Moms who fall through the cracks–too much $ or resources for Medicare, and if self-employed, many private health plans won’t cover maternity at all…or barely cover it.

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  5. 5. umsami 7:38 pm 01/12/2010

    Also, it’s elective major abdominal surgery. Elective surgery always has risks–as does any surgery. Increased risk of blood clots, infection (uterus, incision site, etc.), injury to bowel/bladder, adhesions, and increased maternal mortality (death!).

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  6. 6. Benson 3:57 am 01/13/2010

    Birthing is natural. When we think we know it more than nature and God then things start getting wrong. Allow natural childbirth(Vaginal birth) and mother nature will take control. Technocrats are for the scapel. lets be humanistic and moral in approach to childbirth. midwives, where are you to promote natural childbirth without unnecessary interventions?.Just a word of caution mothers: be cautious when one advices you for elective caeserian C?S. It has become a money making surgical proceedure.Let CS be done when there is absolute indications.

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  7. 7. Aussie Mum 6:42 am 01/13/2010

    Wow, great comments. Where are the midwives? Well they have been totally gutted by the power of the medical lobby. Where are the politicians prepared to stand up to this thievery? Women in the US and in Australia (where I am from) have no real choice in childbirth. Instead they are pawns of a billion dollar industry that will only survive if it keeps fooling women that their bodies are faulty and that normal birth is dangerous. Obstetrics for majority of women is totally unnecessary and inherently dangerous (on the basis of the raft of interventions that create harm without any benefit).
    Women who speak up are labelled as ‘mad’ or natural birth Nazi’s. When will women be credited with understanding their bodies and having the ability to decide what, or indeed what is not done to them?
    The costs of surgical birth is robbing from areas of greater need where patients are actually sick and in need of healthcare. The "Men of Science" are merely peddlers ‘selling sickness’.

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  8. 8. Quinn O 5:19 am 01/14/2010

    >>Hmmm…major abdominal surgery or normal birth, equal choices, I don’t think so<<
    Nobody said they were equal choices; I said it should be the mother’s decision. The article doesn’t provide the relevant stats to weigh the risks and benefits of one against the other.

    Who pays is a separate issue. My argument is not that elective procedures should be covered.

    The first article you posted suggests an increased risk to the baby IF the c-section is done prior to 39 weeks. The complications are respiratory in nature and due to the fact that the baby’s lungs may not be fully developed (not due to the c-section).

    Other sources suggest that the risks to the baby and mother are not widely disparate for the two options.$=relatedreviews&logdbfrom=pubmed

    I think midwifery should be an option as well.

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  9. 9. Aussie Mum 6:14 am 01/14/2010

    Quinn O
    The respiratory distress is due to the mode of birth (C/S) because a natural birth squeezes and stimulates the lungs as the baby passes through the birth canal and spreads the surfactant across the lung surface. Prematurity is another issue. In Australia 70% of babies born by c/s spend time in special care nurseries due to respiratory distress as a result of a surgical birth. 10% of babies are cut during the procedure, babies born from c/s are less likely to be breastfed. This poses significant health deficit as the child does not receive the immunological benefits (established for life).

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  10. 10. Quinn O 8:07 am 01/14/2010

    Aussie Mum,
    "The respiratory distress is due to the mode of birth (C/S) because a natural birth squeezes and stimulates the lungs as the baby passes through the birth canal and spreads the surfactant across the lung surface."
    The article to which my comment referred attributed the respiratory complications solely to lack of complete lung development.

    "In Australia 70% of babies born by c/s spend time in special care nurseries due to respiratory distress as a result of a surgical birth."
    I question whether the respiratory distress is really attributable to the surgery, or the result of prematurity. What’s the source of your info?

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  11. 11. 10:40 am 01/14/2010

    The conclusion in this report by the WHO is flawed, and media reports in the last few days demonstrate that journalists are not reading the full study for themselves. Instead, they are relying on the distorted summary provided by the WHO researchers.

    If you read the study and look at its tables of data (before the WHO researchers reorganize the data into a special ‘index’ of results that supports a vaginal delivery bias), it is clear that planned cesarean without medical indication is NOT less safe than a planned vaginal delivery.

    This study should not be used to criticize women for making a perfectly legitimate birth plan decision.

    If interested, you can read my full commentary on the study here (non-commercial link):

    Link to this
  12. 12. theresa2009 2:20 pm 03/12/2010

    This is clearly a biased study probably funded by interested parties (insurance co?). I’m very familiar with the stats. Elective, planned cesarean is actually a lot safer for the baby and slightly riskier than *uncomplicated" normal delivery. Read carefully and you will see that a complicated vaginal delivery is much riskier for everybody and nobody knows how theirs will turn out. In a planned elective cesarean the risk of complications are minimal and again, is a lot safer for the baby.

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  13. 13. theresa2009 2:23 pm 03/12/2010

    you are correct…the stats are conspicuously missing. it is actually safer for the baby to have an elective planned cesarean. The respiratory distress other are talking about only applies to premature babies. for normal c sections is a myth.

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  14. 14. livesimplytolivewell 6:38 pm 06/16/2010

    It’s important to bring a safe baby into the world and to make sure the mother is safely delivered. The proliferation of C-section is having the opposite effect, it seems. For example, I have a hard time believing that 70% of C-section babies in Australia are premature, thus explaining the respiratory distress. Although I agree that empirical data would be helpful.

    Link to this

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