Shocked! A response to ABC.com article weighing ‘pros’ & ‘cons’ of elective c-sections.

ABC.com News posted an article about the ‘pros’ and ‘cons’ of an elective c-section in January of 2009. The article is in response to a new study published in the New England Journal of Medicine that finds, “…more than a third of c-sections are performed too early — before 39 weeks — putting newborns at greater risk for a variety of health problems.” http://a.abcnews.com/Health/story?id=3291512&page=1

The ABC article goes on to explain that the study found c-sections performed “before the recommended 39 weeks, (makes) babies more likely to visit the intensive care unit, have infections and develop respiratory distress.”

This first portion of the article, which is recapping a recent study, is very reasonable. The second part of the article contains a list of ‘pros’ and ‘cons’ for both a vaginal birth and an elective c-section birth. This list is taken word for word from http://www.babycenter.com/. The article posted on Babycenter.com is said to be “a physician panel-reviewed list of ‘pros’ and ‘cons’ of both vaginal birth and c-sections.” I found the list here: http://www.babycenter./0_elective-cesarean-is-it-for-you_1498696.bc?page=3.

I am reluctant to believe any respectable physician reviewed the Babycenter list and no professional editor approved its use, out of context, in the ABC article, as the list implies an equal consideration for factors of extremely diverse risk, repeats factors in different wording and includes factors that are not scientifically proven.

Certainly the risk of death is a more serious threat than perceived psychological discomfort, however both articles treat these issues with equal consideration. On the ABC article,  negative possibilities of vaginal births are a “Fear of childbirth may cause maternal distress,” and “Labor, with the need for frequent vaginal examinations, can be traumatic,” while the negative possibility of an elective c-section is “Twice the risk of infant mortality.”

Other items in the lists are repeated. Of the six ‘pros’ listed for an elective c-section, the first and the sixth are the same, worded differently:

#1. “Can be more convenient for a woman, and reduce her stress about anticipation of labor,”

#6. “Women feel a greater sense of control knowing when their baby will be born, and can plan for family help, a baby nurse, furniture delivery, work leave, and so forth” i.e. it’s more convenient.

Apparently convenience is such a ‘pro’, it needed to be listed twice.

Also distressing is that the ABC article fails to acknowledge that two of the elective c-section ‘pros’ are not scientifically proven. The two unverified c-section ‘pros’ are:

#2 “Possible decreased risk of incontinence”,

#3” Possible decreased risk of sexual dysfunction for first three months postpartum”

The excerpt discussed earlier in the Babycenter article is, “For the mother, a common concern is pelvic floor damage that leads to urinary and fecal incontinence and sexual dysfunction. But while urinary incontinence is higher at three months postpartum in women who deliver vaginally, the connection between vaginal birth and long-term or later incontinence is still unclear.”

The Babycenter article goes on to cite two studies which refute the belief that vaginal births cause incontinence or sexual dysfunction:

“Many women who’ve never given birth develop incontinence — for instance, a study conducted at the University of Rochester found that nearly 50 percent of post-menopausal nuns reported incontinence — and some researchers suggest there’s a hereditary link…

…And research results are still mixed on the question of whether vaginal deliveries contribute to long-term sexual dysfunction. In one study, done at three months postpartum, women who delivered vaginally reported less sexual satisfaction than those who had their babies via c-section, but by six months there was no significant difference in pain during intercourse related to mode of delivery.”

It is unclear why the Babycenter ‘pros & cons’ list does not make a note that these factors as unproven. It is inexcusable that the ABC article does not mention this ambiguity at all, and it leads one to the conclusion that the ABC author did not actually read the entire Babycenter article.

The ‘pros’ listed for an elective c-section are really just two; convenience for the parents and less chance of oxygen deprivation to the child. The 7 ‘pros’ of a vaginal birth listed in the article are:

Less risk of maternal hemorrhage, infection, blood clots, damage to internal organs

Less risk of baby having specific respiratory problems

Baby potentially less likely to develop allergies, asthma, or lactose intolerance

Shorter hospital stay and quicker physical recuperation

In later pregnancies, labor may be shorter and offer quicker delivery

Mother may breast-feed more effectively

Mother much less likely to require c-section in subsequent pregnancies.

There are, of course, other ‘pros’ not listed here, like the emotional fulfillment a mother experiences having a vaginal birth, the ability to bond with the baby faster, and decreased risk of postpartum depression. It is interesting that the list on ABC and Babycenter includes negative emotional states, such as fear of childbirth, but doesn’t list its obvious counterpart, the feeling of empowerment and achievement after giving birth vaginally.

Now lets examine the ‘cons’ of an elective c-section. According to both the ABC and Babycenter lists there are eight serious issues:

“Twice the risk of infant mortality”

“Slightly higher mortality rate for mother”

“Higher risk of infection and blood clots for the mother”

“Risk of complications from anesthesia (pneumonia, allergic reactions, low blood pressure)”

“Increased maternal blood loss and risk of needing a transfusion”

“Risk of damage to the mother’s bowels and/or bladder”

“Decreased bowel function after surgery”

And of course, an elective c-section sets one up for future risks. “In later pregnancies, risks to mother increase”

It would appear that the ‘cons’ of an elective c-section are of a much more dangerous nature than those of a vaginal birth.

When we scrutinize the vaginal birth ‘cons’ we can eliminate one, “Risk of unforeseen complications during labor such as hemorrhaging.”

Clearly everything in life has the option of an unforeseen complication, therefore eliminating this as a factor. For example, the unforeseen complication of getting to the hospital is a car accident. Perhaps I’m being a little cynical here, but in all fairness, the unforeseen complication factor ought to be listed on the c-section ‘cons’ list as well.

So that leaves us with two actual risks to consider with a vaginal birth:

“Risk of perineum tearing,” and
“Risk of… trauma to baby when passing through birth canl (this would include oxygen deprivation)l, or from forceps or vacuum extraction.”

After examining the ‘pros & cons’ list it becomes obvious that the vaginal birth ‘pros’ seriously outweigh the c-section ‘pros’ while the c-section risks are much more dangerous than the ‘cons’ listed for a vaginal birth. We can speculate that the original Babycenter list and that pasted onto ABC is what I call an intervention centered or hospital centered mindset. The author writes the article from the perspective that birth is a medical condition that requires intervention and hospitalization. In fact childbirth is a natural event that occasionally requires medical assistance.

From this ABC article I have taken a moment to revise the ‘pros & cons’ list. It needs more consideration, but the following list is much more realistic and comprehensive than the list on ABC:

REVISED PRO/CON list.

Vaginal birth	Elective cesarean
Pros:	Pros:
Less risk of maternal hemorrhage, infection, blood clots, damage to internal organs	Can be more convenient for woman, and reduce her stress about anticipation of labor
Less risk of baby having specific respiratory problems (TTN and persistent pulmonary hypertension)	Reduced risk of birth trauma to baby, (including oxygen deprivation) sometimes sustained from passing through birth canal, or from forceps or vacuum extraction
Baby potentially less likely to develop allergies, asthma, or lactose intolerance
Shorter hospital stay (one to three days) and quicker physical recuperation
Mother may breastfeed more effectively
Mother much less likely to require c-section in subsequent pregnancies
In later pregnancies, labor may be shorter and delivery quicker
Less risk of post partum depression
Mother may bond more quickly with baby
Feeling of empowerment and elation for mother
Cons:	Cons:
Risk of perineum tearing (from first degree slight tear to fourth degree extensive tearing into rectum)	Possible pre-term delivery if due date calculation is inaccurate
Risk  trauma to baby when passing through birth canal, including oxygen deprivation, or from forceps or vacuum extraction	Rare: Possible infant injury when the doctor makes the uterine incision
	Risk of damage to the mother’s bowels and/or bladder
	Increased maternal blood loss and risk of needing a transfusion
	Risk of complications from anesthesia (pneumonia, allergic reactions, low blood pressure)
	Slightly higher mortality rate for mother
	Twice the risk of infant mortality
	Higher risk of infection and blood clots for the mother
	Decreased bowel function after surgery
	Risk of lower Apgar scores for the baby
	Longer hospital stay (three to five days) and longer recovery period
	Possible complications with breastfeeding
	Possible increased likelihood of clinical postpartum depression
	Potentially more expensive — your insurance may not cover an elective cesarean
	Internal scar tissue may cause problems in future c-sections
	In later pregnancies, risks to mother increase, whether she delivers by VBAC or cesarean

As I continue to inform and encourage women to consider a vaginal birth, particularly a vaginal birth after cesarean, I can only hope they review the articles available online with more integrity than the editors of ABC health.