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Cesarean risks hard to pin down

March 30, 2006 By Helen Pearson This article courtesy of Nature News.

Meeting stirs debate over rocketing rate of C-sections.

An expert panel convened to advise healthy women about the risks of caesarean sections concluded that they cannot do so, because there is so little hard evidence. But at least some specialists feel that the procedure should be discouraged.

Nearly 30% of babies born in the United States today arrive by caesarean section, compared to some 20% a decade ago, and many other countries are seeing similar rises. The common perception is that more and more women are demanding elective C-sections to fit their busy schedules and bypass the pain of labour.

The phenomenon has stirred intense controversy because it is not clear whether the rise is really driven by women, or by the changing advice of doctors. Furthermore, it is not known whether mothers who have C-sections without a clear medical reason face higher health risks.

Not clear cut

To try and settle the debate, the US National Institutes of Health convened an expert panel. At a three-day meeting this week, the panellists considered a specially commissioned review of medical literature (one of the most comprehensive done so far) and heard presentations from experts before issuing a report of their conclusions.

But the final report offers little guidance because, the panel said, there is such a paucity of studies. For many women, "We don't feel [elective caesarean] should be encouraged or discouraged," says Mary D'Alton, head of obstetrics and gynaecology at Columbia University Medical Center, New York, and chair of the panel.

The panel could not conclude whether a caesarean for a perfectly healthy woman is more or less medically risky than a vaginal birth, for example. The procedure, in which the abdomen wall is cut open, is linked to problems such as dangerous blood clots, infections and babies' respiratory problems; vaginal births are associated with incontinence and fetal birth injuries, amongst others.

Early days

The panel did conclude that elective C-sections are risky for women who want to have two or three children, because the risks of placenta problems in subsequent births rise after a caesarean and with each subsequent one. They also recommended against the procedure prior to 39 weeks of pregnancy, when a baby's lungs may not be fully developed. Other cases should be decided on an individual basis by discussion between the patient and doctor, they advised.

Part of the panel's difficulty in assessing elective caesareans was that they found very few studies looking specifically at healthy women who choose this method of birth. Instead, most studies included women with medical problems that may have warranted the procedure.

One way to help resolve this would be a clinical trial in which women were randomly assigned to have a caesarean or vaginal birth. But it could be very difficult to find women willing to participate.

Doctors' advice

The lack of clear advice frustrated some experts. Carol Sakala of Childbirth Connection, a non-profit maternity care organization in New York City says that the panel were mistaken to concentrate only on women who request a caesarean. "My feeling is they squandered this opportunity," she says.

A large part of the rise in caesareans is down to doctors recommending the technique, she and others say. And, they add, perhaps this isn't justified. Doctors may be increasingly favouring the procedure for convenience and fear of litigation if things go wrong with a vaginal birth.

Sakala says that the focus should be on helping women to make an informed choice and using known measures such as labour support to cut the risks associated with vaginal births. "Unless there is a clear, compelling, well-supported reason then vaginal birth is likely to be the safest," she says.

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