A look at the NIH panel report on cesarean delivery on maternal request.On March 27-29, 2006, the National Institutes of Health (NIH "Not invented here." See digispeak. NIH - The United States National Institutes of Health. ) brought together a panel of health professionals and public representatives to review scientific literature and discuss and prepare a state-of-the-science statement regarding cesarean cesarean /ce·sar·e·an/ (se-zar´e-an) see under section. ce·sar·e·an or cae·sar·e·an or cae·sar·i·an or ce·sar·i·an adj. Of or relating to a cesarean section. delivery on maternal request (CDMR CDMR Cesarean Delivery on Maternal Request CDMR Cyclic Data Management Routine ). The panel included twelve physicians, one nurse midwife nurse midwife Certified nurse midwife, see there , one nurse, three professors, and one attorney. There were 18 speakers during this conference including obstetricians, a urogynecologist, a pediatrician, professors in statistics and epidemiology, a research analyst, and a health correspondent for PBS PBS in full Public Broadcasting Service Private, nonprofit U.S. corporation of public television stations. PBS provides its member stations, which are supported by public funds and private contributions rather than by commercials, with educational, cultural, . Following the conclusion of the conference a state-of-the-science statement was prepared as a summary of the conference and was made available to the media and the public. The goal of the conference was to assess the available scientific evidence that is relevant to the following four questions: * What is the trend and incidence of cesarean delivery over time in the United States Time in the United States, by law, is divided into nine standard time zones covering the states and its possessions, with most of the United States observing daylight saving time for part of the year. and other countries? * What are the short-term (less than one year) and long-term benefits and harms to mother and baby associated with cesarean delivery by request, versus attempted vaginal delivery? * What factors influence benefits and harms? * What future research directions need to be considered to get evidence for making appropriate decisions regarding cesarean delivery on request or attempted vaginal delivery? Trends in Cesarean Section cesarean section (sĭzâr`ēən), delivery of an infant by surgical removal from the uterus through an abdominal incision. The operation is of ancient origin: indeed, the name derives from the legend that Julius Caesar was born in this Not surprisingly, the trend since the 1970s has been an increase in the incidence of cesarean section, with a slight decline from the late '80s to mid '90s. The national cesarean rate in 2004 was 29.1 percent with the projected rate for 2005 even higher. The increase in primary cesareans parallels the total cesarean delivery rate. This means that the increase in the total cesarean delivery rate cannot be explained by the decreasing availability of VBAC VBAC abbr. vaginal birth after cesarean VBAC Vaginal birth after cesarean. Mentioned in: Cesarean Section VBAC Vaginal birth after cesarean section, see there . The report states that the primary cesarean delivery is increasing in all ethnic and age groups. "In the absence of any increase in known clinical risk factors for primary cesarean delivery, it is plausible that some of the primary cesarean delivery increase is because of cesarean delivery on maternal request" (italics mine). Though the report acknowledges that cesarean delivery on maternal request is not clearly and accurately documented in any existing studies or databases, the report estimates that 4-18 percent of cesarean deliveries in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. and internationally are by maternal request, admitting, "but there is little confidence in the validity of these estimates." What the report fails to emphasize is that the statistics presented come from hospital discharge data and birth certificate records, both recognized as highly inaccurate means of data representation. In response to the proposed ideal of a 15 percent cesarean delivery rate, the report states: "There is no consistency in this ideal, and artificial declarations of an ideal rate should be discouraged. Goals... should be based on maximizing the best possible maternal and neonatal outcomes, taking into account available medical and health resources and maternal preferences." What Does Research Tell Us About Planned Vaginal Delivery Versus Cesarean Delivery on Maternal Request Outcomes? Because there is no data that specifically identifies cesarean delivery on maternal request, some assumptions needed to be made in order to evaluate the short-term and long-term effects associated with cesarean delivery by maternal request. The planned cesarean delivery group was assumed to consist of women who elected to have a cesarean delivery by 39-40 weeks gestation GESTATION, med. jur. The time during which a female, who has conceived, carries the embryo or foetus in her uterus. By the common consent of mankind, the term of gestation is considered to be ten lunar months, or forty weeks, equal to nine calendar months and a week. , including those who had experienced the onset of spontaneous labor prior to their scheduled cesarean delivery date. The planned vaginal delivery group consists of women electing vaginal delivery who had spontaneous or assisted vaginal delivery or indicated cesarean delivery after the onset of labor or spontaneous rupture of membranes Rupture of membranes (ROM) is a term used during pregnancy to describe a rupture of the amniotic sac at the onset of, or during, labor. This is colloquially known as "breaking water". . The report acknowledges that quality evidence directly assessing the differences in outcomes between planned cesarean delivery and planned vaginal delivery is sparse. Using an evidence quality grading scale, the evidence in the reviewed studies was indicated to be either level 1 (strong evidence), level 2 (moderate evidence), level 3 (weak evidence), or level 4 (absence of evidence). In review, there was no level 1 evidence found. Three study outcomes had level 2 evidence, and the remaining study outcomes consisted of level 3 or level 4 evidence (see sidebar). "Interpretation of many outcome variables was confounded by a lack of appropriate comparison groups, a lack of consistency in outcome definitions, and the frequent use of composite outcomes." While it is admirable that the report honestly reflects the weakness of the evidence reviewed, even this 'honest' evaluation did not reflect the true depth of the flaws in its evidence analysis. These flaws include the use of studies that were too small to be statistically significant or to be able to measure specific outcomes with accuracy, the inclusion of studies where there was no vaginal birth comparison group, the inclusion of studies looking specifically at mode of delivery outcomes for breech birth Breech Birth Definition Breech birth is the delivery of a fetus (unborn baby) hind end first. Between 3-4% of fetuses will start labor in the breech position, which is a potentially dangerous situation. , and the clear omission of the only available national data about cesareans on maternal request from the mothers themselves, provided by the second national Listening to Mothers survey that was released just prior to the meeting. Conclusions Made by the NIH Panel The panel concluded: "With the exception of three outcome variables with moderate quality evidence (maternal hemorrhage hemorrhage (hĕm`ərĭj), escape of blood from the circulation (arteries, veins, capillaries) to the internal or external tissues. The term is usually applied to a loss of blood that is copious enough to threaten health or life. , maternal length of stay, and neonatal respiratory morbidity [which all favor planned vaginal birth!]), all remaining outcome assessments considered by the panel were based on weak evidence. This significantly limits the reliability of judgments regarding whether an outcome measure favors either cesarean delivery on maternal request or planned vaginal delivery." Though the statement does provide some explanation for each of the outcome variables, the majority of the information is presented with an evident bias toward validating cesarean delivery on maternal request. For example, maternal hemorrhage, which is one of the moderate quality evidence variables, is noted to be more frequent with a combination of planned vaginal delivery and unplanned cesarean delivery than with planned cesarean delivery. The immediate thought might be that a planned cesarean delivery reduces maternal bleeding and is, therefore, a safer choice. What is not mentioned is the type of labor management in the planned vaginal delivery group, nor are the reasons that lead to the unplanned cesareans mentioned. This is crucial information to consider if one is to be able to make a fair comparison. The discussion centering on surgical and traumatic complications indicates that there is a lower risk with elective than unplanned cesareans resulting from an attempted vaginal delivery. The planned vaginal delivery group includes assisted deliveries and in-labor cesareans and is associated with a significantly higher rate of obstetric ob·stet·ric or ob·stet·ri·cal adj. Of or relating to the profession of obstetrics or the care of women during and after pregnancy. obstetrical, obstetric pertaining to or emanating from obstetrics. trauma based on the weak quality evidence that favors cesarean delivery on maternal request. Again, there is no mention of the medical management of the labors included in the planned vaginal delivery group. That, coupled with the abundant confounding confounding when the effects of two, or more, processes on results cannot be separated, the results are said to be confounded, a cause of bias in disease studies. confounding factor factors present in the "weak quality" evidence, makes it impossible to draw any real conclusion. Yet a conclusion seems to have been made in this paper with regard to this variable: "The net direction of the evidence thus far favors planned cesareans." The panel seems willing to draw conclusions in some areas even though the evidence is weak, and yet uses the excuse of weak evidence or lack of adequate evidence as a reason not to discuss other variables. For example, the variable of subsequent stillbirth Stillbirth Definition A stillbirth is defined as the death of a fetus at any time after the twentieth week of pregnancy. Stillbirth is also referred to as intrauterine fetal death (IUFD). seems to be more likely in subsequent pregnancies in women who have had a previous cesarean delivery. Yet, the panel writes: "... the lack of documentation of the indication for the prior cesarean delivery limits interpretation for this outcome." Looking at neonatal outcomes, the panel concludes that higher rates of intracranial hemorrhage intracranial hemorrhage n. The escape of blood within the cranium due to the loss of integrity of vascular channels and frequently leading to formation of a hematoma. are consistently observed in operative vaginal delivery and cesarean delivery in labor, suggesting cesarean delivery on maternal request should be associated with lower risk of intracranial hemorrhage than the aggregate of spontaneous and assisted vaginal deliveries that comprise planned vaginal delivery. Again, there is no mention or discussion of the labor management in the planned vaginal delivery group, which is directly related to neonatal outcomes in this area. Additionally, the panel concludes that infants born by planned vaginal delivery have more evaluations for infection than do infants delivered by planned cesarean surgery. The actual incidence of infection is also increased. Again, there is no discussion beyond this conclusion that looks at the labor management of the planned vaginal delivery group. With the current state of obstetrics obstetrics (ŏbstĕ`trĭks), branch of medicine concerned with the treatment of women during pregnancy, labor, childbirth (see birth), and the time after childbirth. in this country--the frequency of artificially rupturing the amniotic membranes Amniotic membrane The thin tissue that creates the walls of the amniotic sac. Mentioned in: Premature Rupture of Membranes , the frequency of internal exams and other invasive procedures Invasive procedure may refer to:
n. Regional anesthesia produced by injection of a local anesthetic into the epidural space of the lumbar or sacral region of the spine. which increases the risk for maternal fever and, therefore, neonatal work-ups--it is no wonder that there is more incidence of infection in the planned vaginal delivery group. Jose Gorrin-Peralta, MD, MPH, FACOG FACOG Fellow of the American College of Obstetricians and Gynecologists. FACOG abbr. Fellow of the American College of Obstetricians and Gynecologists , an international member of CIMS CIMS Courant Institute of Mathematical Sciences (New York University) CIMS Center for Integrated Manufacturing Studies (Rochester Institute of Technology) CIMS Chemical Ionization Mass Spectrometry writes: "the panel absolutely refused to consider normal physiological vaginal delivery and, instead, used obstetrical obstetrical, obstetric pertaining to or emanating from obstetrics. obstetrical anesthesia an anesthetic procedure designed especially for patients undergoing cesarean operation or intrauterine manipulation of the fetus. management of the birth process as an alternative. The only conclusion that can be reached from such a model is that obstetricians have managed to complicate vaginal birth to such a degree that its risks approach those of cesarean section." Throughout this section of the state-of-the-science statement, the panel opts to support cesarean delivery on maternal request rather than promoting practices that support normal birth. If normal birth were supported across the board, by medical practitioners, hospital policies, medical insurance companies and the consumers themselves, the majority of the negative outcome variables associated with planned vaginal birth would be reduced or eliminated. Influential Factors The third section of the state-of-the-science statement looked at factors that might influence benefits and harms. Amongst these factors are maternal age maternal age, n the age of the mother at the period of conception. , use of reproductive technologies, number of pregnancies, obesity, the accuracy of estimating gestational age ges·ta·tion·al age n. See estimated gestational age. Gestational age The estimated age of a fetus expressed in weeks, calculated from the first day of the last normal menstrual period. , and psychological factors. The panel writes: "Personality factors, such as the need to be in control of the birth process ... life altering experiences, such as interpersonal violence, traumatic delivery or infant death Noun 1. infant death - sudden and unexpected death of an apparently healthy infant during sleep cot death, crib death, SIDS, sudden infant death syndrome , can lead to symptoms of posttraumatic stress disorder Posttraumatic stress disorder An anxiety disorder in some individuals who have experienced an event that poses a direct threat to the individual's or another person's life. , depression, or feelings of guilt that influence a woman's decision.... Anxiety about delivery and feelings of inadequacy regarding labor can complicate the decision-making process. Given the potential of such potent psychological factors, the line between what constitutes an acceptable 'medical indication' and what is not medically indicated becomes less clear." The personal challenges women face based on these psychological factors are real and cannot be minimized. But offering patient-choice cesareans as a solution to these factors undermines the work that women can do prenatally to move beyond these challenges and fears towards an empowering normal birth. It deprives women of what can be a transforming and empowering life experience. It also overlooks the responsibility of the obstetrician obstetrician /ob·ste·tri·cian/ (ob?ste-trish´in) one who practices obstetrics. ob·ste·tri·cian n. A physician who specializes in obstetrics. or other medical care-giver to help women explore their fears and point them towards other, more holistic, options for dealing appropriately with their specific concerns. Cultural and societal issues influencing birth are also discussed briefly. There is recognition by the panel that some cultures do value active participation in the birth process and understand that there are both physical and psychological benefits to a normal birth. But the panel also notes that some women may value more highly the control over the birth process that a planned cesarean provides. In making a decision as to whether or not a cesarean delivery on maternal request is an appropriate choice for a woman, the panel indicates that the cultural and personal importance of labor and birth for a woman should be evaluated. There is no mention, however, of the importance of promoting informed choice. There is an acknowledgement that the increasing cesarean delivery rate normalizes this mode of birth, promoting greater public acceptance. A brief mention of the impact of media coverage highlights the fact that the public may become more interested in cesarean delivery on maternal request as the media focuses even more on the concerns of risk and potential maternal and/or fetal morbidity linked with planned vaginal delivery: "Such a shift in acceptance by patients and providers may lead to an increase in cesarean delivery on maternal request." The impact of media focus on elective cesareans is profoundly understated by the panel. A cursory cur·so·ry adj. Performed with haste and scant attention to detail: a cursory glance at the headlines. [Late Latin curs internet search for information related to elective cesarean and cesarean delivery on maternal request produced numerous articles and press releases resulting from the release of the NIH state-of-the-science statement itself. While a number of the articles mentioned some of the risks associated with elective cesarean, there were many that focused on the climbing cesarean section rate and the false argument that it is the increase in cesarean delivery on maternal request that is partly to blame. Without citing strong evidence to support their discussion points, many authors of these articles and press releases indicate the benefit of elective cesareans in reducing pelvic floor The pelvic floor or pelvic diaphragm is composed of muscle fibers of the levator ani, the coccygeus, and associated connective tissue which span the area underneath the pelvis. issues (an argument that has been refuted in many studies) and in increasing optimal outcomes for women of advanced maternal age having their first child. There is no mention in most, if not all, of these brief articles and press reports of the impact of labor management on either of the above-mentioned topics. The only true national data on cesarean delivery on maternal request stems from the second Listening to Mothers survey. Of the 1,574 women surveyed, only one woman said that she chose to plan her cesarean delivery, recognizing that there was no medical indication to do so. There were 480 cesareans in the group of 1574 women surveyed, equating to a 0.2 percent rate of cesarean delivery on maternal request. This is well below the 4-18 percent rate mentioned by the NIH convened panel. A number of the media reports did not even present the possible range indicated in the state-of-the-science statement, mentioning only the 18 percent patient choice statistic and, without any real science behind the statement, write that the numbers of cesarean delivery on maternal request is on the rise. There are a number of concerning issues and questions resulting from the release of this state-of-the-science statement: * Why did the panel feel it appropriate to release this document to the general public when the science behind the statement is so overwhelmingly weak? And what should we (the public) infer from the fact that there was a complete draft of the statement ready immediately following the conclusion of the conference? (Had they already reached their conclusions before hearing from the expert panel?) * Why was there no mention in the state-of-the-science statement of the second Listening to Mothers survey and the data regarding cesarean delivery on maternal choice when this information was presented during the conference? * Was the panel aware that the media would pick up on the release of this information and spin it to the public, emphasizing a false association between the rising cesarean section rate and elective cesarean delivery? * Will the media attention to cesarean delivery on maternal request create a self-fulfilling prophecy self-fulfilling prophecy, a concept developed by Robert K. Merton to explain how a belief or expectation, whether correct or not, affects the outcome of a situation or the way a person (or group) will behave. ? Childbirth Connections (formerly the Maternity Center Association), in its response to the NIH conference statement (NIH Cesarean Conference: Interpreting Meeting and Media Reports) writes: "A growing number of pregnant women, their caregivers and others are likely to believe that this [cesarean delivery on maternal request] is a notable and safe trend, and they may initiate maternal request cesareans as a result of this focus, further driving up the cesarean rates ... the continued misplaced mis·place tr.v. mis·placed, mis·plac·ing, mis·plac·es 1. a. To put into a wrong place: misplace punctuation in a sentence. b. focus on 'maternal request' cesareans draws attention away from the legal, clinical, financial and social factors that are playing a major role in the escalating cesarean rate. Although the verbal summary of the panel recommendations at the NIH conference underscored that it is not appropriate for health professionals to recommend cesarean section in the absence of a clear medical indication, the guidance was not included in the panel's written statement." Gene Declerq and Judy Norsigian, in their article titled, "Mothers aren't behind a vogue for cesareans" (Boston Globe, April 3, 2006), wrote "There is much we still don't know Don't know (DK, DKed) "Don't know the trade." A Street expression used whenever one party lacks knowledge of a trade or receives conflicting instructions from the other party. about the impact of cesarean or vaginal birth on health outcomes. What is clear, however, is that the growth in cesareans--which includes mothers of all ages, races and across all medical conditions--is the result of a complicated shift in professional practice that deserves careful scrutiny. It is not primarily about mothers pressuring doctors for cesareans, as contemporary media coverage would have us believe." What to do? As childbirth educators, doulas, midwives, and other supporters and promoters of normal birth, this is an essential time and opportunity to not only educate women and families on the importance of normal birth and cesarean prevention, but also to help the women and families in our care be able to understand and appropriately evaluate the abundant misinformation mis·in·form tr.v. mis·in·formed, mis·in·form·ing, mis·in·forms To provide with incorrect information. mis about cesarean delivery in circulation. That the NIH panel is releasing a state-of-the-science statement that has at its base a complete lack of high quality research and analyses, and that it is using this statement to guide policy-making pol·i·cy·mak·ing or pol·i·cy-mak·ing n. High-level development of policy, especially official government policy. adj. Of, relating to, or involving the making of high-level policy: , practice guidelines practice guidelines Medical practice A set of recommendations for Pt management that identifies a specific or range of range of management strategies. See Peer review organization, Practice standards. Cf 'Cookbook' medicine. , public education, and future research decisions is inappropriate, unprofessional and unfair. But nothing will happen to illuminate the problems inherent in this report or the media spin unless the consumers and birth professionals are willing to counter the media hype with their truth. Further Resources The complete NIH statement can be found at: www.consensus.nih.gov/2006/2006CSectionSOS027html. htm The Boston Globe article by Gene Declerq and Judy Norsigian can be found at: www.boston.com/news/globe/editorial_opinion/ oped/articles/2006/04/03/mothers_arent_behind_a_vogue_for_caesareans/ The Childbirth Connection posted an alert to help women, health professionals and others interpret the formal reports and media reporting from the NIH cesarean conference which can be found at: www.childbirthconnection.org/article.asp?ck=10087 There are many available resources for both birth professionals and those interested in supporting women-centered normal birth and addressing cesarean delivery on maternal request: www.acnm.org www.cfmidwifery.org www.childbirthconnection.org www.ican-online.org www.lamaze.org www.midwife.org Quality of Evidence Used in the Statement Maternal outcomes with moderate quality evidence favoring vaginal delivery () Hemorrhage () Maternal length of hospital stay Maternal outcomes with weak quality evidence favoring vaginal delivery () Infection () Anesthetic anesthetic Agent that produces a local or general loss of sensation, including pain, and therefore is useful in surgery and dentistry. General anesthesia induces loss of consciousness, most often using hydrocarbons (e.g. complication () Subsequent placenta previa Placenta Previa Definition Placenta previa is a condition that occurs during pregnancy when the placenta is abnormally placed, and partially or totally covers the cervix. () Breastfeeding Maternal outcomes with weak quality evidence favoring CDMR () Urinary incontinence Urinary Incontinence Definition Urinary incontinence is unintentional loss of urine that is sufficient enough in frequency and amount to cause physical and/or emotional distress in the person experiencing it. () Surgical and traumatic complications Maternal outcomes with weak quality evidence sensitive to parity and planned family size () Subsequent uterine rupture Uterine rupture is a potentially catastrophic event during childbirth by which the integrity of the myometrial wall is breached. In an incomplete rupture the peritoneum is still intact. () Hysterectomy hysterectomy (hĭstərĕk`təmē), surgical removal of the uterus. A hysterectomy may involve removal of the uterus only or additional removal of the cervix (base of the uterus), fallopian tubes (salpingectomy), and ovaries () Subsequent fertility Maternal outcomes with weak quality evidence that favor neither delivery route () Anorectal a·no·rec·tal adj. Relating to the anus and the rectum. anorectal pertaining to, emanating from or affecting the anorectum. anorectal abscess see perianal fistula. function () Sexual function () Pelvic organ prolapse prolapse Protrusion of an internal organ out of its normal place, usually of the rectum or uterus outside the body when supporting muscles weaken. The membrane lining the rectum can push out through the anus, most often in old people with constipation who strain during () Subsequent stillbirth () Maternal mortality Neonatal outcomes with moderate quality evidence favoring vaginal delivery () Respiratory morbidity Neonatal outcomes with weak quality evidence favoring vaginal delivery () latrogenic prematurity () Neonatal length of hospital stay Neonatal outcomes with weak quality evidence favoring CDMR () Fetal mortality () Intracranial hemorrhage, neonatal asphyxia asphyxia (ăsfĭk`sēə), deficiency of oxygen and excess of carbon dioxide in the blood and body tissues. Asphyxia, often referred to as suffocation, usually results from an interruption of breathing due to mechanical blockage of the , and encephalopathy encephalopathy /en·ceph·a·lop·a·thy/ (en-sef?ah-lop´ah-the) any degenerative brain disease. AIDS encephalopathy HIV e. anoxic encephalopathy hypoxic e. () Birth injury and laceration laceration /lac·er·a·tion/ (las?er-a´shun) 1. the act of tearing. 2. a torn, ragged, mangled wound. lac·er·a·tion n. 1. A jagged wound or cut. 2. () Neonatal infection By Randi Bigelow, Director of Childbirth Educator Training |
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