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Multicentre study on risks and benefits of caesarean delivery, Latin America.

A multicentre, prospective study assessing the risks and benefits associated with caesarean delivery, compared with vaginal delivery, prompted a large number of rapid responses on the BMJ website. The study, part of the 2005 WHO global survey on maternal and perinatal health, examined data from nearly 97,000 deliveries during a three-month period in 120 facilities from 24 areas in eight Latin American countries (all randomly-selected). Women undergoing caesarean deliveries, either intrapartum or elective, had double the risk for severe maternal morbidity and mortality, and up to five times the risk of post-partum infection compared with vaginal delivery. Although caesarean section has a slightly reduced risk of fetal death at birth, with cephalic presentation it is significantly associated with an increase in severe neonatal morbidity and mortality, independent of fetal distress and gestational age. With breech presentation, caesarean delivery substantially reduces risks to the baby. Any net benefit from the liberal use of caesarean delivery remains to be demonstrated, with the exception of fewer severe vaginal complications after birth and better fetal outcomes among breech presentations. It is also more expensive. (1) However, because of the complex nature of decisions about mode of birth and the uncertainty about outcomes, randomised controlled trials are unlikely to provide definitive answers about which mode of birth is best for a particular woman. Future work should help to establish a consistent set of probabilities for a range of outcomes, according to risk factors, to inform women's decisions. (2) One response argues that a large, prospective, long-term study is needed to compare outcomes for women without absolute indications for caesarean who plan to give birth by caesarean versus those who plan to give birth vaginally. Another response points out that we should be trying to avoid the two most damaging delivery methods in terms of maternal mental health--emergency caesareans and traumatic vaginal deliveries. (3)

(1.) Villar J, Carroli G, Zavaleta N, et al. Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study. BMJ 2007;335:1025-29.

(2.) Shorten A. Maternal and neonatal effects of caesarean section: more accurate estimates of benefits and harms are needed to support informed childbirth choices. BMJ 2007;335:1003-04.

(3.) Davies S. Caesarean section: points raised in responses. BMJ 2007;335:1226.
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Title Annotation:ROUND UP: Maternal Mortality
Publication:Reproductive Health Matters
Article Type:Clinical report
Geographic Code:0LATI
Date:May 1, 2008
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