CMAJ • November 7, 2006; 175 (10). doi:10.1503/cmaj.1060106.
© 2006 CMA Media Inc. or its licensors
All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association.
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Letters

Not safer and not cheaper?

Michael Klein

Centre for Community Child Health Research, BC Child and Family Research, Institute, Vancouver, BC

Roberto Palencia and associates,1 in their analysis of the economic outcomes of the Term Breech Trial, report that planned cesarean birth is both safer and cheaper for breech fetuses than planned vaginal birth. However, the authors have analyzed only their early results, in which newborn outcomes favoured planned cesarean birth.2 They have not referred to their own results at 2-year follow-up, which showed no difference in outcome for the babies or the mothers,3,4 thus demonstrating the resilience of both the newborns and of the mothers' pelvic floor. In addition, in their economic analysis, Palencia and associates looked only at immediate costs, thus vastly underestimating the real costs of elective cesarean for breech or any birth. Since most women will have more than one birth, the presence of a uterine scar will expose women to increases in placenta previa and placenta acreta,5 ectopic pregnancy,6 abruption,5 infertility,7 stillbirth8 and excess hospital readmissions because of the cesarean9 and adhesion-related intestinal obstruction.10 All of these costs have been ignored.

This analysis led to headlines in the popular press that cesarean births are both safer and cheaper. This lack of nuance fuels societal views that increasingly suggest that cesarean section is just another way of giving birth; in addition, it undermines the confidence of a generation of women who are coming to believe that they cannot give birth without massive technological assistance.

REFERENCES

  1. Palencia R, Gafni A, Hannah ME, et al. The costs of planned cesarean versus planned vaginal birth in the Term Breech Trial. CMAJ 2006;174(8):1109-13.[Abstract/Free Full Text]
  2. Hannah M, Hannah W, Hewson S, et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomized multicentre trial. Lancet 2000;356:1375-83.[CrossRef][Medline]
  3. Hannah ME, Whyte H, Hannah WJ, et al. Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: the international randomized Term Breech Trial. Am J Obstet Gynecol 2004;191(3):917-27.[CrossRef][Medline]
  4. Whyte H, Hannah M, Saigal S, et al. Outcomes of children at 2 years after planned cesarean birth vs planned vaginal birth for breech presentation at term: the international randomized Term Breech Trial. Am J Obstet Gynecol 2004;191(3):864-71.[CrossRef][Medline]
  5. Lydon-Rochelle M, Holt VL, Easterling TR, et al. First-birth cesarean and placental abruption or previa at second birth(1). Obstet Gynecol 2001; 97(5 Pt 1):765-9.[CrossRef][Medline]
  6. Hemminki E, Merilainen J. Long-term effects of cesarean sections: ectopic pregnancies and placental problems. Am J Obstet Gynecol 1996;174(5):1569-74.[CrossRef][Medline]
  7. Hemminki E. Impact of caesarean section on future pregnancy – a review of cohort studies. Paediatr Perinat Epidemiol 1996;10(4):366-79.[Medline]
  8. Smith G, Pell J, Dobbie R. Cesarean section and risk of unexplained stillbirth in subsequent pregnancy. Lancet 2004;362:1779-84.
  9. Lydon-Rochelle M, Holt VL, Martin DP, et al. Association between method of delivery and maternal rehospitalization. JAMA 2000;283(18):2411-6.[Abstract/Free Full Text]
  10. Al-Took S, Platt R, Tulandi T. Adhesion-related small bowel obstruction after gynecologic operations. Am J Obstet Gynecol 1999;180(2):313-5. [CrossRef][Medline]



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Not safer and not cheaper?
Victoria M. Allen
CMAJ, 27 Nov 2006 [Full text]
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