Cesarean trends
===============

* Gabriel M. Leung
* Tai-Hing Lam
* Lai-Ming Ho
* Thuan Q. Thach

In commenting on the study by Eason and colleagues1 Scott Farrell appears to have inferred from their findings that there is support for elective cesarean birth as a way of reducing the risk of anal incontinence after vaginal delivery.2 We disagree with his interpretation. Furthermore, from a public-health perspective this line of argument is alarming. 

Eason and coworkers showed a cumulative incidence of fecal (3.1%) and flatal (25.5%) incontinence. However, these figures include the category “less than once weekly” — a category of dubious clinical significance and, likely, one associated with little disruption to quality of life. 

Nonetheless, we agree with Farrell that obstetricians and mothers should take an explicit risk–benefit approach when discussing the option of cesarean delivery. We recently studied 8327 consecutive births by women resident in Hong Kong. We found that cesarean section compared to normal vaginal delivery was a risk factor for not initiating breast-feeding (adjusted odds ratio [OR] 1.52, 95% confidence interval [CI] 1.34–1.73) and for breast-feeding less than 1 month (OR 1.25, 95% CI 1.00–1.56), and remained a significant hazard against total breast-feeding duration (hazards ratio [HR] 1.16, 95% CI 1.04–1.30).3 Although it is generally recognized that most mothers recover from birth-related pelvic injury within months of giving birth, the adverse health and developmental effects for infants due to low breast-feeding rates persist well into childhood and adolescence.4

The global epidemic of cesarean section is a matter deserving international attention. For instance, Hong Kong's caesarean section rate rose rapidly from 22% in 1993 to 27.4% in 1999, benchmarked against the WHO's recommended upper limit of 15%.5 We must not allow the upward trend to continue, certainly not based on inappropriate extrapolation and interpretation of data collected for another purpose.

**Gabriel M. Leung** Clinical Assistant Professor **Tai-Hing Lam** Chair Professor and Head **Lai-Ming Ho** Computer Officer **Thuan Q. Thach** Statistician University of Hong Kong Medical Centre Hong Kong 

## References

1.  1. Farrell SA. Cesarean section versus forceps- assisted vaginal birth: It's time to include pelvic injury in the risk–benefit equation. CMAJ 2002; 166 (3):337-8.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxNjYvMy8zMzciO3M6NDoiYXRvbSI7czoyMjoiL2NtYWovMTY3LzIvMTI0LjEuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

2.  2. Eason E, Labrecque M, Marcoux, Mondor M. Anal incontinence after childbirth. CMAJ 2002; 166(3):326-30.
    
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5.  5. Leung GM, Lam TH, Thach TQ, Wan S, Ho LM. Rates of cesarean births in Hong Kong: 1987-1999. Birth 2001;28:166-72.
    
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