Planned elective cesarean section: A reasonable choice for some women?

Dear Editor,

Mary Hannah’s commentary (CAMJ 170(5):813) seems to suggest that elective caesarean section is a reasonable choice for women. We wish to question her argument as there are several crucial areas which require critical analysis before we can define what is ‘reasonable’, namely: ethics, evidence and consumer choice. We also question the suggestion of this and another recent commentary (Ecker 2003) that a trial of routine section versus vaginal delivery is justified.

First, Hannah states that ‘a growing number of women are requesting delivery by caesarean section without an accepted “medical indication” and physicians are uncertain how to respond’. The view that the rising caesarean section rate is fuelled by consumer demand has taken hold strongly in the medical literature, the image presented of increasing numbers of women pressurising obstetricians to use their surgical skills. Where is the evidence for this, beyond the anecdotal accounts of some obstetricians based on encounters with small numbers of women? In the recent UK national caesarean section audit, the primary indication for an elective procedure in 7% of cases was maternal request, but this also included other clinical indications (Thomas and Paranjothy 2001). With a national planned c/s rate of 9.3% (DoH 2003), extrapolation of these data means that less than 1% of births in the UK are caesareans performed because of maternal request.

In a recent study of maternally requested c/s, one of us (JW) experienced considerable difficulty identifying women who requested the procedure without clinical indication. Furthermore, when interviewed, a proportion of these women reported previous traumatic experience and fear (for various reasons) and one could argue that there was a clinical, or perceived clinical, substrate to their request. Additionally, sometimes it was difficult to work out whether the woman had asked of her own volition or been guided in that direction by clinicians. In an earlier large- scale study to explore women’s expectations and experiences of childbirth, only one woman spontaneously expressed interest in c/s for non-clinical reasons, whilst many described disappointment with lack of continuing and sensitive support from professionals and experience of routinely medicalised births which were often very frightening (McCourt et al 1998; McCourt & Pearce 2000, Harper-Bulman & McCourt 2002).

Perhaps we should ask what influences and what shortcomings in the existing maternity services subsequently generate such requests from a minority of genuinely frightened or traumatised women. In a recent article Bewley and Cockburn (2002) ask why, given the fears that some women suffer, we are not focusing our efforts on ensuring that conditions to support a satisfactory and safe birth experience are met, using the considerable existing evidence to support us to achieve this.

In the light of these and other studies (Béhague 2002, Belizan et al 1999, Castro 1999), the ‘too posh to push’ headline of some British newspapers (Independent 26th October 2001) appears as a stereotype that represents the perspectives of a very small number of women in particular social worlds, which does no justice to the postnatal and longer-term experiences of women who do undergo c/s, a major surgical procedure. We should not be surprised if, in a technological society, where some high profile obstetricians advocate c/s or where the ability to ‘demand’ surgical birth is associated with wealth and status, if some women are beginning to view surgical birth as a better, safer, option. But is this really free and informed choice, even for that minority, when childbirth is being increasingly presented as highly risky and so little is being done to offer women the conditions and support that will enable them to give birth physiologically, without trauma and fear?

Second, and most importantly, ethically, justification for performing major surgery without a good indication requires weighing up the available evidence on the balance of risk and benefit. While the evidence is complex, there are robust studies suggesting that overall maternal mortality rate is three to seven times greater following caesarean birth than vaginal birth, and risk of major maternal morbidity is greater, even with elective caesarean when confounding factors are controlled for (Hall & Bewley 1999, Lilford et al. 1990; Lydon-Rochelle et al 2000). This alone should make proposed RCTs of primary elective section and vaginal birth unethical, as it could be argued that equipoise has been lost. It appears that increasingly in technologically ‘advanced’ societies, maternal death is no longer considered a serious issue – it may be rare, but no outcome could be more serious. This disregard was reflected in the tone of Hannah’s commentary, which treats decisions around childbirth as though they are simple matters of consumer choice.

The ethical reason is crucial, but if we set that aside we might ask – why not? Surely if we believe that physiological birth is safer than surgery, then a trial would simply confirm this? Surely this is a straightforward matter of evidence-based practice? We don’t think it’s that simple. The advocates of primary elective c/s argue that as a proportion of spontaneous labours will result in emergency c/s, one cannot compare rates of complications straightforwardly between vaginal and c/s birth. The limitations of this argument and the weight of existing evidence for the risks and benefits for mother and baby have been discussed in detail by Bewley and Cockburn (2002). Whilst we won’t repeat their arguments here, we are concerned that Hannah seeks to extrapolate findings from a trial with a high-risk group (women with breech babies) who experienced an emergency c/s rate of over 40% to a normal population. As Bewley and Cockburn (2002) argue, this is not only inappropriate use of evidence, but the study showed a significant, if small, increased risk of maternal death from elective c/s even in this high-risk group with a very high emergency c/s rate.

Given the problems in maternity service provision in the UK and elsewhere, a trial could not be sure to only include women with a reasonable chance of delivering ‘naturally’, since this depends strongly on the environment of birth and support available (Hodnett et al. 2004). There is a real danger that a trial, however pragmatic, could simply confirm and entrench an unsatisfactory status quo of over-medicalised birth – its results could appear technically correct but lack validity, in effect be ‘untruthful’ at a fundamental level. The gradual erosion of the environment conducive to most women having a physiological labour, means a high proportion of a potential ‘control’ group will end up with emergency operative delivery, or suffer other adverse outcomes as a consequence of often unnecessary intervention and compared with the totally medicalised ‘intervention’.

Its interesting too, that the language and tone of commentaries such as Hannah’s make physiological birth sound like a medical intervention just like any other, needing to be subject to rigorous testing before it is implemented, and to ‘normalise’ major medical interventions. As your previous respondent (Levesque) points out, physiological birth is the base point, not an intervention, and there is a great deal that we do not know, or are only recently learning about the complexity of that physiology and its outcomes.

While RCTs have great value as tests of interventions, they are not the only, or complete, answer to all research or clinical questions. There are alternative evidence sources that are available with less ethical or financial costs – such as epidemiological analysis of routine data across a range of countries. We already know that countries with high c/s rates do not ‘perform’ well in terms of mortality and morbidity rates when compared to countries with lower rates that are socio-economically similar. In a recent methodological study, reviewing a number of RCTs and other controlled studies, a leading UK researcher in EBP has also challenged the assumption that RCTs always provide superior or different evidence to other well designed studies (Britton et al. 1998)

To return to ethical issues, Hannah’s argument is unethical on a political economy basis in a context of limited and uneven distribution of health care resources. Economic analysis (Audit Commission, Petrou and Glazener 2002) have shown considerable excess cost of c/s. This means opportunity costs – other types of care, or care that may be required by other groups of women - may be restricted. Much of the care that would or could not be afforded in the scenario Hannah suggests, of consumer- style routine caesarean section involves low-cost, low technology forms of care, such as doula support, that have a very solid evidence base, and carry no known risks to women (Hodnett at al. 2004). Similarly, in a context of extremely limited research funds for important clinical research it would be unethical to spend the enormous funds that would be required to mount such a trial, since they would consequently not be available for other work.

Finally, we want to ask why trials are being proposed from various quarters, in whose interest, and why the ‘myth’ of maternal demand has taken such hold. It seems to us that the language and spirit behind the principles of women’s choice are being appropriated in quite cynical and sometimes misogynistic ways - women are typecast as silly things, afraid of pain or of childbirth, seeing c/s as an easy way out, or demanding women who put their own convenience or satisfaction above the needs or safety of their child, sometimes in wanting c/s, sometimes in wanting an alternative such as home birth. We are sure that this is not the intent in Hannah’s case, but we wonder if she is being naïve in not considering the wider social, cultural and political issues that might be at play. Hannah does not present the media-driven stereotype, and instead rightly argues that women’s choices should be taken seriously. We agree, but suggest instead that more research is needed to look at the ways in which the current provision and cultural context of maternity care is shaping and constraining the ‘reasonable’ choices that women can make.

Chris McCourt, Reader, Maternity, health and social science

Debra Bick, Professor of Midwifery and Women’s Health

Jane Weaver, Senior lecturer, Midwifery

Thames Valley University, London

Key references

Audit Commission. First class delivery: improving maternity services in England and Wales. Audit Commission. 1997:1-98..

Béhague D, Victora C, Barros F.,Consumer demand for caesarean sections in Brazil: informed decision making, patient choice, or social inequality? A population based birth cohort study linking ethnographic and epidemiological methods BMJ 2002;324:942 ( 20 April )

Belizan J, Althabe F, Barros F, Alezander S. Rates and implications of caesarean sections in Latin America: ecological study. BMJ 1999; 319: 1397-1402 and commentary: Castro A. Increase in caesarean sections may reflect medical control not women's choice.

Bewley S, Cockburn J. The unfacts of request caesarean section. BJOG: an international journal of obstetrics and gynaecology June 2002;109:597- 605.

Britton A, McKee M, Black N, McPherson K, Sanderson C, Bain C. Choosing between randomised and non-randomised studies: a systematic review. Health Technology Assessment 1998; Vol. 2: No. 13.

Department of Health UK Statistical Bulletin NHS Maternity Statistics, England: 2001-02 http://www.doh.gov.uk/public/sb0309.htm (accessed 05/09/03)

Ecker JL, Once a pregnancy, always a cesarean? Rationale and feasibility of a randomized controlled trial. American Journal of Obstetrics and Gynecology (2004) 190,314-8. (Clinical opinion)

Hall MH, Bewley S. Maternal mortality and mode of delivery. Lancet 1999;354:776.

Harper-Bulman K, McCourt C, Somali refugee women’s views and experiences of maternity care in West London. Critical Public Health. December 2002

Lilford RJ, van Coeverden de Groot HA, Moore PJ, Bingham P. The relative risks of caesarean section (intrapartum and elective) and vaginal delivery: a detailed analysis to exclude the effects of medical disorders and other acute pre-existing physiological disturbances. British Journal of Obstetrics and Gynaecology 1990;97:883-92.

Lydon-Rochelle M, Holt VL, Martin DP, Easterling TR. Association between method of delivery and maternal rehospitalization. JAMA 2000; 283: 2411-6.

McCourt C, Page L, Hewison J, Vail A. Evaluation of One-to-One Midwifery: Women's Responses to Care. Birth: 25 1998

McCourt C, Pearce, A. Does continuity of carer matter to women in minority ethnic groups? Midwifery 16(2): 145-154 (2000).

Murray S, Pradenas F. Health sector reform and rise of caesarean birth in Chile. Lancet 1997; 349: 64[Medline].

Paterson-Brown S. Should doctors perform an elective caesarean section on request? Yes, as long as the woman is fully informed. BMJ 1998;317:462-5.

Petrou S, Glazener C. (2002). The economic costs of alternative modes of delivery during the first two months postpartum: Results from a Scottish observational study. British Journal of Obstetrics and Gynaecology, 109 (2): 214 – 217.

Sargent C, Stark N. Surgical birth: interpretations of cesarean delivery among private hospital patients and nursing staff. Soc Sci Med 1987; 25: 1269-1276

Thomas J, Paranjothy S. (2001). RCOG Clinical Effectiveness Support Unit. The National Sentinel Caesearen Section Audit Report. London. RCOG Press.

Weaver J personal communication – report on the study will be forthcoming later in 2004.

Conflict of Interest:

None declared

It is perhaps useful to categorize the various responses that are sure to arise as a result of Dr. Hannah's opinion piece, and the current debate regarding on-demand cesarean sections, using Beauchamp and Childress' 4 principles of medical ethics (Ref.: Beauchamp, Tom L. and James F. Childress. Principles of Biomedical Ethics. 4th ed. New York: Oxford University Press, 1994. Analysis, defense, and applications of principles of autonomy, non-maleficence, beneficence, and justice.) There will be those that cite concerns regarding non-maleficience by pointing out the increased morbidity and mortality associated with c-sections. Others will actually argue that c-sections can reduce certain morbidities (e.g. urinary or fecal incontinence) and under certain limited circumstances (e.g. breech presentation), can reduce mortality. These individuals will be citing, sometimes out of context, the issue of beneficience. Unfortunately, there will always be trials to support one or the other viewpoint. Then there will be those that beat the drum of autonomy, deferring to the principle of free choice for the fully informed patient. But how can one fully inform a patient about an elective procedure with an almost limitless combination of possible complications?

What will perhaps be less obvious is the principle of justice, on several levels. How does one justify an arguably superfluous procedure for the few, funded by the ailing many? How will these procedures affect other, more urgent operations? And perhaps most importantly in a system still marked by lack of access due to geographical and socioeconomic considerations, who will ensure that all individuals will have equal access to these procedures? Who will ensure that any possible attributes of beneficience and autonomy will still apply to a woman on the fringes of our society or with no easy access to specialist care?

These are the questions that perhaps should be troubling us the most. And the issues that will ultimately quell the current interest surrounding on-demand cesarians in our public, and just, health care system.

David Ponka, MD, CCFP Director of Family Medicine Weeneebayko General Hospital PO Box 34 Moose Factory, ON P0L 1W0 Tel (705) 658-4544 Fax (705) 658-5877

Conflict of Interest:

None declared

To the Editor: I apologize for the somewhat muddled third paragraph of my letter and wish to elaborate. Dr. Hannah states that cesarean section can be a safer alternative for the fetus/newborn. This is true for certain entities. For example--see references in my first letter, one can prevent one subarchnoid hemorrhage for every approximately 7000 cesareans and one brachial plexus injury for about every 2200 births (most will be temporary)as shoulder dystocia is almost only associated with vaginal birth. One the other side of the equasion, however, for every 333 cesareans one will cause a significant newborn feeding problem. For every 69 cesarean sections one will cause a respiratory problem in the newborn,largely transient tachypnea of the newborn, which while transient will result in separation of the newborn from the mother. And for every 317 cesareans one will cause one newborn to be so sick as to require a respirator for more than 24 hours. Unpublished data from Canada my look slightly better, probably due to our universal health care system. Clearly, women who request pre-emptive cesarean sections are not likely to have this kind of detail presented. But if not, informed consent is a sham.

Michael C. Klein Emeritus Professor of Family Practice and Pediatrics Head Division of Maternity and Newborn Care Department of Famiy Practice, UBC

Conflict of Interest:

None declared

Mary Hannah's opinion piece arrives at a time when more than ever women are losing confidence in the ability of their bodies to birth vaginally. To even suggest possible equivalence of maternal or newborn outcome for cesarean and vaginal birth in the face of a wealth of confusing information in the literature is to further contribute to an epidemic of fear of vaginal childbirth and of course a rise in cesarean section. Dr. Hannah suggests that the only real way to answer the question is an RCT. Who would join such a trial? Do we imagine that women could be found who are in enough equipoise re vaginal versus cesarean to join such a trial. And if they could be found, could they be representative enough so that any generalizations could be made?

Dr. Hannah reviews the literature on maternal mortality and concludes as most others have, that cesarean is more dangerous in current and future pregnancies, but then she goes on talk about pelvic floor issues, concluding that the risk of urinary incontinence (UI) is higher for vaginal births. Most of the studies of UI are flawed by follow-up that is limited to 3-6 months (1-6) and fail to specify the difference between trivial UI and UI important enough to wear a pad. Moreover, few ask women if it interferes with their quality of life.(7,8) Population-based studies report either no difference in UI by route of birth(9)or a baseline rate of UI that is high and only somewhat improved by cesarean compared with vaginal birth(10)And UI is high even in nuns.(11) Hence there are many factors that contribute to UI, and the role of pregnancy and birth needs much more exploration. Rather than promote cesarean section as a means of avoiding perineal and pelvic floor issues, we need to concentrate on how we can employ non-surgical and life-style improvement to prevent this important problem.

Dr. Hannah suggests that elective cesarean may benefit the fetus, reducing stillbirth and a few other outcomes. But such a discussion needs detail, including the adverse fetal respiratory outcomes and how many cesareans would be necessary to achieve these desired outcomes (between 80 and 400 depending on the outcome).(11-13) Is this likely to be a part of the informed consent process advocated?

Dr. Hannah muses that conventional birth in our contemporary hospital settings: inductions, long labors, continuous electronic fetal heart monitoring, augmentation, epidurals, forceps, episiotomy, multiple caregivers can hardly be considered "natural." Good point! But who is responsible for this unnatural environment? Dr. Hannah's own study on post-term pregnancy(14)is the bedrock upon which our current epidemic of post-term inductions is based--leading in our institution among first births to a cesarean section rate in excess of 40% compared to about 8% for those in spontaneous labour. From Dr. Hannah's work and the work of others, it may take between 500 and 2000 post-term inductions to avoid one stillbirth. And in the process, a "cascade" of accepted "side-effects" ensue, exposing the mother to excess morbidity and mortality for herself. This needs fixing but cesarean is not the appropriate repair.

Dr. Hannah uses her Term-Breech trial to make the point that cesarean section is preferable to vaginal birth for mother and baby. It is not appropriate for any purpose to extrapolate to a normal population of women whose fetuses are in vertex position, data from a complex population of women whose fetus are in breech position.

While Dr. Hannah supports informed choice and decision-making, the process of doing this well is passed over. How long does it take to cover the complex and often ambiguous literature about maternal and newborn morbidity and mortality, bowel, bladder and sexual functioning--as well as the joy, power and transformative nature of vaginal birth? It is likely to take in excess of an hour. And the person doing the informing, usually the surgeon who will do the operation, serves to benefit by gaining some control over an otherwise difficult and unpredictable professional life. There is obvious conflict of interest that must be acknowledged. And if consent does not cover all this detail, as well as a sensitive exploration of the requesting woman's values, fears and hopes, informed consent will not have occurred.

To appropriate the word "choice" and to encourage elective cesarean section as a normal decision and a woman's "right" in today's chaotic and industrialized birth environment, is unjustified. Better for us all to work on improving the environment that has caused the issue to even be considered. This means providing women with all the support that they need, making doula care the norm, reserving birth technology for those that need it, reconsidering the role of induction timing and fetal surveillance for the post-dates fetus and making birth truly woman- centered rather than professional and institution centered.

Michael C. Klein Professor Emeritus Family Practice and Pediatrics Head Division of Maternity and Newborn Care Department of Family Practice University of British Columbia

References: 1.Dimpfl, T., U. Hesse, and B. Schussler, Incidence and cause of postpartum urinary stress incontinence. European Journal of Obstetrics & Gynecology and Reproductive Biology, 1992. 43: p. 29-33. 2.Viktrup, L., et al., The frequency of urinary symptoms during pregnancy and puerperium in the primipara. International Urogynecology Journal, 1993. 4: p27-30. 3.Wilson, P.D., R.M. Herbison, and G.P. Herbison, Obstetrics practice and the prevalence of urinary incontinence three months after delivery. British Journal of Obstetrics and Gynaecology, 1996. 103: p. 154-61. 4.Meyer, S., et al., The effect of birth on urinary continence mechanisms and other pelvic-floor characteristics. Obstetrics & Gynecology, 1998. 92:613-8. 5.Chaliha, C., et al., Antenatal prediction of postpartum urinary and fecal incontinence. Obstetrics & Gynecology, 1999. 94: p. 689-93. 6.Farrell, S.A., V.M. Allen, and T.F. Baskett, Parturition and urinary incontinence in primiparas. Obstet Gynecol, 2001. 97(3): p. 350-6. 7.Brown, S. and J. Lumley, Maternal health after childbirth: results of an Australian population based survey. Br J Obstet Gynaecol, 1998. 105(2): p. 156-61. 8.Lydon-Rochelle, M.T., V.L. Holt, and D.P. Martin, Delivery method and self-reported postpartum general health status among primiparous women. Paediatr Perinat Epidemiol, 2001. 15(3): p. 232-40 9.MacLennan, A.H., et al., The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. British Journal of Obstetrics and Gynaecology, 2000. 107: p. 1460-70. 10.Rortveit, G., et al., Urinary incontinence after vaginal delivery or cesarean section. N Engl J Med, 2003. 348(10): p. 900-7. 11.Buchsbaum, G.M., et al., Prevalence of urinary incontinence and associated risk factors in a cohort of nuns. Obstet Gynecol, 2002. 100(2): p. 226-9. 10.Dublin, S., et al., Maternal and neonatal outcomes after induction of labor without an identified indication. Am J Obstet Gynecol, 2000. 183(4): p. 986-94. 11.Levine, E.M., et al., Mode of delivery and risk of respiratory diseases in newborns. Obstet Gynecol, 2001. 97(3): p. 439-42. 12.Morrison, J.J., J.M. Rennie, and P.J. Milton, Neonatal respiratory morbidity and mode of delivery at term: influence of timing of elective caesarean section. Br J Obstet Gynaecol, 1995. 102(2): p. 101-6. 13.Parilla, B.V., et al., Iatrogenic respiratory distress syndrome following elective repeat cesarean delivery. Obstet Gynecol, 1993. 81(3): p. 392-5. 14.Hannah, ME et al., Induction of labor as compared with serial antenatal monitoring in post-term pregnancy. A randomized controlled trial. The Canadian Multicenter Post-term Pregnancy Trial Group. N Engl J Med 1992;326:1587-92

Conflict of Interest:

None declared

To The Editor of the CMAJ

It was with utter dismay and surprise that I read the article “Planned elective caesarian section: A reasonable choice for some women?” written by Dr Mary Hannah. In this day and age, we as a medical profession are trying to practice evidence-based medicine and those of us working in teaching centres are aggressively encouraging this approach by our learners. Since there has never been any scientific proof of benefit from unindicated surgery, how can one use the literature for indicated procedures to justify our willingness to acquiesce to wishes of the consumer? Just because indicated procedures have low rates of complication and appear safe does not allow us to use that literature to bend to the current trends in consumerism. Are we so afraid of disappointing the consumer that we will perform these unnecessary procedures? I find it rather hypocritical that we allow ourselves to recommend this by misusing and contorting literature to justify our position and then to turn around and call ourselves scientists practicing evidenced based medicine. Am I the only one who sees conflicting principles here??? If we want to practice cosmetic surgery then by all means do so and bill the patient for these services independently. Are provincial health plans going to cover these cosmetic procedures when most don't cover other cosmetic surgeries? Soon enough I expect that a lawyer will find grounds to launch litigation for the complications encountered by a patient when the procedure had no scientifically supportable justification. The legal justification for the lawsuit will undoubtedly be that the patient truly did not appreciate the risks and that we as a medical professional did not clearly identify the risks. Keep in mind that ANY complication of an unnecessary surgical procedure is unnecessary. Sincerely, John R Fernandes MDCM FRCSC FRCPC Assistant Professor Department of Pathology and Molecular Medicine Forensic Pathologist (and Obstetrician/gynaecologist) Hamilton Health Sciences Centre McMaster University

Conflict of Interest:

None declared

After analyzing what she considers the pros and cons of planned elective caesarean delivery versus natural vaginal birth, Dr. Hannah concludes “…if a woman without an accepted medical indication requests delivery by elective caesarean section and, after a thorough discussion about the risks and benefits, continues to perceive that the benefits to her and her child of a planned elective caesarean outweigh the risks, then most likely the overall health and welfare of the woman will be promoted by supporting her request.”[i]

The big question revolves around what can be assumed to be essential to fully informed consent. Alas, it seems to me that we only see what we want to see. Do arguments based on known comparative mortality, short term morbidity or anticipated long term morbidity for women (ie: urinary incontinence) describe the whole picture? The actual debate falls short of encompassing the full reality of the complex and incompletely understood nature of the birth phenomenon.

It took millions of years for Nature to build things as they are. As health care providers, our duty is to maintain, or restore as best as we can, the physiological functions of our patients. In doing so, we should a priori respect the plans of Nature assuming, as Aristotle stated, that: “Nature does nothing in vain.” During pregnancy, labor, birth and the immediate postnatal period, a complex array of events takes place to allow the harmonious construction and survival of a new human being. The immediate postnatal period can be best described as a factual extension of pregnancy as the child is totally dependent on the care of his/her mother. To make sure that mother and child function as a true biological unit, Nature laid down specific mechanisms supported by a complex mixture of hormones like oxytocin, neurotransmitters like endorphins or opioids and neural pathways to functionally tighten the bond. When asked about their birthing experience, women who had a C-section often mention they feel as if “something is missing”. What is it thats missing? Maybe part of the answer lies in the regulation of affiliation relations with the newborn. As demonstrated by Nissen et al., a natural flow of oxytocin occurs in the mother’s blood, and presumably in the brain also, during the first post partum hour.[ii] Oxytocin is best described as the “hormone of love” as it provokes a nurturing drive in animals and humans. This surge of oxytocin seems to be blurred in the breastfeeding mother who has had a surgical delivery.[iii] Furthermore, many studies show that caesarean section disrupts the proximity between mother and child and delays breastfeeding. Does this really matter? You bet it does.

Let’s take an example. Man is a social animal and as such, the cohesion of human society relies on appropriate relationships between individuals. During the very first few months of his/her life, the infant child learns to interact with others in his/her mother’s arms. Is there a difference as far as socialization of the child is concerned between those born by caesarean and by natural birth? The answer seems to be yes. Rowe- Murray and Fisher studied the influence of the mode of delivery on early mother-infant interactions. They found that operative delivery had a significantly adverse effect on the mother’s mind that persisted at least eight months into the postnatal period. They wrote: “… since the mother so clearly frames the infant’s world, it is plain that her emotional state will be of importance to the infant’s optimal development even at this early stage of life.”[iv] What happens at the time of initiation of labor and during the birth process? The placenta is a neuroendocrine organ as it produces neurohormones that act on the brains of both the mother and foetus. Florio P et al. showed that there are differences in the levels of chromogranin A, inhibin A and inhibin B in the maternal and cord blood in relation to the mode of delivery.[v],[vi] Facchinetti F et al. showed a higher concentration of plasma opioids during the first day of life in the child born vaginally as compared to the child born by cesarean delivery.[vii] What’s the function of these substances? We don’t yet know, but it surely matters, otherwise, why did Nature make them? In a meta- analysis published in 1996, DiMatteo et al, looked at 23 psychological outcomes of childbirth and found significant differences in “affiliative” behaviour between mothers who delivered vaginally and by caesarean section.[viii] Just to say that vaginal birth seems to be different from caesarean birth ; mothers are not the same, babies are not the same.

Unfortunately, science took a long time to address these “social” and clinically non- appealing issues and we are just beginning to discover this new world opening before us. Our serious lack of knowledge in these fields should make experts careful about the potentially harmful consequences of apparently well-meaning but inappropriate guidelines on this topic. There is no question about the appropriate performance of medically justified C-sections. Nature is not perfect and sometimes needs a helping hand. But a planned elective caesarean delivery constitutes an intervention in a natural event which, in most cases, would have occurred without complication. At the moment, the few pieces we have do not permit us to perceive the whole puzzle. What are the risks of planned elective caesarean delivery on the most meaningful human qualities ; compassion, nurturing, care of others ? What are the repercussions of this disruption of the evolutionary planned natural mode of delivery on individuals, families, societies and humanity? Who can seriously pretend that these questions are trivial at a time when the C-section rates in our country have reached an unequalled high; implying that more and more women give birth today without displaying the “cocktail of love hormones” planned over time by Nature ? We are just reaching the end of a long and heartrending debate between breastfeeding and artificial feeding for the child which has shown that man’s intervention isn’t always welcome in natural process. Are we now starting a new, upsetting intervention only to discover in the near future that it wasn’t the best for humanity? Specific studies are urgently needed on the impact of the mode of delivery on the development of the child and, entering the anticipated era of planned elective caesarean section, this should become a public health priority.

The real questions are: Can we reasonably present the elective planned caesarean section as equivalent or as a safe alternative to natural, vaginal birth ? Do we know enough to provide sufficient information to our patients to allow them to make the best choice for themselves and their children? Until we can be confident in our answers, it seems to me that the Precautionary Principle must fully apply.

Pierre Lévesque MD

Obtetrician-Gynecologist

Rimouski, Qc

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[i] Hannah ME

Planned elective cesarean section : A reasonable choice for some women ?

CMAJ 2004; 170: 813-814

[ii] Nissen G, et al.

Elevation of oxytocin levels early post partum in women

Acta Paediatr 1994; 83: 29-32

[iii] Nissen K, et al.

Different patterns of oxytocin, prolactin but not cortisol release during breastfeeding in women delivered by Caesarean section or by the vaginal route

Early Human Dev 1996; 45: 103-108

[iv] Rowe-Murray HJ, Fisher JR

Operative intervention in delivery is associated with compromised early mother-infant interaction

BJOG 2001; 108: 1068-1075

[v] Florio P, et al.

High levels of human chromogranin A in umbilical cord plasma and amniotic fluid at parturition

J Soc Gynecol Investig 2002; 9: 32-36

[vi] Florio P, et al.

Activin A, inhibin A, inhibin B and parturition : changes of maternal and cord serum levels according to the mode of delivery

BJOG 2000; 107: 704-705

[vii] Facchinetti F, et al.

Plasma opioids in the newborn in relation to the mode of delivery

Gynecol Obstet Invest 1986; 21: 6-11

[viii] DiMatteo MR, et al.

Cesarean childbirth and psychosocial outcomes : a meta-analysis

Health Psychol 1996; 15: 303-314

Conflict of Interest:

None declared

I was extremely disturbed to read the story outlining the possibility of the SOGC supporting the option of medically unnecessary c-sections. While I agree that I women should have the right to choose the course of care that suits her situation the best, I am very disappointed that this option would be offered while little consideration is given to options at the other end of the spectrum.

Proponents of c-section on demand contend that a patient has the right to choose their course of care. While this is entirely true, the fact remains that this has historically not been the case. Personally I was denied my choice of a VBAC by three different physicians. My choice then was to give birth under the care of a midwife, a choice that the Alberta government forced me to pay for. If women are given the option to choose a c-section, when medically unnecessary, they should have to pay for thier course of care in the same fashion. It is an outrage that c- section on demand (a medically unnecessary, costly procedure) is covered by Alberta health care while midwifery (a proven, safe, economical option) continues to be excluded.

If the SOGC and CMA truly want to allow women to choose their course of maternity care they have to fully support and champion the entire range of options available. This includes unmedicated physiologic birth attended by a midwife. If you are concerned about patient's choice, work to ensure that we ALL have access to the services we choose.

Conflict of Interest:

None declared