The pros and cons of Caesarean section

Profiled as the smartest way to have a baby, and promoted as guaranteeing muscle tone in a critical zone, Caesarean section is increasingly being touted by all comers as yet another option in childbirth.

But should we demand that doctors perform more of them, as a matter of policy? Gene Kerrigan, writing recently in the Sunday Independent, wonders whether doctors should not be more willing to cut babies out. He has called for a public debate on this issue, forgetting that medical practice is supposed to be based on evidence, not on public opinion.

With almost one in four Irish babies being delivered by Caesarean, one would think this operation was already sufficiently common. And, with the recent introduction of Caesarean tax breaks, it looks as though the State is already doing its bit to promote what is, after all, a major operation.

Kerrigan suggests that if more Caesareans were performed, fewer babies would, or might, be lost. He cites a recent article in a British medical journal which looked at Caesarean rates in the three main Dublin maternity hospitals. Perinatal death rates declined from 1979-2000, and Caesarean section rates rose.

The authors’ argument, and it is a spurious one, is that this statistical correlation, because it is consistent, must be meaningful.

But to suggest that, because one graph goes up and another comes down, this actually means anything is a bridge too far.

When two events are associated often enough, such as smoke and fire, it is tempting to conclude that one causes the other. In some areas, for example, birth rates vary according to the size of the stork population.

In the period immediately following the Second World War, to take another example, the sale of nylon stockings rose, as did deaths from lung cancer.

To have a Caesarean section is to undergo major abdominal surgery. A recent Cambridge study indicates that women are unaware of the risks, especially to the baby. According to our own Institute of Obstetricians and Gynaecologists, Caesareans are a leading cause of medical litigation in this country.

The assumption seems to be that Caesarean is safe, as safe as the alternative, namely, normal birth. But death rates from planned, Caesareans suggest otherwise. An analysis of the deaths of women in childbirth in England and Wales showed that the death rate in non-emergency Caesareans was 4.5 times higher than that of vaginal birth.

In 1999, the death took place in a Dublin maternity hospital of a 34-year-old woman described as having "no risk factors other than a Caesarean section". She died from a cardiac arrest, after developing a clot in her lung.

There is plenty of evidence to show that mothers who have had this surgery tend to be ill more frequently than those who have not. Research shows that Caesarean mothers are 5-10 times more likely to be ill than mothers who have given birth to their babies themselves.

Kerrigan does not acknowledge any increased risk to the mother. Indeed, the only risk he mentions is the risk to the baby of respiratory problems. But there is another serious risk to the baby and that is the risk of prematurity. Premature babies are at greater risk of dying than full-term infants. Babies can also suffer lacerations during surgery, and some do.

Moreover, having a Caesarean requires an anaesthetic, and anaesthetics are not risk-free, for either mother or baby. Research shows that 60 per cent of Caesarean deaths are associated with anaesthetic complications.

Caesarean advocates should remember that giving an epidural, for example, is a highly skilled procedure. There is very slight risk of paralysis; the magnitude of the risk depends on the anaesthetist’s skill and experience. A small number of cases of paralysis have occurred and one such case was reported in a Dublin maternity hospital as recently as 2001.

Epidurals also carry a slight of "dural tap" which can result in severe headaches. Dural taps occur when the needle punctures the dura or protective covering around the spinal cord, causing the surrounding liquid to leak out.

Do epidurals cross the placenta? This is disputed, but some studies show that epidural babies tend to sleep more after birth, to be less alert to their surroundings and to have more feeding problems than infants who have not been subjected to these drugs.

The alternative to an epidural or a spinal is a general anaesthetic. But this is no better: babies born under general anaesthetic are more likely to have breathing difficulties at birth, to need intensive resuscitation and to be admitted to intensive care. Mothers may suffer nausea. Some suffer psychologically, feeling deprived of the experience of giving birth. Contact between mother and baby is generally restricted for the first 24 hours, and many mothers suffer as a result. Post-operative pain makes breast-feeding more difficult, and decreased mobility is another given.

But one way or another, Caesarean babies are much more likely to have breathing difficulties, as the hormonal changes that occur in the baby's lungs during normal labour do not take place. Full-term, normal weight Caesarean babies are often admitted to intensive care for what is called "transient tachapnoea of the newborn".

A 1995 Cambridge study of over 33,000 births showed that the incidence of breathing difficulties in scheduled Caesarean babies - whose mothers had not undergone labour - was seven times higher than in naturally born babies.

Caesarean poses more dangers for mothers than for babies, however. Urine, chest, breast, wound and womb infections have all been reported following the operation. Today, the risks posed by hospital infections have increased. With the advent of superbugs, no hospital is likely to be free of MRSA. In addition, the changing profile of infections in Irish maternity units means that open womb surgery, as Caesarean has been described, has become somewhat more perillous. Maternity units now harbour a range of infectious diseases such as Group B streptococcus, (which can be fatal to newborns), hepatitis B, tuberculosis, syphilis, and HIV, as well as hepatitis C, which is an increasing problem in Dublin maternity hospitals.

In a recent study of 2, 647 Caesarean women, the overall rate of complications during the operation was 15 per cent. Lacerations to the womb and bleeding were the most common complications. The overall sickness rate among these mothers was 36 per cent. One in four developed a fever, and some lost a litre of blood or more, while four per cent developed a subcutaneous swelling of clotted blood, and 3 per cent got a urinary tract infection.

As if all of this wasn’t bad enough, there is evidence that a history of Caesarean puts the mother at risk in a subsequent pregnancy or birth. Placenta praevia, where the placenta separates from the wall of the womb, is a potentially serious complication of pregnancy, as is placenta accreta, where the placenta sticks to the uterus. Both are recognised as potential hazards in a pregnancy following Caesarean section; either may lead to serious haemorrhaging during birth, which may require a Caesarean hysterectomy, a a procedure generally performed as a last resort to save the mother’s life.

Two years ago in a Dublin hospital, an otherwise healthy mother died at the age of 30, following a planned Caesarean section for placenta praevia; she had had a Caesarean on her first child for "failure to progress" in labour. She died in theatre following a cardiac arrest.

There is no evidence to support the notion that Caesarean is better than vaginal birth - for mothers or their babies - and plenty to show that it is worse. As for the view that Caesarean saves lives, we will have to await proof. Right now, we don’t have it.

In Dublin, the density of TV aerials correlated strongly with infant mortality, not because television was lethal to babies, but because the clustering of aerials reflected poor housing, overcrowding and poverty. Could greater wealth not be the reason why perinatal deaths have dropped in the Dublin hospitals over the past 22 years? Wealth is health, after all.

©Marie O’Connor
Northern Standard on 8 May 2003

© National Birth Alliance An Chomhghuallaiocht Naisiunta Breithe