Monday, January 01, 2007

What Do Physicians Think of On-Demand C-Section?

The "Green Journal" has a lot of interesting articles for January 2007. Among them:

Bettes BA, Coleman VH, Zinberg S, Spong CY, Portnoy B, DeVoto E, Schulkin J. Cesarean delivery on maternal request: obstetrician-gynecologists' knowledge, perception, and practice patterns. Obstet Gynecol. 2007 Jan; 109(1):57-66.
ACOG Fellows (practicing OB/GYNs who are part of a national obstetrics and gynecology organization) were interviewed by mailed questionnaire about elective c-sections. Their findings:
-92.2% reported that their department or practice has no policy on maternal request cesareans. Of those with a policy, 72.2% stated the policy is to support maternal requests.
-53% reported having done c-sections in response to maternal request, "with the majority of those performing them once or twice per month or more rarely"
-58.4% reported an increase in maternal requests for c-sections in the past year.
-When asked about what they would choose if they or their spouse were pregnant (for a term, uncomplicated, head first, single delivery), "Fewer than 20% (n=102, 17.8%) of respondents reported that they would choose or recommend a cesarean delivery on maternal request in this situation, due to concerns for the mother’s (64.8%) or the neonate’s (19.4%) well-being; 15.7% would choose cesarean delivery on maternal request for convenience."
-54.6% believe a woman has the right to c-section on request without any medical indication, and 57.4% would perform one. Those who believed it was a right/appropriate were more likely to say they would perform one.
-The clinicians were asked to agree or disagree with 14 risks and 14 benefits. 0.8% endorsed none of the risks, while 11.8% endorsed none of the benefits.
-"The most frequently endorsed benefit was the reduced risk of perineal damage (76.2%), followed by risk of dystocia or birth trauma (63.4%), pelvic organ prolapse (56.8%), long-term incontinence (54.8%), lacerations (53.9%), and complications from labor (49.6%). "
-"The most frequently endorsed risk was intraoperative risks to the mother such as bleeding and damage to internal organs (93.7%). "
-Female respondants were more negative about the procedure on maternal request than were male respondants.

The article does not include a detailed comparison of the clinician's perception of risk and benefit versus the incidence of these occurances and outcomes in the medical evidence. It would be interesting to see how correct the physicians are in their assessments of risk and benefit. Given the varying percentages, it is clear that not all physicians agree on the risks and benefits of the procedure, and many do not think they should be available on request where there is no medical indication. I think a lot of women tend to take "My doctor says" as some kind of gospel, not realizing that there may be considerable debate about a topic. Something to consider when consulting with your physician about this - he or she may not agree with the doctor just next door.

The National Intitutes of Health held a conference on the topic in spring of 2006, and released a statement, downloadable as a PDF. An Agency for Healthcare Research and Quality abstract on the topic states, "Virtually no studies exist on CDMR, so the knowledge base rests chiefly on indirect evidence from proxies possessing unique and significant limitations. Furthermore, most studies compared outcomes by actual routes of delivery, resulting in great uncertainty as to their relevance to planned routes of delivery. Primary CDMR and planned vaginal delivery likely do differ with respect to individual outcomes for either mothers or infants. However, our comprehensive assessment, across many different outcomes, suggests that no major differences exist between primary CDMR and planned vaginal delivery, but the evidence is too weak to conclude definitively that differences are completely absent." Essentially, they state that they find no evidence for differences between planned vaginal birth and planned c-section, but that the available evidence is too limited to make a real conclusion.

Technorati Tags: ; ; ;
MeSH Tags: Cesarean Section; maternal request (keyword; in a combined search, try adding "elective" and "on demand")

1 Comments:

Blogger CanuckedBrit said...

I'm disappointed to see high c-section rates. But I also find it disturbing to read disapproval to on-demand c-sections.

Hopefully, a dr confronted with a woman requesting a primary c-section would recommend vaginal and provide information on the risks of a c-section. But ultimately, it is the woman's body. She should have the choice. Vaginal birth is more successful when a woman is relaxed and trusts her body. A woman afraid of vaginal delivery is likely to have a self-fulfilling prophecy. In my opinion, it's better to let her have the c-section birth that would result in a pleasant birth experience for her over a traumatic, frightening vaginal birth experience for her.

8:35 AM  

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