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Harms of Cesarean Versus Vaginal BirthDownload harms of cesarean versus vaginal birth core documents:
Why the review comparing harms of cesarean and vaginal birth was carried out How the review comparing harms of cesarean and vaginal birth was carried out Review results Ongoing work to use review results to educate professionals, women and the media and to improve practice Why the review comparing harms of cesarean and vaginal birth was carried outCesarean section is on the rise and at a record level in the U.S. With increasingly casual use, including use with no medical indication, it is essential to understand relative harms of cesarean and vaginal birth and to use this knowledge to inform key stakeholders, set policies, and guide clinical decisions.There is controversy among professionals and childbearing women about risks and benefits of cesarean delivery compared with vaginal birth. There is growing confusion and disagreement about the relative safety of these ways of giving birth and the role that cesarean section might play in pelvic floor dysfunction, such as incontinence in later life. This confusion and uncertainty are reflected in large practice variation in cesarean rates across hospitals, individual caregivers, types of caregivers, and geographic areas. In this environment, media reporting on these issues has often been misleading, incomplete, and inaccurate. In November 2003, the American College of Obstetricians and Gynecologists (ACOG) issued a policy statement approving cesarean section in healthy women with no medical indication. This statement contrasts with policies of other professional groups that do not support elective cesarean surgery. These groups include: International Federation of Gynecology and Obstetrics, International Confederation of Midwives, Society of Obstetricians and Gynecologists of Canada, and American College of Nurse-Midwives. When the ACOG statement was released, no systematic review of the relative harms of cesarean and vaginal birth was available, and the statement acknowledged research uncertainties. Existing more conventional "narrative" reviews differed widely in their conclusions and appeared to reflect their authors' values and preferences rather than a commitment to understanding lessons from the best research. Childbirth Connection (then known as Maternity Center Association) undertook a systematic review to identify the full range of harms that differ between vaginal and cesarean birth out of concern that belief and practice were rapidly changing without benefit of a systematic assessment of available research. Without access to carefully gathered and evaluated information, women's informed consent or informed refusal for this important decision was not possible, and their caregivers were not in a good position to provide informed guidance. How the review comparing harms of cesarean and vaginal birth was carried outThe review team used established principles for systematic review, by developing and carrying out a formal plan that specified the key questions, outcomes of interest, types of studies, populations of interest, and method of identifying and incorporating relevant studies. These criteria determined whether a study would be included or not, without reference to its conclusions. Details and full bibliography are included in the methods and sources document (see link in box above), with additional information at the beginning of 6 evidence tables (also available above).Many national non-profit organizations across the full spectrum of health professional and consumer groups in the field were invited to participate by commenting on the initial concept, sharing their related reports and statements, commenting on drafts of the review and consumer booklet, and considering endorsing and distributing the final booklet. Many groups did participate in multiple ways, and the products had extensive input from obstetricians, family physicians, pediatricians, midwives, nurses, childbirth educators, doulas, advocates, researchers and others. Over 25 organizations endorsed the consumer booklet. Review resultsThe review identified dozens of adverse effects that appear to differ by mode of birth. Documents listed in the box, above, provide full details.Overall, results strongly favored vaginal birth. Harms that differed and favored vaginal birth included
The review found that planned cesareans have advantages relative to unplanned cesareans with respect to short-term surgical injury and emotional toll. However, a planned cesarean is still major surgery, involving excess short-term risk relative to vaginal birth and potential for iatrogenic respiratory problems in babies. Planned and unplanned cesareans are likely to involve similar harms for conditions associated with scarring and adhesions, such as chronic pelvic pain, bowel obstruction, and all of the harms of cesarean for women's future reproductive capacity and babies in future pregnancies. A much shorter list of harms favored cesarean: brachial plexus injury in babies and the following outcomes in mothers: perineal/vaginal pain, any urinary incontinence, and any bowel incontinence. Existing evidence suggests that overall pain intensity and duration are worse with cesarean. Unfortunately, the review team found it impossible to interpret the incontinence literature for 2 reasons:
The review team did not find a single study that either attempted to compare cesarean delivery to safest and most appropriate vaginal birth practice or attempted to adjust for the use of undesirable vaginal birth management practices. In addition, measurement problems noted above must be sorted out to shed better light on these questions. It is thus inappropriate at present to conclude that “vaginal birth” per se causes pelvic floor dysfunction and to promote cesarean as a preventive measure. The main conclusion of the review was as follows: Without clear, compelling and well-supported justification for cesarean section or assisted vaginal birth, a spontaneous vaginal birth that minimizes use of interventions that may be injurious to mothers and babies is the safest way for women to give birth and babies to be born. Ongoing work to use review results to educate professionals, women and the media and to improve practiceChildbirth Connection has prepared a broad range of resources that incorporate review results for both health professionals and childbearing women. The box at the top of the page provides access to key documents that are currently available.Childbirth connection carries out ongoing media, professional and consumer outreach to bring results of the review to these key audiences, and works with individuals and organizations to improve practice. Childbirth Connection served as an institutional referee on a draft federal evidence report entitled Cesarean Delivery on Maternal Request and will participate in a National Institutes of Health State-of-the-Science Conference to discuss the final report. Childbirth Connection is also releasing relevant results from its second national U.S. Listening to Mothers® survey, which polled women who gave birth in 2005 about their childbearing experiences. Most recent page update: 3/10/2006
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Childbirth Connection is a national not-for-profit organization founded in 1918 as Maternity Center Association. Our mission is to improve the quality of maternity care through research, education, advocacy and policy. Childbirth Connection promotes safe, effective and satisfying evidence-based maternity care and is a voice for the needs and interests of childbearing families. |
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Help Transform Maternity Care!  Please join our efforts to make quality maternity care a top national priority. Your support will help make the transformation possible. View 2009 Supporter Roster  New Mothers Speak Out National Report Released The latest report in Childbirth Connection's Listening to Mothers series is now available. Get an eye-opening look at the reality of life as a mother of young children in the United States, based on national surveys conducted by Harris Interactive. Learn more, get the report Read the Wall Street Journal story and listen to the podcast Download Quick Facts (PDF) Why does the national U.S. c-section rate keep going up? Current research points to an optimal cesarean section rate of 5% to 10%, but 1 pregnant woman in 3 is giving birth by major surgery in the United States. Why the surge and is this safe? A new page - and a PDF handout for journalists, policy makers, students and others - answer these questions. Read more about the rising cesarean section rate New Content!
March/April 2009 evidence column is now available.
Features: National Quality Forum endorses consensus perinatal performance measures; systematic reviews on induction of labor, environmental tobacco smoke and fetal health, and HPV infection and cervical neoplasia Get the column Popular Pages
"I wish I had a doctor who explained more about things and was not so rushed."
Every woman has the right to choose a midwife or a physician as her maternity care provider. Both caregivers skilled in normal childbearing and caregivers skilled in complications are needed to ensure quality care for all.
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