Caesarean section? Vaginal birth? Your choice!

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Much has been said and written about an article in The Age this weekend. The article is about a randomised study that will compare the outcomes of 500 women who choose a caesarean and 500 women who choose a vaginal birth. The study will explore psychological and physical outcomes for the women and their babies, including depression and breastfeeding rates. It will only compare vaginal births with caesareans for healthy women with uncomplicated pregnancies.

The study has created much debate, including issues of ethics (beneficence, autonomy, non-maleficence) and professional duty of care. I wonder if part of the "answer" will not be answered by this study, since the study only addresses outcomes from the first pregnancy, but most women do not have one child, they have two, on average. It's reasonable to assume that a woman who has an elective caesarean for her first baby, will go onto have an elective caesarean for her second baby.

In the current maternity system in NSW, a woman who chooses a vaginal birth for her first baby has the following outcomes:

  • only 52% women having their first baby will have a normal birth
  • 33% will be induced
  • 23% will have forceps or vacuum
  • 25% will have a caesarean - and of these women, only 12% will have a vaginal birth in their subsequent pregnancy.
  • In other words, only 75% of first time mums who elect to have a vaginal birth will actually have one.

    In contrast, a first time Mum who chooses a vaginal birth with a private midwife has about a 95% chance of having a vaginal birth.

    The real question isn't the outcomes of a first-time Mum's pregnancy when she chooses a vaginal birth or a caesarean, but rather, what happens for the average woman who has two children, who has elected a caesarean with her first versus a vaginal birth with her first baby. In other words, how about we compare the outcomes of women who have two caesareans, with women who elect to have a vaginal birth the first time around, 75% of whom will birth vaginally, and 25% of whom will have a caesarean.

    Such a study would address the issue of second caesarean risks. Serious maternal morbidity (eg placenta praevia, placenta accreta, uterine rupture, need for hysterectomy and blood transfusion) increases progressively with increasing number of cesarean sections a woman has. The first caesarean is generally very safe but increasing numbers of caesareans are perhaps not so safe.

    A further issue with the study is that it does not suggest any method or support for the women who elect to birth vaginally. Will they be supported with one-to-one midwifery care, as this is known to increase vaginal birth rates? Will they include homebirthing women who are highly motivated to birth normally and without interventions? Or will it be standard obstetric / hospital-based births with high rates of intervention that are already known to result in reduced breastfeeding rates and a dissatisfaction with the birthing experience? I will wait to read the results.