New Lancet study on method of delivery

The Lancet just published an article entitled “Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007—08”. Here’s the conclusion:

We obtained data for 109 101 of 112 152 deliveries reported in 122 recruited facilities (97% coverage), and analysed 107 950 deliveries. The overall rate of caesarean section was 27·3% (n=29 428) and of operative vaginal delivery was 3·2% (n=3465). Risk of maternal mortality and morbidity index (at least one of: maternal mortality, admission to intensive care unit [ICU], blood transfusion, hysterectomy, or internal iliac artery ligation) was increased for operative vaginal delivery (adjusted odds ratio 2·1, 95% CI 1·7—2·6) and all types of caesarean section (antepartum without indication 2·7, 1·4—5·5; antepartum with indication 10·6, 9·3—12·0; intrapartum without indication 14·2, 9·8—20·7; intrapartum with indication 14·5, 13·2—16·0). For breech presentation, caesarean section, either antepartum (0·2, 0·1—0·3) or intrapartum (0·3, 0·2—0·4), was associated with improved perinatal outcomes, but also with increased risk of stay in neonatal ICU (2·0, 1·1—3·6; and 2·1, 1·2—3·7, respectively).
To improve maternal and perinatal outcomes, caesarean section should be done only when there is a medical indication.

Haven’t read the full text yet, but I will.

(Hat tip, Pushed Birth)


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3 responses to “New Lancet study on method of delivery

  1. Read the study carefully and you will find out something surprising. The study shows that the safest form of delivery is C-section WITHOUT a medical indication! Tables 3 and 4 make this quite clear.

    The authors tried to hide this finding by burying it within a perinatal “index” and a maternal M&M “index”.

    An index of outcomes can be useful if there are a great deal of possible complications, all of approximately the same severity. So an index might have been useful had the possible complication of surgery been for example: transfusion, ICU admission, wound infection, IV antibiotics, hospital readmission, etc.

    An index is inappropriate if there are only a few outcomes (as in this paper) or if it combines outcomes of wildly different severity (as in this case). In such situations and index is often use to OBSCURE outcomes. The WHO group desperately wanted to conclude that vaginal delivery was “safer” than C-section with no indications. The data, of course, show otherwise. There were fewer hysterectomies and maternal deaths in the C-section group, so they added in transfusions and ICU admissions to create an “index” that made vaginal delivery look better.

    • MomTFH

      Ah, why am I not surprised that Dr. Amy thinks any study, even one published in the Lancet, that contradicts her point of view is somehow flawed?

      Along with maternal morbity, the outcomes they are measuring are the most effective way to estimate the morbidity of method of delivery. These would be the main major complications of childbirth, and mortality. An index is simply a way of counting more than just mortality, which is not the only issue with method of delivery. In fact, maternal mortality is so uncommon, especially in the institutions they chose, which have more than 1000 deliveries a year, I would think it would be flawed for them not to create an index of morbidity.

      I personally think admission to ICU is an excellent choice, since it covers many morbidities that would be hard to count individually. There was a 9.9 times increased risk of being admitted to ICU with an elective cesarean.

      We use admission to NICU as an accepted way of measuring outcomes for the infant. Why is that not acceptable for the mother, too?

      I suggest you write a letter to the Lancet, and criticize their analysis. Make sure you include the strong accusation that they are intentionally obscuring results. Let’s see if you can substantiate that other than with pure bluster and attitude.

      Secondly, out of 109 101 cases, only 1515 were considered to be an antepartum cesarean without indications. I think that was an enormously small group to say that it was the group with the best outcomes. What kind of confounders would there be for a small group like that in the countries examined? You argue about natural birth advocates being elitist – how many women in that region could afford or even have access to an elective cesarean? The study said it cost an average of 1200 pounds more. No wonder 1% of 1% even tried this option. And could afford ten times the risk of having to stay in an ICU.

      The study acknowledges that using an index may exaggerate the risk of cesarean slightly, but considering their results have major face validity, considering the vast majority of the body of research on this topic agrees with them, I would argue that there is not much basis for saying they are so wrong, the opposite of their conclusions are true. In fact, in their discussion, they were more comfortable with the strength of their conclusions on elective cesarean being clearly more risky and having worse outcomes, and had more trouble with the indicated surgeries, for obvious reasons.

  2. Pingback: Reply turned post, blogging civility style « Mom’s Tinfoil Hat

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