A new study will add fuel to the complicated and controversial issue of whether a woman who has had one baby by caesarean section should choose vaginal delivery for her next one.
The risk of mortality for a baby delivered vaginally after the mother had a previous caesarean is about one in 775, says the study of more than 22,000 births in Scotland. That is more than 11 times the risk of perinatal death when mothers chose a second caesarean, says a report appearing in tomorrow’s issue of the Journal of the American Medical Association. In 9,000 such births, only one baby died.
But those numbers should not be decisive in making a choice, says Dr. Gordon C. S. Smith, professor of obstetrics and gynecology at the University of Cambridge and leader of the study. Other factors must also be considered, he adds.
One of those factors is “the downside of having another major surgical procedure for the mother,” says Dr. Frederic Frigoletto, professor of obstetrics and gynecology at Harvard Medical School (news – web sites) and a past president of the American College of Obstetricians and Gynecologists (ACOG).
“This study obviously has provided some good information to put into the equation, but the equation has more than one variable,” he says.
The other variables include not only the risk to the mother but also the facilities available in the hospital where the birth will take place, Frigoletto says.
About one in five deliveries in the United States is done by C-section. It was once a medical fact of life that a woman who had one baby by caesarean had all subsequent ones that way, but that is changing. Concerned over the rising rate of the procedure, doctors offered women the option of delivering a subsequent child vaginally. The rate of vaginal deliveries after a C-section was about 27 percent in 1997.
The great value of the new study is that it concentrates on pregnancies that went to full term, Smith says.
“Previous quantifications of risk have included a lot of premature births, and the risk I present is lower than those,” he says. “The vast majority of women do get to the end of the pregnancy.”
He and Frigoletto agree on one thing: It’s the woman’s decision to make.
“We must give her all the information and let her decide whether the risk is acceptable or unacceptable,” Smith says.
“The principle is one of informed consent,” Frigoletto says. “We try to provide the mother with as much information as possible and support her in any decision she makes. The exception is when we regard her decision as unjustifiable.”
The new study is bound to be controversial, because every study on the subject is controversial, says Mona Lydon-Rochelle, a midwife who is a senior research fellow at the University of Washington Center for Women’s Health Research.
“The field is very polarized,” she says. “There are Web sites that are totally dedicated to one side or the other of the issue. We have these polarized reactions in the United States, but the issue doesn’t seem to resonate in Europe.”
One reason for strong emotions here is that some health maintenance organizations have promoted vaginal delivery after C-sections as a way to save money.
An accompanying article in JAMA, by Dr. W. Benson Harer, Jr., of the Riverside County Regional Medical Center in California, notes that one California medical center adopted a policy requiring vaginal deliveries on the grounds that it cost $2,300 less than a second caesarean. The policy was dropped after two years, but more than $24 million has been paid thus far to settle claims of adverse outcomes, Harer says.
ACOG has no one overall recommendation on the issue, Frigoletto says. What it does have, he adds, is “some very specific guidelines about what are the ideal patient characteristics for considering vaginal delivery after caesarean, and what resources, human and physical, should be considered in making the decision.”
What To Do
Keep in mind that the risk presented in this study is relative. The overall risk of problems if you decide to deliver vaginally after having had a C-section is still low.