Category Archives: Cesareans

Brazilian women fight cesarean trends

Going natural in Rio?

More than half of all Brazilian children are born by cesarean section, making Brazil one of the most “sectioned” countries in the world. If you’re a woman lucky enough to have health insurance there, the chance of a surgical birth jumps even higher: 82%. In some private hospitals the rates are well into the 90s. Vaginal birth is about as rare as quadruplets in some areas.

A small anti-cesarean movement had begun in Brazil in recent years, but a tipping point was reached recently when a medical regulating agency in Rio de Janeiro banned doctors from performing home births, and–in a move that’s pretty hard to justify–banned doulas from accompanying women to hospitals.

That did it. Women–some marching bare-breasted, others with painted pregnant bellies–took to the streets as demonstrations against hyper-medicalized birth broke out in dozens of cities across the country.

That seems to have gotten the doctors’ attention:

“We need to have a serious discussion in this country to see what can be done to change this culture,” said Olimpio Moraes Filho, one of the head doctors with the Brazilian Association of Obstetricians and Gynecologists. “Women are starting to rebel, and they should.”

Ok, fine…time to discuss a problem that’s been out of hand for a few decades. But how did it get this way in the first place?

There are many threads to the issue, and all of them led to one common path: a medical culture that has turned normally progressing births into unnecessarily stressful, painful ordeals. To Brazilian women terrified of the rough examinations, inductions, forceps, episiotomies, and lack of labor support that often come with vaginal birth, cesareans can sounds like a pretty good deal. (Sounds a lot like the U.S. in the not-so-distant past, come to think of it.)

And Brazilian hospitals do their best to make sure the money-making surgery stays popular:

Safaris?

“Private clinics are often happy to make that dream come true by turning delivery into something akin to a weekend retreat in a birth-themed five-star hotel. At the Perinatal Clinic in Rio de Janeiro, mothers can get free hairstyling, manicures and makeup sessions, and for a fee, can have their rooms decorated in a safari or teddy bear motif. Once the new mom is ready for visitors, a catering service complete with waiters can also be arranged.”

Teddy bears? Waiters? Dang! I want a c-section, too!

The times appear to be a-changin’ for real. In the last year and a half the Brazilian government has put over a billion dollars into a program designed to “humanize” natural birth. Whether that will make a real dent in Brazil’s cesarean-saturated medical culture, though, remains to be seen…

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“Optimal Care in Childbirth,” by Henci Goer and Amy Romano: A review

I’m a pediatrician. My interest in childbirth, from the time I finished my obstetrics rotation in medical school until I began writing my book, Birth Day, in the mid-2000s, was focused on what I needed to know in the course of preparing for the arrival of a sick newborn. What’s the gestational age? Any maternal illnesses? How’s the fetal heart tracing? Then I’d set out my tools and watch and wait until my new patient emerged from his mother.

I confess I did not give much thought to what was being done to the mother in the course of her giving birth, whether it was an induction, an episiotomy, or as happened more and more frequently over the years, a cesarean. Babies were my business; I was only peripherally aware of any obstetrical controversies smoldering behind the scenes.

My research for Birth Day was a crash course in the science and politics—especially the politics—of childbirth. I was introduced to the deep divide between what I’ve come to think of as the right and left wings of American maternity care.

At the extremes I saw a clash of incompatible cultures: the “all technology, all the time” (right-wing) camp–which viewed childbirth as a potentially lethal affair and managed laboring women accordingly–versus the solo, unassisted (lefty) birthers whose only desire was to be ignored by doctors and their interventions as nature took its wise, benign course. From many of the the emails I received from Birth Day readers, there really didn’t seem to be much in between.

The research literature of childbirth is the battlefield on which these “baby wars” have long been fought, a landscape littered with studies–some excellent, some awful–that support just about any conclusion an observer might want to make. Take a hot-wire topic like cesarean section. Depending on the biases and prejudices of the author, the same operation can be an unqualified boon to mankind or the devil’s own handiwork. Separating the research wheat from the chaff, the solid evidence from the cherry-picked, can be a daunting task.

So where can a maternity care provider turn for reasonable and reasoned advice? In their new book, Optimal Care in Childbirth: The Case for a Physiologic Approach (Classic Day Publishing), Henci Goer and Amy Romano seek to be that go-to resource—and they succeed.

Professional life has not been easy for Goer and Romano. In the introductory chapters of Optimal Care they describe the conflict between the birth-as-pathology-oriented medical management (MM) model of care so prevalent in the U.S. (the obstetric right wing, in my mental construct), and the low-intervention physiologic care (PC) model that emphasizes birth as a normal event and a major life milestone marking

Henci Goer

the transition to parenthood. Despite the authors’ declaration that “every group that has ever set out to design a healthy maternity care system has articulated the principles and practices” of the PC model, change in the American way of birth has been slow and incremental.

“The [PC model] wheel has been reinvented repeatedly, yet somehow we cannot get it rolling. The obvious question then becomes, Why not?”

Goer and Romano then line up the suspects, usual and not, for the maddeningly unmovable status quo. There’s money, of course—the perverse economic incentives that support hospital maternity wards and the expensive technologies that come with them—and the inertia of entrenched habits and practices. Too, there is the belief held by many women, often reinforced by their maternity care providers, that their bodies are not competent for the task of giving birth.

Interestingly, Goer and Romano also cite the rise of “evidence-based decision-making” in medicine (or, as the late Canadian obstetrician Phil Hall described it, “decision-based evidence making”) as a self-reinforcer of conventional obstetric care. When an evidence-gathering framework designed to evaluate the treatment of  illness is instead applied to a normal physiologic process, the result is an increasingly narrow definition of “normal” and a much broader one of “pathology.”  Of such thinking, the authors conclude, comes the likes of early labor induction, routine episiotomies, and skyrocketing cesarean rates—and the incredibly difficult task of trying to change an obstetric culture so committed to the MM model that the benefits of all births being cesareans is actually considered a legitimate topic of discussion.

“By now you may be thinking that the situation is hopeless; resistance is futile.”

Well, yes, that thought does cross a reader’s mind. The research deck does seem to be stacked in favor of medical management. So, given decades of crying in the childbirth wilderness, what keeps Goer and Romano going? Why haven’t they surrendered to the inexorable march of techno-birthing? How have they not gone completely nuts?

“It is not [hopeless],” Goer and Romano insist, “but those wanting to reform maternity care need a solid foundation in what the obstetric evidence does, does not, or only seems to support, as well as an

Amy Romano

understanding of the impediments to change…”

In other words, you have to fight “science” with science, and that is what Goer and Romano do so well in this fine book.

Optimal Care is a hefty volume–nearly 600 pages—and not every reader will want to plow through it from start to finish. There’s really no need to, though—the book’s structure invites focused reading. Each of its eight sections is divided into chapters that hone in on specific aspects of a more general topic. A reader interested in the subject of episiotomies, say, need read only the twenty pages of Chapter 15 to learn why episiotomies are rarely necessary, and why, despite that evidence, they are still commonly performed. Meanwhile, those who wish to read about a more complicated topic like cesarean section will find an in-depth discussion of the science and politics of that surgery spread over the three chapters of Section II, “The Cesarean Epidemic.”

I found two features of Optimal Care in Childbirth particularly helpful for busy clinicians. At the end of each chapter are concise, bulleted “Strategies for Optimal Care” designed to promote physiologic birth in a variety of settings.  Following that are “Mini-Reviews”—summaries of topic-related research which include, notably, the authors’ reasons for including and excluding certain studies. Goer and Romano are refreshingly upfront about their PC model biases—literally from page one—an honest and rare thing to see in the highly polarized world of modern maternity care.

Optimal Care in Childbirth is a welcome addition to the ever-expanding library of maternity care books. By using science in the service of physiologic birth, Henci Goer and Amy Romano offer a welcome push-back to the all too common view of uncomplicated childbirth as a disaster just waiting to happen.

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Filed under Book review, Cesareans, Maternal-child health, Natural childbirth, Politics

Midwives take a stand

The nation’s leading midwifery organizations–the American College of Nurse-Midwives (ACNM), the Midwives Alliance of North America (MANA),  and the National Association of Certified Professional Midwives (NACPM)– recently issued a statement titled: “Supporting Healthy and Normal Physiologic Childbirth: A Consensus Statement by ACNM, MANA, and NACPM” 

Despite that rather sedate-sounding title the statement is remarkable, both for what it says and because of the politics that went into its making.

The purpose of the statement is to define “normal physiologic childbirth,” and to identify the factors that  promote–and interfere with–such a birth. The intent is to serve as a guide for providers, decision-makers, and pregnant women who wish to “protect, promote, and support human childbearing physiology and to avoid overuse of interventions, thus achieving better care, better health, and lower costs.”

It’s hard to argue with that.

Some definitions from the statement:

Normal physiologic birth

•             is characterized by spontaneous onset and progression of labor;

•             includes biological and psychological conditions that promote effective labor;

•             results in the vaginal birth of the infant and placenta;

•             results in physiological blood loss;

•             facilitates optimal newborn transition through skin-to-skin contact and keeping the mother and infant together during the postpartum period; and

•             supports early initiation of breastfeeding.

Factors that disrupt normal physiologic childbirth

•             induction or augmentation of labor;

•             an unsupportive environment, i.e., bright lights, cold room, lack of privacy, multiple providers, lack of supportive companions, etc.;

•             time constraints, including those driven by institutional policy and/or staffing;

•             nutritional deprivation, e.g., food and drink;

•             opiates, regional analgesia, or general anesthesia;

•             episiotomy;

•             operative vaginal (vacuum, forceps) or abdominal (cesarean) birth;

•             immediate cord clamping;

•             separation of mother and infant and/or

•             any situation in which the mother feels threatened or unsupported.

The statement’s authors call for systemic changes in clinical practice, education, research, and health policy to support physiologic birth whenever and wherever possible. It’s a measure of how glacially slowly progress comes in the field of obstetrics that this statement isn’t much different from one issued by the World Health Organization in 1996.

Given that 16 year-old WHO report, a reader might well ask: So what’s new about this? Hasn’t vaginal birth always been the “norm”?

Yes, for the vast majority of human history vaginal birth was the only viable way for a baby to leave the womb. But things have changed dramatically in the last few decades, as technological intervention–particularly cesareans and labor induction–has become so pervasive as to blur the boundaries of what constitutes the healthiest way for a low-risk woman to give birth.

Don’t get me wrong–I love medical technology when there’s an emergency or a complicated patient at hand. It’s just that the use of technology tends to beget the use of more technology, often in less and less urgent situations. An example: if elective cesareans (i.e., those performed without medical need) are performed frequently, at some point it becomes “normal” for healthy, low-risk women to opt for elective cesareans.

The joint statement is an effort to put a stake in the ground, to define “normal physiologic birth” even as the slope toward technological birth becomes ever slipperier. The goal is the promotion of low-intervention vaginal birth and the appropriate use of technology, not its elimination. For healthy, low risk women that means ready access to the kind of care that promotes “normal physiologic birth.”

* * * * *

A word about politics…

I think that most casual observers would assume that the conflict over American maternity care practices exists mainly between midwives and doctors, facing off over a Great Childbirth Divide—a battle between the Forces of Nature and the Techno-People, if you will. Yet there have long been disagreements within the field of midwifery itself, as reflected by the fact that there are three professional midwifery organizations in the U.S.

Most of American midwifery’s internal disagreements have revolved around issues of training, certification, and governance–questions of what qualifications a midwife should have, for example, and how midwifery as a profession should interface with the larger medical-obstetrical  world. The lack of a unified midwifery voice has sometimes made it easier for professional obstetrics organizations to downplay, and sometimes ignore, the very legitimate concerns raised by midwives.

This joint statement is a major step toward the goal of unifying that voice, a process that will ultimately be of great benefit to mothers and babies.

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Oops…

The perils of the virtual world…

Ahem… I’ve just been told that Science & Sensibility is having some spam problems, so apparently my post went up and came down quickly. Should be up again soon. In the meantime here’s the post (below). Check in at Science & Sensibility later to follow any comments that surface, or to further sabotage the site, as you see fit.

And no, I’m not the spammer…

* * *

Unintended consequences: Cesarean section, the gut microbiota, and child health.

When I first learned some years ago that cesarean section was associated with an increased risk of childhood asthma and eczema, I eagerly awaited the rest of the story. What could the link possibly be? Epidurals? Anesthetics? Antibiotics? Something strange and exotic was afoot, I was certain.

Imagine my surprise, then, when a growing body of evidence pointed to an unexpected source: the newborn gastrointestinal tract and the microorganisms that live there.

How might intestinal bacteria play such a major role in the health and well-being of newborns and children? The answer lies in an ancient, mutually beneficial relationship, one that modern birth technology has dramatically altered.

 * * *

Some friendly faces…

“Microbiota” is the term used to describe the community of microorganisms—bacteria, viruses, and fungi—that normally live in or on a given organ in the body. There’s a unique microbiota that inhabits the mouth, for example, another that lives on the skin, and still another that populates the intestine, or gut. Given an intestinal surface area of about 2,700 square feet—more or less the size of a tennis court—the microbiota inhabiting the gut is the largest and most diverse in the body.

How large and diverse? The gut microbiota contains roughly one quadrillion cells—at least ten times as many cells as does the human body itself. More than 1,000 bacterial species having been identified to date, with unknown numbers yet to be discovered.

How do all those bacteria get there? The fetal intestine, in the absence of congenital infection, is sterile in utero. The bacteria that come to colonize the bowel are acquired during birth and shortly afterwards, a process that is very much influenced by how a baby is born.

The gut microbiota and mode of delivery

In vaginally-born babies the colonizing bacteria originate primarily in the maternal birth canal and rectum. Once swallowed by the newborn during birth, these bacteria pass through the stomach and upper intestine and colonize the lower intestine, a complicated initial process that takes about a week.

Infants born by cesarean section—particularly cesareans performed before labor begins—don’t encounter the bacteria of the birth canal and maternal rectum. (If a cesarean is performed during labor the infant may be exposed to these bacteria, but to a lesser degree than in vaginal birth.) Instead, bacteria from the skin and hospital environment quickly populate the bowel. As a result, the bacteria inhabiting the lower intestine following a cesarean—the gut microbiota—can differ significantly from those found in the vaginally-born baby.

Whatever the mode of delivery, a core gut microbiota is well established within a few weeks of life and persists largely intact into adulthood. A less stable peripheral microbiota—one that is more sensitive to changes in diet and environmental factors, like antibiotics—is created as well. Between one and two years of age, when weaning from breast milk typically leads to a diet lower in fat and higher in carbohydrates, the gut microbiota takes on its final, mature profile.

Development of the newborn immune system

The dramatic first steps in immune system development take place at the same time the core microbiota is being formed, and the gut bacteria play a key role in that process.

In the hours and days following birth, the newly-arrived bacteria of the gut microbiota stimulate the newborn’s production of white blood

A t-lymphocyte

cells and other immune system components, as well as antibodies directed at unwelcome, disease-causing microorganisms. The bacteria of the microbiota also “teach” the newborn’s immune system to tolerate their own advantageous presence—to differentiate bacterial friend from foe, in other words.

In a cesarean birth the fledgling immune system is confronted with unfamiliar, often hostile bacteria—including Clostridium difficile, a particularly troublesome hospital-acquired bug. In addition, the healthy probiotic bacteria associated with vaginal birth that the newborn’s immune system expects to see arrive later and in lower numbers. These changes in the composition of the normal gut microbiota occur during a critical time in immune system development.

The cesarean-asthma theory (in a nutshell)

Here’s how cesareans and asthma are likely connected:

Humans evolved right along with the gut microbiota normally acquired during vaginal birth. When the composition of that microbiota is imbalanced, or unusual germs like Clostridium difficile appear, the immune system doesn’t like it. A low-grade, long-lasting inflammatory response directed at these intruders begins at birth, leading to a kind of “leakiness” of the intestinal lining. Proteins and carbohydrates that normally would not be absorbed from the intestinal contents—including large food molecules—make their way into the infant’s bloodstream.

To make a very long story short, that inflammation and the abnormal digestion and absorption of food that results appears to increase the risk of asthma and eczema—and diabetes, obesity, and other chronic illnesses—later in life.

* * *

Normalizing the post-cesarean gut microbiota

Reducing the cesarean rate is an obvious best practice in promoting a healthy gut microbiota. But there will always be a need for cesarean section, and so researchers are now beginning to focus on “normalization” of the gut microbiota of cesarean-born babies. Although there are as yet no proven therapies, here are some possibilities:

  • Probiotics. Though administering healthful probiotic bacteria to correct an imbalanced microbiota makes intuitive sense, studies to date have been disappointing. However, research into “good” bacteria and how they become established in the intestine is active and ongoing.
  • Direct transfer of maternal secretions. Placing maternal vaginal and rectal material into the newborn’s mouth has been proposed—more or less mimicking natural colonization—but to date there are no published studies to support the practice.
  • Fecal transplantation. Direct transfer of fecal material from healthy adults into the gastrointestinal tract of people suffering from Clostridium difficile infections has shown promise. Using healthy parents as “donors” for their babies has been proposed, but applying such technology to otherwise healthy newborns is highly impractical at present, to say the least.

Conclusion

A cesarean section doesn’t automatically doom a child to a lifetime of asthma or eczema, just as a vaginal birth isn’t an absolute guarantee of perfect health. But cesarean birth, by altering normal gut microbiota development, does appear to moderately increase the risk of these and other chronic health conditions. A woman who has the option of choosing her mode of delivery should consider this along with the many other factors she must weigh in deciding how her baby will be born.

Mark Sloan M.D.

Selected references:

1)    Effects of mode of delivery on gut microbiota composition

Biasucci G, Rubini M, Riboni S, et al (2010). Mode of delivery affects the bacterial community in the newborn gut. Early Human Development 86:S13-S15

Penders J, Tjhijs C, Vink C, et al (2006). Factors influencing the composition of the intestinal microbiota in early infancy. Pediatrics 118(2):511-521.

Salimen S, Gibson GR, McCartney AL (2004). Influence of mode of delivery on gut microbiota in seven year old children. Gut 53:1388-1389.

2)    Development of the newborn immune system

Huurre A, et al (2008). Mode of delivery: Effects on gut microbiota and humoral immunity. Neonatology 93:236-240.

Johnson C, Versalovic J (2012). The human microbiome and its potential importance to pediatrics.  Pediatrics (published online April 2, 2012; DOI: 10.1542/peds2011-2736).

Vael C, Desager, K (2009). The importance of the development of the intestinal microbiota in infancy. Current Opinion in Pediatrics 21(6):794-800

3)    Cesarean birth, gut microbiota, and asthma/atopic disease

Azad M, Korzyrkyj A (2012). Perinatal programming of asthma: The role of the gut microbiota. Clinical and Developmental Immunology Volume 2012; Article ID 932072; doi:10.1155/2012/932072

Thanvagnanam S, Fleming J, Bromley A, et al (2008). A meta-analysis of the association between caesarean section and childhood asthma. Clinical & Experimental Allergy 38(4): 629-633.

van Nimwegen F, Penders J, Stobberingh E, et al (2011). Mode and place of delivery, gastrointestinal microbiota, and their influence on asthma and atopy. Journal of Allergy and Clinical Immunology 128(5):948-955.e3

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Filed under Asthma, Cesareans, Maternal-child health, Natural childbirth, Obesity, Science

Science & Sensibility, part 2

Science & Sensibility, Lamaze International’s “Research Blog About Healthy Pregnancy, Birth & Beyond,” just posted an essay of mine titled “Unintended Consequences: Cesarean Section, the Gut Microbiota, and Child Health.” It’s an explanation of the probable link between cesareans and childhood asthma, eczema, and other chronic health problems. Stop by and have a read!


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Science & Sensibility

I recently wrote a guest post for Lamaze International’s excellent Science & Sensibility blog. The subject was the study by Huh and colleagues about the association of cesarean birth and childhood obesity. (See my own blog post about the study here.) Interesting discussion going on. Please weigh in if you feel so inclined!

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More on cesareans and obesity

Cesareans? Really?

Does cesarean birth put a baby at increased risk for obesity in the future? Seems a little far-fetched at first glance, but Dr. Susanna Huh and her Harvard colleagues just published a study that makes the link a bit more “near-fetched.” (The study itself is available here.)

Huh’s team found that children born by cesarean section were twice as likely to be obese at 3 years of age than were those born vaginally. This relationship held up even when factors like the mother’s weight, ethnicity, age and how many babies she’d already had  were taken into account. Interestingly, it didn’t make a difference whether the cesarean was performed before or after labor started.

The study wasn’t designed to look at the reasons for the increased risk in obesity, but the Harvard team suggested several possibilities:

The first is the alteration of the gut microbiota–the sum total of all the bacteria found in the human bowel–caused by a cesarean birth. (More detail on that here and here.) This alteration can lead to low-level inflammation in the bowel which is associated with obesity.

The second possibility is that cesarean birth is just a stand-in for something else that’s happening at the same time. In this case, Huh and colleagues wonder about all the antibiotics given to women who are having cesareans. Antibiotics are known to alter the gut microbiota, but research results are mixed as to whether this is a lasting effect.

Finally, it’s possible (though unlikely) that all of this has nothing to do with the gut microbiota. There are hormones and other factors related to inflammation that surge in a mother’s bloodstream (and her baby’s) during labor, and these, obviously, are missing if a mother undergoes a cesarean before she starts labor. The lack of maternal stress response during labor could adversely impact the development of the newborn immune system, leading to the inflammation associated with obesity.

My best guess: it’s a big moosh of all of the above, plus other factors no one has even dreamed of yet. In the meantime, the issue of increased obesity risk is one more thing physicians and pregnant women should consider before deciding on how a baby is to be born.

It’s a complicated matter, this business of hatching healthy humans…

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