Harms of Cesarean Versus Vaginal Birth
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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
With about one in three babies born surgically, cesarean delivery is the most common operating room procedure in the United States. Over the past two decades, the cesarean rate has increased among women with and without prior cesareans, in both preterm and term pregnancies, in women at low and high risk of complications, and across all ages, races, and ethnicities. As cesarean rates increase, proportionally more low-risk women experience cesarean delivery. Overuse of cesarean delivery in low-risk women exposes more women and babies to potential harms of cesarean with minimal likelihood of benefit. Of particular consequence are downstream effects including childhood chronic illness and placental complications in any subsequent pregnancies. These include life-threatening complications that occur more frequently with accumulating surgeries. In light of these and other concerns, in 2012, the National Priorities Partnership, a consortium of major national organizations facilitating coordinated action within targeted areas of health and healthcare improvement, convened a Maternity Action Team to address inappropriate and unsafe maternity care. A major goal of the Maternity Action Team is to reduce cesarean delivery in low-risk women to 15% or less.
With escalating multi-stakeholder attention on cesarean overuse, an ever-growing body of evidence, and new opportunities for consumer education and shared decision making, Childbirth Connection undertook a scientific review to summarize for all stakeholders the most current best evidence on the health consequences of cesarean delivery. While the expected benefits of cesarean delivery vary depending on the indication and would be minimal in low-risk women, the potential harms are generally intrinsic to surgical delivery. Thus, the report focuses on adverse consequences of cesarean, and also explores adverse outcomes that may be intrinsic to labor or vaginal birth.
The 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.
Our comprehensive assessment reveals the following: Of 14 maternal adverse outcomes in the current pregnancy, sufficient evidence demonstrates that 8 favor vaginal or planned vaginal birth, and limited evidence suggests the remaining 6 favor vaginal or planned vaginal birth. Of 4 neonatal adverse outcomes, sufficient evidence demonstrates that 1 favors vaginal or planned vaginal birth, limited evidence suggests that 2 favor vaginal or planned vaginal birth and evidence is conflicting for the remaining 1 outcome. Of 4 childhood chronic diseases, sufficient evidence demonstrates that 3 favor vaginal or planned vaginal birth and evidence is limited and conflicting for the remaining 1. Seven adverse outcomes are unique to cesarean delivery while 3 are unique to vaginal birth. Of 3 psychosocial outcomes examined, evidence conflicts but suggests a possible association with cesarean delivery for all 3. In subsequent pregnancies, of 9 adverse maternal outcomes, sufficient evidence demonstrates that 6 favor vaginal birth in the prior delivery and limited evidence suggests the remaining 3 also favor prior vaginal birth. Of 6 perinatal adverse outcomes in subsequent pregnancies, limited evidence suggests that 2 favor prior vaginal birth, and data conflict for the remaining 4. Of 5 outcomes related to pelvic floor dysfunction, none favors vaginal birth, mode of birth makes no difference for 2, and 3 favor cesarean delivery, but of these 3, 2 favor cesarean only in the short term or only with respect to mild or moderate symptoms. Of 4 outcomes related to delivery injury of the baby, mode of birth appears to make no difference for 3, none favors vaginal birth, and limited evidence suggests that 1 favors cesarean.
The main conclusion of the review was as follows:
The findings of this report overwhelmingly support striving for vaginal birth in general and spontaneous vaginal birth in particular in the absence of a compelling reason to do otherwise. To improve both the quality and value of maternity care in the United States and promote the optimal health of women and infants, clinicians, policy makers, and other stakeholders should prioritize identifying and promulgating practices that promote safe, spontaneous vaginal birth and reduce the use of cesarean delivery.
Most recent page update: 2/7/2013
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