Friday, October 19, 2007

Caesarean in Malaysia

Although official statistics on caesarean rates here are not available, the medicalisation of childbirth can be expected to prevail here as modern healthcare practices rule our lives. The following are 2 local studies that provide some statistics related to childbirth and caesarean.

Sudden Maternal Deaths
A local study of maternal deaths in Malaysia that occurred within 24 hours of delivery, abortion or operative termination of pregnancy (defined as sudden deaths) in the years 1995-1996 at the Seremban Hospital revealed the following:

There were 131 sudden maternal deaths (20.6% of all maternal deaths). Postpartum haemorrhage, obstetric embolisms, trauma and hypertensive disorders of pregnancy where the main causes.

The proportion of mothers who had no obstetric risk factors in the pregnancy were the main causes.

20 mothers died after a caesarean section.

(Source: “Sudden Maternal Deaths in Malaysia: A Case Report”, by Jegasothy R., Department of Obstetrics and Gynecology, Seremban Hospital , published in Journal of Obstetrics and Gyneacology Research, August 2002)

Birth Defects

Another local study which looked at major birth defects in births during the perinatal period in Kinta district, Perak, over a 14-month period, using a population-based birth defect register, found the following:

There were 253 babies with major birth defects in 17,720 births, giving an incidence of 14.2/1000 births, a birth prevalence of 1 in 70.

There were 80 babies with multiple birth defects and 173 with isolated birth defects.

The babies with major birth defects were associated with lower birth weights, premature deliveries, higher caesarean section rates, prolonged hospitalization and increased specialist care.

(Source: “A Population-based Study of Birth Defects in Malaysia” by the Department of Pediatrics of the University of Malaya’s Faculty of Medicine, which appeared in the Annals of Human Biology, March-April)

Friday, October 5, 2007

Risks and Complications of Caesarean Surgery

No evidence supports the ideas that caesarean are as safe as vaginal birth for mother or baby. In fact, the increase in caesarean births risks the health and well-being of childbearing women and their babies.

According to a study published in the February 13, 2007 issue of the Canadian medical association journal, women who have planned caesarean had an overall rate of severe complications more than 3 times that of women who planned vaginal deliveries.

For elective (ie voluntary) repeat caesarean, the consensus of dozens of studies totaling tens of thousands of women is that elective repeat caesarean section is riskier for the mother and not any safer for the baby. Recent studies used to conclude otherwise are both seriously flawed and have been misrepresented in the media.

In addition to the hazards of caesarean section per se, the risk of certain complications increase with accumulating surgeries. Studies also show that with a history of previous caesarean, 7 out of 10 women or more who are allowed to labour without undue restrictions will give birth vaginally, thus ending their exposure to the dangers of caesarean section.

Hazards to the mother

Women run 5-7 times the risk of death with caesarean section compared with vaginal birth.

Complications during and after the surgery include surgical injury to the bladder, uterus and blood vessels (2 per 100), hemorrhage (1-6 women per 100 require a blood transfusions), anesthesia accidents, blood clots in the legs (6-20 per 1,000), pulmonary embolism (1-2 per 1,000), paralyzed bowel (10-20 per 100 mild cases, 1 in 100 severe), and infection (up to 50 times more common). (Infection can occur at the incision site, in the uterus and in other pelvic organs such as the bladder.)

1 in 10 women report difficulties with normal activities 2 month after the birth, and 1 in 4 still report pain at the incision site as a major problem. 1 in 14 still report incisional pain 6 months or more after delivery.
Twice as many women require rehospitalisation as women having normal vaginal birth.

Especially with unplanned caesarean section, women are more likely to experience negative emotions, including lower self-esteem, a sense of failure, loss of control, and disappointment.

They may develop postpartum depression or post-traumatic stress syndrome. Some mothers express dominant feelings of fear and anxiety about their caesarean as long as 5 years.
Women having caesarean sections are less likely to decide to become pregnant again.

As is true of all abdominal surgery, internal scar tissue can cause pelvic pain, pain during sexual intercourse, and bowel problems.

Reproductive consequences compared with vaginal birth include increased infertility, miscarriage, placenta previa (placenta overlays the cervix), placental abruption (the placenta detaches partially or completely before the birth), and premature birth. Even in women planning repeat caesarean, uterine rupture occurs at a rate of 1 in 500 versus 1 in 10,000 in women with no uterine scar.Reaction to medications: there can be a negative reaction to the anesthesia given during a caesarean or reaction to pain medication given after the procedure.

Hazards to the baby

Especially with planned caesarean, some babies will inadvertently be delivered prematurely.

Because doctors are not as good as they would like to be in estimating, even with ultrasound, the baby ‘s gestational age- ie whether the pregnancy has gone long enough- too often a caesarean section is done too soon, resulting in a premature birth. Prematurity is a big killer of new-born babies (and also carries a higher risk of brain damage to the baby). Babies born even slightly before they are ready may experience breathing (and breastfeeding) problems. Because all the water is not squeezed out of the baby’s lungs as is normally done during a vaginal birth, more babies born after caesarean section develop serious respiratory distress syndrome, one of the biggest killers of newborn babies.

1-2 babies per100 will be cut during the surgery. [“The first danger to the baby during caesarean surgery is the 1.9% chance the surgeon’s knife will accidentally lacerate the fetus (6.0 % when there is a non-vertex fetal position). Obstetricians may be less aware of this risk-in one study only 1 of the 17 documented fetal lacerations was recorded by the obstetrician doing the surgery.”- Marsden Wagner in “Choosing Caesarean Section” in The Lancet, Vol. 356, 11 November 2000)]

Studies comparing elective caesarean section or caesarean section for reasons unrelated to the baby with vaginal birth find that babies are 50% more likely to have low Apgar scores, 5 times more likely to require assistance with breathing, and 5 times more likely to be admitted to intermediate or intensive care. [The Apgar score is a simple test that helps doctors assess the general physical condition of newborn infant’s system to see if the baby needed immediate medical care. It rates a baby’s appearance, pulse, responsiveness, muscle activity, and breathing with a number between 0 and 2 (2 being the strongest rating).]

Babies born after elective caesarean section are more than 4 times as likely to develop persistent pulmonary hypertension compared with babies born vaginally. Persistent pulmonary hypertension is life threatening.

Babies are less likely to be breastfed. This may be because women are less likely to hold and breastfed their infants after birth and have rooming-in and because of the difficulties of caring for an infant while recovering from major surgery. (Hence mothers are more likely to have difficulties forming an attachment with the infant.) The adverse health consequence of formula feeding are numerous and can be severe. [Breast milk has agent (called antibodies) in it to help protect infant from bacteria and viruses. Recent studies show that babies who are not exclusively breastfed for 6 months are more likely to develop a wide range of infectious diseases including ear infections, diarrhoea, and respiratory illnesses and have more hospitalizations.

Also, infants who are not breastfed have a 21% higher postneonatal infant mortality rate (in the US). Some studies suggest that infants who are not breastfed have higher rates of sudden infant death syndrome (SIDS) in the first year of life, and higher rates of Type 1 and Type 2 diabetes, lymphoma, leukemia, Hodgkin’s disease, overweight and obesity, high cholesterol and asthma (American Academy of Pediatrics,2005)]

Wednesday, October 3, 2007

Why Caesareans are Increasing

Soaring Caesarean rates today are mostly influenced by non-medical factors. Where medically related, it’s due to a weakness – improper medical care and to protect doctors’ interests!

To boost doctors’ earnings

In CHINA, it is reported that one of the reasons for the sharp rise in Caesareans is because doctors recommend C-section delivery to boost their earning power (Xinhua Economic News 15.2.07).

“Caesarean sections earn doctors higher profits so doctors tent to persuade pregnant women to have a Caesarean,” a doctor there was quoted as saying.

In Beijing’s hospitals, the operation and hospital tees for a Caesarean section are 3 – 4 times higher than that of a natural birth.

In some countries it has been observed that Caesarean rates are higher for women who have private medical insurance, are private rather than public clinic patients, are older, are married, have higher levels of education and are in a higher socio-economic bracket.

As noted by the WHO: “In the United States the profit motive explained hospital specific Caesarean section rates that were high even by United State standards.” (Wagner 2000)

In BRAZIL, where Caesareans accounts for 82% of the childbirth paid for by medical plans, a sociologist, Jacqueline Pitanguy, revealed: “For more than 20 years now the federal government has been taking measures.. to combat the money effect.. but it didn’t have much of an effect.”

In TAIWAN, a recent study commissioned by the Bureau of Medical Affairs and conducted by the Taiwan Association of Obstetrics and Gynecology, found that 1 of the top 4 reasons women choose C-section by the national health insurance program.

For doctor's own convenience

by the WHO: “In the United States the profit motive explained hospital specific Caesarean section rates that were high even by United State standards.” (Wagner 2000)

In BRAZIL, where Caesareans accounts for 82% of the childbirth paid for by medical plans, a sociologist, Jacqueline Pitanguy, revealed: “For more than 20 years now the federal government has been taking measures.. to combat the money effect.. but it didn’t have much of an effect.”

In TAIWAN, a recent study commissioned by the Bureau of Medical Affairs and conducted by the Taiwan Association of Obstetrics and Gynecology, found that 1 of the top 4 reasons women choose C-section by the national health insurance program.

As a form of defence for doctors

Many doctors point the concern over increased malpractice risks for vaginal delivery as the cause for increasing Caesareans today. For example failure to perform C-sections early enough to save a distressed baby can bring on big lawsuits.

According to Dr Joshua A.Copel, director of Maternal and Fetal Medicine at Yale University School of Medicine, the disturbing trends in Caesarean birth owe themselves to “malpractice”. He believes that a decision favoring Caesarean delivery is but an offshoot of the doctor’s fear of litigation. “Not much has changed about the American population to account for (its) increase in Cesarean birth”.

Unlike for a natural birth, it is difficult to take action against a doctor for having carried out a Caesarean birth done unnecessarily, says Jorge Francisco Kuhn dos Santos, a professor of obstetrics at the federal University of Sao Paulo.

“Even it there’s complication, people thing: “at least the doctor used the best technology available”, he says. This same doctor could be questions judicially if he had opted, under the same circumstances, for a normal birth.

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