A lot of random musings from a surgeon and clinical researcher, but here
goes:

First, we must be very careful any time we look at historical data
comparing the risks of childbirth.  There are so many confounders that
simply are not accounted for in most analyses.  We should keep in mind
that pregnancy today is not like pregnancy centuries ago -- women are
older and pregnancies are more likely to be multiple.  Women are achieving
pregnancy through interventions like IVF.  We are maintaining pregnancies
through prenatal care and interventions that would not have been
maintained, due to maternal illness (cardiac disease, diabetes, even
cancer), fetal illness (congenital abnormalities), or pregnancy-specific
illness (preeclampsia, infections, etc.)  Additionally, pregnancy care is
different than it was centuries ago.  Women tend to receive care through
intermittent, intense visits with a physician rather than casual but
continuous relationships with a midwife.  Difference between
industrialized and nonindustrialized countries are significantly more
complex than simply C-section rates.

Second, we have to keep in mind the difference between "efficacy"
and "effectiveness."  One modality may appear superior or equivalent under
tightly controlled research conditions, but not in the real world.  Or
vice-versa.  Vaginal deliveries tend not to be performed without
interventions.  Cesarean sections tend not to be performed with
appropriate post-natal breastfeeding support.  How would things pan out
under ideal circumstances?  Who knows?

Third, a treatment may be effective but may still be less than ideal.
Surgical treatment for obesity (via gastric bypass) is currently the most
effective treatment, despite a long list of potential side effects which
includes death (a side effect which I have unfortunately seen at least
once).  That's because we live in a culture that values quick, definitive
interventions and devalues slower or more difficult interventions.
Patients are unprepared and unsupported in making dietary changes outside
of surgery, and failure rates are high.  Given a culture change, where
McDonalds becomes a pariah and exercise becomes more standard, the
conditions may have altered enough that the risk/benefit of surgery no
longer makes sense.  If more women did their Kegels, the benefits of C-
section may completely drop out.

Fourth, it all depends on how you define your outcomes, as previously
stated.  If a good outcome is patient satisfaction, one may
appear "better."  If a good outcome is long-term health of mom or long-
term health of baby, or decreased medical costs, or peaceful birth
processes, or live baby/live mom or however you define it, you will get
different results.  Which explains some of the conflicting studies and the
disagreements between good people.

Fifth, personally, I am concerned about the impact on training for
deliveries.  An excellent article in Mothering pointed out that OBs these
days are unprepared to deliver a breech baby vaginally, and in some
conditions, that missing skill may cost lives.  In general surgery, a
parallel is the effects of laparoscopic cholecystectomy (gallbladder
surgery).  Outside of certain areas, open choles are so rarely done that
surgeons are unprepared for the times when a laparoscopic surgery is
contraindicated or unsuccessful.  I do foresee medicine reaching a point
where OBs are simply not trained well enough to perform a vaginal delivery
under anything but the most basic conditions.  Once C section rates reach
that pinnacle, the surgical risks will begin to manifest themselves.  To
use made-up numbers, if the C-section risks are 3% and the vaginal
delivery risks are 5% in the patients currently undergoing C-sections, but
overtime the less risky vaginal deliveries start to be incorporated, that
may reduce the population vaginal risk to 1%, and the C-sections will be
hurting more patients than it helps.  That may even be the case today, as
I'm not sure if the studies truly reflect the patient populations that are
undergoing C-sections (since patients at major medical centers, where
research tends to occur, tend to be of higher acuity and physicians tend
to have the most refined surgical skills due to volume and academic
environment.)

Have I rambled on long enough?  I am enjoying this discussion immensely,
even when the BFing link is not as strong as usual discussions.

Dr. Wight, I would be very interested in reading more about the lack of
evidence for the "wet lung" theory, if you have that reference available.
Thanks!

Shannon McElearney, MD
PGY4, Department of Surgery
Research Fellow
University of Virginia

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