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 *********************************************** To temporarily stop your subscription: set lactnet nomail To start it again: set lactnet mail (or digest) To unsubscribe: unsubscribe lactnet All commands go to [log in to unmask] The LACTNET mailing list is powered by L-Soft's renowned LISTSERV(R) list management software together with L-Soft's LSMTP(R) mailer for lightning fast mail delivery. For more information, go to: http://www.lsoft.com/LISTSERV-powered.html