Imagine if we did a study on triple bypass heart surgery and divided patients into three groups. The first group contains people who have no heart trouble and don’t have surgery. The second group contains people who have no heart trouble but have surgery anyway. The third group contains people who have unstable angina and undergo surgery. Guess which group would have the best health outcomes. Not surprisingly it would be the group who have no heart trouble and don’t undergo surgery. That’s because they were healthiest to begin with and were not exposed to the risks of surgery.
That’s pretty much the study that the World Health Organization did on C-section in Asia, Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007—08. They compared three groups: women who had no reason for C-section and underwent vaginal delivery, women who had no reason for C-section and had a C-section anyway (subdivided into antepartum and intrapartum C-sections), and women who had medical necessitating C-section and underwent a C-section (subdivided into antepartum and intrapartum C-sections). They also include a group for women who had operative vaginal delivery (forceps or vacuum) though they did not specify whether there were medical indication. It would hardly be surprising if the group that had no medical complications and underwent uneventful vaginal delivery would be the group with the best neonatal outcomes. And that would not be an indication that C-section was dangerous or inappropriate because we would expect that women experiencing complications would have higher rates of neonatal mortality.
What is surprising is what the WHO researchers actually found: the group of babies with the lowest neonatal mortality were born to women with NO reason to have a C-section but who had one anyway! In fact, the babies of women who had C-sections without a medical indication had the best results on every possible indicator.
For reasons that I cannot fathom, the World Health Organization is insisting that the interpretation of this study is simple:
To improve maternal and perinatal outcomes, caesarean section should be done only when there is a medical indication.
But that’s certainly not what the data on perinatal outcomes shows.
How about maternal outcomes?
Both blood transfusion and ICU admission were increased in the women who underwent C-section without medical indication, but the rate of hysterectomy was zero and the rate of maternal death was zero.
I don’t understand how the WHO researchers can justify their conclusions based on the data that they gathered. In fact, I’m not sure exactly what they thought they were studying. If we want to find out the safety and efficacy of a procedure (like C-section) we identify specific conditions or risk factors and divide patients into the treatment group (C-section) and the control group (vaginal delivery). We certainly don’t compare all women who had C-sections with all women who had vaginal deliveries because they are going to differ in very important ways.
I just don’t get it. This is a poorly designed study that can’t possibly yield any valid results. The authors compounded their error by misinterpreting (basically ignoring) the results that they got and instead reached a conclusion decrying C-section that seems to have been pre-determined before the study began.
