A few things happened to me last week which led me to decide to re-share an article that I first wrote in 2002. First, someone asked for it, which is always interesting with an older article. I’m aware that students are now told to focus on new research and writing (which I find sad, given how much insight and wisdom can be found in tracing the history of information, even if current research has overturned findings or sharpened our insight). Then, while looking out the article, I was also reading some of the current news stories relating to information on the internet, and the juxtapositioning of these things led me to decide to re-share this piece more widely. So please remember that the study findings are now somewhat old, but see if you agree with me (and the student midwife who requested the article) that some of the issues remain the same…
The World Wide Wonder
In this time of global electronic communication, it is hard to imagine how different things must have been before the days of e-mail, the Internet and information wiring services. In the May 22-29 2002 issue of the Journal of the American Medical Association, Smith et al (2002) reported – among other things – an analysis of the outcomes of 15,515 women who gave birth vaginally following a previous caesarean section. Within days of this research study being published, four things had happened:
- A number of news distribution services had sent their précis of the study whizzing around the world.
- Newspapers had picked this story up and told their readers how the researchers had shown VBAC to be far more dangerous than a repeat caesarean section.
- Within hours of these publications hitting the streets, pregnant women were logging in to bulletin boards and chat rooms late at night to discuss their options, understandably worried about the potential ramifications of this research on the choice they had made.
- Concerned midwives, doctors and birth activists had started to e-mail each other to discuss the basis for the claims being made in the press.
It seems there is cause for concern. Although the article suggests that the authors’ analysis of the data shows repeat caesarean section to be safer than a vaginal birth after caesarean, this is not borne out by analysis of the paper. The way the women were allocated to the analysis of the “trial of labour” or “repeat caesarean” groups is dubious; women who experienced placental abruption or uterine rupture before labour were included in the “trial of labour” group. (Of course, the use of the term “trial of labour” in itself tells us a lot about the philosophy of the writers and their degree of trust in women’s ability to succeed). Clearly, the mortality rate for these emergency scenarios is high, and this then artificially increased the mortality rate for the “trial of labour” group. Without wishing to dismiss the gravity of these kinds of emergency scenarios for women, they are no less likely to happen to a woman who has planned a repeat caesarean section at 39 weeks of pregnancy than to a woman who aims to give birth vaginally.
Another important issue is the lack of concern shown by the authors of the study to the kind of management these women experienced. With the exception of prostaglandins, the authors did not consider the effects of medical intervention on the women. Some of the interventions routinely imposed on women choosing VBAC in hospital may create problems in themselves. The obvious examples here are the impact of women’s position and movement being restricted by the use of continuous fetal monitoring or intravenous lines and the effect of the increased observations and vaginal examinations that these women often experience. There is no discussion in the study of the effect of oxytocic drugs to induce or augment labour – it may be that these interventions were a cause of increased morbidity or mortality.
For both of these reasons, in the same way that the Canadian Term Breech Trial did not tell us anything useful about physiological breech birth, in that it only evaluated caesarean section and obstetrically-managed breech delivery, this study clearly highlights the dangers of obstetric management for women choosing vaginal birth after caesarean section without giving any irrefutable evidence that physiological VBAC is a dangerous event in itself. As Henci Goer highlighted in a review of the paper, “The real take-home message of this study is: ‘to improve infant outcomes, don’t do more repeat caesareans; do fewer first ones.’”
Aside from the eternal issue of how we can enable women to make choices based on the totality of information rather than one perspective, the speed of electronic communication raises some other questions. It was only a few years ago that some of us were referring to the Internet as “the world wide wait”. Personal computers are now faster and better, allowing speedy access to all sorts of information. The number of informational sites on the net is increasing exponentially and pregnant women were accessing these news reports within hours of their release. Inevitably, the Internet mirrors the bias towards the technocratic approach to birth found in other areas of the mass media.
On the other hand, the Internet is also a tool for those urging caution when reading such studies; the number of web sites promoting choice and a midwifery model approach is also increasing. Within ten days of the paper being published, there were public-access sites on the web where an alternative perspective on this research can be viewed.
But is it too late? Are the women who read this worrying report and stayed up late to talk about it going to return and search the net a few days later to see what else has been said? Will their midwife have had a chance to read the study and its subsequent criticisms by the time they see her to discuss their options? Are the newspapers that published items about the research going to publish the alternative perspectives on this? Or has the story already become last week’s news as yet more new and exciting information is flying across the wire services? (It’s not called “new”s by accident!)
When it comes to global communication, I feel torn. I love the fact that, while I have been sitting at my computer writing this article, I have enjoyed live message conversations with friends across the world. I sent an email to check something I wanted to write and got a reply within minutes. But sometimes I feel that I would like to be a midwife in a place where women weren’t continually exposed to the world wide doubt that they can give birth normally, and where life, information and maybe pregnancy could move at a slower pace. If this was the case, I have the feeling we might all be able to enjoy these things more.
Smith GCS et al (2002). Risk of perinatal death associated with labor after previous cesarean delivery in uncomplicated term pregnancies. JAMA 287(20):2684-90.
Hannah ME et al (2000) Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. The Lancet 356: 1375-83.