Important update:

On October 15, the study’s lead author, interviewed by ABC Babytalk, said:

“In all seriousness, I think that at the end of the day, I think what we’re going to find when we do further studies, I’m sure we’re going to find, if anything, is that these effects are relatively small compared to the home environment. So you can’t get away from the fact that what really matters for a child’s development is what goes on in the home, not so much the mode of delivery.”

Original Caesarean Birth article:

“A lie can travel halfway round the world while the truth is putting on its shoes.”  (attributed to Mark Twain in Chapter 8 of our book)

In their study, The relation between cesarean birth and child cognitive development Scientific Reports 7, Article number: 11483 (2017), Melbourne researchers Cain Polidano, Anna Zhu and Joel C. Bornstein measure differences in the cognitive performance of 3,666 children aged 4 and 9 years whose mode of birth was caesarean (n.1,080) or vaginal (n.2,586); see Table 1.

The researchers do make some effort to control for risk factors that may have led to the caesarean birth, but fundamentally, this is a study looking at ALL caesarean outcomes (i.e. mixed data), seeking to inform decisions about maternal request caesareans.

Importantly, the researchers cite the WHO’s (still) shocking recommendation of a “15% ceiling“, without question (which is always a red flag), and raise concerns about “reduced fertility” (countered by the NIH in 2006 in the context of maternal request) and other “established links” between caesareans and “asthma, type I diabetes, allergies and obesity” (these are not established for maternal request).

Why target maternal request?

So how can it be that “the key message to medical practitioners is to take a precautionary approach when formulating birth plans, especially when there are no apparent elevated health risks from vaginal birth.”

– There are always elevated pelvic floor risks.

And “Informing mothers of the risks and benefits of cesarean birth should be a priority, which may be formalized by incorporating education sessions into practitioner guidelines.”

– Informing mothers of the risks and benefits of vaginal birth should be an equal priority.

Especially when the researchers admit, “This does not mean that we have established causal relations because bias from unobserved confounding is still possible.”

– Absolutely.

Moreover, “Specifically, we find that child cognitive outcomes are positively associated with mothers that are college educated (3-year bachelor degree), who give birth at an older age, who are partnered, who have private health insurance, are employed and have fewer previous births.”

– This describes just the type of woman who may be better able to access a maternal request caesarean, especially when faced with opposition.

Risks of vaginal birth are still relevant 

  • 24.4% of first-time mothers in the UK have forceps or ventouse births (RCOG data 2013-14), and pelvic floor damage risk is higher with instrumental deliveries.
  • Between 4 and 7% of first-time mothers will suffer a third or fourth degree tear during a vaginal birth and require ongoing treatment in the long-term (RCOG data 2013-14).
  • Episiotomy rates for first-time mothers are between 35.5% and 88.7% (RCOG data 2013-14).
  • Stillbirth and serious infant birth injuries can occur in a planned vaginal birth where a caesarean birth is withheld or delayed when needed or wanted (see NHSLA reports, litigation cases).

 Media reports need greater balance

I’ve worked in 24-hour broadcast news, so I understand the pressure to report on a new press release or research paper with very limited time available.

But of every article I’ve opened so far, not one has contained a link to the actual study, and most have made little or no effort to challenge, counter or balance the study’s “key message” on maternal request.

These key messages will be repeated around the world in the coming days:

“The researchers said their study underlined the need for a precautionary approach in responding to requests for a planned caesarean when there are no apparent elevated risks from vaginal birth.” The Chronicle

“If a kid were to miss 35 days of school, a sixth of the school year, that’s about how far behind they are.” 3AW

“Professor of physiology Joel Bornstein said it was possible gut bacteria picked up in the birth canal by babies born by vaginal delivery may give them a distinct developmental advantage down the track.” MouthsofMums

“Approximately 30 per cent of all births in Australia are by caesarean section- that’s way higher than the World Health Organisation’s recommended figure of 15 per cent for developed countries.” Herald

Access to caesarean birth plans

Interestingly, the researchers note: “Important in the context of this study, maternal requested cesarean birth (without any medical risk factors) is not covered by the public health system. While mothers without private health insurance can still elect for cesarean birth in a public hospital, this is uncommon because they would incur all medical costs. It is much more common for elective cesareans to occur in private hospitals under the cover of private health insurance. This explains the 11 percentage point higher rate of private health insurance among cesarean born children than among vaginally born children.”

As such, my takeaway from the study is concern for the women who cannot afford private health insurance, and therefore access to a maternal request caesarean.

It is unfair that only the wealthiest, most educated or sharp-elbowed pregnant women can access this informed birth plan, especially when you consider other Australian research that reported a 9.25/10 mean satisfaction rate among 78 first-time mothers who requested a caesarean.

Or research in “Sweden, when responses from 91 women who had planned a cesarean birth with no medical indication were compared with 266 women who had planned a vaginal birth (both groups first-time mothers with no known complications), at two days, and again three months after the birth, the cesarean group reported a better birth experience than the vaginal group.” Extract from our book.

Research must be relevant to birth plan

I don’t claim that a caesarean birth is risk free, and I do think studies such as this one are important.

However, so is context, and so is balance.

No one, not doctors, not midwives, and certainly not economists, should be making recommendations for antenatal education and guidelines around maternal request caesareans based on mixed caesarean data, or in the absence of well documented vaginal birth risks.

The World Health Organization, and those who repeat its dangerous caesarean rate recommendations, may not care to consider stillbirth or pelvic floor risks (for example), but many women do, and they deserve to be informed of these facts, together with what may or may not happen with their child in Grade 3.

Then they can make their own choice.

  • Written by author and journalist Pauline Hull