From the most recent Lamaze newsletter:

June 2006

NIH Fails to Provide Unbiased Evaluation of Elective Cesarean Surgery

by Henci Goer

On March 29, 2006, the National Institutes of Health published a report purporting to assess the state-of-the-science on what it deemed “maternal request” cesarean compared with “attempted vaginal delivery.” The report states: “There appear to be relatively similar degrees of risk from both pathways in women intending to limit their childbearing to one or two children.”

The evaluation process should have produced a thorough, objective assessment of the research. The report was prepared by a supposedly impartial panel of health professionals and public representatives based on:

a commissioned systematic review of the literature,
papers by reviewers presenting the review’s findings,
papers by additional investigators working in relevant areas,
comments by conference attendees. (I was present on behalf of Lamaze International.)

However, to achieve this goal, the foundational systematic review must be sound, comprehensive, and report all relevant results and the reviewers and panel members objective and open-minded. Unfortunately, neither was the case here.

Papers based on the systematic review contained numerous omissions, misrepresentations, and erroneous assumptions. (See the analysis on the Childbirth Connection Web site.) The reviewers knew of these problems. The statement made by Carol Sakala, PhD, MSPH, at the conference indicated that Childbirth Connection served as peer reviewers of the systematic review, and the final draft failed to incorporate their corrections.

The review team, led by urogynecologist Anthony Visco, MD, implicitly acknowledged having an agenda. He and others repeatedly rebuffed criticism by responding that they could not go beyond their tasking. Gary Hankins, MD, epitomized their attitude, saying, “I’m a good soldier. When I’m given an assignment, I carry out the assignment.”

The panel was not neutral, as half of its 18 members had livelihoods dependent on the assumptions inherent in obstetric management (obstetrics, anesthesiology, urology). With the possible exception of a hospital-based nurse-midwife, not one panelist came from a field explicitly supportive of normal birth. Confirming their bias, the panel’s report reflected the systematic review essentially unaltered despite acknowledging the weakness of the evidence, audience testimony pointing out the flaws, and even in the face of contradictory data from conference papers.

The consequences for normal birth will likely be dire. In particular the report:

explicitly undermines national (Healthy People 2010) and international (World Health Organization) cesarean-rate goals, characterizing them as “artificial declarations” based on the opinion of “some authors,”
depicts cesarean surgery as benign, even advantageous compared to planned vaginal birth in many circumstances,
justifies cesarean surgery on such grounds as “need to be in control of the birth experience,” “anxiety about delivery and feelings of inadequacy regarding labor,” “availability of . . . operating rooms and staff,” “unpredictability of timing and length of labor for a provider’s lifestyle and fatigue level,” and “scheduling conflicts,”
calls for establishing a new diagnostic code for maternal request cesareans. Use of this code by providers undoubtedly will create the misimpression that maternal request is common as well as force insurance companies to reimburse for these unnecessary surgeries, and
obscures the real issue: the harms of conventional obstetric management.

After listing non-medical reasons influencing provider recommendations for cesarean surgery, the report states, “Because of . . . the potential for biased recommendations, women should be fully informed about these issues and actively participate in the decision making process.” Take that as marching orders. As the Childbirth Connection analysis states, “All mothers should have access to safest vaginal birth practices. We should not expect them to choose between vaginal birth with avoidable harms and cesarean section.”

Christine H. Morton, PhD

Research Sociologist, Doula

Lecturer, Seattle University

Founder, ReproNetwork

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