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Caesareans linked to longer-term risks and benefits

Lower risk of incontinence and prolapse, but future miscarriage or placenta previa more likely

Louise Prime

Thursday, 25 January 2018

Women who have a caesarean birth are less likely than those who give birth vaginally to suffer urinary incontinence or pelvic organ prolapse, but also more likely to have a miscarriage, stillbirth or placenta previa with future pregnancies – and children delivered by caesarean section (CS) were also more likely than those born vaginally to go on to suffer from asthma and obesity, UK-led research has found. The team said their review*, published in PLOS, could be valuable in counselling women on mode of delivery, even though it was observational and so could not prove causation.

The researchers, working at the Royal Infirmary of Edinburgh and Tommy’s Centre for Maternal and Fetal Health in Edinburgh, conducted a systematic review to clarify the long-term risks and benefits of caesarean delivery for mother, baby, and subsequent pregnancies. They included one randomised controlled trial and 79 cohort studies, all from high income countries, involving a total of 29,928,274 participants.

They reported that compared with vaginal delivery, CS was associated with decreased risk in the mother of urinary incontinence (odds ratio 0.56) and pelvic organ prolapse (OR 0.29). But it was also associated with an increased risk in future pregnancies of miscarriage (OR 1.17) and stillbirth (OR 1.27), but not perinatal mortality, as well an increased risk of placenta previa (OR 1.74), placenta accreta (OR 2.95), and placental abruption (OR 1.38). Furthermore, children born by CS had an increased risk of being obese by the age of five-years (OR 1.59) and having asthma up to the age of 12 years (OR 1.21).

They noted that as their review is based on primarily observational data, causality may not be inferred, and their results should be interpreted with caution. Nevertheless, they concluded: “When compared with vaginal delivery, caesarean delivery is associated with a reduced rate of urinary incontinence and pelvic organ prolapse, but this should be weighed against the association with increased risks for fertility, future pregnancy, and long-term childhood outcomes. This information could be valuable in counselling women on mode of delivery.”

In a separate paper** published in the BMJ today, a team of World Health Organization researchers report that CS rates have increased in most countries during the past decade, particularly among the richest fifth, which they warn indicates an increase in wealth-related inequality over time. National rates ranged from 0.6% in South Sudan to 58.9% in the Dominican Republic.

But they also found a high degree of within-country variation in CS rates in some nations: in 29% of the countries they studied, “rates in the poorest fifth were less than 10%, indicating under-use, while rates in the richest fifth were more than 15% indicating overuse”.

They urged: “Country-specific strategies should address these inequalities to improve maternal and newborn health.”

* Keag OE, Norman JE, Stock SJ. Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis. PLoS Med 2018; 15(1): e1002494.
** Boatin AA, Schlotheubern A, Betran AP, et al. Within country inequalities in caesarean section rates: observational study of 72 low and middle income countries. BMJ 2018; 360: k55.

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