Caesarian Birth: Messing with Mother Nature

The birth process involves a complicated interplay during pregnancy, birth, and nurturing between the mother and the eventual infant.  What we think of as “maternal instinct” is really a sequence of timed releases of chemicals that—along with physical changes—produce the necessary responses.  Evolution has produced this procedure as an efficient path toward a survivable infant.  Interrupting or modifying this process can lead to unforeseen difficulties because medical researchers are not in a position to claim they understand everything that is going on.

Of particular interest at the moment is our recently recognized dependence on the microorganisms that inhabit our bodies.  Since bacteria are the most fundamental unit of life, and all animal and plant life developed from these bacteria, we have evolved bathed in a soup of microorganisms.  The term “microbiome” was created to recognize this coupling and interdependence between our visible physical bodies and our less visible allies.  A popular and exciting area of research is to discover the role that non-normal distributions of these creatures, particularly in our digestive system, play in causing various physical and mental maladies.  Unfortunately, it is quite easy to upset these populations and cause adverse effects.  Every time we change our diet, change our hygienic procedures, or take antibiotics, we are participating in a game of chance because we do not understand what the consequences might be.

One of the ways in which natural processes are commonly disrupted is via Caesarian birth in which the baby is surgically removed from the woman’s uterus rather than the intended vaginal delivery.  There are reasons why this form of delivery might be necessary.  Medical experts have concluded that in 10-15% of cases a Caesarian (or C-section) birth is better for the mother and/or the infant.  What is troubling is that the operation that can be lifesaving in certain circumstances is now being used routinely as a substitute for vaginal birth even when there are no medical justifications.  This is not a trivial concern.  Wikipedia provides this data on mothers:

“In those who are low risk, the risk of death for Caesarian sections is 13 per 100,000 and for vaginal birth 3.5 per 100,000 in the developed world.”

And this outcome for babies delivered by C-section:

“Higher infant mortality risk: In C-sections performed with no indicated risk (singleton at full term in a head-down position), the risk of death in the first 28 days of life has been cited as 1.77 per 1,000 live births among women who had C-sections, compared to 0.62 per 1,000 for women who delivered vaginally.”

Enhanced mortality is only one of the reasons this increased utilization of C-sections should be of concern to us.

A recent article in The Economist discusses this issue: Caesar’s legions.  Brazil is suggested as being the worst offender, with C-sections being more common than vaginal births overall, and consisting of about 90% of the deliveries in private health care.

“A year ago a hospital in São Paulo announced that its maternity ward would henceforth only admit clients from 10am to 4pm, Monday to Friday. The message was clear: births by appointment only—that is, by Caesarean section. For Arthur Chioro, Brazil’s health minister, it was equally unequivocal: the country’s attitude to birth ‘has become absurd’.”

“In 2009 Brazil became the first country where less than half of babies were born as nature intended. At the last count, in 2013, fully 57% of births were by Caesarean section, in which the baby is delivered through an incision in the abdomen and uterus—almost double the proportion two decades ago. In Brazil’s private health-care system, Caesareans now account for nearly nine in ten births. Brazilian mothers say, only half jokingly, that their obstetricians would not know how to pull out a baby without cutting them open.”

The reason why C-sections are so popular in Brazil is obvious.  As always, follow the money.

“….a study last year found that at the start of pregnancy, two-thirds of Brazilian women wished to deliver vaginally. That less than half end up doing so suggests they are being steered.”

“Hospitals’ neonatal wards profit handsomely from Caesareans, which tend to be performed pre-term. So do obstetricians, who are generally paid per delivery. In the time it takes to assist a single natural birth, a medic might perform several Caesareans. Some charge patients who insist on the time-consuming natural route ‘standby fees’, though they are not supposed to.”

The article provided this tabulation of the percentage of births by C-section versus maternal mortality.  Note that both axes have logarithmic scales.

Essentially all developed countries are performing C-sections at rates considerably higher than medically necessary, and many have higher than expected maternal mortality rates.  For the poorest countries, the highest levels of mortality arise from the inability to provide C-sections when they are medically necessary.

Mortality is not the only problem encountered.  Infants must develop the necessary cadres of microorganisms if they are to survive.  It is believed that an infant acquires its original population of bacteria from the mother.  One of the major opportunities for transfer is the long and intimate descent down the birth canal which is rich in vaginal bacteria.  A C-section eliminates this process entirely.  C-sections are major surgeries, and all surgeries are performed with antibiotics.  The effect of antibiotics taken by the mother before birth on the development of the infant’s microbiome is unknown.

Why the concern?  A study of Danish records compared health outcomes of children born vaginally with those of children born via C-section.

“In the study, recently published in the journal Pediatrics, Bisgaard and colleagues examined the correlation between C-sections and immunological disorders in two million Danish children born over a period of 35 years between 1973 and 2012.”

“The scientists were able to determine from the Danish register of births that:

Children born by C-section have been more frequently hospitalised than those born vaginally due to asthma, juvenile rheumatoid arthritis, inflammatory bowel disorder, immune system defects, leukaemia, and other tissue disorders during their lives.
 

More specifically, the risk of developing asthma is 20 per cent higher if you are born by C-section. The researchers conclude that there is an approximately 40 per cent greater risk of developing immune defects and a 10 per cent greater risk of developing juvenile rheumatoid arthritis.”

One researcher was concerned enough about this to begin collecting specimens containing vaginal emissions from mothers undergoing a C-section to see if smearing the material on the newborn might help it establish a more normal post-birth bacterial distribution.  Carey Goldberg provided Research: Could Birth-Canal Bacteria Help C-Section Babies?

“The usual drill is to wipe the effluvia of birth off of newborn babies, cleaning them up and readying them for snuggling.”

“But in a fascinating departure, researchers have begun to experiment with the opposite: collecting birth-canal bacteria and wiping them onto babies after birth.”

“Dr. Maria Gloria Dominguez-Bello, an associate professor in the Human Microbiome Program at the NYU School of Medicine, presented some preliminary results on that research at a recent conference of the American Society for Microbiology here in Boston. Those initial findings suggest that indeed, using gauze to gather a mother’s birth-canal bacteria and then impart them to babies born by C-section does make those babies’ bacterial populations more closely resemble vaginally born babies — though only partially.”

Dr. Dominguez-Bello also provided this insight:

“There is a lot of stress in labor and some people think that stress is healthy for both the mother and the baby. It’s a long process, so during all those hours, physiological changes occur in the mom and the baby. So I think we have not studied labor enough and tried to understand what it is about labor that is healthy.”

“Plus, with the restoration we did, we do restore the bacteria partially but not completely. And also, the mother’s body prepares to breastfeed, for example — and who knows how many other things — much better after a natural birth than a C-section. A C-section is a sudden interruption of a process before the process finishes. So the body of the mother doesn’t even know that the baby’s out. It takes a while for the body to realize, ‘Oh, there is no baby.’ It’s really an insult to a process that ideally should end naturally, and only by necessity should it be interrupted.”

Messing around with natural processes is risky.  And it is especially outrageous when the motivation is greed.  The birth process is more complicated than just squeezing a large head through a small aperture.  We don’t understand what all is involved, but clearly there are negative effects when the natural process is not followed—and we don’t know what other consequences are yet to be discovered.