Where Are the Advantages Mentioned?

Indications for and Risks of Elective Cesarean Section by Prof. Dr. med. Dr. h.c. Ioannis Mylonas and Prof. Dr. med. Klaus Friese in issue 29–30/2015

Unfortunately, despite being mentioned in the title, the advantages of cesarean section are not adequately discussed in the article (1). The authors only cite a ten-year-old study, demonstrating a protective effect of cesarean section on urinary incontinence, even though many convincing and, above all, more recent studies are available indicating a protective effect (2). This also applies to the problem of pelvic organ prolapse (3). Also surprising is the unequal distribution of the studies mentioned: The authors list 12 studies on breastfeeding and cesarean section alone, but only a fraction of that number on pelvic floor injuries. This is despite the fact that pelvic floor injuries, in particular, are among the main reasons for litigation after childbirth; consequently, an increasing number of obstetricians calls for an approach to measuring the quality of obstetric care that is based on the extent of pelvic floor injury.

It is also beyond comprehension why only one study—the rightly controversial Term Breech Trial on breech presentation at term—is cited by the authors to address the criterion of maternal morbidity. At the same time, the most recent study on the topic with superior methodology which provides evidence of the advantages of elective cesarean section for breech deliveries is not mentioned at all (4). Besides, it is completely arbitrary to compare maternal morbidity associated with cesarean section and vaginal delivery only in such a specific patient group.

In the meantime, numerous sibling studies have invalidated the frequently heard argument against cesarean section that it increases the risk of chronic diseases, including type 1 diabetes, bronchial asthma and autism. Here, the authors only concede that there is inconclusive evidence on this topic, but do not mention the counter-evidence in favor of cesarean section. These examples show that this non-systematic review omits arguments in support of cesarean section and makes its benefits appear less significant than they actually are, based on the available evidence from studies. This creates a bias against cesarian section.

DOI: 10.3238/arztebl.2016.0191a

Dr. med. Martina Lenzen-Schulte

Medical editor and author

Conflict of interest statement

Dr. Lenzen-Schulte receives royalties on her book “Königsweg Kaiserschnitt“ and has her own blog “Mein-Wunsch-Kaiserschnitt“.

References

1. Mylonas I, Friese K: The indications for and risks of elective cesarean section. Dtsch Arztebl Int 2015; 112: 489–95

2. Gyhagen M, Bullarbo M, Nielsen TF, Milsom I: The prevalence of urinary incontinence 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery. BJOG 2013; 120: 144–51

3. Volløyhaug I, Mørkved S, Salvesen Ø, Salvesen KÅ: Pelvic organ prolapse and incontinence 15–23 years after first delivery: a cross-sectional study BJOG; 2015; 122: 964–71

4. Vlemmix F, Bergenhenegouwen L, Schaaf JM, et al.: Term breech deliveries in the Netherlands: did the increased cesarean rate affect neonatal outcome? A population-based cohort study. Acta Obstet Gynecol Scand 2014; 93: 888–96