It is stated in [1] that “Overuse of caesarean section (SC) adversely affects the health of the mother and the child” [1] with references to [2,3]. However, there are no such or similar statements in [2,3]. The first sentence of [2] reads: “Caesarean delivery can improve maternal and child health” [2]. It is also pointed out that “much of the evidence linking caesarean delivery to chronic disease is observational” [2]. The commentary [3] concludes: “Given the lack of evidence for substantial benefit from elective CS and the possibility of substantial harm, research is also needed” and “From a different perspective, many are arguing about the need for a trial comparing elective SC versus an attempt to deliver vaginally” [3], which can be agreed with. CS as a form of delivery is associated with a higher risk in areas with limited medical facilities; however, surgical procedures generally tend to improve. In industrialized countries, CS has become a safe intervention owing to mastered surgical techniques, improved anesthesia, routine use of infection and thrombosis prophylaxis [4]. Moreover, the literature seems to be generally biased in favor of the vaginal delivery as the “natural” and less expensive procedure. Indirect evidence in favor of bias is the frequently mentioned supposed association of CS with long-term offspring outcomes such as asthma, diabetes mellitus type 1, atopy and gastrointestinal diseases, although the evidence is poor. The proposed mechanisms through which CS could impact the development of the immune system are largely hypothetical e.g. by altering bacterial colonization of the intestine [4]. If it is so indeed, the lack of exposure to certain microorganisms at CS could be compensated by probiotics [5]. Animal experiments might clarify the matter. Importantly, there is no evidence for an association of the mode of delivery and long-term child mortality [4].
The well-known advantage of elective CS is the relatively low risk of fetal injury as well as negative association with neonatal mortality and morbidity in term pregnancy [6]. Some reports on enhanced maternal morbidity and mortality may be biased as they confound CS with diseases related to maternal death that do not depend on the mode of delivery [7,8]. Therefore, CS may be a potential marker for pre-existing morbidities rather than a risk factor of itself [9]. In a logistic regression model adjusted for 5 maternal age groups and severe preeclampsia, women who had CS were not at significantly higher risk for pregnancy-related death compared to those who had vaginal delivery [9]. Moreover, in regard to certain maternal complications e.g. pelvic floor injury and postpartum urinary incontinence elective CS was reported to be protective compared to vaginal delivery and emergent CS [10,11].
Finally, CS facilitates tubal sterilization. It should be mentioned that tubal ligation has been associated with a decreased risk of endometrioid and serous ovarian cancers [12], that female sterilization probably has a positive impact upon sexuality (unless the woman has been ambivalent over the procedure) [13], and that the majority of women are pleased with their decision to be sterilized [14]. In the author’s opinion, CS with tubal sterilization or hysterectomy (in the presence of indications), should be considered for women not planning further pregnancies, which is of particular importance for populations with excessive birth rate [15]. Certainly, the latest delivery is not necessarily the last one, since circumstances may change after the delivery, including death of the child and changed socio-economic settings. Therefore, other factors may be taken into account: the age, attitude of the male partner etc. In the author’s opinion, a systematic performance of CS combined with tubal sterilization could be an efficient birth control method, which would also counteract gender imbalance in the most relevant regions of the world [16]: the sex ratio at birth e.g. in China was reported to increase significantly with the age and number of parities, being very high in non-primipara [17].
References
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