 Good afternoon. On behalf of the McLean Center, the Department of Obstetrics and Gynecology, and the Bucksbaum Institute, I welcome you to the seventh lecture in our 2016-17 series on reproductive ethics. It's a pleasure to introduce our speaker today, Paul Bircher, MD, PhD. Dr. Bircher did his fellowship with us in the McLean Center in 2014-15. And, sadly, I had the dates a little wrong. Dr. Bircher is now an associate professor of obstetrics and gynecology at the Albany Medical College. Is also the program director of the residency there. And is the associate director of the Alden March Bioethics Institute at Albany. Professor Bircher received his MD from the University of Arizona College of Medicine and a PhD in philosophy from the University of Oregon. Paul Bircher's publications have focused on the doctor-patient relationship, physician empathy, and, more recently, on ethical issues in clinical obstetrics. He has written to defend home births. In this conference, we've heard some vigorous attacks on home births, including a recent article by Dr. Bircher entitled, I think I've got this title right. There is no place like home. The limits of institutional change and why home birth remains a rational choice. Currently, Paul has engaged in a research project studying cesarean section regret in an effort to develop strategies to reduce dissatisfaction and regret among women who undergo C-sections. Dr. Bircher is also co-editing a textbook on reproductive ethics that will be published by Springer in April of 2017. Dr. Bircher remains clinically active as a practicing obstetrician and gynecologist and enjoys his work with medical students and residents. He was the recipient of the Association of Professors of Gynecology and Obstetrics Excellence and Teaching Award in 2015 as well as resident teaching awards from Albany in 2014 and 2015. Today, Dr. Bircher is going to talk to us on the following title. Cesarean Delivery on Maternal Request, Did We Let Birth Choice Override Safety? Please join me in welcoming Dr. Paul Bircher. Thank you, Dr. Siegler and thank you, Dr. Chor, for inviting me. I appreciate the opportunity to speak here. It's wonderful being back in Chicago. I was reminded last night of all the fabulous restaurants here. Albany is good, but it does not rival Chicago. So what I'm gonna be talking about is what the American College of OB-GYN refers to as CDMR, which stands for Cesarean Delivery on Maternal Request, or you could also think of it as Maternal Choice Cesarean Birth. So I'm gonna review essentially the history of CDMR in the literature and then talk about kind of a changing understanding of the ethics of CDMR and ACOG in particular shifted its position on CDMR between 2007 and 2013 and I'm gonna talk about why that shift may have occurred. And then I'm gonna end with a suggestion that perhaps a medical application of the precautionary principle might be a useful way of framing this discussion about the ethics of CDMR. And if I am guilty of OB speak, meaning that I start using abbreviations or medical terminology that I haven't properly defined, please just stop me and I will do that. I forget that not all of you have to live and breathe obstetrics the way I do. So as I said, the term that I'm gonna use is CDMR, which means an elective cesarean section requested by the pregnant woman. That is actually different than the term elective cesarean section. A survey of women who were postpartum actually found that the more common cause of an elective cesarean section was a physician initiated elective cesarean section. So a woman initiated is actually less common than physician initiated. But an elective cesarean section in general means one that doesn't have a medical indication. And so an elective cesarean section where the woman makes the request is then CDMR. We don't have a really great hold on how many CDMR cesarean sections occur. And the reason is is there's no, I guess it's ICD-10 code. There is no code for CDMR. And so the ways of sort of getting at what the true number is difficult. Most of the literature places the number at somewhere between two and 8% of cesarean sections, although the NIH actually estimated that it was higher than that. And some of the more recent literature has also sort of intimated that even that 8% number may be too low. I used the two to 8% number to say that the exact number then would be somewhere between 30 and 100,000 per year. And that's based on the fact that there are 1.3 million cesarean births in America per year. And our overall cesarean section rate in America currently is running at just over 32%. The first paper in the literature that sort of tracing the ancestry of CDMR was an opinion piece in the New England Journal published in 1985. There was no, this was not a study, there was no new data. They were essentially extrapolating from the literature and making the case that elective cesarean sections should be offered to women. And here was their reasoning. We do know, and this is actually pretty solid data, that an elective cesarean section has less morbidity and mortality for a woman than a cesarean section after labor. So an indicated C-section where the woman has either failure of arrest or dilation or dissenter for any of the medical indications that we normally use for cesarean section. Once a woman has labored, a C-section is actually more dangerous for her than a scheduled elective cesarean section prior to labor. And they argued that if we simply did elective cesarean sections on all women at 39 weeks, one week before their due date, where there's no risk of iatrogenic prematurity for the baby, that we would actually be reducing stillbirths and hypoxic ischemic esophilopathy. That is a baby that's been damaged by lack of oxygen during birth, okay? So brain damage to the baby because of lack of oxygen. And that by simply eliminating labor between 39 and 42 weeks, we would be reducing stillbirths and essentially eliminating hypoxic injuries to newborns. And by their math, they calculated that essentially five to 10 babies' lives would be saved by their best guess would have one excess maternal death. So they said, oh, that looks pretty favorable. So based upon that, this is something that should be offered and discussed with all the patients. Another interesting point in this article, which is that again, by their math, they said if the C-section rate were to ever get above 27%, then elective cesareans might actually be safer in that pregnancy than planned vaginal birth because again, so many women would be suffering complications from the cesarean sections after labor and that complication rate is higher than simply having an elective cesarean section that above 27%, it might be more favorable from the woman's perspective to simply be doing elective cesarean sections on everybody. And of course, we are above 27% right now. Now, after that paper, if you look at the literature, the historic evolution from there is as follows. In the 1990s to 2004, again, the literature was trying to sort of get a handle on how much CDMR was actually occurring, but most of the literature was in favor of showing a trend upward for CDMR during the 90s and early 2000s. FIGO, which is the International Federation of Gynecologists and Obstetricians in their ethic statement in 1999, and by the way, this was a big document essentially about all sorts of ethical issues and obstetrics and there's exactly one paragraph on this and I've quoted most of it, okay? So it's not like there was a lot of argumentation here, but what they said was at present, because hard evidence of net benefit does not exist, performing cesarean section for non-medical reasons is ethically not justified. So they took a purely sort of net benefit beneficence-based argument and said, there's not good evidence of a net benefit, we should not be doing CDMR. This is more of a world body, it does not so much representing the views of American obstetricians. Five years later, two very prominent OB ethicists, Howard Minkoff and Frank Schervenak, who spoke here a couple of weeks ago, right? Published in the New England Journal and Opinion piece where they actually took the opposite view. They said, based on the fact that the risks and benefits of CDMR are actually relatively balanced, or at least we can't make a strong case that one option is safer or better than the other, that we feel that a maternal autonomy is sort of the most important principle here and that it's ethically permissible to accept a request for CDMR. Now, they also said though that because there was no net benefit, that this was not something we should be offering our patients, but that if a patient requested it, that in the presence of a robust informed consent discussion, we could accept that request. And actually the same year, ACOG, the American College of Obstetrics and Gynecology, in a bulletin that had to do with surgical decision making, not with CDMR specifically, just surgical decision making, they essentially said the same thing about CDMR, they said, it looks like the risks and benefits are comparable in a setting of good informed consent. We think that patient autonomy argues in favor of accepting requests for CDMR. Two years later, there was an NIH consensus panel convened about the question of CDMR and these are the conclusions of their findings. They said, it does appear that CDMR is increasing, it's hard to get a good handle on it. The upper limit number of 18% seems really too high for me, but it is unclear exactly how often this is occurring. There's obviously never been a randomized controlled trial where we took pregnant women and said, you're gonna get an elective cesarean section, you're gonna have a trial of labor, so our evidence is all indirect regarding the safety and risks of this. They said in the discussions with patients, that you should have individualized, essentially sort of a shared decision-making model where you look at the risks and benefits for that patient specifically. They reaffirmed the idea that elective cesarean section should not be occurring below 39 weeks because then you would potentially be incurring additional risks to the fetus in terms of iatrogenic prematurity. And then they said, well, but here's two cases where we don't think it's such a good idea in case of maternal obesity or in a case where there's an intended large family size. Well, neither of those terms did they define. So they didn't say at a BMI of 35, it's no longer a good idea that there was no quantitation of what they meant by that or how big is a large family. So their conclusion statement was after thorough discussion and review, cesarean delivery on maternal request may be a reasonable alternative to planned vaginal delivery. Sort of a neutral to essentially positive conclusion. ACOG followed a year later with now a committee opinion specifically on CDMR, opinion number 394. And they said, they essentially reviewed the data in the same way that the NIH did. So I'm gonna go over essentially, their findings were essentially lockstep with NIH. They said there are five outcome variables where we think the data is good enough to sort of render an opinion about the risks and benefits. In terms of maternal hemorrhage, that data actually surprisingly favors cesarean sections. So that there are actually worse hemorrhages associated with vaginal birth than with elective cesarean sections. And so on the basis of maternal hemorrhage, that's an outcome variable that favors an elective cesarean section. Obviously maternal length of stay favors a vaginal birth. Women stay one to two days in a hospital after a vaginal birth. It largely has to do with establishing breastfeeding and bonding and things like that. That it's not as medically indicated as it is for a woman who stays three to four days post C-section because she's recovering from major abdominal surgery. Neonatal respiratory morbidity. Certainly the pediatricians in the audience recognize that babies are much more likely to go to the NICU after a cesarean section than after a vaginal birth. And the primary reason that they go to the NICU is because they have wet lungs, right? TTN, transient tachypnea of the newborn. That in the process of a vaginal birth, the baby sort of gets squeezed dry and comes out ready to breathe where in a cesarean section they sort of get plucked from the pool and they come out wet and maybe not ready yet to breathe and they may require more support, more oxygen, et cetera. So let me define a couple terms here. So problems with the placenta in future pregnancies and this is a topic we're gonna talk about a lot more in this, that favors vaginal birth. So placenta previa is when the placenta implants too low in the uterus and is covering the cervix and that can lead, it does lead off into prematurity, maternal hemorrhage and sometimes hysterectomies. A placenta acreta is when the placenta, and this is often associated with the placenta previa, is when the placenta actually grows into the wall of the uterus and sometimes beyond the wall of the uterus. So in the case of a placenta per creda, the placenta can actually grow beyond the uterus into the vessels of the pelvis, into the bladder, into the bowel, right? So a very, very serious complication that requires significant surgical subspecialty support. That almost never happens in subsequent pregnancies after a vaginal birth. It is increased significantly with caesarean sections and I'm gonna show you some data on that. And then if you have a caesarean section, you have a scar in your uterus and then with future pregnancies, there's the possibility of that scar opening up. If you try to labor, that risk is about one to two per hundred, but there are cases of actual uterine rupture even prior to labor. So the uterine rupture is a potential complication with caesarean section in future pregnancies, even if you plan on having future caesarean sections. This table is from the ACOG committee opinion and what I'm gonna have you focus on is this. So you can see that once you have, once you're having more than one caesarean section, additional caesarean section, the risk of placenta acreta now becomes substantial and you can see it increases dramatically with additional caesarean sections. The same is true for the risk of hysterectomy. They went on to say that surprisingly that they felt that these were four areas that they felt the data was either inconsistent or too weak to pass judgment on or to make decisions regarding the viability of CDMR. So remember the paper from New England Journal in 1985 that actually argued that one of the reasons we should do elective caesarean sections was stillbirth. They said, well, no, because although in the index pregnancy and in that particular pregnancy, the risk of stillbirth goes down if you simply deliver the baby at 39 weeks, but in future pregnancies, stillbirth rates are actually increased by a prior caesarean section. So they essentially cancel each other out. All right. Pelvic organ prolapse, I think it's, we consider it sort of common knowledge that caesarean sections reduce pelvic organ prolapse. And that's true to some extent, but the number needed to treat, that is the number of caesarean sections you would need to do to prevent a single case of pelvic organ prolapse that requires surgical intervention is so high that that's not a good argument for performing caesarean sections. Specifically, if you look at stress and continence, involuntary loss of urine after a pregnancy, in the first year after a vaginal birth, women who have had a caesarean section have less stress incontinence than a vaginal birth, but if you look at two years, there's actually no difference. So the incidence of stress incontinence two years out from a birth is no different between a caesarean section and a vaginal birth. Maternal mortality, again, I want to focus here that this is in dealing with that specific pregnancy, the index pregnancy. There's no evidence that there's a substantial difference in maternal mortality between an elective caesarean section and a trial of labor. And somewhat surprising to me at least, that thromboembolism wasn't increased by a caesarean section because certainly we tend to think of pelvic surgery as increasing thromboembolism, but they said the evidence wasn't strong for this. So the recommendations that ACOG 394 made were they reaffirmed the 39 week rule. They said that the request for CDMR should not be based on an unavailability of effective pain management, and this is a Hollywood representation of what that would look like. That if the issue is a fear of inadequate pain relief, that that should be dealt with at an institutional level, not by performing elective caesarean sections. And again, they said that it's not for women, they would not recommend it for women who desire several children, again, without defining what that would be and where they think that cut off should be. So the ACOG Committee Opinion 394 essentially took a neutral to permissive stance on CDMR, saying in the setting of informed consent with adequate discussion of risks and benefits and shared decision making, it's okay to go ahead with a CDMR request. I wanna break this down now looking at the four biomedical principles. I will say all my images came from Google Images, and I found this one particularly striking because what I Googled was maternal autonomy, and what I got was a headless pregnant woman. So I just thought that was worth pointing out. So now, going back to autonomy for a moment. All right, so what ACOG essentially said was, we think that the privileging of maternal autonomy is appropriate in this circumstance, given that we don't have a clear risk or benefit reason not to privilege autonomy, so that in the setting of informed choice, individualized recommendations can be made and in the setting of shared decision making, it's okay. So the literature has expressed a couple concerns regarding this privileging of autonomy. One is, it's a paper that I will talk more about further, that interviewed women after they'd already made a decision in favor of CDMR. And in that qualitative study, actually none of the participants could name a long-term risk of CDMR after they had already signed their consent for CDMR. The second concern that I have and that others have shared is that the United States couples and women in the United States consistently underestimate our fecundity. That is, we have more children than we intended. We are the only developed country where that's true. And on average, we tend to have about one more child than we initially planned. I will say for myself, when I was a young man, if you had asked me, I would have said I want 1.2 children, one child and a small dog, right? And I have three, right? So in that sense, I'm a typical American, right? And so obviously the estimated family sign is an important factor in the safety of CDMR. And if we consistently underestimate our actual family versus intended family, that's a problem with our decision-making. Staying on the topic of autonomy, there's sort of two views about how we should understand the decision-making regarding CDMR. I think the view of NIH and the view of ACOG is that a request for CDMR is essentially an assertion of a positive right of autonomy, that we have sort of a presumption toward vaginal birth. That's sort of the evolutionary default and that someone is requesting something different than the default. And therefore, while a request could be acceded to if the risks are commensurate, it's not something that you have to provide, right? Because it's a positive right, which is obviously more circumscribed than negative rights of autonomy. There's a counterargument which you can see in that very first paper from the New England Journal where I think that they are implicitly making the opposite argument. They're essentially saying, no, there's really two ways to give birth, right? 70% of women deliver vaginally, about 30% of women deliver by caesarean section. They both have different risk profiles and therefore it should be patient choice. More like analogous to mastectomy versus lumpectomy and radiation. There are two ways to treat this and women should be offered both options and they should be the ones making the decision, right? Under this model, where the difference is, is that if you accept this, then this is actually something that we should be offering to all of our patients. It's one of the two ways that a woman could give birth and so everyone essentially should have a conversation regarding the pros and cons of CDMR. I would say that's the minority position. The feminist bioethics literature has pushed back on CDMR saying, no, CDMR is not an expansion of maternal autonomy. That's a misconception of this whole debate. So Sylvia Burroughs in the American Journal of Bioethics made the argument that first of all, for it to be an autonomous decision, it requires informed consent, right? That's a given. And that there's so much lack of clarity regarding the real risks and benefits of CDMR that you can't really make an autonomous decision. As both the NIH and ACOG said, the risks going both ways, a lot of the evidence is poor, a lot of the evidence is indirect. Therefore, this is not really an autonomous decision. Furthermore, that women have been socialized into essentially fearing childbirth and believing that there's a technological, what she calls a technological imperative, that you think about how childbirth in America happens. You go into a hospital, you get an IV, you're on a monitor. 80% of our patients get an epidural in labor. So the appearance is that birth is made safe by technology. And if that's the case, then obviously, then the ultimately safe birth would be the most technological birth, which would be a caesarean section, right? So this technological imperative actually sort of coerces women into thinking that the caesarean section is the best option for birth. Moving on now to the second principle of biomedical ethics beneficence. What I would say about this is that there's a lot of distortion regarding why women are actually choosing CDMR and the media is certainly not helping this. So in a paper where Dr. Wax looked at sort of all the studies about why women were choosing elective caesarean sections, the overwhelming reason is not what you might think. It's not convenience, it's not the high-powered mom, it's actually fear of labor. And that most of these women were of a lower socioeconomic class, they had higher rates than average of depression and anxiety, and a lot of them actually had prior trauma. Some of them prior birth trauma, some of them prior traumatic experiences in their life. Now I wanna step aside one moment and say, I recognize that this is actually different than the rest of the world. So in a lot of the developing world, CDMR actually is sort of a upper-class sort of phenomenon associated with the wealthy, but that actually appears not to be true in the United States. Then in this qualitative study that I referenced previously from the Journal of Midwifery, where they interviewed women who were going to have a CDMR birth, the way the women spoke, and again this echoes what Sylvia Burroughs was talking about, was very much of, one of the women said, well, I've never given birth, I don't know anything about it, but the doctor has delivered thousands of babies, so I just wanna turn it all over to him, and because he's the expert, so I'm gonna let him take care of this, sort of a switching off, right? And that what they wanted was the baby, they had, there was literally no privileging of sort of the birth experience or the birth as an event itself. So what I wanna contrast this with is the popular conceptions about CDMR that as I suggested, actually, the literature I said are wrong, but I think this actually distorts the whole conversation regarding CDMR, so I just wanna spend a moment talking about that. I also wanted to say that I didn't understand the pun of this until, so we did this paper published in birth doing a content analysis of the media representations of CDMR, and I think we put in the first paragraph, we used that term too posh to push, and I actually didn't even understand it at the time that the paper was published, it had to be explained to me that that's a pun, right? Because this is Victoria Beckham who her name as a spice girl was posh spice, right? She had four elective Caesarean sections and hence the term too posh to push arose related to her choice to have elective Caesarean sections. But what I wanna point out is that in popular media representations, the fear of labor which as I said is the overwhelming driver of CDMR is essentially completely ignored, right? And instead the popular perception is this too posh to push, that this is what rich people do, this is what high powered people do. Also in the popular media, the risks of Caesarean section are essentially never discussed. And the other thing that's never discussed is the fact that there's significant physician ambivalence around CDMR, right? So in surveys of obstetricians in America at least, between 43 to 48% of them actually will not perform a CDMR Caesarean section. And only 18% of them think that that there would be some circumstance where they would find it acceptable for themselves or for their partner. So the perception in the popular media is that physicians are all gung-ho about this and that it's the rich and famous for getting it. And that's actually not the reality. The justice issues are also muddier than you would think. So my own view prior to looking at this was, well obviously from a distributive justice sense it does not make sense to be performing an unindicated surgery, right? Obviously Caesarean sections are much more expensive. Than a vaginal birth, in fact, they're about twice as expensive. But the problem is that we have, with a C-section rate of 30%, the most expensive patients are actually the ones who labor and then get a Caesarean section, because then they take up all those resources sometimes for more than a day on labor and delivery and then still take up all the surgical resources. So our C-section rate being as high as it is actually makes the justice issues sort of a wash. But that's true only for the index pregnancy, meaning that for that particular pregnancy. For future pregnancies, we know that repeat Caesarean sections are obviously much more expensive than repeat vaginal births. And that for those more complicated repeat pregnancies, the ones complicated by previous, accretives, et cetera, those are incredibly expensive births and incredibly complicated. So between 2007 and 2013, something shifted. And this is what I find so interesting. So this is the, in 2013, ACOG disavowed the 394 communion. In fact, it's actually really hard to find because they take it off their website. They even take it off previous editions of the Green Journal. It actually took some digging to find the exact wording of the original, of the original committee opinion and then issued this new committee opinion. What's in red are the changes between 394 and 559. So they added the word pre-labor and then they ended the abstract with this. Given the balance of risks and benefits, the Committee on Obstetric Practice believes that in the absence of maternal or fetal indications for Caesarean delivery, a plan for vaginal delivery is safe and appropriate and should be recommended to patients. Well, it gets even more interesting than that, all right? Because there's no new references. The whole evidence section is a cut and paste from the previous committee opinion. There's no change. They use the exact, the same citations, same references, same discussion of risks and benefits. So actually they don't explain why they make the change anywhere in the new committee opinion. The pre-labor part is also sort of an interesting addition. When this committee opinion came out, we were actually in final revisions for our own paper from the Green Journal where we had argued against CDMR in labor. And well, I'd love to flatter myself and think that that was because of my paper. I think that they reached the same conclusions that we reached independently, which is that informed consent in active labor, given the sort of wide-ranging discussion you're supposed to have with a woman regarding CDMR, that it just doesn't seem practical that you're going to adequately do that with a woman in active labor, both with the time constraints and everything else. And then the additional problem with why I think they added the word pre-labor is that, remember, the risks and benefits are supposed to be balanced. But once a woman is actually in labor, performing a caesarean section at that point is actually riskier than a vaginal birth. And so it's reasonable at that point to say, well, actually now this is no longer something that should be on the table because the risks of a caesarean section at this point, in terms of infection and hemorrhage, et cetera, are higher and so it's really no longer a good option. But it's clear also that their wording has, despite the fact that they don't discuss any new evidence, has shifted from a neutral position to one where they're actually favoring vaginal birth and recommending against CDMR. Now, Dr. Ecker is the next person to speak in this series. And I think in this opinion piece published in JAMA right around the same time, he is giving the logic behind the change of the committee opinion. So he said, importantly, these evaluations, the NIH consensus statement, and I would argue, the earlier ACOG committee opinion, consider only the index pregnancy and not outcomes in future pregnancies in which a prior caesarean delivery may lead to increased complication rates. I think that that is the explanation for the shift, that they realized that perhaps they had focused too much on only that pregnancy and not looked at the long-term consequences of elective caesarean sections. This is a paper from the Green Journal published two years before the 2013 change that looked at, it is an association, it's not implied causality, but what they found was that in 1998, the caesarean section rate was 21%, and the maternal mortality was 10 per 100,000. By the year 2004, the caesarean section rate had climbed by eight points, and the maternal mortality rate, maternal mortality, had also climbed. And they at least hypothesized that the increase in multiple caesarean sections, which we know is associated with significant complication rates and hysterectomy rates may be one of the drivers of the increase in maternal mortality. This paper from 2015 digs a little deeper on that question. So when I was a resident in the early 1990s, I can count on one hand how many placenta acridas we took care of at University of Rochester. And it was, I think, three and four years, even though we had a very large catchment area. And I remember one of them distinctly, because one of them was a patient who was delivered at a community hospital rather than being transferred to the university hospital, and she actually died on the table. So she was a maternal mortality related to a placenta acridas, and the obstetrician was roundly criticized for not transferring her to the tertiary care center. So I think while these statistics are somewhat reassuring, the problem with this study from the Green Journal is that it was looking at the outcomes only from tertiary care centers, where we have a lot of experience dealing with acridas. I will tell you that experience has increased dramatically. So now, in contrast to my experience as a resident, we deal with one to two placenta acridas per month at Albany Medical Center. We have an acreta team, right? And so we go from three and four years to one to two a month, but the caesarean section rate in the 1990s had just climbed to like 16%, right? And now we're looking at, our caesarean section rate at Albany Medical Center is almost 40%, almost 40. We also have almost no low-risk births. Almost all of our births are high-risk transfers. I say that to excuse us. So this paper from the Green Journal said yes, the rates of placenta acreta are increasing. They recommended tertiary care delivery, but the problem is is that you only identify about half of the acridas prior to the birth, which means that a lot of acridas are actually being delivered in community hospitals. And this paper actually doesn't address the outcomes in community hospitals. In fact, there has not been a paper addressing what the outcomes are for acridas in community hospitals. And this may be a silent driver of increased maternal mortality. This number is actually artificially low because a number of these abnormal placentas were only focal acridas. In the ones that were true acridas, the average blood loss was over 3,000 ccs. And you can tell this is artificially low because they have a 70% hysterectomy rate and true acridas, the hysterectomy rate approaches 100%. The other number that I thought was a little bit low is only one-third being admitted to the ICU. We essentially admit all of our accretive post-hysterectomy patients to the ICU, at least for the first night because of usually the massive amount of fluids that they receive. So this paper from the Journal of Maternal Field Medicine argued that essentially, that our increasing caesarean section rate, and particularly our elective caesarean section rate is actually driving an increase in maternal mortality. I'm sorry. Well, he acknowledges that, at least for the first caesarean section, it's not clear whether maternal mortality is actually increased or not. He said the evidence is pretty compelling that with multiple repeat caesarean sections, there's a higher rate of maternal mortality. And that ACOG's position of taking a neutral permissive stance is actually going to have the effect, if it's not already having the effect of increasing maternal mortality. And the other point he made is, remember that the first caesarean section after an elective caesarean section isn't that much riskier than the original caesarean section. It's the next one and the next one where the risks really start mounting. So he said there's really about a six year lag before you're going to start seeing a significant increase in maternal mortality because of this. Marion MacDoran, who is a CDC epidemiologist published in the Green Journal just this year, actually just a couple months ago, a paper regarding the uncertainty involving maternal mortality. So I didn't know this, but apparently, since 2007, the CDC's statistics on maternal mortality have been unofficial. And the reason is, is because in 2007, there was a change in the reporting requirements so that states were supposed to adopt some specific questions regarding maternal mortality on death certificates so that they could follow that. The problem is is that some states adopted it right away, some states have yet to adopt it and some states adopted it but modified it. And so our maternal mortality reporting is now sort of a mess. And as she tried to dig down on it, what she said is what is clear is that, I'm sorry, is that there has been a real increase. Remember in the 1990s, the maternal mortality was 10 per 100,000. The best estimate right now is that it's close to 24 per 100,000, all right? Now some of that may be better reporting, but she said it's clearly not all better reporting. I will try not to comment on the fact that Texas's maternal mortality has doubled. And the quote from the paper where she said that this appears to be real, not an artifact of reporting and that the only time they've ever seen that kind of change in such a short period of time is in wartime. California, on the other hand, that has worked actually hard in terms of trying to get the state to propose hospital-based initiatives to reduce maternal mortality has actually been very successful with strategies at dealing with hemorrhage and preeclampsia. So it is possible to drive the maternal mortality rate down, but it takes a concerted effort. The Sylvia Burrow article that I mentioned earlier references something that I think a lot of obstetricians have also reflected on and thought about and even talked about, which is, does the mere presence of elective cesarean sections drive up the cesarean section rate more than just the elective cesarean sections? We've all sort of heard on labor and delivery that it's like, well, now we can do a C-section for any reason, this one's not going so well, let's just throw in the towel. So the idea that are we throwing in the towel earlier now that you don't really need an indication for a cesarean section? So is there a multiplier effect? That's on the physician side. And then on the patient side, similarly, and this is what Sylvia Burrow was addressing, is are women less and less confident in their own ability to give birth and therefore more and more willing to simply throw in the towel or even request a cesarean birth? You may notice that I actually changed the title from here to the one I gave today. I dropped the word maternal safety and just said safety. And the reason is is because there's some new evidence that I've only recently been made aware of. It was actually a third year medical student that actually pointed me to this literature about the potential consequences for the baby of elective cesarean sections. So ACOG just recently issued a committee opinion where they acknowledged that babies born by cesarean section actually have higher rates of asthma, autoimmune disease, cardiovascular disease, and obesity. And the presumed reason is actually differences in gut flora. And this is fascinating to me. This paper from the American Gut Project actually looked at the gut flora of adults born by cesarean section and by vaginally, and their gut flora was still different. So if you were born by cesarean section, your gut flora was less diverse and closer to skin flora than to, than the sort of the enteric flora that you would expect. And elective cesarean sections may be worse than labored cesarean sections because if you've labored, most of the time your water has broken, and so the baby has been exposed to maternal flora through the vagina. Whereas with an elective cesarean section, there's no exposure. This paper from JAMA Pediatrics, again just two to three months ago, and this is the one the student showed me, is very intriguing. So a prospective cohort following 22,000 children from 1996 to the present, they were aware of the potential confounding factors. So they were very careful about trying to adjust for obviously maternal BMI, gestational diabetes, et cetera. But even after adjusting using regression analysis, they found that cesarean birth was associated with a 15% higher rate of obesity in children compared to vaginal birth. And that if the birth appeared to be elective, that is there was no indication for the cesarean section, then the number doubled. So again, suggesting that an elective cesarean section has actually potentially more harm than a labored cesarean section. The 64% increase, so what this is saying is if you look at a single family where you have three children, two born vaginally, one born by a cesarean section, the one born by a cesarean section is 64% more likely to be obese than its siblings. Conversely, a child who is born by vaginal birth after cesarean being compared to their older sibling has a 31% reduction in obesity. So given the long-term health consequences of pediatric obesity, these are significant findings and should be disturbing at least. So on the basis of the lack of clarity regarding maternal mortality and the issues surrounding pediatric obesity, autoimmune disease and asthma, what I'd like to conclude with is sort of saying, is this a case where we should be invoking a medical precautionary principle? So taking this paper from the Journal of Medicine and Philosophy, where he makes the case that it would be appropriate to take a precautionary principle to mitigate or prevent harms that are plausible and serious. The precautionary principle is the idea that you don't need to have certainty in order to act. If you have a plausible risk that's real and the preventive measures are reasonable and not too draconian, then maybe we should act before the jury's completely settled on these issues. And I think this may be a case where our precautionary principle is appropriate. So again, the plausible part being it doesn't, you don't have to have, it nailed down quantitatively if you see a potential risk that could be responded to. I think in a certain sort of way, this is what ACOG did when it shifted its reasoning between the two committee opinions. Going from neutral to essentially recommending against CDMR. I think you could make the argument that essentially what they were doing was implicitly invoking this principle, right? Because obviously making a recommendation is proportional and physicians making recommendations to their patients is certainly a realistic strategy. I think there's no question, I hope that you believe at this point there's no question that there's some plausible risks associated with elective cesarean section both on the maternal side and on the side of the baby. The one concern I do have is whether this recommendation alone is actually sufficient to reduce the harms associated with CDMR. Julie, I don't know what your experience is, but my experience is that most obstetricians are actually unaware that ACOG has now taken a position sort of more negative on CDMR. I think most obstetricians still sort of view it as, yeah I can do it if I want and ACOG doesn't really care. And that's actually really not what the most recent committee opinion says. So conclusions would be, I think early on the way the ethics was viewed was that at least for the index pregnancy that the risks and benefits seemed to be relatively balanced and that that was what they initially made their decision on, right? And that what changed was that they began to look more to the future once you've had a cesarean section. So CDMR probably does increase the maternal mortality with additional cesarean sections. I think the evidence is suggestive that the risk of harm is increased for children of cesarean sections. And I think that ACOG's changed their recommendation now against CDMR is fully justified. Thank you. Yes, Mo, please. Thank you. Thank you very much since I'm an old obstetrician and I went through the ACOG 207 and 213. My question is actually about the patients that who are hypertensive, preclamptics and all these patients that end having cesarean section. Is there a, is it the C-section that make the babies hypertensive down the road or they inherited something from their parents? Is there a genetic factor in causing their hypertension or just the action of cesarean section, which is just, it doesn't, for an old obstetrician, it's not convincing to me. This is number one. And I'll ask my next question after you answer. I mean, we know that the first point that you made is absolutely true, that the children of preclamptic moms do suffer from higher rates of hypertension, actually suffer from higher rates of obesity themselves, right, and that's all true, although the JAMA article actually was looking at specifically, they were looking at elective cesarean sections, so if you had preeclampsia, you would have been eliminated from that pool. Although they showed that for all cesarean sections that the rate of obesity, et cetera, was 15%, but that if you didn't have any indication, so that would eliminate those preeclampic women, the rate of obesity actually doubled to 30%. So the answer is yes and yes. I'm not taking everybody's time, I have to leave. But my second question is, the question of seeding of the baby's mass with virginal flora, I mean, this is, took off and then people, half of the people are with it and the others say that it's just a fade and you should not subject these children for virginal flora, that may cause problems for them in the future. We don't know, you're taking infection and putting it in the baby's mouth and you're hoping to get the virginal flora to be. Yeah, so let me give you a little background here. So the concern about babies born by cesarean section not getting the maternal flora, one of the responses to that, particularly, and this is more in the alternative communities, et cetera, is essentially to propose that we should be doing something called vaginal seeding, which is if you have a cesarean section to take like a four by four swab and to swab the mother's vagina and then to sort of paint the baby with that to get so that the baby gets the flora from the vagina. In the mouth. Oh, the mouth. Hmm? In the mouth. Well, mouth and skin. I mean, they're different proposals. And ACOG, I think it was just two weeks ago actually came out against that saying, while it's clear that it may be true that being exposed to the maternal microbiome has benefits, we have no reason to know that this is of any benefit and could certainly have some risk. It's not been studied and people shouldn't just sort of widespread, adopt this policy. And I certainly agree with that. Better. Great talk. How are you? I bother. So, you know, there's a clear, I guess correlation to be made for breast surgery and contralateral prophylactic mastectomy, right? Where women have a breast cancer on one side and before it was just BRCA carriers, but now people with high family risk or even just anxiety about having another breast cancer want a contralateral prophylactic mastectomy. And so we've seen, despite the fact that multiple physician groups have come out and published that there's increased risk with no oncologic benefit. More and more people sign up for it until just recently when insurance companies have said we're not paying for it. So you discussed the increased cost. Is there any discussion about who's paying for this and how that's gonna affect this? I think early on, there were people that expected insurance companies to say we won't pay for elective cesarean sections. And they have not done that. And the argument that I have heard is that the fear that if you denied a woman an elective cesarean section and then she went on to have a stillbirth or a traumatic birth with HIE, that they would lose millions of dollars so that they're just not willing to deal with it is like. So at this moment, at least there's not been any pushback from insurance companies. Yes, Julie. Hi, Paul, thank you so much for that really in-depth talk. One point that I really wanted to explore was under the issues regarding autonomy and decision-making at the time of labor and the concern about counseling and consenting during labor. And that being one of the reasons, perhaps, that ACOG chose to write pre-labor. Gonna add that to the text. Going down that road seems very dangerous to me. We do a lot of counseling and consenting during labor. And I think that argument can be used also when we are talking about tubal ligation and can be used both to support counseling for sterilization or against counseling for sterilization. Can you just talk about some of the parameters that you may have with regards to those concerns about counseling during labor? So we do it all the time for small things and large things. So when I wrote that paper for the Green Journal, that's where I got pushback, was on that very point. And what I would say, because I want to be clear in it, and I would say also that my wife, who has a PhD in philosophy, actually really helped me write it in a more nuanced way to be clear that what I was not suggesting is that women somehow lose capacity during labor. That is not the argument I am making. The argument that I am making would be in the same way that I would not think it a good idea to start a conversation with a woman in labor about whether she should then have a postpartum tubal in a few hours after labor. That that kind of elective decision-making sort of doesn't belong in the moment of labor. Not that a woman lacks the capacity to make a decision about medically indicated caesarean or not or anything else than that, but that when you're talking about something that has far-ranging life consequences and that is purely elective, that the time to have that conversation is not labor. That the time to have that conversation is prior to labor. I hope you would agree that you would have some reservation about a woman at seven centimeters saying, and would you please tie my tubes as soon as this is done when it's the first time she's ever brought it up? Right? And somehow we need to obviously be careful about not making statements that diminish a woman's decision-making ability or capacity while acknowledging that labor may not be the time for a purely elective decision. That's the line I'm trying to say. Yeah, I mean, I think that the argument that the risks change in labor to me is a much stronger argument, just because I do think that, as you said, I mean, that's a pretty, that statement or that line of argument can be really misused. Thank you. Thanks for expanding. I recognize the fears that it invokes and the history that we have, that our profession has routinely denied women decision-making power. And yet I still think there's a place for saying active labor is not the time for an elective, for an elective decision like that. And I think the only two limitations I would give is would be a postpartum tubal or an elective caesarean saccharine. I think those are the only ones that I have reservations about. Let me ask you the question. In the light of ACOG's change policy, and I thought I heard you say that many US OBs are not aware of the change. Has there been a national survey or even a local survey of what OBs are currently doing with regard to maternal requests? The only one that I know is that it looks like, so that 43% number is the most recent number of what percent of OBGYNs are willing to perform a CDMR delivery on their patients. That number, and that number are not willing, I'm sorry, are not willing. The older number was actually 48%. So it actually, if anything, it seems like more obstetricians are now willing to perform CDMR than used to be. So if anything, by that logic, it doesn't look like ACOG's position has had a lot of effect. Does anybody know what we do here? It's not very common to do this. I have a few colleagues in the background that do agree. I know maybe in order to provide a nice lay of the situation on that. But it is not commonly done. Absolutely. Right. Thank you. Dan and then Larry. Yeah, nice talk, Paul. It seems like this is one of those cases where as more facts come to light, the sort of question of what's the ethical way to frame the decision-making changes radically. And if it wasn't, if it was no change in sort of the health outcomes, my first question is, if there were no change in the health outcomes, would then it be ethical to sort of offer this procedure to every woman? Are there other sort of mitigating factors, like I mean the aesthetic factors or the goodness of naturalness, I don't know, that would lead you not to make this purely a choice of a woman. And it seems to me too that as we were moving this age of increasing patient autonomy, that what is the level of risk that we then allow patients to make these kinds of decisions about their future? I actually like the way the statement is currently worded, which is not a blanket policy against CDMR, but more a recommendation against it, but still acknowledging that individual circumstances need to be accounted for. So a book chapter that I just wrote actually, now I'm gonna confuse the issue, I wrote a book chapter sort of in favor of that women who have a fetus with a fatal condition are one of the cases where it might be quite reasonable to perform an elective caesarean section. So we had a patient where we did an ethics consult on who had a baby with a fatal anomaly that was going to die shortly after birth, but she was 41 years old, it was an IVF pregnancy and it was her last embryo. And she said, and the MFMs said, well the likelihood of this baby dying in labor is over 60%. And she said, I wanna hold a living baby and I know it's gonna die, but I'm willing to go through a caesarean section to hold a living baby. And she's not gonna have another pregnancy. And she's not gonna have another pregnancy. And I sort of walked over to that consult expecting to sort of take the hard line and I walked out writing a consult saying, go ahead and do the C-section. So I do think there's a place for individualization of care here and that I'm glad that we're not taking a position simply blanket against elective caesarean sections that you have to look at the individual circumstances. Robert. That was great. The concept of the vaginal birth after C-section being accepted and having a C-section is sort of elective. A lot of obstetricians will give a woman the choice to do either one. Where does that fit into this scenario? Is that the same? Well, so I think, so if you think about the fact that tocophobia, fear of labor, is the reason that most women are choosing or making a CDMR request. I think if they've had a caesarean section with that first pregnancy, it's extremely unlikely that that woman is then gonna request a trial of labor after caesarean with the subsequent pregnancy. There was one piece of data that I find really interesting and it was from the wax paper that looked at sort of all the studies on why women were choosing CDMR. And it said that women who actually didn't get a CDMR, who had tocophobia and then went on to labor and deliver vaginally, actually had much higher patient satisfaction and self-esteem than the women who got their caesarean section. So that in a certain sort of way that by doing the caesarean section, you're essentially confirming their fear rather than giving them the opportunity to overcome it. Yeah, but you have an increased risk of rupture as you mentioned. No, yes, yes. Such a different scenario. What I mean is that if, yes, but I mean that if I think that once you've had a caesarean section and the first one was elective, I think it's extremely unlikely that you're gonna choose something that they're putting in. Let's say the first one was not elective. Let's say the first one was not elective. The second one now, you're given the option to have an elective one with the increased risk of whatever small percentages of rupture. Would that fit into your scenario there or would it be a totally different situation? It's a totally different situation because ACOG's position on that really hasn't changed which is that once a woman has had a caesarean section, it's a whole different set of risks and benefits as you look at it. But that really is a case where there's risk of uterine rupture if you try to labor and if you have repeat caesarean sections, you have some of the risks that we talked about. And so ACOG's position is this is a woman's choice and you give her all the information and you let her make that decision. What I will say is I've heard now, again, just because I talk to women who have more alternative sort of birthing ideas and strategies that some of them who have had caesarean sections are now responding to this data by saying I'm gonna wait until I go into labor before I have my caesarean section so that the baby potentially gets inoculated with the flora before I then have my repeat caesarean section. Yeah, I was, I mean with the rise in the incidents of caesarean sections, as you say, your institution is now up to 40%. I have not been aware of these risks to the babies. Are those risks only for elective caesareans or do they apply also to caesareans after labor? So at least the pediatric JAMA study suggests that they apply to all babies born by a C-section but that at least in the case of obesity, it's doubled if it was an elective caesarean section compared to an indicated one. So 15% versus 30. But still, I mean, even for the non-elective caesarean sections. Yes, the increase in childhood asthma is some. Were other people aware of that? Yeah, you were. You were too. Is that right? I'm not seeing anything. Have they seen that as well? Question is whether other countries have seen this increased risk for the kids? You know, the country that I wish had more data coming out of it was Brazil because Brazil is very interesting because the upper socioeconomic classes of Brazil have almost 100% C-section rate. Really? And the lower socioeconomic classes have much lower caesarean section rates. And you would obviously expect the children of the upper class women to be much healthier. But are they experiencing higher rates of asthma and other problems compared to their poor country people? I don't know. I don't know. I haven't seen any data coming out of the country. A lot of Latin America has extremely high elective caesarean section rates in the affluent groups. And I wish we were studying that. Last question because you've got the mic. Has anybody looked at electively breaking the water and then doing a C-section? Not that I'm aware of. Well, that's all. I'm not so. Yeah. But if you can. Yeah. So if a 39-week scheduled C-section, a lot of times the woman's cervix is still completely closed, you couldn't do it. Well, join me, please, and thank you very much.