The abstract of the CME article on urinary incontinence in women ends with the concluding sentence: “Preventive measures against pelvic floor dysfunction should be offered during pregnancy and post partum” (1). Why was this not the first sentence? This is a successful option these days (2).
According to the German Continence Society incontinence affects 1 million men and 4.5 million women (Statista data from 2011). This does not have to be accepted as destiny/fate and cannot be explained with different pelvic floor anatomy. A recent Swedish study including almost 60 000 women from the age of 45 provides a clear answer (3). The women had undergone surgery for prolapse/incontinence. The reference group consisted of 2.3 million women in the same age group in the general population.
After a vaginal delivery, the risk of needing prolapse surgery was increased by a factor of 23 than after cesarean section. This increase in absolute risk was even higher after repeated vaginal deliveries. This was not the case for women after repeated exclusive cesarean deliveries. Their later risk for surgery because of impaired pelvic floor functioning was no higher than in nulliparous women.
According to the Swedish data, vaginal birth entails the biggest risk for impaired pelvic floor functioning (3).
In conclusion: if a pregnant woman expresses the desire for a cesarean section in order to protect her pelvic floor then—according to a decision of the German Federal Court of Justice (BHG judgment of 28 August 2018, file no. VI ZR 509/17—this falls under a woman’s right to self-determination when choosing the delivery mode. While this has to be accepted by all parties involved in the birth, it is removed from reality. If a pregnant women opts for a selective cesarean section under the aspects mentioned above, this is not included in the range of services covered by the sickness funds/health insurers and she will have to bear the costs herself. The court considered prolapse surgery results as well as comparable risks of both delivery modes.
Footnotes
Conflict of interest statement
The author declares that no conflict of interest exists.
References
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