In commenting on the study by Eason and colleagues1 Scott Farrell appears to have inferred from their findings that there is support for elective cesarean birth as a way of reducing the risk of anal incontinence after vaginal delivery.2 We disagree with his interpretation. Furthermore, from a public-health perspective this line of argument is alarming.
Eason and coworkers showed a cumulative incidence of fecal (3.1%) and flatal (25.5%) incontinence. However, these figures include the category “less than once weekly” — a category of dubious clinical significance and, likely, one associated with little disruption to quality of life.
Nonetheless, we agree with Farrell that obstetricians and mothers should take an explicit risk–benefit approach when discussing the option of cesarean delivery. We recently studied 8327 consecutive births by women resident in Hong Kong. We found that cesarean section compared to normal vaginal delivery was a risk factor for not initiating breast-feeding (adjusted odds ratio [OR] 1.52, 95% confidence interval [CI] 1.34–1.73) and for breast-feeding less than 1 month (OR 1.25, 95% CI 1.00–1.56), and remained a significant hazard against total breast-feeding duration (hazards ratio [HR] 1.16, 95% CI 1.04–1.30).3 Although it is generally recognized that most mothers recover from birth-related pelvic injury within months of giving birth, the adverse health and developmental effects for infants due to low breast-feeding rates persist well into childhood and adolescence.4
The global epidemic of cesarean section is a matter deserving international attention. For instance, Hong Kong's caesarean section rate rose rapidly from 22% in 1993 to 27.4% in 1999, benchmarked against the WHO's recommended upper limit of 15%.5 We must not allow the upward trend to continue, certainly not based on inappropriate extrapolation and interpretation of data collected for another purpose.
Gabriel M. Leung Clinical Assistant Professor Tai-Hing Lam Chair Professor and Head Lai-Ming Ho Computer Officer Thuan Q. Thach Statistician University of Hong Kong Medical Centre Hong Kong
References
- 1.Farrell SA. Cesarean section versus forceps- assisted vaginal birth: It's time to include pelvic injury in the risk–benefit equation. CMAJ 2002; 166 (3):337-8. [PMC free article] [PubMed]
- 2.Eason E, Labrecque M, Marcoux, Mondor M. Anal incontinence after childbirth. CMAJ 2002; 166(3):326-30. [PMC free article] [PubMed]
- 3.Leung GM, Lam TH, Ho LM. Breast-feeding and its relation to smoking and mode of delivery. Obstet Gynecol 2002;99:785-94. [DOI] [PubMed]
- 4.Cunningham AS, Jelliffe DB, Jelliffe EF. Breast-feeding and health in the 1980s: a global epidemiologic review. J Pediatr 1991;118:659-66. [DOI] [PubMed]
- 5.Leung GM, Lam TH, Thach TQ, Wan S, Ho LM. Rates of cesarean births in Hong Kong: 1987-1999. Birth 2001;28:166-72. [DOI] [PubMed]