[Three of the authors respond:]
Michael Klein argues against our conclusion1 that planned cesarean section was safer and less expensive than planned vaginal birth during the period reported in the Term Breech Trial. He bases his arguments on other studies by us,2,3 which “showed no difference in outcome for the babies or the mothers” at 2-year follow-up. He also claims that by looking only at the duration of the Term Breech Trial we have “vastly underestimate[d] the real costs of elective cesarean for breech or any birth.” While we agree that a longer-term analysis might be useful, we disagree with these arguments.
The argument that our own studies show no difference at 2 years represents a misunderstanding of the results of those trials.2,3 The appropriate interpretation of those results is that the benefits of planned cesarean section are limited to reducing perinatal and neonatal mortality and serious neonatal morbidity during the first 6 weeks of life. These remain important benefits for the baby, the mother, the family and the health care providers.
Regarding the question of what will happen to the costs of planned cesarean section and planned vaginal birth after, say, 2 years, the answer is “we do not know.” Any argument that the costs will be higher is nothing more than speculation. For example, we agree with the assumption that most women will have more than one birth, but we do not know if breech presentation will occur for the first birth, the last birth or a birth in between. Also, our experience from the Term Breech Trial has taught us that until actual resource utilization is measured in a controlled environment, it is not easy to predict what will happen. We thought that planned cesarean section would be more expensive than planned vaginal birth, but found that it was not. Furthermore, there was no single specific factor that explained why the costs of planned cesarean section were lower, which tells us that it is dangerous to try to predict (rather than measure) future costs.
Finally, we do not feel responsible for the headlines and content of what is published in the popular press. The Interpretation section of our paper discusses the study's limitations and the consequent constraints on any conclusions drawn.
REFERENCES
- 1.Palencia R, Gafni A, Hannah ME, et al. The costs of planned cesarean versus planned vaginal birth in the Term Breech Trial. CMAJ 2006;174(8):1109-13. [DOI] [PMC free article] [PubMed]
- 2.Hannah ME, Whyte H, Hannah WJ, et al. Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: the international randomized Term Breech Trial. Am J Obstet Gynecol 2004;191 (3):917-27. [DOI] [PubMed]
- 3.Whyte H, Hannah M, Saigal S, et al. Outcomes of children at 2 years after planned cesarean birth vs planned vaginal birth for breech presentation at term: the international randomized Term Breech Trial. Am J Obstet Gynecol 2004;191(3):864-71. [DOI] [PubMed]