To the Editor: In a recent article, de Costa and Robson1 suggest that Australia’s high rates of caesarean surgery — currently among the highest in the Western world — may be beneficial, and causally related to our low perinatal mortality rate.

In support, they cite a single article that reports the outcomes from three large hospitals in Dublin between 1979 and 2000.2 In these hospitals, as in most of the Western world, caesarean rates increased and perinatal mortality rates declined over this 21-year period. The authors of the article ascribe a causal relationship, but admit that “. . . it was not possible to allow for the confounding effect of time”.2 The time factor also confounds the interpretation of Australian data.

Furthermore, results from an earlier Dublin study “. . . do not support the contention that the expansion in cesarean birth rates has contributed significantly to reduced perinatal mortality in recent years,”3 and there are many other articles with similar conclusions.4

Moreover, de Costa and Robson do not acknowledge the significant morbidity associated with caesarean surgery, nor the risks to mother and baby in subsequent pregnancies. A recent large retrospective cohort study in Scotland found that women whose first baby had been born by caesarean section had twice the risk of unexplained stillbirth at term in the subsequent pregnancy.5 There are also well documented increased risks of placental pathology (placenta praevia, accreta and percreta) in this group. Such problems are likely to increase in Australia in proportion to the increase in caesarean rate.

I note also that King et al, who discuss maternal mortality in the same issue of the Journal, specifically mention the contribution of previous caesarean surgery to severe obstetric haemorrhage and emergency hysterectomy.6 They report that maternal death from amniotic fluid embolism occurred in association with induction in five of seven cases. Australian rates of induction and augmentation are among the highest in the Western world.

Finally, as regards onus of proof, I agree with the statements by Enkin et al7 that “. . . the only justification for practices that restrict a woman’s autonomy, her freedom of choice, and her access to her baby, would be clear evidence that these restrictive practices do more good than harm; and second, that any interference with the natural processes of pregnancy and childbirth should also be shown to do more good than harm”, and “. . . the onus of proof rests on those who advocate any intervention that interferes with either of these principles”.

In reply: Buckley makes some important points regarding caesarean section, but overlooks the fact that our brief was to explore childbirth options from the viewpoint of the baby, not the mother.

The Irish study of Matthews (a paediatrician) and colleagues took as its outcome measure deaths during pregnancy or within one week of birth of normally formed infants weighing > 2.5 kg.1 This was done because two of the main contributors to crude perinatal mortality rates (in Australia and other developed countries) are lethal abnormalities and very low birthweight — neither of which is likely to be improved by increasing caesarean section rates. More than 400 000 births over 22 years were studied retrospectively. While the time factor is acknowledged, the authors clearly show that as caesarean section rates have risen mortality among these normally formed babies of normal weight has fallen. They state that “. . . the caesarean section rate is an important part of the overall package of care delivered”, a “package” that includes the advances in antenatal surveillance and neonatal care of the past 22 years, as well as wider indications for caesarean section. The authors invite other centres to publish “similar matching caesarean section and mortality rates . . . to see whether some hospitals are capable of delivering packages of care that include low caesarean section rates (? < 15%) and perinatal mortality rates of < 1.5/1000 for normally formed babies of normal birthweight”. To date, none have done so, but there have been reports from other large maternity hospitals of similar findings to those of Matthews et al. One of these adds that “[our] low incidence of intrapartum hypoxic ischaemic encephalopathy (1.3/1000 births) . . . suggests that a policy of more liberal caesarean section may benefit babies in ways other than simply avoiding death”.2,3 In other words, this very large and careful study, and others resulting from it, strongly support the view that current caesarean section rates are good for babies.

To the Editor: The article by de Costa and Robson1 is a timely reminder that the ideology and politics surrounding maternity services could have an adverse impact on Australia’s excellent record as one of the safest countries in the world in which to be born.2 de Costa and Robson highlighted continuity of care as the attribute of antenatal supervision and birthing that women value most highly, and they quote evidence of the safe care provided by a midwife or general practitioner in a “low-tech” environment.

This type of care is currently provided by a diminishing number of GP obstetricians and midwives in small obstetric units throughout rural Australia, where continuity of carer ensures the continuity of care that leads to maternal satisfaction and good health outcomes.

Data show a lower rate of adverse events in small rural hospitals compared with urban hospitals. Studies in diverse environments suggest communication breakdowns and handovers between multiple carers are major risk factors.3,4 These points of vulnerability are minimised in the close environment of a small rural hospital. National and international data demonstrate the safety of small rural maternity services,5 and yet rural obstetric units continue to be closed at an alarming and accelerating rate.

The proponents of “de-medicalising” birth and improving maternal satisfaction through continuity of care are focused on perceived problems in the delivery of obstetric care in large urban hospitals. The evidence presented by de Costa and Robson confirms that women are most satisfied with care by a midwife and GP in a “low-tech” environment. While this option may now be unavailable in many urban areas, it is generally the model that exists in rural areas.

Unfortunately, the politics of change is resulting in the application of urban- and ideology-based processes to rural maternity units, where they are often inappropriate and can lead to reduced support for rural procedural obstetricians. This is likely to result in the eventual closure of the maternity units — a situation in which women, their babies, local healthcare professionals and their communities will all lose out in the end.

For rural communities, the risk in local maternity services is not to the standard of care, but to the continued existence of their services.

Transferring alternative urban models of maternity care to country hospitals may be superficially attractive to budget-focused health authorities or ideologues, but it is rural people and their babies who will have to live with the consequences.