Throwing the baby out with the spa water?

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.