Thursday, December 15, 2016

Thomas van den Akker: Who pays the price? (Foreign) women, future siblings

First Amsterdam Breech Conference, Day 1
Thomas van den Akker, MD PhD
Who pays the price? (Foreign) women, future siblings

Thomas van den Akker, MD PhD, is an obstetrician at Leiden University Medical Center. The slides from his presentation are available here.

Of all the presentations during the 2-day-long conference, Thomas van den Akker's was the most powerful and most memorable. Future siblings and foreign women are now paying the price for Western countries' fear of breech.

Thomas opened with the comment that “not every breech delivery is a hallelujah delivery.” He doesn’t have a clean record like Dr. Frank Louwen. But he’s still here to defend the option of a vaginal breech birth. His only conflict of interest is the woman in a faraway land who might pay the price for our fear of the breech.

He’s not a fan of the 2000 Hannah Term Breech Trial because it has a flawed data set. But assuming that the TBT is true and not flawed, what are the outcomes of a policy of universal cesarean for breech presentation? For term breech babies in the Netherlands, the Number Needed to Treat (NNT) comes to 338 based on a 2014 study by Vlemmix et al. In other words, doctors needed to perform 338 cesareans to save one breech baby’s life. However, looking only at these numbers is shortsighted (for one example of shortsightedness, he pointed to this 2015 article by Joseph et al in Obstetrics and Gynecology).

What do you miss when you only look at the NNT?

1. The mother
2. Subsequent pregnancies
3. The rest of the world—much of the rest of the world is really missing from the conclusions and ramifications of the Term Breech Trial, such as remote hospitals far away from urban centers.

These three questions are hard to answer because there’s under-reporting of adverse outcomes, limited and/or little long-term follow-up on the mothers and babies, and fear of litigation.

The TBT gives a very limited answer about maternal morbidity.

Figures from the Netherlands give us a better look at how a policy of cesarean affects women. These figures are clear: severe acute maternal morbidity is higher with cesarean section than with vaginal breech birth. Peripartum hysterectomy is higher in the cesarean groups. (See Van Dillen et al. Severe acute maternal morbidity and mode of delivery in the Netherlands. Acta Obstetrica 2010).

Between 2000-2002, four Dutch women died after having an elective cesarean section for breech, which comprised 7% of the Netherlands’ direct maternal mortality. (See Schutte et al. Maternal Deaths after elective caesarean for breech presentation in the Netherlands. Acta Obstetrica 2007.)

Thomas reiterated that if we do a lot of cesareans, some women are going to die from them. Others will be injured in the short term.

There are also long-term consequences from cesarean sections for breech. Maternal morbidity in subsequent pregnancies is higher.

Perinatal death is subsequent pregnancies is higher.

Again, from the Dutch data, for every 10,000 babies delivered by elective cesarean section for breech, 26 will be saved in that pregnancy. But...27 babies will be lost when the woman has her next baby, assuming a policy of VBAC. 

This raises an ethical question: Does performing 997 elective cesarean sections justify saving the lives of 3 babies? What about the costs?

In our context (resource-rich, developed world, easy access to hospitals), the difference in outcomes for a mother's first child is small. But there are enormous consequences of a cesarean-only policy in other parts of the world.

Remember the NNT of 338? (338 elective cesareans for breech presentation needed to prevent one fetal death.) In other parts of the world, the dangers of cesarean sections are amplified. In Tanzania, those 338 cesareans would result in 6 maternal deaths. In a district hospital in Malawi, 3 women would die for every one baby saved. And that’s just in the short run. (See Van Roosmalen and van den Akker BJOG 2014 and Van Roosmalen Lancet 2014).

In addition, fertility rates can be much higher than in the Western World, so the impact of that cesarean section for breech is multiplied.

Thomas concluded that our messages about breech are doing harm elsewhere. We need to take into account a woman’s complete fertile life, especially if she’s living in more dangerous circumstances where cesareans are much less safe than they are in developed countries. Dealing with a breech is not simply black and white.


Q (Australian OB Andrew Bisits): Women have difficulty processing these numbers, but even for us OBs it’s difficult. How do we know that what we are presenting is comprehensible? Women are processing not just the numbers, but a whole lot of other factors that go into their decisions.
We’re dealing with very small numbers of adverse events. We should at least be able to learn something from the adverse events to make things even safer.
A: Yes, agreed completely. We should take into account adverse events, but in a much wider context and setting. We need to give the other numbers—the ones I presented today—to confront people pushing ECS for all breeches.


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