C-section is no longer cutting edge

The new family planning policy prompted hundreds of thousands of couples to register to have a second child, but a reliance on cesarean deliveries is causing misery for many

Fang Yan should have had a baby in early July. It would have been the family's second child, conceived after Fang and her husband joined the 700,000 couples that registered to have another child following the 2014 announcement of amendments to China's family planning policy.

The new rules allow couples to have a second baby if one partner, like Fang's husband, is an only child. The couple, both 38, had their first child, a boy, three years ago. In October, they were overjoyed to learn that Fang was pregnant again.

However, bad news quickly followed. Fang was diagnosed with a cesarean-scar pregnancy - a rare occurrence. The fertilized egg had become embedded in the scar from the cesarean she had at age 35. The situation could have been life-threatening, so Fang terminated the pregnancy.

"It's difficult to describe the sadness of losing this baby. My son was born via cesarean section because I was scared of the pain of a natural, first delivery, and also worried about potential problems I might encounter because of my age," she says in a choked voice. "Three years ago, we didn't plan to have another child because of the family planning policy, and we never imagined that a cesarean scar might be a bomb that would kill my second child."

Fang is not alone. In early January, He Rui, 31, who is also eligible to have a second child, was told that the scar from a cesarean she had four years ago was too thin and there was a potential risk of uterine rupture during pregnancy.

The 31-year-old had her first child, a girl, via a cesarean delivery because she and her husband wanted the baby to be born before Sept 1, and start school a year earlier. "We really wanted to have another child so our son would not grow up alone. The new policy could have made our dream come true. It's hard to accept that our dream has been destroyed by this scar," says He, from Kunming, the capital of the southwestern province of Yunnan.

Cesarean section accounts for about 47 percent of all births in China. That's the highest rate for the procedure worldwide - the recommended rate is less than 15 percent - according to a 2010 report by the World Health Organization. Statistics released at a national seminar in April indicated that nearly 25 percent of cesareans performed in China have no medical rationale.

Trial of labor

About 40 percent of women who wanted to have a second child in cities such as Beijing, Shanghai and Shenzhen in Guangdong province, had their first child via C-section, according to a report by Xinhua News Agency in July. The report quoted a doctor at a hospital in Anhui province who said she treated one or two women every week who had to be dissuaded from a second pregnancy because of problems caused by a previous cesarean.

In July, Lang Jinghe, director of the obstetrics department at Peking Union Medical College Hospital, told a medical conference that the problem of China's high C-section rate will be clearly revealed by the new policy.

Attempting a vaginal birth after a cesarean section is known as Trial of Labor after Cesarean, or TOLAC. According to the American College of Obstetricians and Gynecologists, a uterine rupture is the most serious risk associated with the procedure.

The risk of rupture of the uterus after a previous low-transverse C-section, a horizontal incision at the lower end of the uterus, is about 1 percent, whereas the risk after a "classic" C-section with a T-shaped incision, a method once widely used in China, is 8 to 10 percent, according to ACOG.

"The risk of uterine rupture for women who get pregnant after a C-section is not very high, but a rupture would be very dangerous for both mother and baby," says Zhang Lihua, a retired obstetrician who worked at the Beijing Obstetrics and Gynecology Hospital for 35 years.

"The placenta is like the root of a tree. As the baby grows, the placenta also needs to grow to seek more nutrition. The scar left by a previous cesarean delivery is not the best place to obtain sufficient nutrition, and the growth of the placenta will lead to a life-threatening condition," she says.

It's best for women who want to have a second child to go through their first birth on their own if there is no compelling reason for a C-section, according to Zhang. Once surgery has been performed on the uterus, it will no longer be a perfect "home" for the baby, even if most women can still get pregnant and deliver via another C-section or a natural birth, she says.

"If fertilized eggs lodge on the scar on the uterus caused by a C-section, the patient must terminate the pregnancy, and then try to get pregnant again," Zhang says. "The abortion will be followed by the possible risk of bacterial infection and the inevitable trauma to the uterus."

The incidence of cesarean-scar pregnancy ranges between approximately one per 8,000 natural births and one per 2,500 cesarean deliveries, according to ACOG. Diagnosing the condition is difficult, and if the patient is bleeding heavily or has a uterine rupture, surgical intervention is unavoidable.

Safe, natural delivery

Although some mothers who have had a cesarean section encounter problems during second pregnancies, many still can have a second child, and doctors encourage them to try giving birth naturally.

"Natural birth, which is decided by evolution, is definitely the best choice for both mother and baby, if there are no medical reasons for a C-section. Even if they have a cesarean history, we still encourage mothers to try natural birth if the conditions allow," says Ye Ronghua, an obstetrician at Peking University Third Hospital.

According to Ye, the C-section is an intervention rooted in medical developments, and its purpose is to save the lives of both mother and child in conditions that do not support a safe, natural delivery.

"The old adage 'once a C-section, always a C-section' is no longer true. In the past, it was thought that if a woman delivered a baby by C-section, all her other children had to be delivered the same way. Today, many women can have vaginal deliveries after a C-section," Ye says.

Statistics from ACOG suggest that approximately 60 to 80 percent of women who try TOLAC are able to deliver vaginally. The association lists a number of advantages for natural delivery over C-section, such as a shorter period of hospitalization, no abdominal surgery, a faster overall recovery, and a lower risk of blood transfusion and infection. In countries such as the United States, where couples can have an unlimited number of children, natural birth of the first child may prevent multiple future C-sections.

Rise of the doula

Some medical techniques have been shown to reduce the pain and anxiety of natural birth, according to Tian Yangshun, a professor from the obstetrics department of the Fourth Military Medical University's Xijing Hospital in Xi'an, Shaanxi province.

For example, in recent years some hospitals in Beijing and Shanghai have introduced the concept of the doula, a "birth assistant" who helps to comfort and relax the mom-to-be. In many Western countries, the use of doulas has been proved to shorten delivery times, significantly reduce the need for painkilling drugs, and cut the cesarean rate by half.

In 2011, the Beijing Xuanwu District Maternal and Child Care Service Center conducted a research project on 100 pregnant women who were assisted by doulas. Only one insisted on a C-section, even though she had no supportive medical indications. When the center introduced doulas in 2006, its C-section rate was more than 50 percent. By 2011, it had fallen to about 40 percent.

Epidural anesthesia during labor is another option to facilitate natural birth, according to Tian, who says about 60 percent of women in Western countries have epidurals during labor.

"However, less than 5 percent of women in China have access to this option," he says. "Neither doulas nor epidural anesthesia have been promoted in public hospitals nationwide. More new mothers are choosing C-section, so doctors have fewer chances to practice these skills."

He says in the past three years, the National Health and Family Planning Commission has made great strides in its campaign to educate women about the benefits of natural deliveries.

"Many new mothers are better educated, and they have greater access to materials that explain the benefits of natural birth and breast feeding. The number of unnecessary C-sections will definitely fall in the near future," he says.

yangwanli@chinadaily.com.cn

(China Daily Africa Weekly 01/30/2015 page24)