Monday, September 21, 2009

Nearly 5x the risk for infection after cesareans

A new study shows that post-partum infection is yet another reason for concern with the growing cesarean rate.

Post-partum infections are costly and time-consuming to treat, increase hospital re-admission and healthcare costs, and often lead to a difficult and frustrating start to motherhood.

Imagine trying to take care of a new baby and a house and cooking and laundry etc. with a gaping wound like the one shown (from here). Some of these infections and opened wounds literally last for months.

In addition, breastfeeding initiation rates are lower after cesareans, and the stress associated with a difficult delivery, post-operative pain, post-partum infection, and hospital re-admission may impair breastfeeding establishment even further. Breastfeeding is nature's way of protecting the infant immunologically, and reduced or abandoned breastfeeding puts the baby significantly more at risk for illness. Thus, because of its secondary effect of reduced breastfeeding, post-partum infections can have consequences beyond the actual infection itself.

Nearly Five Times The Risk

In this new study the infection rate after cesareans was 7.6%, vs. 1.6% after vaginal births, or about 4.7x the risk.

This means that about 1 out of every 13 women who had a cesarean developed a post-partum infection of some sort. Hardly the "perfectly safe, oh-so-easy" surgical birth some doctors promote.

And that doesn't even address some of the other possible complications of cesareans, like hemorrhage, blood clots, anesthesia problems, etc. Nor does it address the downstream complications of cesareans, like painful scar adhesions, problems with placental placement in future pregnancies, possible increased risk of pre-term birth, etc.

Actual wound infection rates in the study were 5.0% for cesarean moms, vs. 0.08% for vaginal birth moms. That means that about 1 in 20 cesarean moms will have issues with wound infection, versus 1 in 1,200 women who had vaginal births.

Read that again: One in twenty infection rate versus one in more than a thousand. That's a pretty big difference in morbidity.

This is particularly a concern for women of size because the rate of c-section wound infections tends to be even higher in fat women, yet doctors are doing more and more cesareans in "morbidly obese" women in particular.

This means that the risk is likely much higher than one in twenty for fat women, and it also means that the risk difference between vaginal birth and cesarean for fat women is going to be even more stark. All the more reason to be promoting vaginal birth in women of size whenever possible.....yet this is not happening today. Instead the trend is going in the opposite direction.

Here is the abstract of the study; note that three-fourths of the infections were diagnosed only after the mother went home, which is part of what makes it so disruptive in a new family's life.

Recovering from major surgery (and an infection) is hardly the most ideal way to start out motherhood, and the extra care involved is a major financial burden to the healthcare system.

Critics will note that the risk of infection after "emergency" cesarean (which in medical parlance simply means one that was not planned ahead of time, not necessarily one that involves a true emergency) was greater than after a planned "elective" cesarean. Their argument is that it's better therefore to just plan more cesareans without labor in women at higher risk for infections. This is one argument often used to justify a high rate of planned cesareans in "morbidly obese" women.

But this argument is backwards. We know from many studies that even when the cesarean is planned, the risk of infection is still greater than for vaginal births. Why put a whole group of women deliberately at risk for infections when outcomes are so much better with a vaginal birth, and when many can give birth vaginally if given the proper chance?

The answer is not to do planned surgery pre-emptively on every fat woman; the answer is to find the best way to promote vaginal birth in women of size whenever possible, and to research ways to minimize the risk of infection.

Here is the abstract of this new study; note the large size of the study sample, which helps show the robustness of their findings.


Acta Obstet Gynecol Scand. 2009 Jul 29:1-8. Risk of selected postpartum infections after cesarean section compared with vaginal birth: A five-year cohort study of 32,468 women. Leth RA, Møller JK, Thomsen RW, Uldbjerg N, Nørgaard M.Department of Clinical Microbiology, Aarhus University Hospital, Aarhus N, Denmark.
Objectives. To compare the risk of postpartum infections within 30 days after vaginal birth, emergency, or elective cesarean section (CS). Design. Register-based cohort study in Denmark. Participants. A total of 32,468 women giving birth in hospitals in the County of Aarhus, Denmark, during the period 2001-2005. Methods. Data from various hospital registries were combined and infections were identified by positive cultures, prescriptions for antibiotics and, re-operative procedures. Risk of postpartum infection was estimated and adjustment for potentially confounders was performed. Results. Within 30 days postpartum, 7.6% of women who had underwent CS and 1.6% of women having a vaginal birth acquired an infection, yielding an adjusted odds ratio (OR) of 4.71, 95% confidence interval (CI): 4.08-5.43. The prevalence of postpartum urinary tract infection (UTI) was 2.8% after CS and 1.5% after vaginal birth corresponding to an adjusted OR = 1.68, 95% CI: 1.38-2.03. The risk of UTI did not differ between emergency and elective CS. The prevalence of WI [wound infection] was 5.0% after CS and 0.08% after vaginal birth. Moreover, we found a nearly 50% higher risk of postpartum WI after emergency CS compared to elective CS (OR = 1.49, 95% CI: 1.13-1.97). More than 75% (697/907) of postpartum infections appeared after hospital discharge. Conclusions. The risk of postpartum infection seems to be nearly five-fold increased after CS compared with vaginal birth. This may be of concern since the prevalence of CS is increasing.


Etooz said...

Look, I understand the message you are trying to send, but the images you used are making me physically ill-- and there they are, BAM RIGHT IN YOUR FACE on the Fatosphere feed. I really think they should be taken down. Shock tactics should be reserved for the baseless media, no?

Selena said...

I do not think the pictures are too "in your face" at all. Although not as severe as these pictures my csection incision also came open and was infected. It was terrible and women should know what can happen. It took months to recover and my husband had to do the wound care for me. It was disgusting, painful, embarrassing and added to the insult of having a very unnecessary csection. Women are so unaware/under informed of all the risks involved with csections and I'm glad she put these pictures up.

Aerin-sol said...

Well-Rounded Mama: thank you for posting those pictures. Worth 1,000 words.

natjenn said...

I had a c-section 3wks ago, and have an infection. It was the only way to get my baby out - his head was turned so that he could not drop properly to start labour. What I wonder is if I could have avoided infection with better care instruction. My gut instinct was to clean the area with disinfecting stuff, but instead I listened to the dr - just wash and dry normally - and now I have an infection that needs daily care from a home nurse.