Short term outcomes lead to long term questionsBMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7518.698-b (Published 22 September 2005) Cite this as: BMJ 2005;331:698
EDITOR—Lavender et al add evidence to the debate about a randomised controlled trial comparing vaginal birth with caesarean surgery.1 However, we need to think even more widely, and more long term, about this possibility, as highlighted recently by the term breech trial. Researchers randomised breech babies to vaginal birth or caesarean and concluded, in the year 2000, that caesarean birth was safer. Virtually overnight, vaginal breech birth disappeared as an option for women worldwide.
Follow-up of children from the term breech trial at age 2, published in 2004, found that differences between groups had disappeared: vaginal breech birth was no more risky for offspring in the longer term.2 Many health professionals are unaware of this about face, and the equation of caesarean and breech remains unaltered.
The term breech experience highlights the importance of adequate sample size2 and long term follow-up, but even two years is inadequate after a caesarean.Pregnancies after a caesarean have an increased risk of unexpected stillbirth3 as well as ectopic pregnancy, placenta praevia, and placental abruption,4 which increase mortality for mother and baby. If, as with theterm breech trial, the results of a randomised controlled trial lead to more women having caesareans (and subsequent caesareans), these risks will become notable in population terms.
Finally, we must consider our scant understanding of the sophisticated and finely tuned psychoneuroendocrinology of labour and birth, and of the longer term implications of interference in this highly evolved reproductive act.5
Our current ignorance of the implications of depriving mother and baby of normal birth and our recent ignorance of the implications of depriving mother and baby of breast feeding have many parallels. Until we know what we are really offering and include extensive follow-up over decades, a “term cephalic trial” may be as foolish as a randomised controlled trial of breast feeding compared with formula feeding.
Competing interests SJB has had four home births, including one breech birth.