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Introduction

Maternal health is a neglected component of perinatalepidemiology. Even the registry of maternal deathslinked to delivery is incomplete;1 records of maternalmorbidity are presumably even less well recorded.This scarcity of data about the mother is in contrastwith data for the neonate, for whom admission ratesand medical procedures are widely available throughepidemiological surveys and routine annual statisticsof tertiary care perinatal units.

One area of particular neglect has been the health of mothers following caesarean section. Caesareansection rates have increased dramatically over the past30 years, reaching levels in many developed countrieswell above the World Health Organisation recom-mended maximum of 15%. The main justification forthe high rates seems to be as an effort to avoid fetaljeopardy. Severe neonatal asphyxia complicates thesurvival of 2–3% of births,2 and an effort to avoidasphyxia may well push clinicians – and judges, ifthere is a court case – into believing that better obstet-rics requires more caesarean sections.

There must be, however, a law of diminishingreturns in the effectiveness of increased use of cae-sarean section. Difficulties in deciding where thethreshold may lie depend on assessing both the bene-fits to the fetus and the complications to the mother.Caesarean section may not be as benign as oftenthought. In France, maternal mortality was 2.7 times

higher after caesarean section than after vaginal birth,after excluding caesareans associated with maternal or fetal disease.3 There are also data suggesting thatrespiratory complications in caesarean babies mayactually be increased.4

In this issue of Paediatric and Perinatal Epidemiology,Lydon-Rochelle et al. present data on the postpartummorbidity of first-time mothers in Washington State.The study was performed on a sample of 4490 women whose infant was discharged alive. Health was assessed 7 weeks postpartum; 59% of womenresponded. Validated questions were asked aboutgeneral health as well as specific aspects of sexual,urinary and bowel function. In general, women placedthemselves high on the health scores, above 80 forphysical functioning and above 75 for general healthperception, social functioning and daily activities.

The worrying aspect of the study was that self-reported health was significantly less satisfactory inwomen who had had a caesarean section. This wastrue for physical functioning, mental health, generalhealth perception, bodily pain, social functioning anddaily activities. The most important difference was‘bodily pain’, for which mothers with spontaneousvaginal delivery rated themselves at 78 while motherswith caesarean section rated themselves at 66.

For the past 30 years, there has been debate over the merits of caesarean section. While many haveexpressed concern over the rising rates of caesareansection,5 a survey found that 31% of female obstetri-cians preferred to perform caesarean section even in aperfectly normal pregnancy.6 A London professor ofobstetrics was quoted in a recent newspaper interviewas stating that a ‘nice clean cut’ was safer than avaginal birth.7 What has been lacking is scientific evi-dence on either side. We believe that the study pub-lished this month may be a milestone in developing amore rational approach to the debate.

© Blackwell Science Ltd. Paediatric and Perinatal Epidemiology 2001, 15, 241–242

Commentary

Vaginal delivery vs. a ‘nice clean cut’: giving more attention tomothers’ postpartum healthSophie Alexandera and Marie-Hélène Bouvier-Colleb

aEcole de Santé Publique, Université Libre de Bruxelles, Belgium, bINSERM Unité 149, Recherches Épidémiologiques en Santé Périnatale et Santé

des Femmes, Paris, France

Correspondence:Dr S. Alexander, Ecole deSanté Publique, UniversitéLibre de Bruxelles, 808 Routede Lennik, B-1070 Bruxelles,Belgium.E-mail: salexand@ulb.ac.be

It would be desirable to extend the study of post-partum health to other populations and over longerperiods of follow-up. Interactions with other factorsmay need to be taken into account. Saurel-Cubizolleset al.,8 assessed psychological distress in mothers 1 yearafter childbirth. After adjustment for social con-founders, the authors found that distress was twice aslikely if the woman was unemployed and seeking ajob. The direction of the association is unclear, but it isan example of another approach to postpartum healthassessment, and the complexities of the question.Another issue is the collection of data on appropriateconfounders. In France, race and ethnicity of studysubjects are often not obtained, whereas data abouteducation, cohabitation and employment are consid-ered relevant. Both types of data may be important,and the two probably provide complementary infor-mation on the determinants of postnatal health. Butregardless of a study’s scope or design, the paper byLydon-Rochelle et al. in this issue of Paediatric and Peri-natal Epidemiology makes it clear that information oncaesarean section is essential in any assessment ofwomen’s postnatal health and its determinants.

References

1 Atrash HK, Alexander S, Berg CJ. Maternal mortality indeveloped countries: not just a concern of the past.Obstetrics and Gynecology 1995; 86:700–705.

2 MacLennan A. A template for defining a causal relationbetween acute intrapartum events and cerebral palsy:international consensus statement. British Medical Journal1999; 319:1054–1059.

3 Bréart G, Varnoux N, Bouvier-Colle MH. Césariennes. In:Les morts maternelles en France. Editors: Bouvier-Colle MH,Varnoux N, Bréart G. Paris: Inserm, 1994; pp. 39–48.

4 Hook B, Kiwi R, Amini SB, Fanaroff A, Hack M. Neonatalmorbidity after elective repeat cesarean section and trial oflabor. Pediatrics 1997; 100:348–353.

5 Belizan JM, Althabe F, Barros FC, Alexander S. Rates andimplications of caesarean sections in Latin America:ecological study. British Medical Journal 1999; 319:1397–1400.

6 Al Mufti R, McCarthy A, Fisk NM. Obstetricians’ personalchoice and mode of delivery [letter]. Lancet 1996; 347:544.

7 The benefits of having a nice, clean cut. The Times, TuesdayJuly 15, 1997.

8 Saurel-Cubizolles MJ, Romito P, Ancel PY, Lelong N.Unemployment and psychological distress in France oneyear after childbirth in France. Journal of Epidemiology andCommunity Health 2000; 54:185–191.

242 S. Alexander and M. H. Bouvier-Colle

© Blackwell Science Ltd. Paediatric and Perinatal Epidemiology 2001, 15, 241–242