Excerpts from Dr. Eftekhar Ellen Sanjar OBGYN
Writer of the Book: CAESAR VS KAISER
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Street Drugs, Prescription Drugs, Tobacco, and Alcohol Use
Many medical studies consider “substance abuse” as a morbidity and exclude mothers who engage in such behavior. The French study did not take substance abuse into account for exclusion. Moreover, during pregnancy, substances do not need to be “abused” to be harmful; their mere use is enough.
What does “substance” mean? In France, wine and tobacco are commonly consumed. Consumption of these has many influences on pregnancy and delivery. Would wine be considered a substance? Even though wine is harmful and addictive, it is not always considered a “substance.” Was tobacco considered a substance? If so, how many cigarettes did a mother have to smoke per day to count as substance abuse? Were prescription drugs considered as a substance?
Most women, because of concern for their baby, stop drugs and alcohol when they become pregnant. However, as soon as the baby is delivered, they may go back to these habits, increasing the chance of postpartum morbidity and mortality.
The study does not seem to have looked for drug and alcohol abuse. Even if it did, it might not have detected it because often drug abuse is not documented in medical records. Pregnant women (and people in general) hide their drug addictions. Doctors should not be misled that a patient is not a drug user just because the patient may be educated, professional, has a family, exercises, and simply doesn’t look like a drug user. 12
One of the many reasons a mother would hide her addiction can be fear of having the baby taken away by social services or have the drug use be used against her during a possible custody dispute. Thus, even the father may not be aware of the mother’s drug use.
Another effect of drugs and alcohol is that when the mother is high on drugs and is in a haze, she may not realize that she is pregnant. She can go for months after conception and delay the prenatal care needed for herself and the baby.
Studies on maternal mortality or morbidity can easily fail to take drug abuse into account as a morbidity that would be a Cesarean delivery indication.
Borderline, Mild, and Intermittent Morbidities
As the study states, the definitions of Cesarean indications have broadened. Many more Cesarean deliveries are being performed because of indications that are mild, but nevertheless, increase the risk of postpartum mortality. A Cesarean delivery indication may be due to a combination of several mild or borderline morbidities such as borderline hypertension or pre-diabetes. The mother’s postpartum mortality can be caused by a combination of multiple mild morbidities and not just one morbidity. Being borderline or mild, these morbidities may not get documented on medical records and would not be detected by the study.
Stress Before, During, and After Delivery
Stress kills! This is a truism and applies especially to a pregnant mother and her baby. Stress can cause or contribute to a stillbirth. It can continue after delivery and get combined with and get exacerbated by other mental conditions, including postpartum depression. An Ob-Gyn, who is aware of the stresses on her patient, may recommend a Cesarean because a tense and stressed mother may have a prolonged vaginal delivery. Stress is not classified, identified, or recorded as morbidity, and yet it can increase the risk of postpartum mortality. (See the section titled, The Stresses on Women, in the appendix).
Undiagnosed Morbidities
Some morbidities that the study was looking for may not have been diagnosed.
If a morbidity was undiagnosed but did not cause the Ob-Gyn to advise a Cesarean and the morbidity’s occurrence was distributed equally between women who had a Cesarean and women who had a vaginal delivery and equally affected the outcome of Cesarean and vaginal delivery, it would have resulted in the inclusion of high-risk pregnancies and deliveries. If distribution of undiagnosed morbidities among those who had a Cesarean and those who had a vaginal delivery was equal; the inclusion of high-risk deliveries would not have entered indication bias into the study, but it would have entered noise.
To summarize, because of possible missed morbidities, borderline morbidities, undiagnosed morbidities, stress, obesity, frailty, and substance use, more indication bias would have entered into the study in addition to the indication bias due to possible fetal morbidity.
Please watch this interesting operation by Dr. Sanjar