You are on page 1of 52

Vaginal or Cesarean Birth:

What Is at Stake for Women and Babies?


A Best Evidence Review

Contributors
+HQFL*RHU
$P\5RPDQR061&10
&DURO6DNDOD3K'063+
&KLOGELUWK&RQQHFWLRQ
&LWHDV
&KLOGELUWK&RQQHFWLRQ  
9DJLQDORU&HVDUHDQ%LUWK:KDW,VDW6WDNHIRU:RPHQDQG%DELHV"
1HZ<RUN&KLOGELUWK&RQQHFWLRQ
$YDLODEOHRQOLQHDW
KWWSWUDQVIRUPFKLOGELUWKFRQQHFWLRQRUJUHSRUWVFHVDUHDQ
&RPSDQLRQPDWHULDOVIRUZRPHQDYDLODEOHDW
KWWSZZZFKLOGELUWKFRQQHFWLRQRUJFHVDUHDQ

About Childbirth Connection


&KLOGELUWK&RQQHFWLRQLVDQDWLRQDOQRWIRUSURILWRUJDQL]DWLRQIRXQGHGLQ
DV0DWHUQLW\&HQWHU$VVRFLDWLRQ2XUPLVVLRQLVWRLPSURYHWKHTXDOLW\DQG
YDOXHRIPDWHUQLW\FDUHWKURXJKFRQVXPHUHQJDJHPHQWDQGKHDOWKV\VWHP
WUDQVIRUPDWLRQ&KLOGELUWK&RQQHFWLRQSURPRWHVVDIHHIIHFWLYHDQGVDWLVI\LQJ
HYLGHQFHEDVHGPDWHUQLW\FDUHDQGLVDYRLFHIRUWKHQHHGVDQGLQWHUHVWVRI
FKLOGEHDULQJIDPLOLHV7KURXJKWKH7UDQVIRUPLQJ0DWHUQLW\&DUH3DUWQHUVKLS
&KLOGELUWK&RQQHFWLRQZRUNVZLWKVWDNHKROGHUVIURPDFURVVWKHKHDOWKFDUH
V\VWHPWRLPSOHPHQWSULRULW\UHFRPPHQGDWLRQVIURPWKHFRQVHQVXVGLUHFWLRQ
VHWWLQJ%OXHSULQWIRU$FWLRQ6WHSV7RZDUGD+LJK4XDOLW\+LJK9DOXH0DWHUQLW\
&DUH6\VWHP7KLV%OXHSULQWIRU$FWLRQWKHFRPSDQLRQUHSRUW9LVLRQIRUD
+LJK4XDOLW\+LJK9DOXH0DWHUQLW\&DUH6\VWHPDQGRWKHUUHODWHGUHVRXUFHV
DUHDYDLODEOHDWKWWSWUDQVIRUPFKLOGELUWKFRQQHFWLRQRUJ
2

Table of Contents
Executive Summary  4
Introduction and Background  12
Methods 13
Results 15
1. :KDWSK\VLFDOHIIHFWVPD\RFFXULQZRPHQPRUHIUHTXHQWO\ZLWK
FHVDUHDQGHOLYHU\"15
2. :KDWSK\VLFDOHIIHFWVPD\RFFXULQEDELHVPRUHIUHTXHQWO\ZLWK
FHVDUHDQGHOLYHU\"20
3. :KDWUROHPD\FHVDUHDQGHOLYHU\SOD\LQWKHGHYHORSPHQWRIFKLOGKRRG
FKURQLFGLVHDVH"22
4. :KDWFRPSOLFDWLRQVDUHXQLTXHWRFHVDUHDQGHOLYHU\"23
5. :KDWFRPSOLFDWLRQVDUHXQLTXHWRYDJLQDOELUWK"25
6. :KDWDUHSRWHQWLDOSV\FKRVRFLDOFRQVHTXHQFHVRIFHVDUHDQV"26
7. :KDWDUHSRWHQWLDOHIIHFWVRIFHVDUHDQVRQZRPHQLQIXWXUHSUHJQDQFLHV
DQGELUWKV"28
8. :KDWDUHSRWHQWLDOHIIHFWVRIDVFDUUHGXWHUXVRQIXWXUHEDELHV"32
9. 'RHVFHVDUHDQGHOLYHU\SURWHFWDJDLQVWVH[XDOERZHOXULQDU\RUSHOYLF
IORRUG\VIXQFWLRQ"35
10. 'RHVFHVDUHDQGHOLYHU\SURWHFWDJDLQVWLQMXULHVWREDELHV"38

Discussion 40
References 48

Executive Summary

:LWKDERXWRQHLQWKUHHEDELHVERUQVXUJLFDOO\FHVDUHDQGHOLYHU\LVWKHPRVWFRPPRQRSHUDWLQJ
URRPSURFHGXUHLQWKH8QLWHG6WDWHV2YHUWKHSDVWWZRGHFDGHVWKHFHVDUHDQUDWHKDVLQFUHDVHG
DPRQJZRPHQZLWKDQGZLWKRXWSULRUFHVDUHDQVLQERWKSUHWHUPDQGWHUPSUHJQDQFLHVLQZRPHQ
DWORZDQGKLJKULVNRIFRPSOLFDWLRQVDQGDFURVVDOODJHVUDFHVDQGHWKQLFLWLHV$VFHVDUHDQ
UDWHVLQFUHDVHSURSRUWLRQDOO\PRUHORZULVNZRPHQH[SHULHQFHFHVDUHDQGHOLYHU\2YHUXVH
RIFHVDUHDQGHOLYHU\LQORZULVNZRPHQH[SRVHVPRUHZRPHQDQGEDELHVWRSRWHQWLDOKDUPVRI
FHVDUHDQZLWKPLQLPDOOLNHOLKRRGRIEHQHILW2ISDUWLFXODUFRQVHTXHQFHDUHGRZQVWUHDPHIIHFWV
LQFOXGLQJFKLOGKRRGFKURQLFLOOQHVVDQGSODFHQWDOFRPSOLFDWLRQVLQDQ\VXEVHTXHQWSUHJQDQFLHV
7KHVHLQFOXGHOLIHWKUHDWHQLQJFRPSOLFDWLRQVWKDWRFFXUPRUHIUHTXHQWO\ZLWKDFFXPXODWLQJVXU
JHULHV,QOLJKWRIWKHVHDQGRWKHUFRQFHUQVLQWKH1DWLRQDO3ULRULWLHV3DUWQHUVKLSDFRQ
VRUWLXPRIPDMRUQDWLRQDORUJDQL]DWLRQVIDFLOLWDWLQJFRRUGLQDWHGDFWLRQZLWKLQWDUJHWHGDUHDVRI
KHDOWKDQGKHDOWKFDUHLPSURYHPHQWFRQYHQHGD0DWHUQLW\$FWLRQ7HDPWRDGGUHVVLQDSSURSULDWH
DQGXQVDIHPDWHUQLW\FDUH$PDMRUJRDORIWKH0DWHUQLW\$FWLRQ7HDPLVWRUHGXFHFHVDUHDQ
GHOLYHU\LQORZULVNZRPHQWRRUOHVV
:LWKHVFDODWLQJPXOWLVWDNHKROGHUDWWHQWLRQRQFHVDUHDQRYHUXVHDQHYHUJURZLQJERG\RI
HYLGHQFHDQGQHZRSSRUWXQLWLHVIRUFRQVXPHUHGXFDWLRQDQGVKDUHGGHFLVLRQPDNLQJ&KLOGELUWK
&RQQHFWLRQXQGHUWRRNDVFLHQWLILFUHYLHZWRVXPPDUL]HIRUDOOVWDNHKROGHUVWKHPRVWFXUUHQWEHVW
HYLGHQFHRQWKHKHDOWKFRQVHTXHQFHVRIFHVDUHDQGHOLYHU\:KLOHWKHH[SHFWHGEHQHILWVRIFH
VDUHDQGHOLYHU\YDU\GHSHQGLQJRQWKHLQGLFDWLRQDQGZRXOGEHPLQLPDOLQORZULVNZRPHQWKH
SRWHQWLDOKDUPVDUHJHQHUDOO\LQWULQVLFWRVXUJLFDOGHOLYHU\7KXVWKLVUHSRUWIRFXVHVRQDGYHUVH
FRQVHTXHQFHVRIFHVDUHDQDQGDOVRH[SORUHVDGYHUVHRXWFRPHVWKDWPD\EHLQWULQVLFWRODERU
RUYDJLQDOELUWK7KLVUHSRUWSUHVHQWVWKHPHWKRGVILQGLQJVDQGLPSOLFDWLRQVRIWKLVEHVWHYLGHQFH
UHYLHZ&RPSDQLRQFRQVXPHURULHQWHGPDWHULDOVLQFOXGLQJDGRZQORDGDEOHERRNOHWDUHDYDLO
DEOHDWKWWSZZZFKLOGELUWKFRQQHFWLRQRUJFHVDUHDQ


7KLVUHSRUWLQWHQGVWRSUHVHQWWKHEHVWDYDLODEOHHYLGHQFHIRUWKHGLUHFWLRQDQGVWUHQJWKRIWKH
KDUPVDVVRFLDWHGZLWKFHVDUHDQGHOLYHU\YHUVXVYDJLQDOELUWKPHDVXUHGZLWKLQFRQWHPSRUDU\
PDWHUQLW\SUDFWLFHLQKLJKUHVRXUFHFRXQWULHV7REHLQFOXGHGLQWKLVEHVWHYLGHQFHUHYLHZV\V
WHPDWLFUHYLHZVRUVWXGLHVKDGWRKDYHEHHQSXEOLVKHGLQ(QJOLVKLQWKH\HDURUODWHUEHHQ
FRQGXFWHGLQKLJKLQFRPHFRXQWULHV DVGHILQHGE\WKH:RUOG%DQN DQGFRPSDUHGRXWFRPHV
ZLWKFHVDUHDQGHOLYHU\YHUVXVHLWKHUDFWXDORUSODQQHGYDJLQDOELUWK7RH[DPLQHRXWFRPHVXQLTXH
WRVXUJHU\ HJFHVDUHDQVFDUHFWRSLFSUHJQDQF\RSHUDWLYHLQMXU\WRLQWHUQDORUJDQV RUYDJLQDO
ELUWK LHSHULQHDORUJHQLWDOLQMXU\ KRZHYHUZHUHOLHGRQVWXGLHVZLWKRXWFRPSDULVRQJURXSV
:KHUHDQHOLJLEOHV\VWHPDWLFUHYLHZZDVDYDLODEOHWKDWLVDUHYLHZRIVWXGLHVRQDGHILQHG
TXHVWLRQWKDWGHVFULEHGLWVVHDUFKPHWKRGVVSHFLILHGLQFOXVLRQDQGH[FOXVLRQFULWHULDDQGXVHG
PHWDDQDO\VLVZKHQDSSURSULDWHZHXVHGLWDVRXUH[FOXVLYHVRXUFH,IPRUHWKDQRQHHOLJLEOH
V\VWHPDWLFUHYLHZZDVLGHQWLILHGFRYHULQJWKHVDPHWRSLFZHFKRVHWKHPRVWUHFHQWXQOHVV
LQFOXGLQJPXOWLSOHV\VWHPDWLFUHYLHZVHQDEOHGUHSRUWLQJRIDGGLWLRQDORXWFRPHV,IQRHOLJLEOHV\V
WHPDWLFUHYLHZFRXOGEHLGHQWLILHGZHUHVRUWHGWRREVHUYDWLRQDOVWXGLHVRIDQ\GHVLJQLQFOXGLQJ
FRKRUWFURVVVHFWLRQDORUFDVHFRQWURO(YLGHQFHIRUVRPHRXWFRPHVZDVRQO\DYDLODEOHLQFDVH
VHULHVDQGUHSRUWV,QWKLVVLWXDWLRQZHLQFOXGHGRQO\WKHODUJHVWRIWKHFDVHVHULHVH[FOXGLQJ
VLQJOHFDVHUHSRUWVRUVHULHVRIRQO\DIHZFDVHV
4

:KHUHGLIIHUHQFHVEHWZHHQPRGHVRIELUWKFRXOGEHTXDQWLILHGZHUHSRUWHGWKHVL]HRIWKRVH
GLIIHUHQFHV DEVROXWHULVNGLIIHUHQFH RQDVFDOHRIYHU\VPDOOWRYHU\ODUJHDFFRUGLQJWR
RUGHUVRIPDJQLWXGHVWDQGDUGL]HGWRDGHQRPLQDWRURI 6HH7DEOH 7KHVWDQGDUGL]HG
VFDOHDOORZVUHDGHUVWRPDNHFRPSDULVRQVDWDJODQFHDQGZDVFKRVHQDVWKHFRPPRQ
GHQRPLQDWRUWRFDSWXUHWKHZLGHYDULDWLRQLQUDWHVRIYDULRXVRXWFRPHV,QVRPHFDVHVVWXGLHV
UHSRUWHGRQO\RGGVRUULVNUDWLRVZKLFKPHDQWWKDWGLIIHUHQFHVFRXOGQRWEHTXDQWLILHG7KHVH
KDYHEHHQVRQRWHG8QOHVVVWDWHGRWKHUZLVHDOOGLIIHUHQFHVDUHVWDWLVWLFDOO\VLJQLILFDQWWKDWLV
XQOLNHO\WREHGXHWRFKDQFH

Table 1:

0DJQLWXGHRI$EVROXWH5LVN'LIIHUHQFHLQ5HSRUWHG2XWFRPH









9(5</$5*(

WR

/$5*(

WR

02'(5$7(

WR

60$//

WR

9(5<60$//

OHVVWKDQ

RIHYHU\
ZRPHQRUEDELHV


2XUFRPSUHKHQVLYHDVVHVVPHQWUHYHDOVWKHIROORZLQJ2IPDWHUQDODGYHUVHRXWFRPHVLQ
WKHFXUUHQWSUHJQDQF\VXIILFLHQWHYLGHQFHGHPRQVWUDWHVWKDWIDYRUYDJLQDORUSODQQHGYDJLQDO
ELUWKDQGOLPLWHGHYLGHQFHVXJJHVWVWKHUHPDLQLQJIDYRUYDJLQDORUSODQQHGYDJLQDOELUWK2I
QHRQDWDODGYHUVHRXWFRPHVVXIILFLHQWHYLGHQFHGHPRQVWUDWHVWKDWIDYRUVYDJLQDORUSODQQHG
YDJLQDOELUWKOLPLWHGHYLGHQFHVXJJHVWVWKDWIDYRUYDJLQDORUSODQQHGYDJLQDOELUWKDQGHYL
GHQFHLVFRQIOLFWLQJIRUWKHUHPDLQLQJRXWFRPH2IFKLOGKRRGFKURQLFGLVHDVHVVXIILFLHQW
HYLGHQFHGHPRQVWUDWHVWKDWIDYRUYDJLQDORUSODQQHGYDJLQDOELUWKDQGHYLGHQFHLVOLPLWHGDQG
FRQIOLFWLQJIRUWKHUHPDLQLQJ6HYHQDGYHUVHRXWFRPHVDUHXQLTXHWRFHVDUHDQGHOLYHU\ZKLOH
DUHXQLTXHWRYDJLQDOELUWK2ISV\FKRVRFLDORXWFRPHVH[DPLQHGHYLGHQFHFRQIOLFWVEXW
VXJJHVWVDSRVVLEOHDVVRFLDWLRQZLWKFHVDUHDQGHOLYHU\IRUDOO,QVXEVHTXHQWSUHJQDQFLHV
RIDGYHUVHPDWHUQDORXWFRPHVVXIILFLHQWHYLGHQFHGHPRQVWUDWHVWKDWIDYRUYDJLQDOELUWKLQ
WKHSULRUGHOLYHU\DQGOLPLWHGHYLGHQFHVXJJHVWVWKHUHPDLQLQJDOVRIDYRUSULRUYDJLQDOELUWK
2ISHULQDWDODGYHUVHRXWFRPHVLQVXEVHTXHQWSUHJQDQFLHVOLPLWHGHYLGHQFHVXJJHVWVWKDW
IDYRUSULRUYDJLQDOELUWKDQGGDWDFRQIOLFWIRUWKHUHPDLQLQJ2IRXWFRPHVUHODWHGWRSHOYLF
IORRUG\VIXQFWLRQQRQHIDYRUVYDJLQDOELUWKPRGHRIELUWKPDNHVQRGLIIHUHQFHIRUDQGIDYRU
FHVDUHDQGHOLYHU\EXWRIWKHVHIDYRUFHVDUHDQRQO\LQWKHVKRUWWHUPRURQO\ZLWKUHVSHFWWR
PLOGRUPRGHUDWHV\PSWRPV2IRXWFRPHVUHODWHGWRGHOLYHU\LQMXU\RIWKHEDE\PRGHRIELUWK
DSSHDUVWRPDNHQRGLIIHUHQFHIRUQRQHIDYRUVYDJLQDOELUWKDQGOLPLWHGHYLGHQFHVXJJHVWV
WKDWIDYRUVFHVDUHDQ
5



What physical effects may occur in women more frequently with


cesarean delivery?
0DWHUQDOGHDWK0RUHZRPHQDSSHDUWRGLHDVDUHVXOWRIFHVDUHDQGHOLYHU\LWVHOIEXWWKH
H[FHVVQXPEHUFDQQRWEHFDOFXODWHGIURPWKHVWXGLHVH[DPLQHG
&DUGLDFDUUHVW/LPLWHGHYLGHQFHVXJJHVWVWKDWD02'(5$7(H[FHVVQXPEHURIKHDOWK\
ZRPHQPD\H[SHULHQFHFDUGLDFDUUHVWLQDVVRFLDWLRQZLWKFHVDUHDQGHOLYHU\FRPSDUHGZLWK
VLPLODUZRPHQSODQQLQJYDJLQDOELUWK
8UJHQWK\VWHUHFWRP\$60$//WR02'(5$7(H[FHVVQXPEHURIZRPHQKDYLQJLQLWLDOFH
VDUHDQGHOLYHU\XQGHUJRXQSODQQHGK\VWHUHFWRP\FRPSDUHGZLWKZRPHQKDYLQJYDJLQDOELUWK
7KURPERHPEROLFHYHQWV EORRGFORWV $60$//WR02'(5$7(H[FHVVQXPEHURI
KHDOWK\ZRPHQKDYLQJFHVDUHDQGHOLYHU\H[SHULHQFHDEORRGFORW
$QHVWKHWLFFRPSOLFDWLRQV/LPLWHGHYLGHQFHVXJJHVWVWKDWD02'(5$7(H[FHVVQXPEHU
RIKHDOWK\ZRPHQKDYLQJFHVDUHDQGHOLYHU\PD\H[SHULHQFHFRPSOLFDWLRQVZLWKDQHVWKHVLD
FRPSDUHGZLWKVLPLODUZRPHQKDYLQJVSRQWDQHRXVYDJLQDOELUWK
0DMRULQIHFWLRQ/LPLWHGHYLGHQFHVXJJHVWVWKDWD02'(5$7(WR/$5*(H[FHVVQXPEHU
RIKHDOWK\ZRPHQKDYLQJSODQQHGFHVDUHDQGHOLYHU\H[SHULHQFHPDMRUSXHUSHUDOLQIHFWLRQ
FRPSDUHGZLWKZRPHQKDYLQJRUSODQQLQJYDJLQDOELUWK
5DUHOLIHWKUHDWHQLQJFRPSOLFDWLRQV/LPLWHGHYLGHQFHVXJJHVWVWKDWPRUHZRPHQH[SHUL
HQFHDPQLRWLFIOXLGHPEROLVPRUXWHULQHDUWHU\SVHXGRDQHXU\VPDIWHUFHVDUHDQWKDQDIWHU
YDJLQDOELUWKEXWWKHH[FHVVQXPEHUFDQQRWEHFDOFXODWHGIURPWKHVWXGLHVH[DPLQHG
:RXQGLQIHFWLRQ FHVDUHDQRUJHQLWDO $/$5*(H[FHVVQXPEHURIKHDOWK\ZRPHQKDY
LQJFHVDUHDQGHOLYHU\KDYHZRXQGLQIHFWLRQVFRPSDUHGZLWKZRPHQSODQQLQJYDJLQDOELUWK
+HPDWRPD FHVDUHDQRUJHQLWDO /LPLWHGHYLGHQFHVXJJHVWVWKDWD/$5*(H[FHVVQXP
EHURIKHDOWK\ZRPHQKDYLQJFHVDUHDQGHOLYHU\KDYHZRXQGKHPDWRPDVFRPSDUHGZLWK
ZRPHQSODQQLQJYDJLQDOELUWK
:RXQGGLVUXSWLRQ FHVDUHDQRUJHQLWDO /LPLWHGHYLGHQFHVXJJHVWVWKDWD60$//H[FHVV
QXPEHURIKHDOWK\ZRPHQKDYLQJFHVDUHDQGHOLYHU\KDYHZRXQGGLVUXSWLRQFRPSDUHGZLWK
ZRPHQSODQQLQJYDJLQDOELUWK
/HQJWKRIKRVSLWDOVWD\3ODQQHGFHVDUHDQGHOLYHU\LQFUHDVHVOHQJWKRIKRVSLWDOVWD\E\DW
OHDVWWRGD\VFRPSDUHGZLWKSODQQHGYDJLQDOELUWK
+RVSLWDOUHDGPLVVLRQ$02'(5$7(WR/$5*(H[FHVVQXPEHURIKHDOWK\ZRPHQKDYLQJ
FHVDUHDQGHOLYHU\UHTXLUHUHDGPLVVLRQWRWKHKRVSLWDO

3UREOHPVZLWKSK\VLFDOUHFRYHU\:LWKWKHH[FHSWLRQRIWKHSUHVHQFHRIKHPRUUKRLGV
ZKLFKDUHPRUHFRPPRQZLWKYDJLQDOELUWKD/$5*(WR9(5</$5*(H[FHVVQXPEHURI
ZRPHQKDYLQJFHVDUHDQGHOLYHU\H[SHULHQFHSUREOHPVZLWKSK\VLFDOUHFRYHU\LQFOXGLQJJHQ
HUDOKHDOWKERGLO\SDLQH[WUHPHWLUHGQHVVVOHHSSUREOHPVERZHOSUREOHPVDELOLW\WRFDUU\
RXWGDLO\DFWLYLWLHVDQGDELOLW\WRSHUIRUPVWUHQXRXVDFWLYLWLHVFRPSDUHGZLWKZRPHQKDYLQJ
VSRQWDQHRXVYDJLQDOELUWK
&KURQLFSHOYLFSDLQ0RUHZRPHQH[SHULHQFHFKURQLFSHOYLFSDLQDIWHUFHVDUHDQGHOLYHU\WKDQ
DIWHUYDJLQDOELUWKEXWWKHH[FHVVQXPEHUFDQQRWEHFDOFXODWHGIURPWKHVWXGLHVH[DPLQHG

What physical effects may occur in babies more frequently with


cesarean delivery?
1HRQDWDOPRUWDOLW\/LPLWHGHYLGHQFHVXJJHVWVWKDWEDELHVRIZRPHQKDYLQJHOHFWLYHILUVW
FHVDUHDQVPD\EHDWJUHDWHUULVNRIQHRQDWDOGHDWKFRPSDUHGZLWKORZULVNZRPHQSODQQLQJ
YDJLQDOELUWKEXWWKHH[FHVVQXPEHURIGHDWKVFDQQRWEHFDOFXODWHGIURPWKHVWXG\H[DPLQHG
5HVSLUDWRU\GLVWUHVVV\QGURPH:KHQELUWKRFFXUVEHIRUHZHHNVPRUHEDELHVERUQ
E\FHVDUHDQWKDQE\YDJLQDOELUWKH[SHULHQFHUHVSLUDWRU\GLVWUHVVV\QGURPH 5'6 EXWWKH
H[FHVVQXPEHUFDQQRWEHFDOFXODWHGIURPWKHVWXGLHVH[DPLQHG
3XOPRQDU\K\SHUWHQVLRQ/LPLWHGHYLGHQFHVXJJHVWVWKDWD02'(5$7(H[FHVVQXPEHU
RIEDELHVGHOLYHUHGE\HOHFWLYHFHVDUHDQPD\GHYHORSSXOPRQDU\K\SHUWHQVLRQ
1RWEUHDVWIHHGLQJ&RQIOLFWLQJHYLGHQFHVXJJHVWVWKDWEDELHVGHOLYHUHGE\FHVDUHDQPD\
EHDWH[FHVVULVNRIQRWEHLQJEUHDVWIHG

What role may cesarean delivery play in the development of


childhood chronic disease?
$VWKPD&HVDUHDQGHOLYHU\LQFUHDVHVWKHOLNHOLKRRGRIGHYHORSLQJDVWKPDLQFKLOGKRRGEXW
WKHH[FHVVQXPEHUFDQQRWEHFDOFXODWHGIURPWKHVWXGLHVH[DPLQHG
7\SHGLDEHWHV&HVDUHDQGHOLYHU\LQFUHDVHVWKHOLNHOLKRRGRIGHYHORSLQJ7\SHGLDEHWHV
LQFKLOGKRRGEXWWKHH[FHVVQXPEHUFDQQRWEHFDOFXODWHGIURPWKHVWXGLHVH[DPLQHG
$OOHUJLFUKLQLWLV&HVDUHDQGHOLYHU\LQFUHDVHVWKHOLNHOLKRRGRIGHYHORSLQJFKLOGKRRGDOOHUJLF
UKLQLWLVEXWWKHH[FHVVQXPEHUFDQQRWEHFDOFXODWHGIURPWKHVWXGLHVH[DPLQHG
6\PSWRPDWLFIRRGDOOHUJ\/LPLWHGDQGFRQIOLFWLQJHYLGHQFHVXJJHVWVWKDWFHVDUHDQGH
OLYHU\PD\LQFUHDVHWKHOLNHOLKRRGRIGHYHORSLQJIRRGDOOHUJ\LQFKLOGKRRGEXWWKHH[FHVV
QXPEHULIDQ\FDQQRWEHFDOFXODWHGIURPWKHVWXGLHVH[DPLQHG
2EHVLW\/LPLWHGHYLGHQFHVXJJHVWVWKDWD/$5*(H[FHVVQXPEHURIFKLOGUHQGHOLYHUHGE\
FHVDUHDQPD\EHREHVHDWDJH

What complications are unique to cesarean delivery?


2SHUDWLYHPDWHUQDOLQMXU\$PRQJZRPHQKDYLQJILUVWGHOLYHU\YLDFHVDUHDQD02'(5
$7(QXPEHURIZRPHQH[SHULHQFHEODGGHUSXQFWXUHDQGD60$//QXPEHUH[SHULHQFH
ERZHOLQMXU\RULQMXU\WRDXUHWHU
6XUJLFDOFXWVWRWKHEDE\/LPLWHGHYLGHQFHVXJJHVWVWKDWD02'(5$7(QXPEHURIEDELHV
DUHFXWGXULQJFHVDUHDQGHOLYHU\
5HRSHUDWLRQ/LPLWHGHYLGHQFHVXJJHVWVWKDWD02'(5$7(QXPEHURIZRPHQKDYLQJ
FHVDUHDQGHOLYHU\UHTXLUHUHRSHUDWLRQ
3HUVLVWHQWSDLQDWWKHVLWHRIWKHFHVDUHDQLQFLVLRQ/LPLWHGHYLGHQFHVXJJHVWVWKDWD
/$5*(WR9(5</$5*(QXPEHURIZRPHQVWLOOH[SHULHQFHSDLQDWWKHLQFLVLRQVLWH
PRQWKVRUPRUHDIWHUFHVDUHDQGHOLYHU\
&HVDUHDQVFDUHQGRPHWULRVLV/LPLWHGHYLGHQFHVXJJHVWVWKDWD60$//WR/$5*(QXP
EHURIZRPHQKDYLQJFHVDUHDQGHOLYHU\GHYHORSFHVDUHDQVFDUHQGRPHWULRPDV
&HVDUHDQVFDUHFWRSLFSUHJQDQF\HDUO\SODFHQWDDFFUHWD6RPHZRPHQEHFRPLQJSUHJ
QDQWDIWHUFHVDUHDQZLOOH[SHULHQFHDFHVDUHDQVFDUHFWRSLFSUHJQDQF\RUSODFHQWDOLPSODQWD
WLRQZLWKLQWKHXWHULQHVFDUEXWWKHQXPEHUFDQQRWEHFDOFXODWHGIURPWKHVWXGLHVH[DPLQHG
'HQVHLQWUDDEGRPLQDODGKHVLRQV/LPLWHGHYLGHQFHVXJJHVWVWKDWD9(5</$5*(QXP
EHURIZRPHQGHYHORSGHQVHDGKHVLRQVDIWHUFHVDUHDQGHOLYHU\

What complications are unique to vaginal birth?


$QDOVSKLQFWHULQMXU\$/$5*(QXPEHURIZRPHQH[SHULHQFHDQDOVSKLQFWHULQMXU\DW
YDJLQDOELUWK
3HULQHDORUJHQLWDOODFHUDWLRQVRIDQ\GHJUHH([FOXVLYHRIHSLVLRWRP\D9(5</$5*(
QXPEHURIZRPHQH[SHULHQFHWUDXPDWRWKHSHULQHXPRUJHQLWDOVDWYDJLQDOELUWKWKDWUH
TXLUHVVXWXULQJ
3HUVLVWHQWSHULQHDOSDLQ/LPLWHGHYLGHQFHVXJJHVWVWKDWD/$5*(QXPEHURIZRPHQH[
SHULHQFHSHUVLVWHQWSHULQHDOSDLQODVWLQJDWOHDVWVL[PRQWKVZLWKVSRQWDQHRXVYDJLQDOELUWK
DQGD9(5</$5*(QXPEHURIZRPHQH[SHULHQFHSHULQHDOSDLQODVWLQJDWOHDVWVL[PRQWKV
DIWHULQVWUXPHQWDOYDJLQDOGHOLYHU\

What are potential psychosocial consequences of cesareans?


$GYHUVHHIIHFWRQPDWHUQDOFKLOGUHODWLRQVKLS'DWDFRQIOLFWDERXWZKHWKHUFHVDUHDQ
GHOLYHU\KDVDQDGYHUVHHIIHFWRQWKHPRWKHUFKLOGUHODWLRQVKLS
'HSUHVVLRQ'DWDFRQIOLFWRQZKHWKHUFHVDUHDQGHOLYHU\LQFUHDVHVWKHOLNHOLKRRGRISRVWSDU
WXPGHSUHVVLRQ
3RVWWUDXPDWLFGLVWUHVV'DWDFRQIOLFWEXWVXJJHVWWKDWPRUHZRPHQPD\H[SHULHQFH376'
RU376'V\PSWRPVDIWHUFHVDUHDQGHOLYHU\LQJHQHUDODQGXQSODQQHGFHVDUHDQVLQSDUWLFX
ODUEXWWKHH[FHVVQXPEHULIDQ\FDQQRWEHFDOFXODWHGIURPWKHVWXGLHVH[DPLQHG
8

What are potential effects of cesareans on women in future


pregnancies and births?
,PSDLUHGIHUWLOLW\0RUHZRPHQH[SHULHQFHLPSDLUHGIHUWLOLW\DIWHUSULRUFHVDUHDQGHOLYHU\
FRPSDUHGZLWKDIWHUSULRUYDJLQDOELUWKEXWWKHH[FHVVQXPEHUFDQQRWEHFDOFXODWHGIURPWKH
VWXGLHVH[DPLQHG
9ROXQWDU\LQIHUWLOLW\$/$5*(WR9(5</$5*(H[FHVVQXPEHURIZRPHQFKRRVHQRWWR
FRQFHLYHDJDLQDIWHUFHVDUHDQGHOLYHU\
3ODFHQWDSUHYLD$60$//H[FHVVQXPEHURIZRPHQZLWKILUVWGHOLYHU\E\FHVDUHDQGHYHORS
SODFHQWDSUHYLDLQWKHQH[WSUHJQDQF\EXWWKHH[FHVVQXPEHUFDQQRWEHFDOFXODWHGIURPWKH
VWXGLHVH[DPLQHG$/$5*(H[FHVVQXPEHURIZRPHQGHYHORSSODFHQWDSUHYLDDIWHUWZRRU
PRUHSULRUFHVDUHDQV
3ODFHQWDDFFUHWD$60$//H[FHVVQXPEHURIZRPHQZLWKILUVWGHOLYHU\YLDFHVDUHDQGH
YHORSSODFHQWDDFFUHWDLQWKHQH[WSUHJQDQF\$/$5*(H[FHVVQXPEHURIZRPHQGHYHORS
SODFHQWDDFFUHWDDIWHUPXOWLSOHSULRUFHVDUHDQV
3ODFHQWDODEUXSWLRQ$02'(5$7(H[FHVVQXPEHURIZRPHQZLWKILUVWGHOLYHU\YLDFHVDU
HDQKDYHDSODFHQWDODEUXSWLRQLQVXEVHTXHQWSUHJQDQFLHV
+\VWHUHFWRP\$02'(5$7(H[FHVVQXPEHURIZRPHQZLWKSULRUFHVDUHDQGHOLYHU\UH
TXLUHDQXUJHQWK\VWHUHFWRP\GXULQJWKHQH[WGHOLYHU\DGPLVVLRQFRPSDUHGZLWKZRPHQZLWK
RQO\SULRUYDJLQDOELUWK/LPLWHGHYLGHQFHVXJJHVWVWKDWWKHH[FHVVLQFUHDVHVZLWKVXEVH
TXHQWSUHJQDQFLHV
8WHULQHUXSWXUH$02'(5$7(H[FHVVQXPEHURIZRPHQZLOOH[SHULHQFHXWHULQHUXSWXUH
ZLWKSULRUFHVDUHDQGHOLYHU\FRPSDUHGZLWKSULRUYDJLQDOELUWK
,QWHQVLYHFDUHDGPLVVLRQ/LPLWHGHYLGHQFHVXJJHVWVWKDWD/$5*(H[FHVVQXPEHURI
ZRPHQZLWKSULRUFHVDUHDQDUHDGPLWWHGWRLQWHQVLYHFDUHDWWKHQH[WGHOLYHU\FRPSDUHGZLWK
ZRPHQZLWKSULRUYDJLQDOELUWK
+RVSLWDOUHDGPLVVLRQ/LPLWHGHYLGHQFHVXJJHVWVWKDWD02'(5$7(H[FHVVQXPEHURI
ZRPHQZLWKSULRUFHVDUHDQDUHUHDGPLWWHGWRWKHKRVSLWDODIWHUGLVFKDUJHDWWKHQH[WGHOLYHU\
FRPSDUHGZLWKZRPHQZLWKSULRUYDJLQDOELUWK

What are potential effects of a scarred uterus on future babies?


6WLOOELUWK'DWDFRQIOLFWEXWVXJJHVWWKDWD60$//WR02'(5$7(H[FHVVQXPEHURIEDELHV
GHYHORSLQJLQDXWHUXVZLWKDFHVDUHDQVFDUDUHVWLOOERUQ
3HULQDWDORUQHRQDWDOGHDWK'DWDFRQIOLFWEXWVXJJHVWWKDWPRUHEDELHVGHYHORSLQJLQD
XWHUXVZLWKDFHVDUHDQVFDUPD\GLHODWHLQSUHJQDQF\RUGXULQJWKHILUVWZHHNDIWHUELUWKEXW
WKHH[FHVVQXPEHULIDQ\FDQQRWEHFDOFXODWHGIURPWKHVWXGLHVH[DPLQHG
3UHWHUPELUWKDQGORZELUWKZHLJKW'DWDFRQIOLFWRQZKHWKHUSULRUFHVDUHDQGHOLYHU\LP
SRVHVLQFUHDVHGULVNRISUHWHUPELUWKDQGFRQFRPLWDQWORZELUWKZHLJKW

6PDOOIRUJHVWDWLRQDODJH 6*$ 'DWDFRQIOLFWRQZKHWKHUSULRUFHVDUHDQGHOLYHU\LPSRVHV


LQFUHDVHGULVNRI6*$LQWKHQH[WSUHJQDQF\FRPSDUHGZLWKSULRUYDJLQDOELUWK
1HHGIRUYHQWLODWLRQDWELUWK/LPLWHGHYLGHQFHVXJJHVWVWKDWD/$5*(H[FHVVQXPEHURI
EDELHVZKRVHPRWKHUVKDGSULRUFHVDUHDQPD\UHTXLUHYHQWLODWLRQDWELUWKFRPSDUHGZLWK
EDELHVZKRVHPRWKHUVKDGSULRUYDJLQDOELUWK
+RVSLWDOVWD\ORQJHUWKDQGD\V/LPLWHGHYLGHQFHVXJJHVWVWKDWD/$5*(H[FHVVQXP
EHURIEDELHVZKRVHPRWKHUVKDGSULRUFHVDUHDQKDYHKRVSLWDOVWD\VRIPRUHWKDQGD\V
FRPSDUHGZLWKEDELHVZKRVHPRWKHUVKDGSULRUYDJLQDOELUWK

Does cesarean delivery protect against sexual, bowel, urinary, or


pelvic floor dysfunction?
6H[XDOG\VIXQFWLRQ&HVDUHDQGHOLYHU\SURYLGHVPLQLPDORUQRSURWHFWLRQDJDLQVWVH[XDO
G\VIXQFWLRQ
$QDOLQFRQWLQHQFH&HVDUHDQGHOLYHU\SURYLGHVQRSURWHFWLRQDJDLQVWDQDOLQFRQWLQHQFHLQ
HLWKHUWKHVKRUWWHUPRUXSWR\HDUVDIWHUELUWKSODQQHGFHVDUHDQSURYLGHVQRSURWHFWLRQ
FRPSDUHGZLWKFHVDUHDQVGXULQJODERU
8ULQDU\XUJHLQFRQWLQHQFH'DWDFRQIOLFWEXWVXJJHVWWKDWFHVDUHDQGHOLYHU\PD\SURYLGH
VRPHSURWHFWLRQDJDLQVWXULQDU\XUJHLQFRQWLQHQFHRIDQ\GHJUHHLQWKHVKRUWWHUPEXWSUR
WHFWLYHHIIHFWLIDQ\KDVGLVDSSHDUHGE\RQH\HDUDIWHUELUWKDQGVLPLODUSHUFHQWDJHVH[SHUL
HQFHVHYHUHLQFRQWLQHQFH
8ULQDU\VWUHVVLQFRQWLQHQFH$/$5*(WR9(5</$5*(H[FHVVQXPEHURIZRPHQKDYLQJ
YDJLQDOELUWKH[SHULHQFHXULQDU\VWUHVVLQFRQWLQHQFHRIDQ\GHJUHHDWRQH\HDURUPRUHDIWHU
ELUWKFRPSDUHGZLWKZRPHQKDYLQJFHVDUHDQGHOLYHU\EXWUDWHVRIVHYHUHLQFRQWLQHQFHDUH
ORZDQGVLPLODUEHWZHHQFHVDUHDQDQGYDJLQDOELUWKJURXSV
6\PSWRPDWLFSHOYLFRUJDQSURODSVH$/$5*(H[FHVVQXPEHURIZRPHQKDYLQJYDJL
QDOELUWKH[SHULHQFHV\PSWRPDWLFSHOYLFIORRUSURODSVHFRPSDUHGZLWKZRPHQKDYLQJRQO\
FHVDUHDQGHOLYHU\7KHH[FHVVLQFUHDVHVDVWKHQXPEHURIYDJLQDOELUWKVLQFUHDVHVDQGZLWK
LQVWUXPHQWDOYDJLQDOGHOLYHU\FRPSDUHGZLWKVSRQWDQHRXVYDJLQDOELUWK

Does cesarean delivery protect against injuries to babies?


%UDFKLDOSOH[XVLQMXU\/LPLWHGHYLGHQFHVXJJHVWVWKDWD02'(5$7(H[FHVVQXPEHURI
EDELHVERUQYDJLQDOO\H[SHULHQFHEUDFKLDOSOH[XVLQMXU\FRPSDUHGZLWKEDELHVGHOLYHUHGE\
FHVDUHDQEXWWKHH[FHVVLVLQIOXHQFHGE\ZKHWKHUGHOLYHU\LVVSRQWDQHRXVYDJLQDOLQVWUX
PHQWDOYDJLQDORUFHVDUHDQDIWHUIDLOHGLQVWUXPHQWDOGHOLYHU\
)DFLDOQHUYHLQMXU\/LPLWHGHYLGHQFHVXJJHVWVWKDWIDFLDOQHUYHLQMXU\UDWHVGRQRWGLIIHUE\
PRGHRIELUWK
1HRQDWDOQHXURORJLFV\PSWRPV3ODQQHGFHVDUHDQSURYLGHVQRSURWHFWLRQDJDLQVWLQWUD
FUDQLDOKHPRUUKDJHQHRQDWDOVHL]XUHRUDEQRUPDOQHXURORJLFVWDWXVFRPSDUHGZLWKZRPHQ
SODQQLQJYDJLQDOELUWK
&HUHEUDOSDOV\/LPLWHGHYLGHQFHVXJJHVWVWKDWOLEHUDOXVHRIFHVDUHDQGHOLYHU\LVQRWDV
VRFLDWHGZLWKDUHGXFWLRQLQFHUHEUDOSDOV\UDWHV
10


7KHILQGLQJVRIWKLVUHSRUWRYHUZKHOPLQJO\VXSSRUWVWULYLQJIRUYDJLQDOELUWKLQJHQHUDODQGVSRQ
WDQHRXVYDJLQDOELUWKLQSDUWLFXODULQWKHDEVHQFHRIDFRPSHOOLQJUHDVRQWRGRRWKHUZLVH7RLP
SURYHERWKWKHTXDOLW\DQGYDOXHRIPDWHUQLW\FDUHLQWKH8QLWHG6WDWHVDQGSURPRWHWKHRSWLPDO
KHDOWKRIZRPHQDQGLQIDQWVFOLQLFLDQVSROLF\PDNHUVDQGRWKHUVWDNHKROGHUVVKRXOGSULRULWL]H
LGHQWLI\LQJDQGSURPXOJDWLQJSUDFWLFHVWKDWSURPRWHVDIHVSRQWDQHRXVYDJLQDOELUWKDQGUHGXFH
WKHXVHRIFHVDUHDQGHOLYHU\

References
0HQDFNHU)'HFOHUFT(0DFGRUPDQ0)&HVDUHDQGHOLYHU\EDFNJURXQGWUHQGVDQGHSLGHPLRORJ\6HPLQ3HULQDWRO
%R\OH$5HGG\80(SLGHPLRORJ\RIFHVDUHDQGHOLYHU\WKHVFRSHRIWKHSUREOHP6HPLQ3HULQDWRO
%DUEHU(//XQGVEHUJ/6%HODQJHU.3HWWNHU&0)XQDL(),OOX]]L-/,QGLFDWLRQVFRQWULEXWLQJWRWKHLQFUHDVLQJFHVDUHDQGHOLY
HU\UDWH2EVWHW*\QHFRO
%DLFNHU . %XFNOHV .6 &KDQGUD $ *HRJUDSKLF YDULDWLRQ LQ WKH DSSURSULDWH XVH RI FHVDUHDQ GHOLYHU\ +HDOWK $II 0LOOZRRG 
Z
1DWLRQDO3ULRULWLHV3DUWQHUVKLS0DWHUQLW\$FWLRQ7HDP&RQYHQLQJ1333DUWQHUVDQGYDULHGRUJDQL]DWLRQVLQDVSHFLDOL]HGHIIRUW
WRGHYHORSDQGH[HFXWHVWUDWHJLHVWRUHGXFHHOHFWLYHGHOLYHULHVDQGFVHFWLRQVLQORZULVNZRPHQ2FW $FFHVVHG1RY
DWKWWSQTIFRPPSDUWQHUVFRPVH0HHWLQJV3OD\EDFNDVS["PHHWLQJLG 
:RUOG%DQNOLVWRIHFRQRPLHV:RUOG%DQN-XO\ $FFHVVHG-XODWKWWSVLWHUHVRXUFHVZRUOGEDQNRUJGDWD
VWDWLVWLFVUHVRXUFHVFODVV[OV
3DOLQJ-6WUDWHJLHVWRKHOSSDWLHQWVXQGHUVWDQGULVNV%0-

11

Introduction and Background


&HVDUHDQGHOLYHU\LVWKHPRVWFRPPRQRSHUDWLQJURRPSURFHGXUHLQWKH8QLWHG6WDWHVZLWK
DERXWRQHLQWKUHHEDELHVERUQVXUJLFDOO\7KLVUDWHLVDERXWKLJKHUWKDQWKH86UDWHWZR
GHFDGHVDJRDQGLVPRUHWKDQWZLFHWKHWDUJHWUDWHUHFRPPHQGHGE\WKH:RUOG+HDOWK2UJD
QL]DWLRQ7KHFHVDUHDQUDWHKDVLQFUHDVHGDPRQJZRPHQZLWKDQGZLWKRXWSULRUFHVDUHDQVLQ
ERWKSUHWHUPDQGWHUPSUHJQDQFLHVLQZRPHQDWORZDQGKLJKULVNRIFRPSOLFDWLRQVDQGDFURVV
DOODJHVUDFHVDQGHWKQLFLWLHV,QDGGLWLRQUDWHVYDU\FRQVLGHUDEO\DFURVVSURYLGHUVIDFLOLWLHV
DQGVWDWHV7KHVHWUHQGVDQGYDULDWLRQVVXJJHVWWKDWFHVDUHDQUDWHVUHIOHFWFOLQLFLDQSUDFWLFH
SDWWHUQVDQGDUHLQIOXHQFHGE\LQVWLWXWLRQDODQGV\VWHPIDFWRUVLQDGGLWLRQWRPHGLFDOIDFWRUVDQG
ZRPHQVSUHIHUHQFHV
$VFHVDUHDQUDWHVLQFUHDVHSURSRUWLRQDOO\PRUHORZULVNZRPHQH[SHULHQFHFHVDUHDQ
GHOLYHU\:KLOHWKHH[SHFWHGEHQHILWVRIFHVDUHDQGHOLYHU\YDU\GHSHQGLQJRQWKHLQGLFDWLRQ
DQGZRXOGEHPLQLPDOLQORZULVNZRPHQWKHSRWHQWLDOKDUPVDUHJHQHUDOO\LQWULQVLFWRVXUJLFDO
GHOLYHU\2ISDUWLFXODUFRQVHTXHQFHDUHGRZQVWUHDPHIIHFWVLQFOXGLQJFKLOGKRRGFKURQLFLOOQHVV
DQGSODFHQWDOFRPSOLFDWLRQVLQDQ\VXEVHTXHQWSUHJQDQFLHV7KHVHLQFOXGHOLIHWKUHDWHQLQJFRP
SOLFDWLRQVWKDWRFFXUPRUHIUHTXHQWO\ZLWKDFFXPXODWLQJVXUJHULHV%HFDXVHPDQ\ZRPHQODFN
DFFHVVWRYDJLQDOELUWKDIWHUFHVDUHDQ 9%$& WKH\ZLOOJRRQWRKDYHPXOWLSOHFHVDUHDQV7KXV
VDIHO\SUHYHQWLQJWKHILUVWFHVDUHDQHVSHFLDOO\LQORZULVNZRPHQKDVEHFRPHDQDWLRQDOSULRULW\
ZLWKJURZLQJPXOWLVWDNHKROGHUFRQVHQVXVLQFOXGLQJDPRQJSURPLQHQWREVWHWULFOHDGHUV,Q
WKH1DWLRQDO3ULRULWLHV3DUWQHUVKLSDFRQVRUWLXPRIPDMRUQDWLRQDORUJDQL]DWLRQVIDFLOLWDW
LQJFRRUGLQDWHGDFWLRQZLWKLQWDUJHWHGDUHDVRIKHDOWKDQGKHDOWKFDUHLPSURYHPHQWFRQYHQHGD
0DWHUQLW\$FWLRQ7HDPWRDGGUHVVLQDSSURSULDWHDQGXQVDIHPDWHUQLW\FDUH$PDMRUJRDORIWKH
0DWHUQLW\$FWLRQ7HDPLVWRUHGXFHFHVDUHDQGHOLYHU\LQORZULVNZRPHQWRRUOHVV
,Q&KLOGELUWK&RQQHFWLRQ WKHQQDPHGWKH0DWHUQLW\&HQWHU$VVRFLDWLRQODXQFKHGD
&HVDUHDQ$OHUW,QLWLDWLYHWRUDLVHDZDUHQHVVRIFRQFHUQVDERXWWKHULVLQJFHVDUHDQUDWHDQG
LVVXHGDFRQVXPHUERRNOHWWLWOHG:KDW(YHU\3UHJQDQW:RPDQ1HHGVWR.QRZ$ERXW&HVDU
HDQ6HFWLRQ(QGRUVHGE\PRUHWKDQRUJDQL]DWLRQVWKLVERRNOHWVXPPDUL]HGWKHILQGLQJV
RIDQH[WHQVLYHVFLHQWLILFUHYLHZWRLGHQWLI\DQGFRPSDUHDOOKDUPVWKDWPLJKWGLIIHULQOLNHOLKRRG
GHSHQGLQJRQKRZDZRPDQJLYHVELUWK:LWKHVFDODWLQJPXOWLVWDNHKROGHUDWWHQWLRQRQFHVDU
HDQRYHUXVHDQHYHUJURZLQJERG\RIHYLGHQFHDQGQHZRSSRUWXQLWLHVIRUFRQVXPHUHGXFDWLRQ
DQGVKDUHGGHFLVLRQPDNLQJ&KLOGELUWK&RQQHFWLRQUHFHQWO\GHWHUPLQHGWKHQHHGWRXSGDWHWKH
VFLHQWLILFUHYLHZWRVXPPDUL]HIRUDOOVWDNHKROGHUVWKHPRVWFXUUHQWEHVWHYLGHQFHRQWKHKHDOWK
FRQVHTXHQFHVRIFHVDUHDQGHOLYHU\7KLVUHSRUWSUHVHQWVWKHPHWKRGVILQGLQJVDQGLPSOLFD
WLRQVRIWKLVEHVWHYLGHQFHUHYLHZ&RPSDQLRQFRQVXPHURULHQWHGPDWHULDOVLQFOXGLQJDGRZQ
ORDGDEOHERRNOHWDUHDYDLODEOHDWKWWSZZZFKLOGELUWKFRQQHFWLRQRUJFHVDUHDQ

12

Methods
7KLVUHSRUWLQWHQGVWRSUHVHQWWKHEHVWDYDLODEOHHYLGHQFHIRUWKHGLUHFWLRQDQGVL]HRIWKHH[
FHVVOLNHOLKRRGRIWKHKDUPVDVVRFLDWHGZLWKFHVDUHDQGHOLYHU\YHUVXVYDJLQDOELUWKPHDVXUHG
ZLWKLQFRQWHPSRUDU\PDWHUQLW\SUDFWLFHLQKLJKUHVRXUFHFRXQWULHV7RDFFRPSOLVKWKLVJRDOZH
VHDUFKHG3XE0HGE\YDULRXVWHFKQLTXHVFRQVWUXFWLQJ0H6+WHUPVVHDUFKHVHLWKHUGHQRYR
RUXVLQJ0H6+WHUPVIURPUHOHYDQWVWXGLHVLQVHUWLQJWHUPVLQWR3XE0HGVVHDUFKER[DQG
UHYLHZLQJVWXGLHVSURSRVHGE\3XE0HGVUHODWHGFLWDWLRQVIXQFWLRQ7REHLQFOXGHGLQWKLVEHVW
HYLGHQFHUHYLHZV\VWHPDWLFUHYLHZVRUVWXGLHVKDGWRKDYHEHHQSXEOLVKHGLQ(QJOLVKVLQFH
EHHQFRQGXFWHGLQKLJKLQFRPHFRXQWULHV DVGHILQHGE\WKH:RUOG%DQN DQGFRPSDUH
RXWFRPHVZLWKFHVDUHDQGHOLYHU\YHUVXVHLWKHUDFWXDORUSODQQHGYDJLQDOELUWK7RH[DPLQH
RXWFRPHVXQLTXHWRVXUJHU\ HJFHVDUHDQVFDUHFWRSLFSUHJQDQF\RSHUDWLYHLQMXU\WRLQWHUQDO
RUJDQV RUYDJLQDOELUWK LHSHULQHDORUJHQLWDOLQMXU\ KRZHYHUZHUHOLHGRQVWXGLHVZLWKRXW
FRPSDULVRQJURXSV6WXGLHVVSHFLILFDOO\RISODQQHGUHSHDWFHVDUHDQYHUVXVSODQQHG9%$&ZHUH
H[FOXGHGDVWKHDLPRIWKLVUHYLHZZDVWRLOOXPLQDWHWKHVKRUWDQGORQJWHUPFRQVHTXHQFHVRI
SULPDU\FHVDUHDQGHOLYHU\6WXGLHVSXEOLVKHGRQO\DVDEVWUDFWVZHUHDOVRH[FOXGHG
7KHVWUHQJWKRIWKHHYLGHQFHYDULHGJUHDWO\DFURVVRXWFRPHV7RGHWHUPLQHWKHEHVWDYDLO
DEOHHYLGHQFHZHWKHUHIRUHDSSOLHGDKLHUDUFK\WKDWOLNHZLVHYDULHGDFURVVRXWFRPHV:KHUH
DQHOLJLEOHV\VWHPDWLFUHYLHZZDVDYDLODEOHWKDWLVDUHYLHZRIVWXGLHVRQDGHILQHGTXHVWLRQRU
TXHVWLRQVWKDWGHVFULEHGLWVVHDUFKPHWKRGVVSHFLILHGLQFOXVLRQDQGH[FOXVLRQFULWHULDDQGXVHG
PHWDDQDO\VLVZKHQDSSURSULDWHZHXVHGLWDVRXUH[FOXVLYHVRXUFH,IPRUHWKDQRQHHOLJLEOH
V\VWHPDWLFUHYLHZZDVLGHQWLILHGFRYHULQJWKHVDPHWRSLFZHFKRVHWKHPRVWUHFHQWXQOHVV
LQFOXGLQJPXOWLSOHV\VWHPDWLFUHYLHZVHQDEOHGUHSRUWLQJRIDGGLWLRQDORXWFRPHV7KHQH[WVWHS
GRZQLQWKHKLHUDUFK\ZRXOGQRUPDOO\EHUDQGRPL]HGFRQWUROOHGWULDOV 5&7V EXWWKHRQO\5&7
RIZKLFKZHDUHDZDUHWKDWDOORFDWHGZRPHQWRSODQQHGFHVDUHDQGHOLYHU\YHUVXVSODQQHGYDJL
QDOELUWKZDVDWULDORIEUHHFKGHOLYHU\:HH[FOXGHGLWDQGLWVIROORZXSVWXGLHVEHFDXVHEUHHFK
SUHVHQWDWLRQLVDSRWHQWFRQIRXQGLQJIDFWRU,WLVDVVRFLDWHGZLWKDGYHUVHSHULQDWDORXWFRPHVDQG
KLJKUDWHVRIREVWHWULFLQWHUYHQWLRQVDQGLQMXULHVZLWKSODQQHGYDJLQDOELUWKZKLFKPHDQVUHVXOWV
FDQQRWEHJHQHUDOL]HGWRFHSKDOLF KHDGGRZQ SUHVHQWDWLRQ,IQRHOLJLEOHV\VWHPDWLFUHYLHZ
FRXOGEHLGHQWLILHGZHUHVRUWHGWRREVHUYDWLRQDOVWXGLHVRIDQ\GHVLJQLQFOXGLQJFRKRUWFURVV
VHFWLRQDORUFDVHFRQWURO,QWKHFDVHRIUDUHDGYHUVHRXWFRPHVHOHFWURQLFGDWDEDVHVKDYH
HQDEOHGDJURZLQJQXPEHURISRSXODWLRQDQDO\VHVRIVXIILFLHQWVL]HWRGHWHFWGLIIHUHQFHVDFFRUG
LQJWRPRGHRIELUWKDQGHIIHFWVRIPRGHRIELUWKRQRXWFRPHVRIVXEVHTXHQWSUHJQDQFLHV)RU
LQFOXVLRQZHUHTXLUHGWKDWWKHVHGDWDEDVHVWXGLHVWDNHLQWRDFFRXQWFRQIRXQGLQJDQGFRUUHODWLQJ
IDFWRUVWKDWFRXOGERWKOHDGWRFHVDUHDQGHOLYHU\DQGSUHGLVSRVHWRDGYHUVHRXWFRPH(YLGHQFH
IRUVRPHRXWFRPHVZDVRQO\DYDLODEOHLQFDVHVHULHVDQGUHSRUWV,QWKLVVLWXDWLRQZHLQFOXGHG
RQO\WKHODUJHVWRIWKHFDVHVHULHVH[FOXGLQJVLQJOHFDVHUHSRUWVRUVHULHVRIRQO\DIHZFDVHV
,QVRPHVWXGLHVWKHYDJLQDOELUWKJURXSFRQVLVWHGRIZRPHQZKRSODQQHGYDJLQDOELUWKEXW
PLJKWXOWLPDWHO\KDYHJLYHQELUWKE\FHVDUHDQ LQWHQWWRWUHDWVWXGLHV ,QRWKHUVWKHYDJLQDO
ELUWKJURXSZDVFRPSULVHGRIZRPHQZKRKDGYDJLQDOELUWKV(DFKPHWKRGKDVOLPLWDWLRQVZLWK
SODQQHGYDJLQDOELUWKDGYHUVHRXWFRPHVDUHFRQFHQWUDWHGLQWKHVXEVHWRIZRPHQZKRGHOLYHU
E\FHVDUHDQRULQVWUXPHQWDOYDJLQDOELUWK7KLVSURSRUWLRQLVJUHDWO\LPSDFWHGE\ORFDOSUDF
WLFHSDWWHUQVDQGREVWHWULFFXOWXUHDQGWKXVWKHPDJQLWXGHRIKDUPYDULHVZLGHO\DFURVVVWXG\
VHWWLQJVOLPLWLQJH[WHUQDOYDOLGLW\RILQWHQWWRWUHDWVWXG\ILQGLQJV6WXGLHVRIZRPHQZKRKDYH
YDJLQDOELUWKVKRZHYHUSURYLGHDQLQFRPSOHWHSLFWXUHRIWKHOLNHOLKRRGRIYDULRXVRXWFRPHVIRU
DZRPDQSODQQLQJYDJLQDOELUWK%HFDXVHERWKERGLHVRIOLWHUDWXUHFDQLQIRUPRXUXQGHUVWDQGLQJ
RIWKHKDUPVDQGEHQHILWVRIFHVDUHDQYHUVXVYDJLQDOELUWKDQGWRJHWKHUHQDEOHDIXOOHUXQGHU
VWDQGLQJRIWKHUDQJHRIRXWFRPHVWKDWGLIIHUVE\PRGHRIELUWKZHKDYHLQFOXGHGVWXGLHVRIERWK
SODQQHGDQGDFWXDOYDJLQDOELUWK:KHUHWKHSODQQHGYDJLQDOELUWKJURXSLQFOXGHVZRPHQJLYLQJ
ELUWKE\FHVDUHDQZHKDYHUHSRUWHGWKDWFHVDUHDQUDWHLQWKHUHVHDUFKVXPPDULHV
13

:HKDYHFRQILQHGRXUUHVXOWVWRSHUVRQFHQWHUHGRXWFRPHVWKDWLVRXWFRPHVWKDWKDYH
DQLPSRUWDQWLPSDFWRQWKHZRPDQVRUKHUFKLOGVFRQGLWLRQ0DQ\VWXGLHVPHDVXUHVXUURJDWH
RXWFRPHVLHODERUDWRU\PHDVXUHPHQWVSK\VLFDOVLJQVRULQWHUPHGLDWHRXWFRPHVXVHGDVD
VXEVWLWXWHIRUDGLUHFWPHDVXUHPHQWRIKRZDSDWLHQWIHHOVIXQFWLRQVRUVXUYLYHV7KLVLVRIWHQ
GRQHEHFDXVHWKH\RFFXUPRUHIUHTXHQWO\DQGFORVHUWRWKHWLPHRIWKHH[SRVXUHWKDQRXWFRPHV
RIJUHDWHUFRQVHTXHQFHPDNLQJLWHDVLHUWRPHDVXUHGLIIHUHQFHVEXWVXUURJDWHRXWFRPHVDUH
RIWHQSRRUSUHGLFWRUVRIFOLQLFDOO\LPSRUWDQWRXWFRPHV7KHUHIRUHZHKDYHQRWUHSRUWHGRQ
VXFKRXWFRPHVLQFOXGLQJ$SJDUVFRUHVRUFRUGEORRGS+
$QRWKHUVWUDWHJ\IRULQFUHDVLQJDVWXG\VSRZHUWRGHWHFWGLIIHUHQFHLQXQFRPPRQRXWFRPHV
LVWRFRPELQHWKHPLQWRDFRPSRVLWH:HKDYHFKRVHQQRWWRUHSRUWFRPSRVLWHRXWFRPHVEH
FDXVHWKH\RIWHQHQFRPSDVVDUDQJHRIVHYHULW\DQGRFFXUUHQFHUDWHVRIWKHFRPSRQHQWRXW
FRPHVPD\YDU\ZLGHO\
5HVXOWVIRUHDFKRXWFRPHDUHSUHVHQWHGDVDQLWDOLFL]HGRXWFRPHVXPPDU\ZLWKHVWLPDWLRQ
RIDEVROXWHGLIIHUHQFHV ZKHQTXDQWLILDEOH IROORZHGE\DUHVHDUFKVXPPDU\6RPHRIWKHVHRXW
FRPHVXPPDULHVDGGUHVVWKHRYHUDOOVWUHQJWKDQGFRQVLVWHQF\RIWKHERG\RIOLWHUDWXUHDOWKRXJK
QRVWDQGDUGTXDOLW\IUDPHZRUNZDVDSSOLHG,QJHQHUDOOLPLWHGHYLGHQFHUHIHUVWRDVLQJOHPRUH
VXEVWDQWLDOREVHUYDWLRQDOVWXG\RUDVPDOOQXPEHURIVPDOOREVHUYDWLRQDOVWXGLHVDQGGDWDFRQ
IOLFWLQGLFDWHVWKDWVRPHVWXGLHVIRXQGVLJQLILFDQWGLIIHUHQFHVZKLOHRWKHUVIRXQGQRVLJQLILFDQW
GLIIHUHQFHRUIRXQGDVLJQLILFDQWGLIIHUHQFHLQWKHRSSRVLWHGLUHFWLRQ)RUVRPHRXWFRPHVDG
GLWLRQDOLQIRUPDWLRQLVSURYLGHGEHIRUHWKHRXWFRPHVXPPDU\WRSURYLGHDSSURSULDWHFRQWH[WDQG
GHILQHWHUPV7KHVHH[SODQDWRU\SDVVDJHVPD\UHIHUHQFHVWXGLHVRUUHSRUWVWKDWGLGQRWPHHW
LQFOXVLRQFULWHULD,QFOXGHGVWXGLHVLHWKRVHFLWHGLQUHVHDUFKVXPPDULHVDUHGHQRWHGZLWKDQ
DVWHULVN LQWKHUHIHUHQFHOLVW
:KHUHGLIIHUHQFHVEHWZHHQPRGHVRIELUWKFRXOGEHTXDQWLILHGZHUHSRUWHGWKHVL]HRIWKRVH
GLIIHUHQFHV DEVROXWHULVNGLIIHUHQFH RQDVFDOHRIYHU\VPDOOWRYHU\ODUJHDFFRUGLQJWR
RUGHUVRIPDJQLWXGHVWDQGDUGL]HGWRDGHQRPLQDWRURI 6HH7DEOH 7KHVWDQGDUGL]HG
VFDOHDOORZVUHDGHUVWRPDNHFRPSDULVRQVDWDJODQFHDQGZDVFKRVHQDVWKHFRPPRQ
GHQRPLQDWRUWRFDSWXUHWKHZLGHYDULDWLRQLQUDWHVRIYDULRXVRXWFRPHV,QVRPHFDVHVVWXGLHV
UHSRUWHGRQO\RGGVRUULVNUDWLRVZKLFKPHDQWWKDWGLIIHUHQFHVFRXOGQRWEHTXDQWLILHG7KHVH
KDYHEHHQVRQRWHG8QOHVVVWDWHGRWKHUZLVHDOOGLIIHUHQFHVDUHVWDWLVWLFDOO\VLJQLILFDQWWKDWLV
XQOLNHO\WREHGXHWRFKDQFH

Table 1:

0DJQLWXGHRI$EVROXWH5LVN'LIIHUHQFHLQ5HSRUWHG2XWFRPH









9(5</$5*(

WR

/$5*(

WR

02'(5$7(

WR

60$//

WR

9(5<60$//

OHVVWKDQ

14

RIHYHU\
ZRPHQRUEDELHV

Results
1. What physical effects occur in women
more frequently with cesarean delivery?

([FHVVULVNRIPDWHUQDOGHDWKZLWKFHVDUHDQGHOLYHU\LVELRORJLFDOO\SODXVLEOHLQWKDWVXUJHU\LQWUR
GXFHVWKHSRVVLELOLW\RIVXUJLFDOFRPSOLFDWLRQVLQFOXGLQJOLIHWKUHDWHQLQJFRPSOLFDWLRQV
0RUHZRPHQDSSHDUWRGLHDVDUHVXOWRIFHVDUHDQGHOLYHU\LWVHOIEXW
WKHH[FHVVQXPEHUFDQQRWEHFDOFXODWHGIURPWKHVWXGLHVH[DPLQHG
7ZRVWXGLHVRQHLQ1RUWK&DUROLQDDQGRQHLQ)UDQFHKDYHDWWHPSWHGWRGHWHUPLQHZKHWKHU
FHVDUHDQGHOLYHU\GLUHFWO\FRQWULEXWHVWRDQH[FHVVRIPDWHUQDOGHDWKV7KHGHDWKUDWHDVVRFL
DWHGZLWKOLYHELUWKDFFRUGLQJWRELUWKPRGHLQ1RUWK&DUROLQDZDVSHUZLWKFHVDUHDQ
GHOLYHU\FRPSDUHGZLWKSHUZLWKYDJLQDOELUWKRUDQH[FHVVZRPHQSHU
$IWHUWDNLQJLQWRDFFRXQWPHGLFDOFRPSOLFDWLRQVPDWHUQDODJHDQGSUHWHUPELUWKZRPHQZHUH
WLPHVPRUHOLNHO\WRGLHLQFRQMXQFWLRQZLWKFHVDUHDQGHOLYHU\WKDQZLWKYDJLQDOELUWK7KH
)UHQFKVWXG\H[FOXGHGDOOGHDWKVWKDWGLGQRWUHVXOWLQDOLYHELUWK HJHFWRSLFSUHJQDQF\ DQG
DOOSUHJQDQF\FRQGLWLRQVWKDWZRXOGERWKLQFUHDVHWKHULVNRIGHDWKDQGWKHOLNHOLKRRGRIFHVDU
HDQGHOLYHU\VXFKDVSODFHQWDODWWDFKPHQWDEQRUPDOLWLHV$IWHUDGMXVWLQJIRUDJHQDWLRQDOLW\
SDULW\DQGSUHWHUPELUWKZRPHQZHUHWLPHVPRUHOLNHO\WRGLHLQFRQMXQFWLRQZLWKFHVDUHDQ
GHOLYHU\WKDQZLWKYDJLQDOELUWK%RWKVWXGLHVPD\KDYHXQGHUHVWLPDWHGWKHWUXHFHVDUHDQUH
ODWHGPRUWDOLW\UDWHEHFDXVHWKH\H[FOXGHGGHDWKVUHODWHGWRFRPSOLFDWLRQVWKDWDUHDVVRFLDWHG
ZLWKSULRUFHVDUHDQDQGWKDWZRXOGQRW FHVDUHDQVFDUHFWRSLFSUHJQDQF\ RUPLJKWQRW SODFHQWD
SUHYLD UHVXOWLQDOLYHELUWK 6HHEHORZ 
$WKLUGVWXG\DQDO\]HGGHDWKVRFFXUULQJDW+RVSLWDO&RUSRUDWLRQRI$PHULFDKRVSLWDOVD
IRUSURILWKRVSLWDOFKDLQEHWZHHQDQG,WUHSRUWHGGHDWKVSHUFDXVDOO\
UHODWHGWRFHVDUHDQGHOLYHU\FRPSDUHGZLWKGHDWKVSHUFDXVDOO\UHODWHGWRYDJLQDO
ELUWKPXFKORZHUUDWHVLQERWKFDWHJRULHVWKDQWKH1RUWK&DUROLQDVWXG\


/LPLWHGHYLGHQFHVXJJHVWVWKDWD02'(5$7(H[FHVVQXPEHURIKHDOWK\
ZRPHQPD\H[SHULHQFHFDUGLDFDUUHVWLQDVVRFLDWLRQZLWKFHVDUHDQ
GHOLYHU\FRPSDUHGZLWKVLPLODUZRPHQSODQQLQJYDJLQDOELUWK
$ODUJHVWXG\FRPSDUHGKHDOWK\ZRPHQKDYLQJSODQQHGSULPDU\FHVDUHDQIRUEUHHFKZLWKVLPLODU
ZRPHQZLWKDKHDGGRZQIHWXVSODQQLQJYDJLQDOELUWKRIZKRPKDGFHVDUHDQV)LIWHHQPRUH
ZRPHQSHUKDYLQJSODQQHGFHVDUHDQH[SHULHQFHGFDUGLDFDUUHVWEHIRUHKRVSLWDOGLVFKDUJH


$60$//WR02'(5$7(H[FHVVQXPEHURIZRPHQKDYLQJLQLWLDOFHVDUHDQGHOLYHU\
XQGHUJRXQSODQQHGK\VWHUHFWRP\FRPSDUHGZLWKZRPHQKDYLQJYDJLQDOELUWK
15

7KUHHVWXGLHVDFFRXQWHGIRUWKHIDFWWKDWDEQRUPDOSODFHQWDODWWDFKPHQWDQGDQWHSDUWXPEOHHG
LQJFDQOHDGERWKWRFHVDUHDQGHOLYHU\DQGWRK\VWHUHFWRP\DQGDOOIRXQGWKDWSULPDU\FHVDUHDQ
GHOLYHU\ZDVDQLQGHSHQGHQWULVNIDFWRUIRUK\VWHUHFWRP\GXULQJRUDIWHUGHOLYHU\([FHVV
UDWHVYDULHGIURPWRPRUHK\VWHUHFWRPLHVSHUZRPHQKDYLQJSULPDU\FHVDUHDQ


,IGHHSYHQRXVFORWVEHFRPHGLVORGJHGWKH\FDQOHDGWRSXOPRQDU\HPEROLVP EORFNDJHRI
DEORRGYHVVHOLQWKHOXQJ RUVWURNH7KHVHEORRGFORWVRFFXUPRUHIUHTXHQWO\ZLWKFHVDUHDQ
GHOLYHU\FRPSDUHGZLWKSODQQHGRUDFWXDOYDJLQDOELUWK7KLVH[FHVVFDQEHUHGXFHGZLWKURXWLQH
SURSK\ODFWLFPHDVXUHVIRUH[DPSOHXVHRISQHXPDWLFFRPSUHVVLRQGHYLFHVDIWHUVXUJHU\
$60$//WR02'(5$7(H[FHVVQXPEHURIKHDOWK\ZRPHQ
KDYLQJFHVDUHDQGHOLYHU\H[SHULHQFHDEORRGFORW
7ZRVWXGLHVUHSRUWHGLQFUHDVHGOLNHOLKRRGRIWKURPERHPEROLFHYHQWVZLWKFHVDUHDQGHOLYHU\
FRPSDUHGZLWKYDJLQDOELUWK2QHVWXG\FRPSDUHGZRPHQKDYLQJHOHFWLYHFHVDUHDQZLWKZRPHQ
KDYLQJVSRQWDQHRXVYDJLQDOELUWKDQGUHSRUWHGPRUHWKURPERHPEROLFHYHQWV GHHSYHQRXV
FORWHPEROLVPRUVWURNH SHUZRPHQKDYLQJHOHFWLYHFHVDUHDQV7KHRWKHUFRPSDUHG
KHDOWK\ZRPHQKDYLQJSODQQHGFHVDUHDQIRUEUHHFKZLWKKHDOWK\ZRPHQZLWKDKHDGGRZQ
EDE\SODQQLQJYDJLQDOELUWK RIZKRPKDGDFHVDUHDQ ,QYHVWLJDWRUVUHSRUWHGPRUHGHHS
YHQRXVFORWVSHUZRPHQKDYLQJSODQQHGFHVDUHDQ


/LPLWHGHYLGHQFHVXJJHVWVWKDWD02'(5$7(H[FHVV
QXPEHURIKHDOWK\ZRPHQKDYLQJFHVDUHDQGHOLYHU\PD\
H[SHULHQFHFRPSOLFDWLRQVZLWKDQHVWKHVLDFRPSDUHGZLWK
VLPLODUZRPHQKDYLQJVSRQWDQHRXVYDJLQDOELUWK
$ODUJHVWXG\RIZRPHQZLWKQRGRFXPHQWHGPDWHUQDOULVNIDFWRUVRUFRPSOLFDWLRQVUHSRUWHGWKDW
PRUHZRPHQSHUKDYLQJHOHFWLYHFHVDUHDQVKDGDQHVWKHWLFFRPSOLFDWLRQV QRWGH
ILQHG FRPSDUHGZLWKZRPHQKDYLQJVSRQWDQHRXVYDJLQDOELUWK


&HVDUHDQGHOLYHU\LQKHDOWK\ZRPHQLPSRVHVH[FHVVULVNRIPDMRUSXHUSHUDOLQIHFWLRQ HQGR
PHWULWLVIHYHUSHULWRQLWLVS\HPLDVDOSLQJLWLVVHSWLFHPLD FRPSDUHGZLWKYDJLQDOELUWK$QWLELRWLF
SURSK\OD[LVFDQUHGXFHLQIHFWLRQUDWHVDIWHUFHVDUHDQGHOLYHU\ZLWKSUHLQFLVLRQDGPLQLVWUDWLRQ
PRUHHIIHFWLYHWKDQLQWUDSDUWXPDGPLQLVWUDWLRQ7KHVWXGLHVILQGLQJH[FHVVLQIHFWLRQZLWKFHVDU
HDQZHUHFRQGXFWHGLQGHYHORSHGFRXQWULHVGXULQJSHULRGVZKHQURXWLQHDQWLELRWLFSURSK\OD[LV
ZDVOLNHO\WREHWKHQRUPEXWWLPLQJRIDGPLQLVWUDWLRQLVXQNQRZQ,WLVSRVVLEOHWKDWVRPHRIWKH
H[FHVVLVUHGXFLEOHZLWKSUHLQFLVLRQDGPLQLVWUDWLRQ
/LPLWHGHYLGHQFHVXJJHVWVWKDWD02'(5$7(WR/$5*(
H[FHVVQXPEHURIKHDOWK\ZRPHQKDYLQJSODQQHGFHVDUHDQ
GHOLYHU\H[SHULHQFHPDMRUSXHUSHUDOLQIHFWLRQFRPSDUHG
ZLWKZRPHQKDYLQJRUSODQQLQJYDJLQDOELUWK
16

$ODUJHVWXG\FRPSDUHGPDWHUQDORXWFRPHVZLWKLQGD\VDIWHUELUWKEHWZHHQKHDOWK\
ZRPHQKDYLQJHOHFWLYHFHVDUHDQGHOLYHU\DQGZRPHQKDYLQJVSRQWDQHRXVYDJLQDOELUWKVDQG
IRXQGWKDWPRUHZRPHQSHUKDYLQJSODQQHGFHVDUHDQGHOLYHU\KDGPDMRUSXHUSHUDO
LQIHFWLRQV$VHFRQGVWXG\FRPSDUHGKHDOWK\ZRPHQKDYLQJSODQQHGSULPDU\FHVDUHDQIRU
EUHHFKZLWKVLPLODUZRPHQZLWKDKHDGGRZQIHWXVSODQQLQJYDJLQDOELUWKRIZKRPKDGXQ
SODQQHGFHVDUHDQDQGIRXQGWKDWPRUHZRPHQSHUKDYLQJSODQQHGFHVDUHDQGHOLYHU\
KDGPDMRUSXHUSHUDOLQIHFWLRQV


/LPLWHGHYLGHQFHVXJJHVWVWKDWPRUHZRPHQH[SHULHQFHDP
QLRWLFIOXLGHPEROLVPRUXWHULQHDUWHU\SVHXGRDQHXU\VP
DIWHUFHVDUHDQWKDQDIWHUYDJLQDOELUWKEXWWKHH[FHVVQXPEHU
FDQQRWEHFDOFXODWHGIURPWKHVWXGLHVH[DPLQHG
$VWXG\RIDPQLRWLFIOXLGHPEROLVP $)( DQDO\]HGDVXEJURXSRIFDVHVRFFXUULQJDIWHUELUWKLQ
RUGHUWRGHWHUPLQHWKHFDXVHDQGHIIHFWUHODWLRQVKLSEHWZHHQ$)(DQGFHVDUHDQGHOLYHU\DQG
IRXQGWKDWZRPHQKDYLQJFHVDUHDQGHOLYHU\ZHUHQLQHWLPHVPRUHOLNHO\WRH[SHULHQFHSRVWSDU
WXP$)(FRPSDUHGZLWKZRPHQKDYLQJYDJLQDOELUWK7KHPDWHUQDOPRUWDOLW\UDWHDPRQJDOO
FDVHVZDV$V\VWHPDWLFUHYLHZRIFDVHVRIXWHULQHDUWHU\SVHXGRDQHXU\VPDFRPSOLFDWLRQ
WKDWFDQUHVXOWLQOLIHWKUHDWHQLQJKHPRUUKDJHUHSRUWHGWKDWDPRQJWKHFDVHVDVVRFLDWHGZLWK
FKLOGELUWKRFFXUUHGDIWHUFHVDUHDQGHOLYHU\


+HDOWK\ZRPHQKDYLQJFHVDUHDQGHOLYHU\DUHPRUHOLNHO\WRH[SHULHQFHSUREOHPVZLWKWKHDEGRP
LQDOZRXQGWKDQZRPHQKDYLQJYDJLQDOELUWKDUHWRH[SHULHQFHSUREOHPVZLWKDJHQLWDOZRXQG
3UREOHPVLQFOXGHLQIHFWLRQZRXQGGLVUXSWLRQ WKHZRXQGUHRSHQV DQGKHPDWRPD DEORRGILOOHG
VZHOOLQJ )XUWKHUPRUHZLWKDYRLGDQFHRIHSLVLRWRP\DQGSDWLHQFHGXULQJWKHVHFRQGVWDJHRI
ODERUDVXEVWDQWLDOSHUFHQWDJHRIZRPHQKDYLQJYDJLQDOELUWKVGRQRWH[SHULHQFHDQ\JHQLWDO
ZRXQGDQGWKXVWKH\DUHQRWDWULVNIRUZRXQGFRPSOLFDWLRQV

$/$5*(H[FHVVQXPEHURIKHDOWK\ZRPHQKDYLQJ
FHVDUHDQGHOLYHU\KDYHZRXQGLQIHFWLRQVFRPSDUHG
ZLWKZRPHQSODQQLQJYDJLQDOELUWK
$VWXG\UHSRUWHGRQZRXQGLQIHFWLRQLQZRPHQKDYLQJSODQQHGSULPDU\FHVDUHDQFRPSDUHG
ZLWKZRPHQSODQQLQJYDJLQDOELUWKDPRQJZKRPKDGDFHVDUHDQGXULQJODERU,WIRXQG
WKDWPRUHZRPHQSHUKDYLQJSODQQHGFHVDUHDQGHYHORSHGZRXQGLQIHFWLRQ$
VHFRQGODUJHVWXG\UHSRUWHGWKDWPRUHZRPHQSHUKDYLQJFHVDUHDQGXULQJODERU
DQGSHUPRUHZRPHQKDYLQJSODQQHGFHVDUHDQKDGDZRXQGLQIHFWLRQZLWKLQ
GD\VSRVWSDUWXPWKDQZRPHQKDYLQJYDJLQDOELUWK,QYHVWLJDWRUVRQO\SHUIRUPHGVWDWLVWLFDO
DQDO\VLVRQLQIHFWLRQUDWHGLIIHUHQFHVEHWZHHQFHVDUHDQVGXULQJODERU SHU DQG
SODQQHGFHVDUHDQV SHU ILQGLQJDVLJQLILFDQWGLIIHUHQFHEXWKDGWKH\FRPSDUHG
UDWHVZLWKYDJLQDOELUWK SHU LWVHHPVSUREDEOHWKH\ZRXOGKDYHIRXQGDVLJQLILFDQW
GLIIHUHQFHDVZHOO
17


/LPLWHGHYLGHQFHVXJJHVWVWKDWD/$5*(H[FHVVQXPEHURIKHDOWK\
ZRPHQKDYLQJFHVDUHDQGHOLYHU\KDYHZRXQGKHPDWRPDVFRPSDUHG
ZLWKZRPHQSODQQLQJYDJLQDOELUWK
$VWXG\FRPSDUHGKHDOWK\ZRPHQKDYLQJSODQQHGSULPDU\FHVDUHDQIRUEUHHFKZLWKVLPLODU
ZRPHQZLWKDKHDGGRZQIHWXVSODQQLQJYDJLQDOELUWKRIZKRPKDGXQSODQQHGFHVDUHDQDQG
IRXQGWKDWPRUHZRPHQSHUKDYLQJSODQQHGFHVDUHDQGHOLYHU\KDGKHPDWRPDV

/LPLWHGHYLGHQFHVXJJHVWVWKDWD60$//H[FHVVQXPEHURI
KHDOWK\ZRPHQKDYLQJFHVDUHDQGHOLYHU\KDYHZRXQGGLVUXSWLRQ
FRPSDUHGZLWKZRPHQSODQQLQJYDJLQDOELUWK
$VWXG\FRPSDUHGKHDOWK\ZRPHQKDYLQJSODQQHGSULPDU\FHVDUHDQIRUEUHHFKZLWKVLPLODU
ZRPHQZLWKDKHDGGRZQIHWXVSODQQLQJYDJLQDOELUWKRIZKRPKDGXQSODQQHGFHVDUHDQ
DQGIRXQGWKDWPRUHZRPHQSHUKDGWKHZRXQGUHRSHQ


3ODQQHGFHVDUHDQGHOLYHU\LQFUHDVHVOHQJWKRIKRVSLWDOVWD\E\
DWOHDVWWRGD\VFRPSDUHGZLWKSODQQHGYDJLQDOELUWK
7KUHHVWXGLHVFRPSDUHGOHQJWKRIKRVSLWDOVWD\DIWHUSODQQHGFHVDUHDQYHUVXVSODQQHGYDJLQDO
ELUWK$OOWKUHHKDGKLJKFHVDUHDQUDWHVLQWKHSODQQHGYDJLQDOELUWKJURXSV  ZKLFK
ZRXOGUHGXFHREVHUYHGGLIIHUHQFHV7ZRRIWKHVWXGLHVZHUHRIRXWFRPHVUHODWHGWRSODQQHG
PRGHRIELUWKZLWKEUHHFKSUHVHQWDWLRQ0HGLDQKRVSLWDOVWD\LQRQHZDVGD\VZLWKSODQQHG
FHVDUHDQYHUVXVGD\VZLWKSODQQHGYDJLQDOELUWKDQGWKHFHVDUHDQUDWHZLWKSODQQHGYDJLQDO
ELUWKZDV,QWKHRWKHUPHGLDQOHQJWKRIVWD\ZDVGD\VZLWKSODQQHGFHVDUHDQYHUVXV
GD\VZLWKSODQQHGYDJLQDOELUWKDQGWKHFHVDUHDQUDWHZLWKSODQQHGYDJLQDOELUWKZDV
7KHWKLUGVWXG\ZDVRIKHDOWK\ILUVWWLPHPRWKHUVDWWHUPSODQQLQJFHVDUHDQIRUEUHHFKRUHOHF
WLYHFHVDUHDQYHUVXVVLPLODUZRPHQZLWKDKHDGGRZQIHWXVSODQQLQJYDJLQDOELUWK7KHPHDQ
OHQJWKRIVWD\ZDVGD\VZLWKSODQQHGFHVDUHDQYHUVXVGD\VZLWKSODQQHGYDJLQDOELUWK
DQGWKHFHVDUHDQUDWHZLWKSODQQHGYDJLQDOELUWKZDV


$02'(5$7(WR/$5*(H[FHVVQXPEHURIKHDOWK\ZRPHQ
KDYLQJFHVDUHDQGHOLYHU\UHTXLUHUHDGPLVVLRQWRWKHKRVSLWDO
7KUHHVWXGLHVORRNHGDWKRVSLWDOUHDGPLVVLRQUDWHVDFFRUGLQJWRDFWXDORUSODQQHGPRGHRIELUWK
2QHVWXG\FRPSDUHGKRVSLWDOUHDGPLVVLRQUDWHVLQORZULVNZRPHQKDYLQJDSULPDU\FHVDUHDQGH
OLYHU\ZLWKZRPHQKDYLQJDVSRQWDQHRXVYDJLQDOELUWKDQGIRXQGWKDWPRUHZRPHQSHU
KDYLQJFHVDUHDQVZHUHUHDGPLWWHGWRWKHKRVSLWDOZLWKLQWKHILUVWGD\VDIWHUGHOLYHU\:RPHQ
KDYLQJQRPHGLFDORUREVWHWULFFRPSOLFDWLRQVZKRKDGFHVDUHDQVZHUHMXVWDVOLNHO\WREHUHDGPLW
WHGDVZRPHQLQWKHFHVDUHDQGHOLYHU\SRSXODWLRQRYHUDOOZKLFKVXJJHVWVWKDWIDFWRUVLQKHUHQW
18

WRVXUJHU\DUHWKHUHDVRQVIRUWKHUHDGPLVVLRQV$VHFRQGVWXG\FRPSDUHGKRVSLWDOUHDGPLVVLRQ
UDWHVLQZRPHQZLWKQRUHSRUWHGULVNIDFWRUVKDYLQJSULPDU\FHVDUHDQZLWKVLPLODUZRPHQSODQQLQJ
YDJLQDOELUWKDPRQJZKRPKDGDFHVDUHDQGXULQJODERUDQGIRXQGWKDWPRUHZRPHQSHU
ZHUHUHDGPLWWHGWRWKHKRVSLWDOZLWKLQWKHILUVWGD\VDIWHUELUWK0RVWKRVSLWDOUHDGPLV
VLRQVLQWKHSODQQHGYDJLQDOELUWKJURXSZHUHLQZRPHQZKRKDGFHVDUHDQVGXULQJODERUZKLFK
VXJJHVWVWKDWUHGXFLQJWKHFXUUHQWO\OLEHUDOXVHRIFHVDUHDQGHOLYHU\ZLOOUHGXFHUHKRVSLWDOL]DWLRQ
UDWHV7KHWKLUGVWXG\FRPSDUHGUDWHVEHWZHHQORZULVNZRPHQSODQQLQJSULPDU\FHVDUHDQGHOLY
HU\ZLWKVLPLODUZRPHQSODQQLQJYDJLQDOELUWKDPRQJZKRPKDGDFHVDUHDQGXULQJODERU
,WIRXQGWKDWZRPHQSHUKDYLQJSODQQHGFHVDUHDQZHUHUHDGPLWWHGDIWHUKRVSLWDO
GLVFKDUJHFRPSDUHGZLWKZRPHQSODQQLQJYDJLQDOELUWK7KHGLIIHUHQFHGLGQRWDFKLHYHVWDWLVWLFDO
VLJQLILFDQFHEXWWKHVWXG\PD\KDYHHQUROOHGWRRIHZZRPHQ ZRPHQLQHDFKJURXS WRGHWHFW
DWUXHGLIIHUHQFH


:RPHQZKRKDYHFHVDUHDQGHOLYHU\IDFHJUHDWHUFKDOOHQJHVWKDQZRPHQKDYLQJYDJLQDOELUWK
LQSK\VLFDODQGVRFLDOIXQFWLRQLQJDQGFDUU\LQJRXWGDLO\DFWLYLWLHVLQWKHHDUO\ZHHNVDQGPRQWKV
DIWHUELUWK'LIIHUHQFHVLQSK\VLFDOIXQFWLRQLQJDUHDOVRLQIOXHQFHGE\WKHSURSRUWLRQRIZRPHQ
KDYLQJLQVWUXPHQWDOYDJLQDOGHOLYHU\:RPHQKDYLQJYDJLQDOELUWKZLWKYDFXXPH[WUDFWLRQRUIRU
FHSVDPRGLILDEOHIDFWRUKDYHLQFUHDVHGSUREOHPVZLWKSK\VLFDOIXQFWLRQLQJ SDLQOLPLWDWLRQVRQ
DFWLYLW\DQGVH[XDOERZHODQGSRVVLEO\XULQDU\SUREOHPV FRPSDUHGZLWKVSRQWDQHRXVYDJLQDO
ELUWK 6HHEHORZIRUVWXGLHVVSHFLILFDOO\RIWKHHIIHFWRIPRGHRIELUWKRQVH[XDOSUREOHPV
DQGXULQDU\DQGERZHOLQFRQWLQHQFH
:LWKWKHH[FHSWLRQRIWKHSUHVHQFHRIKHPRUUKRLGVZKLFKDUHPRUHFRPPRQ
ZLWKYDJLQDOELUWKD/$5*(WR9(5</$5*(H[FHVVQXPEHURIZRPHQKDYLQJ
FHVDUHDQGHOLYHU\H[SHULHQFHSUREOHPVZLWKSK\VLFDOUHFRYHU\LQFOXGLQJ
JHQHUDOKHDOWKERGLO\SDLQH[WUHPHWLUHGQHVVVOHHSSUREOHPVERZHOSUREOHPV
DELOLW\WRFDUU\RXWGDLO\DFWLYLWLHVDQGDELOLW\WRSHUIRUPVWUHQXRXVDFWLYLWLHV
FRPSDUHGZLWKZRPHQKDYLQJVSRQWDQHRXVYDJLQDOELUWK
7KUHHVWXGLHVRISRVWSDUWXPKHDOWKLQWKHZHHNVDQGPRQWKVDIWHUFKLOGELUWKDOOUHSRUWZRUVH
SK\VLFDOIXQFWLRQLQJZLWKFHVDUHDQGHOLYHU\2QHVWXG\VXUYH\HGILUVWWLPHPRWKHUVDWVHYHQ
ZHHNVSRVWSDUWXPWRDVVHVVJHQHUDOKHDOWKDFFRUGLQJWRPRGHRIELUWK&RPSDUHGZLWKVSRQWD
QHRXVYDJLQDOELUWKZRPHQZLWKFHVDUHDQGHOLYHU\VFRUHGORZHULQSK\VLFDOIXQFWLRQLQJJHQHUDO
KHDOWKSHUFHSWLRQERGLO\SDLQVRFLDOIXQFWLRQLQJDQGDELOLW\WRFDUU\RXWGDLO\DFWLYLWLHV,QVSHFLILF
DUHDVRISK\VLFDOIXQFWLRQLQJIHZHUZRPHQZLWKFHVDUHDQVUHSRUWHGQROLPLWDWLRQLQSHUIRUPLQJ
YLJRURXVDFWLYLWLHVVXFKDVUXQQLQJRUOLIWLQJKHDY\REMHFWV IHZHUSHU SDUWLFLSDWLQJ
LQOHVVYLJRURXVDFWLYLWLHVVXFKDVYDFXXPLQJ IHZHUSHU OLIWLQJDQGFDUU\LQJJURFHU
LHV IHZHUSHU RUFOLPELQJVHYHUDOIOLJKWVRIVWDLUV IHZHUSHU )HZHU
ZRPHQHYDOXDWHGWKHLURYHUDOOKHDOWKDVH[FHOOHQW IHZHUSHU RUDJUHHGWKDWSDLQGLG
QRWLQWHUIHUHDWDOOZLWKXVXDODFWLYLWLHVLQWKHSULRUIRXUZHHNV IHZHUSHU RUWKDWWKHLU
KHDOWKKDGQRWOLPLWHGWKHLUVRFLDODFWLYLWLHVLQWKHSULRUIRXUZHHNV IHZHUSHU )LQDOO\
IHZHUZRPHQSHUZLWKFHVDUHDQGHOLYHU\DJUHHGWKDWWKH\KDGQRGLIILFXOW\DWDOO
ZKHQGRLQJWKHLUXVXDOGDLO\DFWLYLWLHVDQGWDVNVLQVLGHDQGRXWVLGHWKHLUKRPH
$VHFRQGVWXG\VXUYH\HGZRPHQDWDQGZHHNVSRVWSDUWXP&RPSDUHGZLWK
VSRQWDQHRXVYDJLQDOELUWKDWZHHNVZRPHQZLWKFHVDUHDQGHOLYHU\ZHUHPRUHOLNHO\WRUHSRUW
H[WUHPHWLUHGQHVV PRUHSHU WREHWURXEOHGE\ODFNRIVOHHSGXHWRWKHLUEDE\FU\LQJ
PRUHSHU DQGWREHH[SHULHQFLQJERZHOSUREOHPV HJFRQVWLSDWLRQRUGLDUUKHD 
19

PRUHSHU 0RUHZRPHQZLWKFHVDUHDQGHOLYHU\DOVRUHSRUWHGERZHOSUREOHPV
DWZHHNV PRUHSHUQRWVWDWLVWLFDOO\VLJQLILFDQW DQGZHHNV PRUHSHU
VWDWLVWLFDOO\VLJQLILFDQW 
7KHWKLUGVWXG\VXUYH\HGILUVWWLPHPRWKHUVDQGUHSRUWHGGLIIHUHQFHVE\PRGHRIELUWKDW
DQGPRQWKVSRVWSDUWXP$WPRQWKVSRVWSDUWXPIHZHUZRPHQSHUFRP
SODLQHGRIKHPRUUKRLGVDIWHUFHVDUHDQGHOLYHU\WKDQZRPHQDIWHUVSRQWDQHRXVYDJLQDOELUWK$W
PRQWKVSRVWSDUWXPPRUHZRPHQSHUFRPSODLQHGRIH[WUHPHWLUHGQHVVDQG
PRUHZRPHQSHUUHSRUWHGORZHUEDFNSDLQDIWHUFHVDUHDQGHOLYHU\WKDQDIWHUVSRQWDQH
RXVYDJLQDOELUWK$WPRQWKVSRVWSDUWXPPRUHZRPHQSHUZRPHQFRPSODLQHGRI
H[WUHPHWLUHGQHVVDQGPRUHZRPHQSHUFRPSODLQHGRIXSSHUEDFNSDLQZLWKFHVDU
HDQGHOLYHU\WKDQDIWHUVSRQWDQHRXVYDJLQDOELUWK
)LQDOO\DIRXUWKVWXG\UHSRUWHGRQSDLQDORQH:KHQILUVWWLPHPRWKHUVZHUHDVNHGKRZPXFK
SDLQKDGLQWHUIHUHGZLWKURXWLQHDFWLYLW\LQWKHILUVWWZRPRQWKVDIWHUELUWKPRUHZRPHQSHU
ZLWKFHVDUHDQGHOLYHU\UHVSRQGHGTXLWHDELWRUH[WUHPHO\FRPSDUHGZLWKZRPHQKDYLQJ
VSRQWDQHRXVYDJLQDOELUWK


0RUHZRPHQH[SHULHQFHFKURQLFSHOYLFSDLQDIWHUFHVDUHDQGHOLYHU\WKDQDIWHUYDJL
QDOELUWKEXWWKHH[FHVVQXPEHUFDQQRWEHFDOFXODWHGIURPWKHVWXGLHVH[DPLQHG
7ZRVWXGLHVLQDV\VWHPDWLFUHYLHZDQDO\]LQJIDFWRUVFRUUHODWHGZLWKFKURQLFSHOYLFSDLQHYDOX
DWHGWKHUHODWLRQVKLSZLWKFHVDUHDQGHOLYHU\DQGDPHWDDQDO\VLVSRROLQJWKHLUGDWDIRXQGWKDW
ZRPHQZHUHPRUHWKDQWKUHHWLPHVDVOLNHO\WRUHSRUWFKURQLFSHOYLFSDLQDIWHUFHVDUHDQGHOLYHU\
FRPSDUHGZLWKZRPHQZKRELUWKHGYDJLQDOO\

2. What physical effects occur in babies


more frequently with cesarean delivery?
:KHQZRPHQH[SHULHQFHSK\VLFDORUHPRWLRQDOSUREOHPVDVDUHVXOWRIDFHVDUHDQGHOLYHU\LWPD\
LQWHUIHUHZLWKWKHLUDELOLW\WRFDUHIRUWKHLUEDELHV,QDGGLWLRQFHVDUHDQGHOLYHU\UDWKHUWKDQYDJLQDO
ELUWKLVDVVRFLDWHGZLWKLQFUHDVHGOLNHOLKRRGRIEDELHVH[SHULHQFLQJWKHIROORZLQJSUREOHPV


/LPLWHGHYLGHQFHVXJJHVWVWKDWEDELHVRIZRPHQKDYLQJHOHFWLYHILUVWFHVDUHDQVPD\EH
DWJUHDWHUULVNRIQHRQDWDOGHDWKFRPSDUHGZLWKORZULVNZRPHQSODQQLQJYDJLQDOELUWK
EXWWKHH[FHVVQXPEHURIGHDWKVFDQQRWEHFDOFXODWHGIURPWKHVWXG\H[DPLQHG
$QDWLRQDO86VWXG\RIPLOOLRQZRPHQDWQRLQGLFDWHGULVNIRUFHVDUHDQ VLQJOHWRQWHUPYHUWH[
QRPHGLFDOULVNIDFWRUVUHSRUWHGRQWKHELUWKFHUWLILFDWHQRSULRUFHVDUHDQ FRPSDUHGQHRQDWDO
PRUWDOLW\UDWHVEHWZHHQZRPHQKDYLQJSODQQHGFHVDUHDQGHOLYHU\DQGZRPHQSODQQLQJYDJLQDO
ELUWKDPRQJZKRPKDGFHVDUHDQVGXULQJODERU,QYHVWLJDWRUVDGMXVWHGIRUELUWKZHLJKWJHV
WDWLRQDODJHPDWHUQDODJHUDFHRUHWKQLFLW\SDULW\HGXFDWLRQDQGVPRNLQJ7KH\IXUWKHUH[FOXGHG
DOOLQIDQWVZLWKFRQJHQLWDODQRPDOLHVEHFDXVHWKLVFRXOGDIIHFWERWKFKRLFHRIELUWKURXWHDQGPRU
WDOLW\ULVNDQGDOOLQIDQWVZLWK$SJDUVFRUHVOHVVWKDQDVDSUR[\IRUIHWDOGLVWUHVVZKLFKDVZLWK
DQRPDOLHVFRXOGDIIHFWERWKPRGHRIELUWKDQGPRUWDOLW\1HYHUWKHOHVVWKHULVNRIQHRQDWDOGHDWK
ZDVJUHDWHUZLWKSODQQHGFHVDUHDQWKDQZLWKSODQQHGYDJLQDOELUWK
20


(OHFWLYHFHVDUHDQGHOLYHU\LVDVVRFLDWHGZLWKLQFUHDVHGULVNRIQHZERUQEUHDWKLQJFRPSOLFDWLRQV
FRPSDUHGZLWKYDJLQDOELUWKRUFHVDUHDQGXULQJODERUKRZHYHUWKHPDJQLWXGHRIWKHULVNGHFUHDV
HVDVJHVWDWLRQDODJHDGYDQFHVSDVWZHHNV

:KHQELUWKRFFXUVEHIRUHZHHNVPRUHEDELHVERUQ
E\FHVDUHDQWKDQE\YDJLQDOELUWKH[SHULHQFHUHVSLUDWRU\
GLVWUHVVV\QGURPH 5'6 EXWWKHH[FHVVQXPEHUFDQQRW
EHFDOFXODWHGIURPWKHVWXGLHVH[DPLQHG
$V\VWHPDWLFUHYLHZZLWKRXWPHWDDQDO\VLVDQDO\]HGQLQHVWXGLHVFRPSDULQJUHVSLUDWRU\
FRPSOLFDWLRQVDIWHUHOHFWLYHFHVDUHDQYHUVXVDIWHUYDJLQDORUSODQQHGYDJLQDOELUWKDWRUQHDU
IXOOWHUP)RXUVWXGLHVHYDOXDWHG5'6 R[\JHQVXSSOHPHQWDWLRQORQJHUWKDQKSOXV[UD\
ILQGLQJVW\SLFDORI5'6 7ZRRIWKHIRXUUHSRUWHGDVWDWLVWLFDOO\VLJQLILFDQWLQFUHDVHDQGD
WKLUGUHSRUWHGDQLQFUHDVHWKDWGLGQRWDFKLHYHVWDWLVWLFDOVLJQLILFDQFH7KHIRXUWKVWXG\ZDV
VPDOODQGKDGWRRIHZFDVHVWRSHUIRUPDVWDWLVWLFDODQDO\VLV5DWHVUDQJHGIURPWR
SHUZLWKHOHFWLYHFHVDUHDQYVWRSHUZLWKYDJLQDORUSODQQHGYDJLQDO
ELUWKKRZHYHULQWUDVWXG\GLIIHUHQFHVZHUHQRWUHSRUWHGZKLFKSUHYHQWVFDOFXODWLRQRIDEVR
OXWHGLIIHUHQFHV7KHDVVRFLDWLRQGLVDSSHDUHGDIWHUZHHNVJHVWDWLRQ

/LPLWHGHYLGHQFHVXJJHVWVWKDWD02'(5$7(H[FHVVQXPEHURIEDELHV
GHOLYHUHGE\HOHFWLYHFHVDUHDQPD\GHYHORSSXOPRQDU\K\SHUWHQVLRQ
2QHVWXG\LQFOXGHGLQWKHV\VWHPDWLFUHYLHZHYDOXDWHGSXOPRQDU\K\SHUWHQVLRQ FRQWLQXHGIH
WDOFLUFXODWLRQUHTXLULQJR[\JHQVXSSOHPHQWDWLRQWRPDLQWDLQDGHTXDWHR[\JHQDWLRQ ,W
UHSRUWHGDQH[FHVVRIFDVHVSHUZLWKHOHFWLYHFHVDUHDQFRPSDUHGZLWKYDJLQDOELUWK


&RQIOLFWLQJHYLGHQFHVXJJHVWVWKDWEDELHVGHOLYHUHGE\FHVDU
HDQPD\EHDWH[FHVVULVNRIQRWEHLQJEUHDVWIHG
$V\VWHPDWLFUHYLHZH[DPLQHGWKHDVVRFLDWLRQEHWZHHQEUHDVWIHHGLQJDQGFHVDUHDQGHOLYHU\
YHUVXVYDJLQDOELUWKDQGIRXQGWKDWSUHODERUFHVDUHDQQHJDWLYHO\DIIHFWHGHDUO\EUHDVWIHHGLQJ
UDWHV DQ\LQLWLDWLRQRUEUHDVWIHHGLQJDWKRVSLWDOGLVFKDUJH EXWFHVDUHDQVGXULQJODERUGLGQRW
2QO\WZRRILWVFRPSRQHQWVWXGLHVKRZHYHUFRQWUROOHGIRUEUHDVWIHHGLQJLQWHQWDQLPSRUWDQW
SRWHQWLDOFRQIRXQGLQJIDFWRU%RWKRIWKHVWXGLHVDGMXVWLQJIRUEUHDVWIHHGLQJLQWHQWZHUHFRQ
GXFWHGLQ(QJODQG2QHRIWKHWZRVWXGLHVZDVRIILUVWWLPHPRWKHUVDQGUHSRUWHGDVWDWLVWLFDOO\
VLJQLILFDQWUHGXFWLRQLQEUHDVWIHHGLQJDWKRVSLWDOGLVFKDUJHDPRQJZRPHQGHOLYHUHGE\FHVDU
HDQRIZKRPKDGSODQQHGFHVDUHDQVDQGKDGFHVDUHDQVLQODERU7KHRWKHUFRPSDUHG
ZRPHQKDYLQJLQVWUXPHQWDOYDJLQDOGHOLYHULHVZLWKZRPHQKDYLQJFHVDUHDQGHOLYHU\GXULQJWKH
SXVKLQJSKDVHRIODERU,WIRXQGDUHGXFWLRQLQEUHDVWIHHGLQJUDWHVLQWKHFHVDUHDQJURXSWKDW
GLGQRWDFKLHYHVWDWLVWLFDOVLJQLILFDQFH
21

3. What role may cesarean delivery play in the


development of childhood chronic disease?

&KLOGUHQGHOLYHUHGE\FHVDUHDQDUHPRUHOLNHO\WRGHYHORSDXWRLPPXQHGLVHDVHVLQFOXGLQJDVWKPD
7\SHGLDEHWHVDQGDOOHUJLHV,QYHVWLJDWRUVKDYHWKHRULHVDVWRZK\WKLVPD\EHVR2QHLVWKDW
GLIIHUHQFHVLQJXWIORUDZKLFKPHGLDWHLPPXQHLQWROHUDQFHH[SODLQWKHH[FHVV%DELHVGHOLYHUHG
E\FHVDUHDQDUHQRWH[SRVHGWRYDJLQDOEDFWHULDDQGWKHLUPRWKHUVDUHXVXDOO\JLYHQSURSK\ODFWLF
SHULSDUWXPDQWLELRWLFVWRUHGXFHULVNRILQIHFWLRQ$QWLELRWLFVFURVVWKHSODFHQWDDQGDUHIRXQGLQ
EUHDVWPLONWKHUHE\DOVRDIIHFWLQJJXWIORUDFRORQL]DWLRQ$QRWKHUWKHRU\LVWKDWFHVDUHDQERUQ
LQIDQWVDUHPRUHSURQHWRWUDQVLHQWWDFK\SQHDRIWKHQHZERUQ DEQRUPDOO\UDSLGEUHDWKLQJ DQG
5'6ERWKRIZKLFKDUHDVVRFLDWHGZLWKLQFUHDVHGULVNRIDVWKPD

&HVDUHDQGHOLYHU\LQFUHDVHVWKHOLNHOLKRRGRIGHYHORSLQJDVWKPDLQFKLOGKRRG
EXWWKHH[FHVVQXPEHUFDQQRWEHFDOFXODWHGIURPWKHVWXGLHVH[DPLQHG
7ZRV\VWHPDWLFUHYLHZVSXEOLVKHGLQWKHVDPH\HDUUHSRUWRQWKHUHODWLRQVKLSEHWZHHQPRGH
RIELUWKDQGDVWKPD,QFOXGHGVWXGLHVODUJHO\RYHUODSSHGEXWGLIIHUHQFHVLQZKLFKRXWFRPHV
UHYLHZHUVFKRVHWRUHSRUWPDNHLWZRUWKZKLOHWRVXPPDUL]HERWK3RROLQJGDWDIURPVWXGLHV
RQHUHYLHZUHSRUWHGWKDWELUWKE\FHVDUHDQLQFUHDVHGWKHRGGVRIGHYHORSLQJDVWKPDE\
KRZHYHUVWXGLHVZHUHVLJQLILFDQWO\KHWHURJHQHRXV5HVWULFWLQJDQDO\VLVWRVWXGLHVDVFHUWDLQ
LQJDVWKPDRQVHWEHIRUHDJHUHGXFHGKHWHURJHQHLW\ZLWKRXWDOWHULQJH[FHVVULVN5HYLHZHUV
FRXOGQRWDGMXVWIRUFRQIRXQGLQJIDFWRUVEXWREVHUYHGWKDWVWXGLHVWKDWDGMXVWHGIRUEUHDVWIHHG
LQJ VWXGLHV DQGIRUPDWHUQDOVPRNLQJ VWXGLHV GLGQRWILQGWKDWWKLVUHGXFHGWKHHIIHFWRI
FHVDUHDQGHOLYHU\QRUGLGWKHPDMRULW\RIVWXGLHVWKDWDGMXVWHGIRUORZELUWKZHLJKW VWXGLHV 
7KHRWKHUUHYLHZZKLFKSRROHGGDWDIURPVWXGLHVDOVRUHSRUWHGDLQFUHDVHLQRGGVRI
DVWKPDZLWKFHVDUHDQGHOLYHU\ VWXGLHV ZKLFKZRXOGEHH[SHFWHGJLYHQWKHRYHUODS7KH
UHYLHZDOVRIRXQGDLQFUHDVHGOLNHOLKRRGRIKRVSLWDOL]DWLRQIRUDVWKPD VWXGLHV 

&HVDUHDQGHOLYHU\LQFUHDVHVWKHOLNHOLKRRGRIGHYHORSLQJ7\SHGLDEHWHVLQFKLOG
KRRGEXWWKHH[FHVVQXPEHUFDQQRWEHFDOFXODWHGIURPWKHVWXGLHVH[DPLQHG
$V\VWHPDWLFUHYLHZRIVWXGLHVIRXQGWKDWFHVDUHDQFRQIHUUHGDLQFUHDVHLQWKHOLNHOL
KRRGRIGHYHORSLQJ7\SHGLDEHWHVLQFKLOGKRRGFRPSDUHGZLWKFRQWUROSRSXODWLRQV$G
MXVWPHQWIRUSRWHQWLDOFRQIRXQGHUV JHVWDWLRQDODJHELUWKZHLJKWPDWHUQDODJHELUWKRUGHU
EUHDVWIHHGLQJPDWHUQDOGLDEHWHV GLGQRWDIIHFWWKHUHODWLRQVKLS

&HVDUHDQGHOLYHU\LQFUHDVHVWKHOLNHOLKRRGRIGHYHORSLQJFKLOGKRRGDOOHUJLFUKLQLWLV
EXWWKHH[FHVVQXPEHUFDQQRWEHFDOFXODWHGIURPWKHVWXGLHVH[DPLQHG
$V\VWHPDWLFUHYLHZRIVWXGLHVUHSRUWHGDWRLQFUHDVHGOLNHOLKRRGRIDOOHUJLFUKLQL
WLVZLWKFHVDUHDQGHOLYHU\GHSHQGLQJRQWKHVWDWLVWLFDOWHFKQLTXHXVHGWRSRROGDWD
22


/LPLWHGDQGFRQIOLFWLQJHYLGHQFHVXJJHVWVWKDWFHVDUHDQGHOLYHU\PD\
LQFUHDVHWKHOLNHOLKRRGRIGHYHORSLQJIRRGDOOHUJ\LQFKLOGKRRGEXWWKH
H[FHVVQXPEHULIDQ\FDQQRWEHFDOFXODWHGIURPWKHVWXGLHVH[DPLQHG
$V\VWHPDWLFUHYLHZLGHQWLILHGRQO\WZRVWXGLHVRIGHYHORSPHQWRIV\PSWRPDWLFIRRGDOOHUJ\
DFFRUGLQJWRPRGHRIELUWK2QHVWXG\UHSRUWHGQRGLIIHUHQFHDFFRUGLQJWRPRGHRIELUWKEXW
GLGQRWDGMXVWHVWLPDWHVIRUFRQIRXQGLQJIDFWRUV7KHRWKHUDGMXVWLQJIRUIDFWRUVVXFKDVELUWK
ZHLJKWSUHHFODPSVLDUHVWULFWHGIHWDOJURZWKPDWHUQDOVPRNLQJDQGPDWHUQDOHGXFDWLRQIRXQG
WKDWSDUHQWUHSRUWHGIRRGDOOHUJ\ZDVWKUHHWLPHVPRUHSUHYDOHQWE\DJHWZRLQFKLOGUHQGHOLY
HUHGE\FHVDUHDQ6WUDWLILFDWLRQDFFRUGLQJWRZKHWKHUWKHFKLOGVPRWKHUKDGDOOHUJLHVUHYHDOHG
WKDWWKHDGYHUVHHIIHFWRIFHVDUHDQGHOLYHU\ZDVFRQILQHGWRFKLOGUHQRIDOOHUJLFPRWKHUV5H
YLHZHUVIXUWKHUQRWHWKDWSDUHQWUHSRUWRIIRRGDOOHUJ\LVOLNHO\WRRYHUHVWLPDWHLWVSUHYDOHQFH


$VZLWKDXWRLPPXQHGLVHDVHVGLIIHUHQFHVLQJXWIORUDLQLQIDQWVGHOLYHUHGE\FHVDUHDQSURYLGHD
SODXVLEOHH[SODQDWLRQIRUWKHSRVVLELOLW\RILQFUHDVHGULVNRIVXEVHTXHQWREHVLW\2WKHUHIIHFWV
RIPRGHRIELUWKRQLQIODPPDWLRQLPPXQHRUHQGRFULQHIXQFWLRQLQGHSHQGHQWRILQWHVWLQDOFROR
QL]DWLRQPLJKWDOVRLQIOXHQFHIXWXUHREHVLW\
/LPLWHGHYLGHQFHVXJJHVWVWKDWD/$5*(H[FHVVQXPEHURI
FKLOGUHQGHOLYHUHGE\FHVDUHDQPD\EHREHVHDWDJH
$VWXG\DGMXVWLQJIRUPDWHUQDODJHHGXFDWLRQUDFHHWKQLFLW\FKLOGVDJHDQGVH[PDWHUQDO
SUHSUHJQDQF\ERG\PDVVLQGH[ %0, DQGELUWKZHLJKWUHSRUWHGWKDWPRUHFKLOGUHQSHU
GHOLYHUHGE\FHVDUHDQZHUHREHVHDWDJH +RXVHKROGLQFRPHSDWHUQDO%0,PDWHUQDO
VPRNLQJSUHJQDQF\ZHLJKWJDLQELUWKRUGHUPDWHUQDOJOXFRVHWROHUDQFHGXULQJSUHJQDQF\FKLOGV
JHVWDWLRQDODJHDWELUWKLQLWLDWLRQDQGGXUDWLRQRIEUHDVWIHHGLQJWLPLQJRIVROLGIRRGLQWURGXFWLRQ
HQHUJ\LQWDNHDQGWHOHYLVLRQYLHZLQJDWDJHDQGKHLJKWDWDJHGLGQRWFKDQJHHIIHFWHVWLPDWHV
DQGZHUHQRWLQFOXGHGLQWKHDGMXVWHGPRGHO :KHQDQDO\VLVZDVVWUDWLILHGDFFRUGLQJWRPDWHUQDO
SUHSUHJQDQW%0,FKLOGUHQRIZRPHQZLWK%0,OHVVWKDQNJPZHUHDWWULSOHWKHULVNRIREH
VLW\ZKHUHDVFKLOGUHQRIZRPHQZLWK%0,RINJPRUPRUHZHUHRQO\DWDLQFUHDVHGULVN
ZKLFKIXUWKHUVXSSRUWVWKDWKLJKPDWHUQDO%0,ZKLFKLVDVVRFLDWHGZLWKLQFUHDVHGOLNHOLKRRGRI
FHVDUHDQGHOLYHU\DQGLQFUHDVHGOLNHOLKRRGRIKLJK%0,FKLOGUHQZDVQRWWKHPHGLDWLQJIDFWRU

4. What complications are unique


to cesarean delivery?
&HUWDLQFRPSOLFDWLRQVDUHXQLTXHWRVXUJLFDOGHOLYHU\WKXVYDJLQDOELUWKHOLPLQDWHVWKHULVNRI
WKHLURFFXUUHQFH


$PRQJZRPHQKDYLQJILUVWGHOLYHU\YLDFHVDUHDQD02'(5$7(
QXPEHURIZRPHQH[SHULHQFHEODGGHUSXQFWXUHDQGD60$//
QXPEHUH[SHULHQFHERZHOLQMXU\RULQMXU\WRDXUHWHU
23

7KUHHFRKRUWDQDO\VHVUHSRUWRQRSHUDWLYHLQMXU\GXULQJSULPDU\FHVDUHDQ&XPXODWLYH
LQFLGHQFHUDWHVDUHSHUIRUEODGGHUSXQFWXUHSHUIRUERZHOLQMXU\DQGSHU
IRUXUHWHUDOLQMXU\,QMXU\UDWHVZRXOGEHORZHUZLWKSODQQHGFHVDUHDQGHOLYHU\WKDQZLWK
FHVDUHDQGXULQJODERU


/LPLWHGHYLGHQFHVXJJHVWVWKDWD02'(5$7(QXPEHU
RIEDELHVDUHFXWGXULQJFHVDUHDQGHOLYHU\
$ODUJHFDVHVHULHV FDVHV UHSRUWHGUDWHVRIVXUJLFDOFXWVRISHUZLWKSODQQHG
FHVDUHDQYHUVXVSHUDPRQJFHVDUHDQVRYHUDOO7KLVVWXG\GLGQRWUHSRUWRQVHULRXV
QHVVRILQMXU\EXWRWKHUVPDOOHUVWXGLHVUHSRUWHGWKDWVRPHLQIDQWVUHTXLUHGVXWXULQJRUZRXQG
FORVXUHZLWKVWDSOHV,QMXU\UDWHVZRXOGOLNHO\EHORZHUZLWKSODQQHGFHVDUHDQGHOLYHU\WKDQ
ZLWKFHVDUHDQGXULQJODERU


/LPLWHGHYLGHQFHVXJJHVWVWKDWD02'(5$7(QXPEHURI
ZRPHQKDYLQJFHVDUHDQGHOLYHU\UHTXLUHUHRSHUDWLRQ
$VWXG\UHSRUWHGWKDWSHUZRPHQKDYLQJFHVDUHDQGHOLYHU\UHTXLUHGUHRSHUDWLRQ
IRUKHPRUUKDJHSURWUXVLRQRIWKHLQWHVWLQHVWKURXJKWKHDEGRPLQDOZRXQGRULQWUDDEGRPLQDO
DEVFHVV


/LPLWHGHYLGHQFHVXJJHVWVWKDWD/$5*(WR9(5</$5*(
QXPEHURIZRPHQVWLOOH[SHULHQFHSDLQDWWKHLQFLVLRQVLWH
PRQWKVRUPRUHDIWHUFHVDUHDQGHOLYHU\
$VXUYH\RI86ZRPHQUHYHDOHGWKDWDPRQJZRPHQKDYLQJFHVDUHDQGHOLYHU\SHU
UHSRUWHGSDLQDWWKHVLWHRIWKHFHVDUHDQLQFLVLRQODVWLQJPRQWKVRUPRUH$PRQJZRPHQ
ZLWKFHVDUHDQVZKRUHVSRQGHGWRWKHVXUYH\PRQWKVRUPRUHDIWHUGHOLYHU\SHU
UHSRUWHGFRQWLQXLQJSDLQDWWKHLQFLVLRQVLWH$VXUYH\RI$XVWUDOLDQZRPHQUHSRUWHGWKDWDPRQJ
ZRPHQKDYLQJFHVDUHDQGHOLYHU\LQFLVLRQSDLQZDVUHSRUWHGRFFDVLRQDOO\RURIWHQE\SHU
DWPRQWKVSRVWSDUWXPSHUDWPRQWKVSRVWSDUWXPDQGSHU
DWPRQWKVSRVWSDUWXP


&HVDUHDQVFDUHQGRPHWULRVLVLVDSDLQIXOFRQGLWLRQFDXVHGE\LDWURJHQLFVHHGLQJRIHQGRPHWULDO
FHOOVLQWRWKHDEGRPLQDOZDOORUXWHULQHZRXQGGXULQJVXUJHU\,WLVDOVRFDOOHGFHVDUHDQVFDU
HQGRPHWULRPDWRLQGLFDWHWKDWLWLVDGHILQHGPDVV
/LPLWHGHYLGHQFHVXJJHVWVWKDWD60$//WR/$5*(QXPEHURIZRPHQ
KDYLQJFHVDUHDQGHOLYHU\GHYHORSFHVDUHDQVFDUHQGRPHWULRPDV
24

$V\VWHPDWLFUHYLHZRIFDVHVHULHVRIILYHRUPRUHFDVHVRIDEGRPLQDOZDOOHQGRPHWULRPDVUHSRUW
HGWKDWRIFDVHVZHUHDVVRFLDWHGZLWKFHVDUHDQVFDUV2QO\RIZRPHQZLWKDEGRPLQDO
ZDOOHQGRPHWULRPDVKDGDKLVWRU\RIRUVXEVHTXHQWO\GLDJQRVHGSHOYLFHQGRPHWULRVLVWKHVDPHDV
WKHEDFNJURXQGSRSXODWLRQZKLFKVXJJHVWVWKDWVFDUUHODWHGHQGRPHWULRPDVDUHDGHQRYRSKH
QRPHQRQDULVLQJIURPWKHVXUJLFDOSURFHGXUH7KLVFRPSOLFDWLRQKDVVHULRXVFRQVHTXHQFHV)RU
DOPRVWDOOZRPHQSDLQZDVDSUHVHQWLQJV\PSWRPDQGWKHWUHDWPHQWRIFKRLFHLVZLGHH[FLVLRQ
RIWKHWXPRUVRPHWLPHVUHTXLULQJDEGRPLQDOZDOOUHFRQVWUXFWLRQ7KHLQFLGHQFHDIWHUFHVDUHDQ
GHOLYHU\UDQJHGIURPWRSHUEXWWKHUHLVDKLJKSUREDELOLW\WKDWWUXHUDWHVRIFHVDUHDQ
VFDUHQGRPHWULRPDDUHKLJKHU7KHFDVHVHULHVZHUHRIVXUJLFDOO\WUHDWHGFDVHVZKLFKZRXOGOLPLW
WKHPWRZRPHQZKRVHHNDQGREWDLQWUHDWPHQWIRUVHYHUHV\PSWRPV7KHUHYLHZDOVRUHSRUWHGD
UHFXUUHQFHUDWH


(LWKHUWKHHPEU\R HFWRSLFSUHJQDQF\ RUWKHSODFHQWD HDUO\SODFHQWDDFFUHWD PD\LPSODQWZLWKLQ
WKHXWHULQHVFDU7KHVHFRPSOLFDWLRQVDUHIDWDOWRWKHHPEU\RDQGOLIHWKUHDWHQLQJIRUWKHZRPDQ
6RPHZRPHQEHFRPLQJSUHJQDQWDIWHUFHVDUHDQZLOOH[SHULHQFHDFHVDUHDQ
VFDUHFWRSLFSUHJQDQF\RUSODFHQWDOLPSODQWDWLRQZLWKLQWKHXWHULQHVFDU
EXWWKHQXPEHUFDQQRWEHFDOFXODWHGIURPWKHVWXGLHVH[DPLQHG
$V\VWHPDWLFUHYLHZRIWKHOLWHUDWXUHRQHDUO\SODFHQWDDFFUHWDDQGFHVDUHDQVFDUHFWRSLFSUHJ
QDQF\DVVHUWVWKDWPRVWSODFHQWDDFFUHWDVDUHDPDQLIHVWDWLRQRIWKHVDPHXQGHUO\LQJSDWKRORJ\
DVFHVDUHDQVFDUHFWRSLFSUHJQDQF\LHLPSODQWDWLRQZLWKLQWKHSULRUFHVDUHDQVFDU$PRQJ
FDVHVRISODFHQWDDFFUHWDGHWHFWHGDQGWUHDWHGEHIRUHWKHWKLUGWULPHVWHUUHTXLUHGK\VWHUHFWR
PLHV$PRQJFDVHVRIFHVDUHDQVFDUHFWRSLFSUHJQDQF\HQGHGLQK\VWHUHFWRP\5HYLHZ
HUVEHOLHYHWKDWFHVDUHDQVFDUSUHJQDQF\LVXQGHUUHSRUWHG%DVHGRQIUHTXHQF\HVWLPDWHVWKH\
HVWLPDWHWKDWWKHUHVKRXOGKDYHEHHQFDVHVLQLQWKH86DORQHEXWWKHLUUHYLHZRI
WKH86OLWHUDWXUHSXEOLVKHGLQWKHODVW\HDUVRQO\LGHQWLILHGFDVHV


'HQVHDGKHVLRQV LQWHUQDOVFDUWLVVXH PDNHDQ\IXWXUHSHOYLFVXUJHU\PRUHGLIILFXOWDQGPRUH
OLNHO\WRUHVXOWLQRSHUDWLYHLQMXU\DQGPD\FDXVHFKURQLFSDLQDQGLQUDUHFDVHVERZHOREVWUXFWLRQ
/LPLWHGHYLGHQFHVXJJHVWVWKDWD9(5</$5*(QXPEHURIZRPHQ
GHYHORSGHQVHDGKHVLRQVDIWHUFHVDUHDQGHOLYHU\
'DWDFRPHIURPDVWXG\HYDOXDWLQJDGKHVLRQVDWVHFRQGFHVDUHDQDFFRUGLQJWRZKHWKHUWKH
SDULHWDOSHULWRQHXPZDVVXWXUHGFORVHGDWWKHLQLWLDOFHVDUHDQRUOHIWRSHQ WKHPRUHXVXDOSUDF
WLFH 2YHUDOOSHUZRPHQKDGGHQVHDGKHVLRQVSHUZLWKSHULWRQHDO
FORVXUHDQGSHUZLWKRXW

5. What complications are unique to vaginal birth?


7KHFRPSOLFDWLRQVXQLTXHWRYDJLQDOELUWKDUHSHULQHDODQGJHQLWDOWUDXPDDQGFRQVHTXHQWSHUVLV
WHQWORFDOSDLQ7KHJUHDWHVWFRQFHUQLVDQDOVSKLQFWHUODFHUDWLRQEHFDXVHLWLQFUHDVHVWKHOLNHOL
KRRGRIH[SHULHQFLQJSHULQHDOSDLQLQWKHVKRUWWHUPDQGFRQWLQXHGSDLQXSWRVL[ZHHNVDIWHUWKH
ELUWKDQGLWSUHGLVSRVHVWRIHFDOLQFRQWLQHQFH
25

7KHSURSRUWLRQRIZRPHQH[SHULHQFLQJWUDXPDDWYDJLQDOELUWKGHSHQGVRQPRGLILDEOHIDF
WRUVLQFOXGLQJZKHWKHUWKH\KDYHDQLQVWUXPHQWDOYDJLQDOGHOLYHU\ZKHWKHUWKHLQVWUXPHQWLV
DYDFXXPH[WUDFWRURUIRUFHSVZKHWKHUIXQGDOSUHVVXUH SUHVVLQJRQWKHZRPDQVDEGRPHQ 
LVDSSOLHGWRKHOSH[SHOWKHEDE\ZKHWKHUWKH\KDYHDQHSLVLRWRP\ZKHWKHUWKHHSLVLRWRP\LV
PHGLDQRUPHGLRODWHUDO PHGLDQHSLVLRWRP\FRPPRQO\XVHGLQWKH8QLWHG6WDWHVDQG&DQDGD
SUHGLVSRVHVWRDQDOVSKLQFWHUODFHUDWLRQPHGLRODWHUDOPXFKOHVVVRRUQRWDWDOO WKHLUSXVKLQJ
SRVLWLRQDWELUWKDQGZKHWKHUWKHZRPDQSXVKHVIRUFHIXOO\ZKHQGHOLYHULQJWKHKHDG


$/$5*(QXPEHURIZRPHQH[SHULHQFHDQDOVSKLQFWHU
LQMXU\ZLWKRSWLPDOFDUHDWYDJLQDOELUWK
$9(5</$5*(QXPEHURIZRPHQH[SHULHQFHWUDXPDWRWKH
SHULQHXPRUJHQLWDOVDWYDJLQDOELUWKWKDWUHTXLUHVVXWXULQJ
1RV\VWHPDWLFUHYLHZZDVLGHQWLILHGWRHVWLPDWHRYHUDOOLQFLGHQFHRIJHQLWDOWUDFWWUDXPDLQ
YDJLQDOELUWK%HFDXVHHSLVLRWRP\DQGLQVWUXPHQWDOYDJLQDOGHOLYHU\PDUNHGO\LQFUHDVHJHQLWDO
WUDFWWUDXPDDVWXG\ZDVLGHQWLILHGWKDWUHSRUWHGYHU\ORZUDWHVRIWKHVHLQWHUYHQWLRQVLQRUGHU
WRHVWLPDWHWKHLQFLGHQFHDWWULEXWDEOHWRYDJLQDOELUWKLWVHOI7KHVWXG\ZDVDVLQJOHFHQWHU86
UDQGRPL]HGFRQWUROOHGWULDORISHULQHDOPDQDJHPHQWDWELUWKLQZRPHQKDYLQJYDJLQDOELUWK
DWWHQGHGE\H[SHULHQFHGPLGZLYHV,WUHSRUWHGWKDWZRPHQSHUH[SHULHQFHGDQDQDO
ODFHUDWLRQDQGH[FOXGLQJHSLVLRWRP\ZRPHQSHUKDGJHQLWDORUSHULQHDOWUDXPD
WKDWUHTXLUHGVXWXULQJ2YHUDOOKDGLQVWUXPHQWDOYDJLQDOGHOLYHU\DQGKDGDQHSLVL
RWRP\1RHSLVLRWRP\H[WHQGHGLQWRWKHDQDOVSKLQFWHU


/LPLWHGHYLGHQFHVXJJHVWVWKDWD/$5*(QXPEHURIZRPHQH[SHULHQFH
SHUVLVWHQWSHULQHDOSDLQODVWLQJDWOHDVWVL[PRQWKVZLWKVSRQWDQHRXV
YDJLQDOELUWKDQGD9(5</$5*(QXPEHURIZRPHQH[SHULHQFHSHULQHDO
SDLQODVWLQJDWOHDVWVL[PRQWKVDIWHULQVWUXPHQWDOYDJLQDOGHOLYHU\
$86VXUYH\UHSRUWHGWKDWZRPHQSHUUHSRUWHGSHULQHDOSDLQPRQWKVRUPRUHDI
WHUVSRQWDQHRXVYDJLQDOELUWKDQGZRPHQSHUZRPHQUHSRUWHGSDLQDVDSUREOHP
SHUVLVWLQJPRQWKVRUPRUHDIWHULQVWUXPHQWDOYDJLQDOGHOLYHU\

6. What are potential psychosocial


consequences of cesareans?
3RVWSDUWXPSV\FKRORJLFDOPRUELGLWLHVVXFKDVGHSUHVVLYHPRRGRUSRVWWUDXPDWLFGLVWUHVVV\PS
WRPVQRWRQO\FDQKDYHSURIRXQGDGYHUVHHIIHFWVRQZRPHQLPSDLULQJWKHLUIXQFWLRQLQJDWKRPH
DQGZRUNDQGLQFUHDVLQJWKHLUULVNRIVXLFLGHEXWDOVRFDQKDYHDGYHUVHLPSDFWRQERWKFDUHWDN
LQJDQGUHVSRQVLYHQHVVWRWKHLUFKLOGUHQUHVXOWLQJLQEHKDYLRUDODQGHPRWLRQDOSUREOHPVLQWKH
FKLOGDQGWKHLUUHODWLRQVKLSZLWKWKHLULQWLPDWHSDUWQHU,WLVGLIILFXOWKRZHYHUWRGHWHUPLQHWKH
GHJUHHWRZKLFKSV\FKRORJLFDOPRUELGLW\UHODWHVWRPRGHRIELUWKEHFDXVHRIZHDNQHVVHVDQGOLP
LWDWLRQVRIWKHUHVHDUFK7KHVHLQFOXGHVPDOOVDPSOHVL]HVSRVVLEOHVHOHFWLRQELDVHV ZKRDJUHHV
WRSDUWLFLSDWHZKRGURSVRXW ODFNRISURVSHFWLYHDVVHVVPHQWDQGLQDGHTXDWHDQGGLYHUVH
26

DVVHVVPHQWPHDVXUHV6WXGLHVPD\DOVRIDLOWRFRQWUROIRUFRQIRXQGLQJIDFWRUV7KHVH
LQFOXGHQHJDWLYHRUWUDXPDWLFH[SHULHQFHLQSULRUSUHJQDQF\DQGGHOLYHU\FRPSOLFDWLRQVVXFKDV
SUHWHUPELUWKWKDWSUHGLVSRVHERWKWRFHVDUHDQGHOLYHU\DQGWRPDWHUQDOSV\FKRORJLFDOPRUELGLW\
DQGODERUPDQDJHPHQWIDFWRUVVXFKDVLQVWUXPHQWDOYDJLQDOGHOLYHU\RUODERULQGXFWLRQZKLFK
DOVRSUHGLVSRVHWRDGYHUVHSV\FKRORJLFDORXWFRPH,QDGGLWLRQWLPLQJRIGDWDFROOHFWLRQFDQLQIOX
HQFHRXWFRPHV:LWKWKHSDVVDJHRIWLPHDSRVLWLYHH[SHULHQFHRIPRWKHUKRRGPD\VRIWHQD
QHJDWLYHSHUFHSWLRQRIWKHFKLOGELUWKH[SHULHQFHRUVRFLHWDOSUHVVXUHWRYLHZFHVDUHDQGHOLYHU\WR
DKHDOWK\EDE\SRVLWLYHO\PD\PDNHLWGLIILFXOWIRUZRPHQWRDFNQRZOHGJHQHJDWLYHIHHOLQJV


'DWDFRQIOLFWDERXWZKHWKHUFHVDUHDQGHOLYHU\KDVDQ
DGYHUVHHIIHFWRQWKHPRWKHUFKLOGUHODWLRQVKLS
$FFRUGLQJWRDV\VWHPDWLFUHYLHZVRPHVWXGLHVUHSRUWHGWKDWZRPHQGHOLYHULQJE\FHVDUHDQHYDOX
DWHGWKHLUFKLOGUHQOHVVIDYRUDEO\WKDQZRPHQKDYLQJYDJLQDOELUWKDQGRQHVWXG\IRXQGWKDWWKH\
H[KLELWHGOHVVWDFWLOHVWLPXODWLRQFDUHWDNLQJDQGLQWLPDWHSOD\LQWKHILUVWILYHPRQWKV2WKHUVWXG
LHVLQFOXGHGLQWKHUHYLHZKRZHYHUIRXQGQRHIIHFWRQPRWKHUFKLOGLQWHUDFWLRQ


'DWDFRQIOLFWRQZKHWKHUFHVDUHDQGHOLYHU\LQFUHDVHV
WKHOLNHOLKRRGRISRVWSDUWXPGHSUHVVLRQ
$V\VWHPDWLFUHYLHZRIVWXGLHVHYDOXDWLQJWKHOLQNEHWZHHQSRVWSDUWXPGHSUHVVLRQDQGFHVDUHDQ
GHOLYHU\UHSRUWHGGLVDJUHHPHQWDERXWLWVHIIHFWV6WXGLHVPDGHWKHLUHYDOXDWLRQEHWZHHQGD\V
DQG\HDUDIWHUELUWK$PRQJVWXGLHVUHSRUWHGDVWDWLVWLFDOO\VLJQLILFDQWDGYHUVHDVVRFLDWLRQ
UHSRUWHGQRVLJQLILFDQWDVVRFLDWLRQDQGUHSRUWHGPL[HGUHVXOWVPHDQLQJUHVXOWVZHUHDGYHUVH
RUQHXWUDOGHSHQGLQJRQZKLFKPHDVXUHZDVXVHGDQGZKHQGHSUHVVLRQZDVDVVHVVHG(LJKW
VWXGLHVZHUHVXIILFLHQWO\KRPRJHQRXV DOOXVHGWKH(GLQEXUJK3RVWQDWDO'HSUHVVLRQ6FDOHDQG
ZHUHFRQGXFWHGZLWKLQWRZHHNVDIWHUELUWK WKDWWKHLUGDWDFRXOGEHSRROHGLQDPHWDDQDO\VLV
7KLVUHVXOWHGLQDQLQFUHDVHGOLNHOLKRRGRIGHSUHVVLRQDIWHUFHVDUHDQGHOLYHU\FRPSDUHGZLWK
YDJLQDOELUWKWKDWGLGQRWDFKLHYHVWDWLVWLFDOVLJQLILFDQFH)RXURIWKHVWXGLHVZHUHVWURQJHUWKDQWKH
RWKHUVE\YLUWXHRIODUJHVDPSOHVL]HSURVSHFWLYHDVVHVVPHQWXVHRIDVWDQGDUGL]HGJHQHUDOO\
DFFHSWHGPHDVXUHDQGFRQWURORIDWOHDVWVRPHFRQIRXQGLQJIDFWRUV0HWDDQDO\VLVRIWKHVHIRXU
VWUHQJWKHQHGWKHDVVRFLDWLRQWRDQHDUVLJQLILFDQWLQFUHDVHGOLNHOLKRRGRIGHSUHVVLRQDIWHU
FHVDUHDQGHOLYHU\7KHUHYLHZGLGQRWGLVWLQJXLVKEHWZHHQLQVWUXPHQWDODQGVSRQWDQHRXVYDJLQDO
ELUWKRUEHWZHHQSODQQHGYHUVXVXQSODQQHGFHVDUHDQZKLFKLVOLNHO\WRFRQIRXQGUHVXOWVDQGRQH
RIWKHODUJHUVWXGLHVZDVDUDQGRPL]HGFRQWUROOHGWULDORIEUHHFKELUWK7KHVSHFLDOL]HGFRQFHUQV
DURXQGEUHHFKSUHVHQWDWLRQDQGWKHKLJKUDWHRILQVWUXPHQWDOYDJLQDOGHOLYHU\ZLWKDEUHHFKSUH
VHQWDWLRQUDLVHGRXEWVDVWRZKHWKHUUHVXOWVFDQEHJHQHUDOL]HGWRZRPHQZLWKKHDGGRZQEDELHV


'DWDFRQIOLFWEXWVXJJHVWWKDWPRUHZRPHQPD\H[SHULHQFH
376'RU376'V\PSWRPVDIWHUFHVDUHDQGHOLYHU\LQJHQHUDODQG
XQSODQQHGFHVDUHDQVLQSDUWLFXODUEXWWKHH[FHVVQXPEHULIDQ\
FDQQRWEHFDOFXODWHGIURPWKHVWXGLHVH[DPLQHG
27

$V\VWHPDWLFUHYLHZRIVWXGLHVSXEOLVKHGEHWZHHQDQGDVVHVVHGSUHYDOHQFHDQGULVN
IDFWRUVIRUFKLOGELUWKUHODWHGSRVWWUDXPDWLFVWUHVVV\PSWRPV2QO\IRXUVWXGLHVDOOFRQGXFWHGE\
WKHVDPHJURXSVSHFLILFDOO\HYDOXDWHGWKHLPSDFWRIFHVDUHDQGHOLYHU\RQSRVWWUDXPDWLFVWUHVV
V\PSWRPV:KLOHDQDVVRFLDWLRQZDVIRXQGUHYLHZHUVQRWHGWKHVPDOOVL]HRIWKHVHVWXGLHVDVD
OLPLWDWLRQ,QDGGLWLRQWZRRWKHUVWXGLHVLQFOXGHGLQWKHUHYLHZUHSRUWHGDQDVVRFLDWLRQEHWZHHQ
SRVWWUDXPDWLFGLVWUHVVDQGUHVSHFWLYHO\OHYHORIREVWHWULFLQWHUYHQWLRQVDQGXQSODQQHGFHVDUHDQ
3RVWWUDXPDWLFGLVWUHVVV\PSWRPVZHUHDOVRDVVRFLDWHGZLWKLQVWUXPHQWDOYDJLQDOGHOLYHU\ZKLFK
ZRXOGEHDFRQIRXQGLQJIDFWRULQVWXGLHVWKDWGLGQRWGLVWLQJXLVKEHWZHHQPRGHVRIYDJLQDOELUWK
$VXEVHTXHQWV\VWHPDWLFUHYLHZWKDWH[SOLFLWO\EXLOWRQWKHHDUOLHURQHLQFOXGHGVWXGLHV
SXEOLVKHGDIWHUWKHHDUOLHUUHYLHZWKURXJK2FWREHU6WXG\KHWHURJHQHLW\GLGQRWSHUPLW
PHWDDQDO\VLVEXWUHYLHZHUVDGGUHVVHGWKLVSUREOHPE\GHYHORSLQJDTXDOLW\UDWLQJV\VWHPWKDW
ZHLJKWHGLQFOXGHGVWXGLHVDFFRUGLQJWRELDVDQGUHOLDELOLW\RIUHVXOWV5LVNIDFWRUVVLJQLILFDQWO\
DVVRFLDWHGZLWK376'ZHUHWKHQJLYHQDSRLQWVFRUHEDVHGRQWKHUDQNLQJRIWKHVWXG\UHSRUW
LQJWKHP)DFWRUVUHSRUWHGDVQRWDVVRFLDWHGRUQRWDFKLHYLQJDVWDWLVWLFDOO\VLJQLILFDQWDVVRFLD
WLRQZHUHJLYHQQHJDWLYHSRLQWV5HYLHZHUVFOXVWHUHGULVNIDFWRUVZKHUHLQGLYLGXDOFRQFHSWVRU
HYHQWVZHUHVLPLODURUZRXOGEHSHUFHLYHGDVVXFKE\VWXG\SDUWLFLSDQWV7KHWRSUDWHGIDFWRUV
ZHUHVXEMHFWLYHGLVWUHVVLQODERU SRLQWV IROORZHGE\REVWHWULFDOHPHUJHQFLHV SRLQWV 
DFDWHJRU\WKDWLQFOXGHGHPHUJHQF\FHVDUHDQ SRLQWV DQGLQVWUXPHQWDOYDJLQDOGHOLYHU\ 
SRLQWV  1RWH(PHUJHQF\FHVDUHDQLVXVXDOO\XVHGLQWKHREVWHWULFOLWHUDWXUHPHUHO\WRPHDQ
DQXQSODQQHGFHVDUHDQGXULQJODERUDVRSSRVHGWRSODQQHGRUHOHFWLYHFHVDUHDQDQGFDQQRW
EHDVVXPHGWRFRQQRWHXUJHQWFHVDUHDQ 7ZHOYHVWXGLHVUHSRUWHGRQHPHUJHQF\FHVDUHDQRI
ZKLFKQLQHUHSRUWHGDSRVLWLYHDVVRFLDWLRQZLWK376'RU376'V\PSWRPV(LJKWVWXGLHVUHSRUW
HGRQHOHFWLYHFHVDUHDQ SRLQWV RIZKLFKILYHIRXQGDQDVVRFLDWLRQZLWK376'

7. What are potential effects of cesareans on


women in future pregnancies and births?
7KHFRQVHTXHQFHVRIFHVDUHDQGHOLYHU\IRUIXWXUHSUHJQDQFLHVDQGELUWKVPXVWEHWDNHQLQWR
DFFRXQWZKHQFRQVLGHULQJWKHILUVWFHVDUHDQUHJDUGOHVVRIWKHZRPDQVSODQVIRUIXWXUHFKLOGUHQ
EHFDXVHPDQ\ZRPHQZKRGRQRWSODQWRKDYHPRUHFKLOGUHQFKDQJHWKHLUPLQGVRUGHFLGHWR
FRQWLQXHZLWKXQSODQQHGSUHJQDQFLHV2QHWKLUGRI86ZRPHQKDYHWKUHHRUPRUHFKLOGUHQ
&HVDUHDQDWWKHILUVWGHOLYHU\LQFUHDVHVWKHULVNRIFRPSOLFDWLRQVLQIXWXUHFKLOGEHDULQJVRPHRI
ZKLFKDVQRWHGEHORZLQFUHDVHLQOLNHOLKRRGDVWKHQXPEHURIFHVDUHDQVXUJHULHVJRHVXS7KH
LQFUHDVLQJULVNRIVHULRXVFRPSOLFDWLRQVZLWKDFFXPXODWLQJFHVDUHDQVXUJHULHVLVDFUXFLDOFRQ
FHUQEHFDXVHPDQ\ZRPHQKDYHOLPLWHGRUQRDFFHVVWRSODQQHG9%$&LQWKH8QLWHG6WDWHV


/RZHUIHUWLOLW\UDWHVPD\EHLQYROXQWDU\ GLIILFXOW\FRQFHLYLQJDJDLQ RUYROXQWDU\ FKRRVLQJQRWWR
FRQFHLYHDJDLQ 3ULRUFHVDUHDQGHOLYHU\DSSHDUVWREHDVVRFLDWHGZLWKERWK
 
0RUHZRPHQH[SHULHQFHLPSDLUHGIHUWLOLW\DIWHUSULRUFHVDUHDQ
GHOLYHU\FRPSDUHGZLWKDIWHUSULRUYDJLQDOELUWKEXWWKHH[FHVV
QXPEHUFDQQRWEHFDOFXODWHGIURPWKHVWXGLHVH[DPLQHG

28

$V\VWHPDWLFUHYLHZUHSRUWVRQWZRVWXGLHVRQHILQGLQJIHZHUSUHJQDQFLHVZLWKSULRUFHVDU
HDQWKDQZLWKSULRULQVWUXPHQWDOYDJLQDOGHOLYHU\DQGWKHRWKHUILQGLQJLQFUHDVHGOLNHOLKRRGRI
FRQFHSWLRQWDNLQJPRUHWKDQRQH\HDUZLWKSULRUFHVDUHDQFRPSDUHGZLWKSULRUYDJLQDOELUWK
%RWKVWXGLHVDGMXVWHGIRUFRQIRXQGLQJIDFWRUVLQFOXGLQJSDULW\DQGDJH

$/$5*(WR9(5</$5*(H[FHVVQXPEHURIZRPHQ
FKRRVHQRWWRFRQFHLYHDJDLQDIWHUFHVDUHDQGHOLYHU\
7KUHHVWXGLHVSURYLGHHYLGHQFHIRUYROXQWDU\LQIHUWLOLW\2QHVXUYH\HGZRPHQWKUHH\HDUVDIWHU
HLWKHUFHVDUHDQGHOLYHU\GXULQJWKHSXVKLQJSKDVHRIODERURULQVWUXPHQWDOYDJLQDOGHOLYHU\DQG
IRXQGWKDWPRUHZRPHQSHUKDYLQJFHVDUHDQGHOLYHU\FLWHGIHDURIFKLOGELUWKDV
WKHUHDVRQZK\WKH\KDGQRWKDGIXUWKHUFKLOGUHQ$VHFRQGVWXG\LQYHVWLJDWLQJZK\ZRPHQ
KDGQRWKDGDVHFRQGFKLOGUHSRUWHGWKDWPRUHZRPHQZLWKDILUVWFHVDUHDQIRXQGDVSHFWV
RIWKHELUWKSDUWLFXODUO\GLVWUHVVLQJWKDQZRPHQZLWKILUVWVSRQWDQHRXVYDJLQDOELUWK 
YHUVXV EXWGLVWUHVVZDVUHODWHGWRZKHWKHUWKHFHVDUHDQZDVSODQQHGRUGXULQJODERU
YHUVXV &RPSDUHGZLWKZRPHQKDYLQJILUVWVSRQWDQHRXVYDJLQDOELUWKZRPHQ
ZLWKILUVWFHVDUHDQZHUHPRUHOLNHO\WRJLYHWKHIROORZLQJDVUHDVRQVIRUYROXQWDU\LQIHUWLOLW\WKDW
WKH\ZHUHXQZLOOLQJWRH[SHULHQFHSUHJQDQF\FKLOGELUWKDJDLQ YHUVXV UHODWLRQVKLS
ZLWKFKLOG YHUVXV UHFRYHU\SHULRGLQKRVSLWDODQGDWKRPH YHUVXV DQG
LQLWLDOERQGLQJZLWKFKLOG YHUVXV 7KHWKLUGVWXG\ORRNHGDWWKHHIIHFWRIPRGHRI
ELUWKDWILUVWELUWKDFFRUGLQJWRZKHWKHUWKHEDE\ZDVDOLYHRUZDVVWLOOERUQRUGLHGEHIRUHRQH
\HDU,IWKHILUVWEDE\OLYHGSHUIHZHUZRPHQKDGDVHFRQGFKLOGLIWKHILUVWGHOLYHU\
ZDVFHVDUHDQFRPSDUHGZLWKDILUVWYDJLQDOELUWKEXWLIWKHILUVWEDE\GLHGWKHVDPHQXPEHURI
ZRPHQKDGDVHFRQGFKLOGUHJDUGOHVVRIPRGHRIILUVWELUWK)XUWKHUPRUHLIDQLQLWLDOFHVDUH
DQZDVIROORZHGE\D9%$&DVLPLODUSHUFHQWDJHRIZRPHQZHQWRQWRKDYHDWKLUGFKLOG 
SHU DVWKRVHZKRVHILUVWWZRELUWKVZHUHYDJLQDO SHU EXWLIWKHILUVWWZR
GHOLYHULHVZHUHFHVDUHDQVRQO\SHUZRPHQKDGDWKLUGFKLOG


$ZRPDQZLWKDSULRUFHVDUHDQLVPRUHOLNHO\WKDQDZRPDQZLWKDQXQVFDUUHGXWHUXVWRKDYHSOD
FHQWDSUHYLD SODFHQWDRYHUOD\VWKHFHUYL[SDUWLDOO\RUFRPSOHWHO\ SODFHQWDDFFUHWD WKHSODFHQWD
JURZVLQWRRUHYHQWKURXJKWKHXWHULQHPXVFOH RUSODFHQWDODEUXSWLRQ SODFHQWDGHWDFKHVSDU
WLDOO\RUFRPSOHWHO\EHIRUHWKHELUWK LQWKHQH[WSUHJQDQF\3ODFHQWDSUHYLDSODFHQWDDFFUHWDDQG
SODFHQWDODEUXSWLRQLQFUHDVHWKHOLNHOLKRRGRIVHYHUHPDWHUQDOPRUELGLW\LQFOXGLQJVHYHUHKHP
RUUKDJHK\VWHUHFWRP\LQMXU\WRRWKHURUJDQVRUEORRGYHVVHOVGXULQJXUJHQWFHVDUHDQGHOLYHU\
DEQRUPDOFORWWLQJFORWVLQWKHGHHSYHLQVRIWKHOHJVRUIOXLGLQWKHOXQJVDQGWKH\LQFUHDVHWKH
OLNHOLKRRGRISUHWHUPELUWKDQGWKHUHIRUHLWVFRQVHTXHQFHVDOORIZKLFKSXWZRPHQDQGWKHLUEDELHV
DWLQFUHDVHGULVNRIGHDWK7KHOLNHOLKRRGRISODFHQWDSUHYLDDQGSODFHQWDDFFUHWDULVHVZLWK
LQFUHDVLQJQXPEHUVRISULRUFHVDUHDQVEXWWKHOLNHOLKRRGRISODFHQWDODEUXSWLRQGRHVQRW

$60$//H[FHVVQXPEHURIZRPHQZLWKILUVWGHOLYHU\E\FHVDUHDQGHYHORS
SODFHQWDSUHYLDLQWKHQH[WSUHJQDQF\EXWWKHH[FHVVQXPEHUFDQQRWEH
FDOFXODWHGIURPWKHVWXGLHVH[DPLQHG$/$5*(H[FHVVQXPEHURIZRPHQ
GHYHORSSODFHQWDSUHYLDDIWHUWZRRUPRUHSULRUFHVDUHDQV
29

,QYHVWLJDWRUVFRQGXFWHGDV\VWHPDWLFUHYLHZRIVWXGLHVHYDOXDWLQJWKHULVNRISODFHQWD
SUHYLDZLWKILUVWYDJLQDOELUWKFRPSDUHGZLWKILUVWGHOLYHU\YLDFHVDUHDQ7KHUHYLHZLQFOXGHG
VHYHQVWXGLHVORRNLQJRQO\DWWKHQH[WSUHJQDQF\$PRQJWKHVHVHYHQVWXGLHVSULRUFHVDU
HDQZDVDVVRFLDWHGZLWKDLQFUHDVHLQSODFHQWDSUHYLDKRZHYHULQYHVWLJDWRUVGLGQRW
UHSRUWVXIILFLHQWGHWDLOVWRGHWHUPLQHZKHWKHUWKRVHVWXGLHVDGMXVWHGIRUIDFWRUVLQWKHILUVW
SUHJQDQF\OLNHO\ERWKWROHDGWRFHVDUHDQGHOLYHU\DQGWRUHFXULQWKHQH[WSUHJQDQF\7KH
LQYHVWLJDWRUVDOVRLQFOXGHGUHVXOWVIURPWKHLURZQVWXG\ZKLFKDGMXVWHGIRUPXOWLSOHIDFWRUV
DVVRFLDWHGZLWKDQLQFUHDVHGULVNRISODFHQWDSUHYLDLQFOXGLQJSODFHQWDSUHYLDLQWKHILUVW
SUHJQDQF\DQGUHSRUWHGDLQFUHDVHLQULVN7KLVVXJJHVWVWKDWIDLOXUHWRDGMXVWIRUFRQ
IRXQGLQJIDFWRUVDPRQJWKHUHYLHZHGVWXGLHVKDGOLWWOHHIIHFWRQWKHILQGLQJRILQFUHDVHGULVN
$GLIIHUHQWV\VWHPDWLFUHYLHZRIHLJKWVWXGLHVH[DPLQHGWKHULVNRISODFHQWDSUHYLDZLWKLQ
FUHDVLQJQXPEHUVRISULRUFHVDUHDQV5HYLHZHUVUHSRUWHGDUDWHRISHUZLWKRQH
SULRUFHVDUHDQSHUZLWKWZRSULRUFHVDUHDQVSHUZLWKWZRRUPRUH
SULRUFHVDUHDQVDQGSHUZLWKWKUHHRUPRUHSULRUFHVDUHDQV7KHOLNHOLKRRGRI
SODFHQWDSUHYLDUHVXOWLQJLQK\VWHUHFWRP\DOVRURVHZLWKWKHQXPEHURISULRUFHVDUHDQV

$60$//H[FHVVQXPEHURIZRPHQZLWKILUVWGHOLYHU\YLDFHVDUHDQGHYHORS
SODFHQWDDFFUHWDLQWKHQH[WSUHJQDQF\$/$5*(H[FHVVQXPEHURI
ZRPHQGHYHORSSODFHQWDDFFUHWDDIWHUPXOWLSOHSULRUFHVDUHDQV
$VWXG\IRXQGWKDWSHUZRPHQZLWKILUVWELUWKYDJLQDOH[SHULHQFHGSODFHQWDDFFUHWD
LQWKHQH[WSUHJQDQF\FRPSDUHGZLWKSHUZLWKILUVWGHOLYHU\YLDFHVDUHDQ$V\V
WHPDWLFUHYLHZRIIRXUVWXGLHVSURYLGHVLQIRUPDWLRQDERXWDFFXPXODWLQJULVNDVWKHQXPEHURI
FHVDUHDQVULVHV7KHUHYLHZUHSRUWHGDUDWHRIWRSHUZLWKRQHSULRUFHVDUHDQ
SHUZLWKWZRSULRUFHVDUHDQVSHUZLWKWZRRUPRUHSULRUFHVDUHDQV
ZLWKWKUHHSULRUFHVDUHDQVSHUZLWKIRXUSULRUFHVDUHDQVZLWKIRXURU
PRUHSULRUFHVDUHDQVDQGZLWKILYHRUPRUHSULRUFHVDUHDQV

$02'(5$7(H[FHVVQXPEHURIZRPHQZLWKILUVWGHOLYHU\YLDFHVDUHDQ
KDYHDSODFHQWDODEUXSWLRQLQVXEVHTXHQWSUHJQDQFLHV
7KUHHVWXGLHVUHSRUWHGRQSODFHQWDODEUXSWLRQUDWHVLQWKHQH[WSUHJQDQF\ZLWKILUVWGHOLYHU\
YLDFHVDUHDQFRPSDUHGZLWKILUVWELUWKYDJLQDO([FHVVHVZLWKILUVWGHOLYHU\YLDFHVDUHDQ
YDULHGIURPWRSHU$V\VWHPDWLFUHYLHZRIVL[VWXGLHVSURYLGHVLQIRUPDWLRQ
DERXWDFFXPXODWLQJULVNDVWKHQXPEHURIFHVDUHDQVULVHV7KHUHYLHZUHSRUWHGWKDWXQOLNH
SODFHQWDSUHYLDDQGSODFHQWDDFFUHWDLQFLGHQFHRISODFHQWDODEUXSWLRQGLGQRWLQFUHDVHZLWK
LQFUHDVLQJQXPEHUVRIFHVDUHDQV


$02'(5$7(H[FHVVQXPEHURIZRPHQZLWKSULRUFHVDUHDQGHOLYHU\
UHTXLUHDQXUJHQWK\VWHUHFWRP\GXULQJWKHQH[WGHOLYHU\DGPLVVLRQ
FRPSDUHGZLWKZRPHQZLWKRQO\SULRUYDJLQDOELUWK/LPLWHGHYLGHQFH
VXJJHVWVWKDWWKHH[FHVVLQFUHDVHVZLWKVXEVHTXHQWSUHJQDQFLHV
30

6HYHQVWXGLHVRIYDU\LQJGHVLJQVDOODJUHHWKDWSULRUFHVDUHDQLQFUHDVHVWKHULVNRIXUJHQWK\V
WHUHFWRP\GXULQJDVXEVHTXHQWGHOLYHU\DGPLVVLRQ7KUHHVWXGLHVDQDO\]HGSRSXODWLRQEDVHG
K\VWHUHFWRP\UDWHVILQGLQJWKDWWRPRUHZRPHQSHUZLWKSULRUFHVDUHDQKDGDQ
XQSODQQHGK\VWHUHFWRP\WKDQZRPHQZLWKRQO\SULRUYDJLQDOELUWK7ZRDQDO\VHVUHSRUWHG
RQSUHYDOHQFHRISULRUFHVDUHDQDPRQJZRPHQKDYLQJK\VWHUHFWRPLHVDWDQLQGLYLGXDOKRVSLWDO
ILQGLQJWKDWRIZRPHQKDYLQJK\VWHUHFWRP\DURXQGWKHWLPHRIELUWKKDGSULRUFHVDUHDQVDW
RQHKRVSLWDODQGDWWKHRWKHU7ZRVWXGLHVFRPSDUHGZRPHQKDYLQJFKLOGELUWKUHODWHG
K\VWHUHFWRPLHVZLWKFRQWUROZRPHQDQGIRXQGWKDWFDVHVZHUHPXFKPRUHOLNHO\WRKDYHKDGSULRU
FHVDUHDQVYHUVXVLQRQHVWXG\DQGYHUVXVLQWKHRWKHU$V\VWHPDWLF
UHYLHZQRWHGWKDWWZRVWXGLHVVXJJHVWHGWKDWWKHOLNHOLKRRGRIK\VWHUHFWRP\LQFUHDVHGZLWKPXO
WLSOHFHVDUHDQVEXWWKDWDGRVHGHSHQGHQWUHODWLRQVKLSFRXOGQRWEHHVWDEOLVKHG,QRQHRIWKH
VWXGLHVWKHUDWHZDVSHUDIWHUWZRFHVDUHDQVYHUVXVSHUDIWHUVL[RUPRUH


8WHULQHUXSWXUHLVPRUHFRPPRQLQZRPHQZLWKSULRUFHVDUHDQGHOLYHU\5DWHVLQVXEVHTXHQW
SUHJQDQF\LQZRPHQZLWKSULRUFHVDUHDQGHOLYHU\ZLOOGHSHQGRQWKHSURSRUWLRQRIWKHSRSXODWLRQ
ZKRSODQ9%$&DQGPD\EHPRGLILHGE\PDQDJHPHQWGXULQJWKHSULRUFHVDUHDQGHOLYHU\ VLQJOH
YHUVXVGRXEOHOD\HUXWHULQHFORVXUH DQGWKH9%$&ODERU R[\WRFLQXVHIRULQGXFWLRQRUODERU
DXJPHQWDWLRQ 'LIIHUHQFHVLQUDWHVEHWZHHQZRPHQZLWKSULRUFHVDUHDQDQGZRPHQZLWKRXW
SULRUFHVDUHDQDOVRZLOOEHDIIHFWHGE\ODERUPDQDJHPHQWSUDFWLFHVLQZRPHQZLWKRQO\SULRU
YDJLQDOELUWKV XVHRIR[\WRFLQDQGRWKHUDJHQWVIRULQGXFWLRQ 
3ODQQHGUHSHDWFHVDUHDQGRHVQRWHOLPLQDWHWKHSRVVLELOLW\RIXWHULQHUXSWXUH$V\VWHPDWLF
UHYLHZUHSRUWHGDXWHULQHUXSWXUHUDWHZLWKSODQQHGUHSHDWFHVDUHDQRISHU0RUHRYHU
VRPHXWHULQHUXSWXUHVFDQQRWEHDYHUWHGE\SODQQLQJUHSHDWFHVDUHDQEHFDXVHWKH\RFFXULQ
WKHILUVWRUVHFRQGWULPHVWHUDVDUHVXOWRIWKHHPEU\RRUSODFHQWDLPSODQWLQJZLWKLQWKHFHVDUHDQ
VFDU 6HHDERYH
$02'(5$7(H[FHVVQXPEHURIZRPHQZLOOH[SHULHQFHXWHULQHUXSWXUH
ZLWKSULRUFHVDUHDQGHOLYHU\FRPSDUHGZLWKSULRUYDJLQDOELUWK
$VWXG\FRPSDUHGXWHULQHUXSWXUHUDWHVLQWKHQH[WSUHJQDQF\ZLWKILUVWGHOLYHU\YLDFHVDUHDQ
YHUVXVILUVWYDJLQDOELUWKDQGIRXQGWKDWPRUHZRPHQSHUH[SHULHQFHGXWHULQHUXSWXUHZLWK
ILUVWGHOLYHU\FHVDUHDQ$VHFRQGVWXG\UHSRUWHGXWHULQHUXSWXUHUDWHVLQZRPHQZLWKSULRUFHVDUHDQ
RUFHVDUHDQVYHUVXVRQO\YDJLQDOELUWKVDQGIRXQGWKDWPRUHZRPHQSHUH[SHULHQFHGXWHU
LQHUXSWXUHZLWKSULRUFHVDUHDQGHOLYHU\1HLWKHUVWXG\UHSRUWHGZKDWSURSRUWLRQRIZRPHQZLWKSULRU
FHVDUHDQSODQQHG9%$&VRUZKDWSHUFHQWDJHRI9%$&ODERUVUHVXOWHGLQVFDUUXSWXUH


/LPLWHGHYLGHQFHVXJJHVWVWKDWD/$5*(H[FHVVQXPEHURIZRPHQ
ZLWKSULRUFHVDUHDQDUHDGPLWWHGWRLQWHQVLYHFDUHDWWKHQH[W
GHOLYHU\FRPSDUHGZLWKZRPHQZLWKSULRUYDJLQDOELUWK
$VWXG\FRPSDUHGRXWFRPHVLQZRPHQZLWKSULRUYDJLQDOELUWKZLWKRXWFRPHVLQZRPHQZLWKSULRU
FHVDUHDQGHOLYHU\$PRQJZRPHQZLWKSULRUFHVDUHDQSODQQHG9%$&LQWKHFXUUHQWSUHJ
QDQF\RIZKRPKDGDYDJLQDOELUWK7KHVWXG\IRXQGWKDWPRUHZRPHQSHUZLWK
SULRUFHVDUHDQZHUHDGPLWWHGWRLQWHQVLYHFDUH&RQWUROOLQJIRUPDWHUQDO7\SHDQG7\SHGLDEH
WHVDQGK\SHUWHQVLRQGLGQRWDIIHFWUHVXOWV
31


/LPLWHGHYLGHQFHVXJJHVWVWKDWD02'(5$7(H[FHVVQXPEHURIZRPHQ
ZLWKSULRUFHVDUHDQDUHUHDGPLWWHGWRWKHKRVSLWDODIWHUGLVFKDUJHDWWKH
QH[WGHOLYHU\FRPSDUHGZLWKZRPHQZLWKSULRUYDJLQDOELUWK
7KHVDPHVWXG\DVLPPHGLDWHO\DERYHIRXQGWKDWPRUHZRPHQSHUZLWKSULRUFHVDU
HDQZHUHUHDGPLWWHGWRWKHKRVSLWDODIWHUGLVFKDUJHDWWKHLUQH[WGHOLYHU\FRPSDUHGZLWKZRPHQ
ZLWKSULRUYDJLQDOELUWK

:KDWDERXWPDWHUQDOGHDWKLQDQH[WSUHJQDQF\"
:HZHUHXQDEOHWRILQGDQHOLJLEOHVWXG\FRPSDULQJPDWHUQDOPRUWDOLW\
UDWHV ZLWK SULRU FHVDUHDQ FRPSDUHG ZLWK SULRU YDJLQDO ELUWK DQG
PRUHRYHUYDOLGLW\RIVXFKDVWXG\ZRXOGGHSHQGRQFRQWUROOLQJIRU
FRPSOLFDWLRQVLQWKHILUVWSUHJQDQF\WKDWPLJKWOHDGWRFHVDUHDQDQG
DOVR LQFUHDVH ULVN RI GHDWK LQ VXEVHTXHQW SUHJQDQFLHV +RZHYHU
SULRU FHVDUHDQ LQFUHDVHV WKH OLNHOLKRRG RI VHYHUDO OLIHWKUHDWHQLQJ
FRPSOLFDWLRQVLQVXEVHTXHQWSUHJQDQFLHV7KHVHLQFOXGHSODFHQWDO
DWWDFKPHQWFRPSOLFDWLRQVXWHULQHUXSWXUHDQGHFWRSLFSUHJQDQF\
,QDGGLWLRQUHSHDWFHVDUHDQGHOLYHU\WKHQRUPLQWKH8QLWHG6WDWHV
ZKHUHPDQ\ZRPHQKDYHOLPLWHGRUQRDFFHVVWRSODQQHG9%$&
LVDVVRFLDWHGZLWKDVPDOOULVNRIPRUWDOLW\ZKLFKLVWKXVLQGLUHFWO\
UHODWHG WR WKH SULRU FHVDUHDQ $QDO\VLV RI D ODUJH 86 FRKRUW
UHSRUWHGDPDWHUQDOGHDWKUDWHZLWKWUXHHOHFWLYHUHSHDWFHVDUHDQ
WKDWLVUHSHDWFHVDUHDQGHOLYHU\ZLWKQRPHGLFDOLQGLFDWLRQRI
SHU  ZRPHQ ZLWK SULRU FHVDUHDQ 7KH EDFNJURXQG 86
PDWHUQDOPRUWDOLW\UDWHLQUHFHQWGHFDGHVKDVYDULHGIURPWR
SHUZKLFKFDOFXODWHVWRWRPRUHZRPHQSHU
G\LQJRIFDXVHVGLUHFWO\UHODWHGWRUHSHDWVXUJHU\

8. What are potential effects of


a scarred uterus on future babies?
0RVWVWXGLHVWKDWKDYHDWWHPSWHGWRFRQWUROIRUPDWHUQDODQGIHWDOKHDOWKSUREOHPVSRWHQWLDOO\
OHDGLQJERWKWRFHVDUHDQDQGWRUHSHDWLQJLQDVXEVHTXHQWSUHJQDQF\VWLOOUHSRUWDQDVVRFLD
WLRQEHWZHHQDGYHUVHSHULQDWDORXWFRPHVLQWKHQH[WSUHJQDQF\DQGSULRUFHVDUHDQGHOLYHU\
FRPSDUHGZLWKSULRUYDJLQDOELUWK2QHH[SODQDWLRQLVWKHLQFUHDVHGULVNRIDEQRUPDOSODFHQWDO
DWWDFKPHQW VXPPDUL]HGDERYH EXWRWKHUSRVVLELOLWLHVDUHWKDWDVFDUUHGXWHUXVPD\QRWSURYLGH
R[\JHQDQGQXWULHQWVWRWKHGHYHORSLQJIHWXVDVHIIHFWLYHO\FRPSDUHGZLWKDIHWXVGHYHORSLQJLQ
DQXQVFDUUHGXWHUXVRUWKDWPDWHUQDOPDMRUEORRGYHVVHOVVHUYLQJWKHXWHUXVPD\KDYHEHHQFXW
HLWKHULQWHQWLRQDOO\RUDFFLGHQWDOO\GXULQJWKHILUVWFHVDUHDQZKLFKFRXOGDIIHFWSODFHQWDOSHUIX
VLRQLQIXWXUHSUHJQDQFLHV
32


7KHSUHSRQGHUDQFHRIHYLGHQFHVXJJHVWVWKDWDEDE\ZKRGHYHORSVLQDXWHUXVZLWKDFHVDU
HDQVFDUKDVDQLQFUHDVHGULVNRIG\LQJEHIRUHELUWKRUGXULQJODERU VWLOOELUWK FRPSDUHGZLWKD
EDE\ZKRGHYHORSVLQDQXQVFDUUHGXWHUXV7KHHYLGHQFHIRUDQHIIHFWRQGHDWKVGXULQJWKHWLPH
SHULRGEHIRUHDQGVKRUWO\DIWHUELUWK SHULQDWDOGHDWKV LVPXFKZHDNHUEXWVXJJHVWVDSRVVLEOH
HIIHFWDVZHOO7KHH[FHVVQXPEHURIVWLOOELUWKVDQGSHULQDWDOGHDWKVPD\EHJUHDWHUWKDQDS
SHDUVEHFDXVHVRPHVWXGLHVH[FOXGHGZRPHQZLWKOLIHWKUHDWHQLQJFRPSOLFDWLRQVWKDWDUHPRUH
FRPPRQZLWKSULRUFHVDUHDQVXFKDVSODFHQWDSUHYLDSODFHQWDDFFUHWDDQGSODFHQWDODEUXSWLRQ
6HHDERYHIRUUHODWLRQVKLSEHWZHHQSODFHQWDOFRPSOLFDWLRQVDQGSULRUFHVDUHDQ 

'DWDFRQIOLFWEXWVXJJHVWWKDWD60$//WR02'(5$7(
H[FHVVQXPEHURIEDELHVGHYHORSLQJLQDXWHUXVZLWKD
FHVDUHDQVFDUDUHVWLOOERUQ
7HQVWXGLHVKDYHHYDOXDWHGVWLOOELUWKUDWHVLQZRPHQZLWKDSULRUFHVDUHDQYHUVXVZRPHQ
ZLWKQRSULRUFHVDUHDQRQHLQ6FRWODQGWZRLQGLIIHUHQWVWDWHVLQ$XVWUDOLDRQHLQ(QJ
ODQGRQHLQ*HUPDQ\RQHLQ&DQDGDDQGIRXULQWKH862IWKHVWXGLHVLQWKH86
RQHXVHGQDWLRQDOGDWDRQHXVHG0LVVRXULVWDWHGDWDDQRWKHUZDVFRQGXFWHGLQDVLQJOH
0DVVDFKXVHWWVKRVSLWDODQGWKHIRXUWKXVHGGDWDIURPDFRQVRUWLXPRIKRVSLWDOV
6WXGLHVYDULHGLQZKHWKHUWKH\UHSRUWHGRQDQWHSDUWXPGHPLVHDORQHRUZKHWKHUVWLOOELUWK
DOVRHQFRPSDVVHGGHDWKVGXULQJODERU7KLVFRXOGDIIHFWUHVXOWVEHFDXVHSULRUFHVDUHDQ
FRXOGOHDGWRLQWUDSDUWXPGHDWKFRQVHTXHQWWRVFDUUXSWXUHGXULQJ9%$&ODERU6WXGLHVDOVR
YDULHGLQZKDWFRQIRXQGLQJIDFWRUVWKH\FRQWUROOHGIRUWKDWPLJKWOHDGERWKWRFHVDUHDQGH
OLYHU\LQWKHSUHFHGLQJSUHJQDQF\DQGLQFUHDVHGULVNRIVWLOOELUWKLQVXFFHHGLQJSUHJQDQFLHV
6RPHIDFWRUVZHUHGHPRJUDSKLFDQGVRFLDO HJPDWHUQDODJH%0,VRFLDOFODVVWREDFFR
XVH VRPHUHODWHGWRDGYHUVHREVWHWULFKLVWRU\ HJSULRUSUHWHUPELUWKVPDOOIRUJHVWD
WLRQDODJHLQIDQWRUVWLOOELUWK DQGVRPHZHUHFKURQLFKHDOWKSUREOHPV HJK\SHUWHQVLRQ
FDUGLDFGLVHDVHUHQDOGLVHDVH 
(LJKWRIWKHWHQVWXGLHVUHSRUWHGDQH[FHVVRIVWLOOELUWKVLQZRPHQZLWKDSULRUFHVDUHDQ
LQWKHSRSXODWLRQRYHUDOODQGDQLQWKIURP0LVVRXULUHSRUWHGDQH[FHVVDPRQJ
EODFNZRPHQEXWQRWZKLWHZRPHQ6L[RIWKHVWXGLHVILQGLQJH[FHVVVWLOOELUWKVUHSRUWHG
WKDWWKHGLIIHUHQFHZDVVWDWLVWLFDOO\VLJQLILFDQW XQOLNHO\WREHGXHWRFKDQFH ,Q
WZRRIWKHWKUHHVWXGLHVQRWILQGLQJDVWDWLVWLFDOO\VLJQLILFDQWH[FHVVWKHQXPEHURIZRP
HQKDYLQJDSULPDU\FHVDUHDQZDVWRRVPDOOWRGHWHFWDGLIIHUHQFHUHOLDEO\DQGWKHWKLUGGLG
QRWSHUIRUPDVWDWLVWLFDODQDO\VLV$PRQJWKHHLJKWVWXGLHVDOORZLQJFDOFXODWLRQRIH[FHVV
UDWHVZLWKSULRUFHVDUHDQUDWHVUDQJHGIURPPRUHVWLOOELUWKVSHUWRPRUHSHU
7KHQLQWKVWXG\UHSRUWHGDLQFUHDVHLQULVN7KHWHQWKVWXG\DQDWLRQDOVWXG\
IURPWKH86UHSRUWHGQRGLIIHUHQFHLQZRPHQZLWKRQHSULRUELUWKQRXQGHUO\LQJPHGLFDO
FRQGLWLRQV QRWVSHFLILHG DQGDIHWXVZLWKQRVWUXFWXUDORUFKURPRVRPDODEQRUPDOLWLHVKRZ
HYHUWKHDXWKRUVRIWKHVWXG\IURPDFRQVRUWLXPRI86KRVSLWDOVVSHFXODWHWKDWWKHQDWLRQDO
VWXG\PD\KDYHGLIIHUHGIURPWKHLUVWXG\EHFDXVHRIXQGHUUHSRUWLQJRUPLVFODVVLILFDWLRQERWK
RIZKLFKDUHNQRZQSUREOHPVLQYLWDOVWDWLVWLFVGDWDEDVHV7KHVWXG\DOVRXQOLNHDQ\RIWKH
RWKHUVZDVFRQILQHGWRVWLOOELUWKLQWHUPSUHJQDQFLHV

33


'DWDFRQIOLFWEXWVXJJHVWWKDWPRUHEDELHVGHYHORSLQJLQD
XWHUXVZLWKDFHVDUHDQVFDUPD\GLHODWHLQSUHJQDQF\RU
GXULQJWKHILUVWZHHNDIWHUELUWKEXWWKHH[FHVVQXPEHU
LIDQ\FDQQRWEHFDOFXODWHGIURPWKHVWXGLHVH[DPLQHG
7KHGDWDRQWKHHIIHFWRIILUVWFHVDUHDQRQSHULQDWDOGHDWK VWLOOELUWKSOXVHDUO\QHRQDWDOGHDWK 
DUHPXFKZHDNHUWKDQWKRVHIRUVWLOOELUWKEXWGRQRWUXOHRXWDQHIIHFW)LYHVWXGLHVUHSRUWHG
RQSHULQDWDOGHDWKZLWKSULRUFHVDUHDQYHUVXVSULRUYDJLQDOELUWK$PRQJWKHVWXGLHVUHSRUWLQJ
RQVWLOOELUWKWKH*HUPDQVWXG\UHSRUWHGDVLJQLILFDQWLQFUHDVHPRUHZRPHQSHU
ZLWKSULRUFHVDUHDQFRPSDUHGZLWKSULRUYDJLQDOELUWK'LIIHUHQFHVLQSHULQDWDOPRUWDOLW\
UDWHVFDQEHFDOFXODWHGIURPGDWDLQWKH$XVWUDOLDQVWXGLHVSHUPRUHZRPHQZLWK
SULRUFHVDUHDQLQ1HZ6RXWK:DOHVDQGSHULQ6RXWK$XVWUDOLDEXWZHGRQRW
NQRZZKHWKHUWKHVHGLIIHUHQFHVZRXOGDFKLHYHVWDWLVWLFDOVLJQLILFDQFHRUWKHGHJUHHWRZKLFK
DGMXVWLQJIRUFRUUHODWLQJIDFWRUVZRXOGDIIHFWWKHP,QDGGLWLRQD6ZHGLVKVWXG\UHSRUWHG
PRUHSHULQDWDOGHDWKVSHULQWKHQH[WSUHJQDQF\ZLWKILUVWGHOLYHU\FHVDUHDQFRPSDUHG
ZLWKILUVWELUWKYDJLQDODIWHUDGMXVWPHQWIRUPDWHUQDODJHVPRNLQJKHLJKW%0,PXOWLSOHELUWK
SUHWHUPELUWK Z EUHHFKSUHVHQWDWLRQDQGELUWKZHLJKWDGLIIHUHQFHWKDWMXVWPLVVHG
DFKLHYLQJVWDWLVWLFDOVLJQLILFDQFH%\FRQWUDVWD)LQQLVKVWXG\UHSRUWHGDQH[FHVVRI
PRUHSHULQDWDOGHDWKVSHUZLWKSULRUYDJLQDOELUWKWKDWZDVQRWVLJQLILFDQW)LQDOO\D
VWXG\XVLQJ86QDWLRQDOGDWDUHSRUWVRQQHRQDWDOGHDWKV GHDWKRIDOLYHELUWKZLWKLQG 
$PRQJKHDOWK\ZRPHQZLWKRXWDSUHYLRXVSUHWHUPELUWKRU6*$LQIDQWQHRQDWDOGHDWKVIURP
DOOFDXVHVGLGQRWGLIIHUVLJQLILFDQWO\DFFRUGLQJWRPRGHRISULRUELUWKEXWDVSK\[LDUHODWHG
GHDWKVGLGPRUHSHUZLWKSULRUFHVDUHDQ,QYHVWLJDWRUVH[SODLQWKDWWKLVFRXOG
EHEHFDXVHZRPHQDUHPRUHOLNHO\WRKDYHSODFHQWDOG\VIXQFWLRQZLWKSULRUFHVDUHDQ 6HH
DERYHVXPPDU\RISUREOHPVZLWKSODFHQWDODWWDFKPHQW


3UHWHUPELUWKDQGORZELUWKZHLJKW OHVVWKDQJUDPV DUHQHFHVVDULO\LQWHUWZLQHGEHFDXVH
EDELHVERUQHDUO\ZLOOZHLJKOHVV3UHWHUPELUWKSXWVEDELHVDWULVNIRUH[SHULHQFLQJLWVDVVRFLDW
HGVHULRXVDQGOLIHWKUHDWHQLQJFRPSOLFDWLRQVVXFKDVUHVSLUDWRU\GLVWUHVVV\QGURPHQHFURWL]LQJ
HQWHURFROLWLV GHDWKRISRUWLRQVRIWKHEDE\VLQWHVWLQHV VHL]XUHRUEOHHGLQJZLWKLQWKHEUDLQ
'DWDFRQIOLFWRQZKHWKHUSULRUFHVDUHDQGHOLYHU\
LPSRVHVLQFUHDVHGULVNRISUHWHUPELUWKDQG
FRQFRPLWDQWORZELUWKZHLJKW
$PRQJWKHIRXUVWXGLHVWKDWFRQWURORUDGMXVWIRUSUHWHUPELUWKLQWKHSULRUSUHJQDQF\RQHUH
SRUWVDVWDWLVWLFDOO\VLJQLILFDQWH[FHVVRISUHWHUPELUWKVZLWKSULRUFHVDUHDQ PRUHSHU 
RQHUHSRUWVDLQFUHDVHLQGHOLYHULHVEHWZHHQDQGZHHNVZLWKSULRUFHVDUHDQEXWGDWD
GRQRWSHUPLWFDOFXODWLRQRIWKHH[FHVVRQHUHSRUWVDQRQVLJQLILFDQWH[FHVVZLWKSULRUFHVDUHDQ
PRUHSHU DQGRQHUHSRUWVDQRQVLJQLILFDQWH[FHVVZLWKSULRUYDJLQDOELUWK PRUH
SHU 7KHVWXG\UHSRUWLQJDQRQVLJQLILFDQWH[FHVVRISUHWHUPELUWKZLWKSULRUFHVDUHDQDOVR
UHSRUWVDQRQVLJQLILFDQWH[FHVVRIORZELUWKZHLJKWEDELHV PRUHSHU 

34



'DWDFRQIOLFWRQZKHWKHUSULRUFHVDUHDQGHOLYHU\LPSRVHVLQFUHDVHG
ULVNRI6*$LQWKHQH[WSUHJQDQF\FRPSDUHGZLWKSULRUYDJLQDOELUWK
2IWKHIRXUVWXGLHVWKDWFRQWUROOHGRUDGMXVWHGIRU6*$LQWKHSULRUSUHJQDQF\RQHUHSRUWVDVLJ
QLILFDQWH[FHVVZLWKSULRUFHVDUHDQ PRUHSHU RQHUHSRUWVDLQFUHDVHZLWKSULRU
FHVDUHDQEXWGDWDGRQRWSHUPLWFDOFXODWLRQRIWKHH[FHVVRQHUHSRUWVDQRQVLJQLILFDQWH[FHVV
LQZRPHQZLWKSULRUYDJLQDOELUWK PRUHSHU DQGWKHIRXUWKDOVRUHSRUWVDQRQVLJQLIL
FDQWH[FHVVLQZRPHQZLWKSULRUYDJLQDOELUWK PRUHSHU 


/LPLWHGHYLGHQFHVXJJHVWVWKDWD/$5*(H[FHVVQXPEHURIEDELHV
ZKRVHPRWKHUVKDGSULRUFHVDUHDQPD\UHTXLUHYHQWLODWLRQDWELUWK
FRPSDUHGZLWKEDELHVZKRVHPRWKHUVKDGSULRUYDJLQDOELUWK
$VWXG\FRPSDUHGQHRQDWDORXWFRPHVLQZRPHQZLWKSULRUYDJLQDOELUWKZLWKRXWFRPHVLQZRPHQ
ZLWKSULRUFHVDUHDQGHOLYHU\$PRQJZRPHQZLWKSULRUFHVDUHDQSODQQHG9%$&LQWKHFXU
UHQWSUHJQDQF\RIZKRPKDGDYDJLQDOELUWK7KHVWXG\IRXQGWKDWPRUHQHZERUQVSHU
ZKRVHPRWKHUVKDGSULRUFHVDUHDQUHTXLUHGYHQWLODWLRQDWELUWK&RQWUROOLQJIRUPDWHUQDO
7\SHDQG7\SHGLDEHWHVRUK\SHUWHQVLRQGLGQRWDIIHFWUHVXOWV


/LPLWHGHYLGHQFHVXJJHVWVWKDWD/$5*(H[FHVVQXPEHURIEDELHV
ZKRVHPRWKHUVKDGSULRUFHVDUHDQKDYHKRVSLWDOVWD\VRIPRUHWKDQ
GD\VFRPSDUHGZLWKEDELHVZKRVHPRWKHUVKDGSULRUYDJLQDOELUWK
7KHVDPHVWXG\DVWKHRQHLPPHGLDWHO\DERYHIRXQGWKDWPRUHQHZERUQVSHU
ZKRVHPRWKHUVKDGSULRUFHVDUHDQKDGKRVSLWDOVWD\VRIPRUHWKDQGD\V

9. Does cesarean delivery protect against sexual,


bowel, urinary, or pelvic floor dysfunction?

6WXGLHVRIVH[XDOG\VIXQFWLRQPD\QRWWDNHLQWRDFFRXQWPRGLILDEOHFRQIRXQGLQJIDFWRUVDVVR
FLDWHGZLWKYDJLQDOELUWKWKDWFDQDIIHFWSHULQHDODQGYDJLQDOSDLQ7KHVHLQFOXGHLQVWUXPHQWDO
YDJLQDOGHOLYHU\DQGZKHWKHUWKHGHOLYHU\LVE\YDFXXPH[WUDFWLRQRUIRUFHSVHSLVLRWRP\DQG
ZKHWKHUHSLVLRWRP\LVPHGLDQWKHXVXDOW\SHLQWKH8QLWHG6WDWHVDQG&DQDGDRUPHGLRODWHUDO
WKHXVXDOW\SHLQPRVWRWKHUFRXQWULHV1RVWXG\FRQVLGHUVWKHHIIHFWVRISXVKLQJSRVLWLRQDQG
WHFKQLTXHZKLFKFRXOGDIIHFWSHOYLFIORRUPXVFOHWRQH DQGWKHUHIRUHVH[XDOVDWLVIDFWLRQ RU
FHVDUHDQZRXQGSDLQ%UHDVWIHHGLQJLVDOVRDVVRFLDWHGZLWKSDLQIXOLQWHUFRXUVHDSUREOHP
DWWULEXWHGWRKRUPRQDOVWDWXVGXULQJODFWDWLRQDQGFHVDUHDQGHOLYHU\PD\EHDVVRFLDWHGZLWK
GHFUHDVHGOLNHOLKRRGRIEUHDVWIHHGLQJ 6HHDERYH (YHQVRVWXGLHVVKRZFHVDUHDQGHOLYHU\
FRQIHUVOLWWOHRUQRSURWHFWLRQDJDLQVWVH[XDOG\VIXQFWLRQ
&HVDUHDQGHOLYHU\SURYLGHVPLQLPDORUQRSURWHFWLRQDJDLQVWVH[XDOG\VIXQFWLRQ
35

$V\VWHPDWLFUHYLHZRIVWXGLHVRIVH[XDOIXQFWLRQGXULQJSUHJQDQF\DQGDIWHUELUWKLQFOXGHG
GDWDIURPVWXGLHVUHSRUWLQJRXWFRPHVDFFRUGLQJWRPRGHRIELUWK$PRQJWKHVHHLJKWVWXGLHV
ILYHUHSRUWHGQRSURWHFWLYHHIIHFWIRUFHVDUHDQDQGWKUHHIRXQGDSURWHFWLYHHIIHFW5HYLHZHUVGR
QRWTXDQWLI\UHVXOWVEXWGHVFULEHWKHHIIHFWDVVPDOOLQRQHVWXG\OLPLWHGWRWKHHDUO\UHFRYHU\
SHULRGLQDQRWKHUDQGVWDWHRQO\WKDWVH[XDOIXQFWLRQLPSURYHGDIWHUSODQQHGFHVDUHDQGHOLYHU\
FRPSDUHGZLWKEHIRUHGHOLYHU\ LQWKHWKLUG


$VZLWKVH[XDOG\VIXQFWLRQWKHUHODWLRQVKLSEHWZHHQYDJLQDOELUWKDQGERZHOEODGGHUDQGSHOYLF
IORRUIXQFWLRQLVGLIILFXOWWRGHWHUPLQH)DFWRUVWKDWLQFUHDVHOLNHOLKRRGRIG\VIXQFWLRQLQFOXGH
XVHRIHSLVLRWRP\DQGZKHWKHUHSLVLRWRP\ZDVPHGLDQRUPHGLRODWHUDO
XVHRIYDFXXPH[WUDFWLRQRUIRUFHSVWRGHOLYHUWKHEDE\
XVHRIIXQGDOSUHVVXUH
XVLQJFDUHJLYHUGLUHFWHGSXVKLQJZKLFKLVRIWHQPRUHIRUFHIXOWKDQKDYLQJ
WKHZRPDQDQGKHURZQUHIOH[HVJXLGHSXVKLQJ
KLJKPDWHUQDO%0,
VPRNLQJ
,QDGGLWLRQWRDYRLGLQJWKHSUHYLRXVSUDFWLFHVHQJDJLQJLQH[HUFLVHVWRVWUHQJWKHQWKHSHOYLF
IORRUUHOLHYHVRULPSURYHVV\PSWRPVRISHOYLFIORRUG\VIXQFWLRQDVGRHVORVLQJZHLJKWPDNLQJ
WKHXVH RUQRW RIDPHOLRUDWLYHVWUDWHJLHVVXFKDVWKHVHDQRWKHUFRQIRXQGLQJIDFWRU
1RVWXG\KDVFRQWUROOHGIRUDOOIDFWRUVUHOHYDQWWRSHOYLFIORRUVWUHQJWKDQGVRPHPD\QRWKDYH
FRQWUROOHGIRUDQ\1RQHKDVFRPSDUHGZRPHQZLWKRSWLPDOO\FRQGXFWHGYDJLQDOELUWKWRZRPHQ
ZLWKFHVDUHDQGHOLYHU\(YHQVRFHVDUHDQGHOLYHU\RIIHUVQRSURWHFWLRQDJDLQVWDQDOLQFRQWLQHQFH
VSRQWDQHRXVOHDNDJHRIVROLGRUOLTXLGIHFDOPDWHULDORIWHQLQFOXGLQJPXFRLGGLVFKDUJHRUJDV 
LQWKHVKRUWRUPHGLXPWHUPRUVHYHUHXULQDU\LQFRQWLQHQFHZKHWKHUWKLVEHVWUHVVLQFRQWLQHQFH
LQFRQWLQHQFHDVVRFLDWHGZLWKH[HUFLVHODXJKLQJVQHH]LQJRUFRXJKLQJ RUXUJHLQFRQWLQHQFH
VXGGHQQHHGWRYRLGIROORZHGE\LQYROXQWDU\ORVV 6WXGLHVGLVDJUHHRQZKHWKHUFHVDUHDQGHOLY
HU\SURWHFWVDJDLQVWXUJHLQFRQWLQHQFHRIDQ\GHJUHH:KLOHLWSURYLGHVSURWHFWLRQDJDLQVWXULQDU\
VWUHVVLQFRQWLQHQFHRIDQ\GHJUHHDQGSHOYLFIORRUSURODSVHWKHGHJUHHWRZKLFKYDJLQDOELUWKSHU
VHDVRSSRVHGWRVSHFLILFYDJLQDOELUWKSUDFWLFHVLVUHVSRQVLEOHIRUH[FHVVLQFLGHQFHRIWKHVH
SUREOHPVUHPDLQVXQFOHDU

&HVDUHDQGHOLYHU\SURYLGHVQRSURWHFWLRQDJDLQVWDQDOLQFRQWLQHQFH
LQHLWKHUWKHVKRUWWHUPRUXSWR\HDUVDIWHUELUWKSODQQHGFHVDUHDQ
SURYLGHVQRSURWHFWLRQFRPSDUHGZLWKFHVDUHDQVGXULQJODERU
$V\VWHPDWLFUHYLHZRIVWXGLHVIDLOHGWRILQGWKDWFHVDUHDQGHOLYHU\KDGDSURWHFWLYHHIIHFW
DJDLQVWDQDOLQFRQWLQHQFH7KHVDPHZDVWUXHRIWKHVHYHQVWXGLHVWKDWDVVHVVHGLQFRQWL
QHQFHDIWHUIRXUPRQWKVSRVWSDUWXPDGMXVWHGIRUPDWHUQDODJHDQGFDWHJRUL]HGZRPHQDV
KDYLQJRQO\FHVDUHDQGHOLYHULHV1RUGLGUDWHVGLIIHUEHWZHHQHOHFWLYHFHVDUHDQDQGFHVDUHDQ
GXULQJODERULQWKHVL[VWXGLHVPDNLQJWKLVFRPSDULVRQ$\HDUIROORZXSVXUYH\OLNHZLVH
IRXQGWKDWQHLWKHUH[FOXVLYHFHVDUHDQGHOLYHU\QRUSODQQHGFHVDUHDQVSURWHFWHGDJDLQVWIHFDO
LQFRQWLQHQFH LQYROXQWDU\ORVVRIIHFDOPDWHULDO 
36


'DWDFRQIOLFWEXWVXJJHVWWKDWFHVDUHDQGHOLYHU\PD\SURYLGHVRPH
SURWHFWLRQDJDLQVWXULQDU\XUJHLQFRQWLQHQFHRIDQ\GHJUHHLQWKHVKRUW
WHUPEXWSURWHFWLYHHIIHFWLIDQ\KDVGLVDSSHDUHGE\RQH\HDUDIWHUELUWK
DQGVLPLODUSHUFHQWDJHVH[SHULHQFHVHYHUHLQFRQWLQHQFH
$/$5*(WR9(5</$5*(H[FHVVQXPEHURIZRPHQKDYLQJYDJLQDOELUWKH[SHUL
HQFHXULQDU\VWUHVVLQFRQWLQHQFHRIDQ\GHJUHHDWRQH\HDURUPRUHDIWHUELUWK
FRPSDUHGZLWKZRPHQKDYLQJFHVDUHDQGHOLYHU\EXWUDWHVRIVHYHUHLQFRQWLQHQFH
DUHORZDQGVLPLODUEHWZHHQFHVDUHDQDQGYDJLQDOELUWKJURXSV
$V\VWHPDWLFUHYLHZHYDOXDWHGWKHUHODWLRQVKLSEHWZHHQPRGHRIELUWKDQGXULQDU\LQFRQWL
QHQFH'DWDZHUHDQDO\]HGDFFRUGLQJWRZKHWKHUWKHVRXUFHVWXG\ZDVDSRSXODWLRQDQDO\
VLVRUDSURVSHFWLYHFRKRUWVWXG\DQGUHVXOWVZHUHSRROHGDPRQJVWXG\W\SHV5HYLHZHUV
XVHGVWXG\LQYHVWLJDWRUVGHILQLWLRQVRIVHYHULW\
:LWKUHVSHFWWRXUJHLQFRQWLQHQFHZKHQUHVXOWVZHUHSRROHGLQWKHSRSXODWLRQVWXGLHV
VWXGLHV UDWHVZHUHVLPLODUDIWHUFHVDUHDQGHOLYHU\FRPSDUHGZLWKYDJLQDOELUWKIRUERWK
XUJHLQFRQWLQHQFHRIDQ\GHJUHH YHUVXVSHU DQGVHYHUHXUJHLQFRQWLQHQFH
SHUYHUVXVSHU %\FRQWUDVWZKHQUHVXOWVZHUHSRROHGLQWKHFRKRUW
VWXGLHVDWPRQWKVDIWHUELUWKPRUHZRPHQSHUH[SHULHQFHGXUJHLQFRQWLQHQFH
RIDQ\GHJUHH VWXGLHV EXWUDWHVRIVHYHUHLQFRQWLQHQFHZHUHVLPLODU YHUVXVSHU
 ,QWKHVROHFRKRUWVWXG\UHSRUWLQJUDWHVDWPRUHWKDQRQH\HDUVIROORZXSQHLWKHU
UDWHVRIXUJHLQFRQWLQHQFHRYHUDOO SHUYHUVXVSHU QRUUDWHVRI
VHYHUHXUJHLQFRQWLQHQFH SHUYHUVXVSHU GLIIHUHGVLJQLILFDQWO\,Q
WKHVXEVHWRIHOHFWLYHFHVDUHDQVUDWHVZHUHKLJKHUWKDQWKHWRWDOUDWHZLWKFHVDUHDQGHOLYHU\
LQWKHRQHSRSXODWLRQVWXG\DQGWKHWZRFRKRUWVWXGLHVUHSRUWLQJWKLVRXWFRPH:KLOHWKLVLV
SUREDEO\DQDUWLIDFWGXHWRVPDOOQXPEHUVLWVXJJHVWVWKDWQRQODERUFHVDUHDQVSURYLGHQR
DGGLWLRQDOSURWHFWLRQ
:LWKUHVSHFWWRVWUHVVLQFRQWLQHQFHDPRQJWKHSRSXODWLRQVWXGLHVPRUHZRPHQSHU
H[SHULHQFHGVWUHVVLQFRQWLQHQFHRIDQ\GHJUHH VWXGLHV FRPSDUHGZLWKYDJLQDO
ELUWKDQGPRUHZRPHQSHUH[SHULHQFHGVHYHUHVWUHVVLQFRQWLQHQFH VWXGLHV 
$PRQJFRKRUWVWXGLHVPRUHZRPHQSHUZLWKYDJLQDOELUWKH[SHULHQFHGVWUHVV
LQFRQWLQHQFHRIDQ\GHJUHH VWXGLHV EXWUDWHVRIVHYHUHLQFRQWLQHQFHZHUHVLPLODU 
SHUYHUVXVSHU  VWXGLHV $PRQJVWXGLHVUHSRUWLQJUDWHVDWPRUHWKDQ
\HDUDIWHUELUWKPRUHZRPHQSHUZLWKYDJLQDOELUWKZHUHH[SHULHQFLQJVWUHVV
LQFRQWLQHQFHRIDQ\GHJUHH VWXGLHV EXWDVEHIRUHUDWHVRIVHYHUHLQFRQWLQHQFHZHUH
VLPLODU SHUYHUVXVSHU  VWXGLHV ,QWKHVXEVHWRIHOHFWLYHFHVDU
HDQVUDWHVZHUHKLJKHUWKDQWKHWRWDOUDWHLQWKHRQHSRSXODWLRQVWXG\UHSRUWLQJWKLVRXWFRPH
DQGVLPLODULQWKHILYHFRKRUWVWXGLHVUHSRUWLQJWKLVRXWFRPH SHUYHUVXVSHU
 DJDLQVXJJHVWLQJWKDWQRQODERUFHVDUHDQSURYLGHVQRDGGLWLRQDOSURWHFWLRQ

$/$5*(H[FHVVQXPEHURIZRPHQKDYLQJYDJLQDOELUWK
H[SHULHQFHV\PSWRPDWLFSHOYLFIORRUSURODSVHFRPSDUHGZLWK
ZRPHQKDYLQJRQO\FHVDUHDQGHOLYHU\7KHH[FHVVLQFUHDVHV
DVWKHQXPEHURIYDJLQDOELUWKVLQFUHDVHVDQGZLWKLQVWUXPHQWDO
YDJLQDOGHOLYHU\FRPSDUHGZLWKVSRQWDQHRXVYDJLQDOELUWK
37

6WXGLHVFRQVLVWHQWO\ILQGWKDWFHVDUHDQGHOLYHU\UHGXFHVLQFLGHQFHRIV\PSWRPDWLFSHOYLF
IORRUSURODSVHFRPSDUHGZLWKYDJLQDOELUWK2QHVWXG\UHSRUWHGPRUHZRPHQSHU
\RXQJHUWKDQDJHZLWKYDJLQDOELUWKVH[SHULHQFHGV\PSWRPDWLFSURODSVHFRPSDUHGZLWK
ZRPHQRQO\KDYLQJFHVDUHDQGHOLYHULHV$QRWKHUUHSRUWHGWKDWLQZRPHQROGHUWKDQDJH
FRPSDUHGZLWKZRPHQKDYLQJRQO\FHVDUHDQGHOLYHULHVPRUHZRPHQSHU
ZLWKRQHYDJLQDOELUWKPRUHSHUZLWKWZRYDJLQDOELUWKVDQGPRUHSHU
ZLWKWKUHHRUPRUHYDJLQDOELUWKVH[SHULHQFHGV\PSWRPDWLFSURODSVH$WKLUGVWXG\
FRPSDUHGVXUJHU\UDWHVIRUSHOYLFRUJDQSURODSVHLQDSRSXODWLRQRIZRPHQKDYLQJRQO\
FHVDUHDQGHOLYHULHVZLWKDQDJHPDWFKHGVDPSOHKDYLQJYDJLQDOELUWKV,QYHVWLJDWRUVIRXQG
WKDWPRUHZRPHQSHUKDYLQJVSRQWDQHRXVYDJLQDOELUWKVPRUHZRPHQSHU
KDYLQJYDFXXPH[WUDFWLRQDQGPRUHZRPHQSHUKDYLQJIRUFHSVGHOLYHU\
KDGVXUJHU\IRUSHOYLFRUJDQSURODSVHSRLQWLQJWRWKHVLJQLILFDQFHRIPRGHRIYDJLQDOELUWK
$IRXUWKVWXG\RISHOYLFIORRUGLVRUGHUVWR\HDUVDIWHUILUVWELUWKVLPLODUO\IRXQGWKDW
PRUHZRPHQSHUZLWKDWOHDVWRQHVSRQWDQHRXVYDJLQDOELUWKDQGPRUHZRPHQ
SHUZLWKDWOHDVWRQHLQVWUXPHQWDOYDJLQDOGHOLYHU\H[SHULHQFHGSHOYLFIORRUV\PSWRPV
FRPSDUHGZLWKZRPHQKDYLQJRQO\FHVDUHDQVXUJHULHVRFFXUULQJSULRUWRODERU:KHWKHU
ZRPHQKDGWKHLUFHVDUHDQSULRUWRODERUGXULQJODERUEHIRUHIXOOGLODWLRQRUGXULQJODERUGXU
LQJWKHSXVKLQJSKDVHKDGQRHIIHFWRQV\PSWRPSUHYDOHQFH SHU 

10. Does cesarean delivery protect


against injuries to babies?

1HUYHLQMXU\UDWHVGXULQJYDJLQDOELUWKDUHPRGLILDEOHEHFDXVHWKH\GHSHQGODUJHO\RQWKHSURSRU
WLRQRIZRPHQKDYLQJLQVWUXPHQWDOGHOLYHU\ZKLFKLQWXUQLVUHODWHGWRIDFWRUVVXFKDVXVHRIHSL
GXUDODQDOJHVLDDQGFRQWLQXRXVHOHFWURQLFIHWDOPRQLWRULQJ)XUWKHUPRUHXVHRILQVWUXPHQWVWR
GHOLYHUEDELHVWKURXJKWKHFHVDUHDQLQFLVLRQZKLFKKDVEHFRPHFRPPRQLQVRPHLQVWLWXWLRQVPD\
LQFUHDVHLQMXU\UDWHVLQFHVDUHDQGHOLYHULHV0RVWLQMXULHVUHVROYHRQWKHLURZQRUZLWKWUHDWPHQW
/LPLWHGHYLGHQFHVXJJHVWVWKDWD02'(5$7(H[FHVVQXPEHU
RIEDELHVERUQYDJLQDOO\H[SHULHQFHEUDFKLDOSOH[XVLQMXU\
FRPSDUHGZLWKEDELHVGHOLYHUHGE\FHVDUHDQEXWWKHH[FHVVLV
LQIOXHQFHGE\ZKHWKHUGHOLYHU\LVVSRQWDQHRXVYDJLQDOLQVWUX
PHQWDOYDJLQDORUFHVDUHDQDIWHUIDLOHGLQVWUXPHQWDOGHOLYHU\
/LPLWHGHYLGHQFHVXJJHVWVWKDWIDFLDOQHUYHLQMXU\UDWHV
GRQRWGLIIHUE\PRGHRIELUWK
2QHVWXG\FRPSDUHGQHUYHLQMXU\UDWHVDFFRUGLQJWRPRGHRIELUWKEXWGLGQRWGLVWLQJXLVK
EHWZHHQPRGHVRIYDJLQDOELUWKRUWLPLQJRIFHVDUHDQGHOLYHU\,QYHVWLJDWRUVIRXQGWKDWIDFLDO
QHUYHLQMXU\UDWHVGLGQRWGLIIHUVLJQLILFDQWO\EHWZHHQEDELHVGHOLYHUHGE\FHVDUHDQDQGEDELHV
ERUQYDJLQDOO\EXWIHZHUEDELHVSHUGHOLYHUHGE\FHVDUHDQH[SHULHQFHGEUDFKLDO
SOH[XVLQMXU\FRPSDUHGZLWKEDELHVERUQYDJLQDOO\

38



3ODQQHGFHVDUHDQSURYLGHVQRSURWHFWLRQDJDLQVWLQWUDFUDQLDO
KHPRUUKDJHQHRQDWDOVHL]XUHRUDEQRUPDOQHXURORJLF
VWDWXVFRPSDUHGZLWKZRPHQSODQQLQJYDJLQDOELUWK
7ZRVWXGLHVHYDOXDWHGHDUO\V\PSWRPVRIQHXURORJLFLQMXU\DFFRUGLQJWRPRGHRIELUWK$VWXG\
FRPSDUHGZRPHQZKRZHUHFDUU\LQJIXOOWHUPQRUPDOO\IRUPHGIHWXVHVDQGZHUHSODQQLQJ
YDJLQDOELUWK RIZKRPKDGXQSODQQHGFHVDUHDQV ZLWKZRPHQKDYLQJSODQQHGFHVDUHDQ
GHOLYHU\IRUUHDVRQVRWKHUWKDQIHWDOFRQGLWLRQ5DWHVRIDEQRUPDOQHXURORJLFVWDWXVQHRQDWDO
VHL]XUHDQGLQWUDFUDQLDOKHPRUUKDJHZHUHVLPLODUEHWZHHQJURXSV$VHFRQGVWXG\UHSRUWHG
WKDWLQWUDDQGHSLFUDQLDOKHPRUUKDJHUDWHVGLGQRWGLIIHUEHWZHHQEDELHVGHOLYHUHGE\FH
VDUHDQDQGEDELHVERUQYDJLQDOO\1HLWKHUVWXG\VWUDWLILHGUHVXOWVDFFRUGLQJWRVSRQWDQHRXV
YDJLQDOELUWKYHUVXVLQVWUXPHQWDOYDJLQDOGHOLYHU\

/LPLWHGHYLGHQFHVXJJHVWVWKDWOLEHUDOXVHRIFHVDUHDQGHOLYHU\
LVQRWDVVRFLDWHGZLWKDUHGXFWLRQLQFHUHEUDOSDOV\UDWHV
2QHVWXG\VXJJHVWVWKDWOLEHUDOXVHRIFHVDUHDQGHOLYHU\LVQRWDVVRFLDWHGZLWKDGHFUHDVHLQ
SUHYDOHQFHRIFHUHEUDOSDOV\$V\VWHPDWLFUHYLHZIRXQGWKDWFHUHEUDOSDOV\UDWHVLQWKHHDUO\
VZHUHYLUWXDOO\LGHQWLFDOLQ6ZHGHQ$XVWUDOLD(QJODQG,UHODQGDQGWKH8QLWHG6WDWHV
ZKLOHFHVDUHDQUDWHVUDQJHGIURPWRLQWKHILUVWIRXUFRXQWULHVYHUVXVLQWKH
8QLWHG6WDWHV

39

Discussion
2XUFRPSUHKHQVLYHDVVHVVPHQWUHYHDOVWKHIROORZLQJ2IPDWHUQDODGYHUVHRXWFRPHVLQWKH
FXUUHQWSUHJQDQF\VXIILFLHQWHYLGHQFHGHPRQVWUDWHVWKDWIDYRUYDJLQDORUSODQQHGYDJLQDOELUWK
DQGOLPLWHGHYLGHQFHVXJJHVWVWKHUHPDLQLQJIDYRUYDJLQDORUSODQQHGYDJLQDOELUWK2IQHRQD
WDODGYHUVHRXWFRPHVVXIILFLHQWHYLGHQFHGHPRQVWUDWHVWKDWIDYRUVYDJLQDORUSODQQHGYDJLQDO
ELUWKOLPLWHGHYLGHQFHVXJJHVWVWKDWIDYRUYDJLQDORUSODQQHGYDJLQDOELUWKDQGHYLGHQFHLVFRQ
IOLFWLQJIRUWKHUHPDLQLQJRXWFRPH2IFKLOGKRRGFKURQLFGLVHDVHVVXIILFLHQWHYLGHQFHGHP
RQVWUDWHVWKDWIDYRUYDJLQDORUSODQQHGYDJLQDOELUWKDQGHYLGHQFHLVOLPLWHGDQGFRQIOLFWLQJIRU
WKHUHPDLQLQJ6HYHQDGYHUVHRXWFRPHVDUHXQLTXHWRFHVDUHDQGHOLYHU\ZKLOHDUHXQLTXHWR
YDJLQDOELUWK2ISV\FKRVRFLDORXWFRPHVH[DPLQHGHYLGHQFHFRQIOLFWVEXWVXJJHVWVDSRVVLEOH
DVVRFLDWLRQZLWKFHVDUHDQGHOLYHU\IRUDOO,QVXEVHTXHQWSUHJQDQFLHVRIDGYHUVHPDWHUQDO
RXWFRPHVVXIILFLHQWHYLGHQFHGHPRQVWUDWHVWKDWIDYRUYDJLQDOELUWKLQWKHSULRUGHOLYHU\DQGOLP
LWHGHYLGHQFHVXJJHVWVWKHUHPDLQLQJDOVRIDYRUSULRUYDJLQDOELUWK2ISHULQDWDODGYHUVHRXW
FRPHVLQVXEVHTXHQWSUHJQDQFLHVOLPLWHGHYLGHQFHVXJJHVWVWKDWIDYRUSULRUYDJLQDOELUWKDQG
GDWDFRQIOLFWIRUWKHUHPDLQLQJ2IRXWFRPHVUHODWHGWRSHOYLFIORRUG\VIXQFWLRQQRQHIDYRUV
YDJLQDOELUWKPRGHRIELUWKPDNHVQRGLIIHUHQFHIRUDQGIDYRUFHVDUHDQGHOLYHU\EXWRIWKHVH
IDYRUFHVDUHDQRQO\LQWKHVKRUWWHUPRURQO\ZLWKUHVSHFWWRPLOGRUPRGHUDWHV\PSWRPV2I
RXWFRPHVUHODWHGWRGHOLYHU\LQMXU\RIWKHEDE\PRGHRIELUWKDSSHDUVWRPDNHQRGLIIHUHQFHIRU
QRQHIDYRUYDJLQDOELUWKDQGOLPLWHGHYLGHQFHVXJJHVWVWKDWIDYRUVFHVDUHDQ 6HH7DEOH

Table 2:

6XPPDU\RI2XWFRPHV SJV

2XWFRPH

0D\EHPRUH
FRPPRQZLWK
FHVDUHDQGHOLYHU\

0D\EHPRUH
FRPPRQZLWK
YDJLQDOELUWK

1RGLIIHUHQFH

0DWHUQDODGYHUVHRXWFRPHVUHODWHGWRWKHFXUUHQWSUHJQDQF\
0DWHUQDOGHDWK

&DUGLDFDUUHVW

8UJHQWK\VWHUHFWRP\

7KURPERHPEROLFHYHQW EORRGFORW

$QHVWKHWLFFRPSOLFDWLRQV

0DMRULQIHFWLRQ

5DUHOLIHWKUHDWHQLQJFRPSOLFDWLRQV

:RXQGLQIHFWLRQ

+HPDWRPD

:RXQGGLVUXSWLRQ

/RQJHUKRVSLWDOVWD\

+RVSLWDOUHDGPLVVLRQ

3UREOHPVZLWKSK\VLFDOUHFRYHU\

&KURQLFSHOYLFSDLQ

HYLGHQFHLVVXIILFLHQW/ HYLGHQFHLVOLPLWHG& HYLGHQFHFRQIOLFWVEXWVXJJHVWVDQDVVRFLDWLRQLVSRVVLEOH

40

Table 2 contd
1HRQDWDODGYHUVHRXWFRPHV
1HRQDWDOPRUWDOLW\

5HVSLUDWRU\GLVWUHVVV\QGURPH

3XOPRQDU\K\SHUWHQVLRQ

1RWEUHDVWIHHGLQJ

&

&KLOGKRRGFKURQLFGLVHDVH
$VWKPD

7\SHGLDEHWHV

$OOHUJLFUKLQLWLV

6\PSWRPDWLFIRRGDOOHUJ\

/&

&RPSOLFDWLRQVXQLTXHWRFHVDUHDQGHOLYHU\
2SHUDWLYHPDWHUQDOLQMXU\

6XUJLFDOFXWVWRWKHEDE\

5HRSHUDWLRQ

3HUVLVWHQWSDLQDWWKHFHVDUHDQLQFLVLRQVLWH

&HVDUHDQVFDUHQGRPHWULRPDV

&HVDUHDQVFDUHFWRSLFSUHJQDQF\HDUO\SODFHQWDDFFUHWD

'HQVHLQWUDDEGRPLQDODGKHVLRQV

&RPSOLFDWLRQVXQLTXHWRYDJLQDOELUWK
$QDOVSKLQFWHULQMXU\

3HULQHDORUJHQLWDOODFHUDWLRQVRIDQ\GHJUHH

3HUVLVWHQWSHULQHDOSDLQ

3V\FKRVRFLDORXWFRPHV
$GYHUVHHIIHFWRQPDWHUQDOFKLOGUHODWLRQVKLS

&

'HSUHVVLRQ

&

3RVWWUDXPDWLFGLVWUHVV

&

0DWHUQDODQGSODFHQWDOFRPSOLFDWLRQVLQIXWXUHSUHJQDQFLHV
5HGXFHGIHUWLOLW\

9ROXQWDU\LQIHUWLOLW\

3ODFHQWDSUHYLD

3ODFHQWDDFFUHWD

3ODFHQWDODEUXSWLRQ

+\VWHUHFWRP\

8WHULQHUXSWXUH

0DWHUQDOLQWHQVLYHFDUHXQLWDGPLVVLRQ

+RVSLWDOUHDGPLVVLRQ

HYLGHQFHLVVXIILFLHQW/ HYLGHQFHLVOLPLWHG& HYLGHQFHFRQIOLFWVEXWVXJJHVWVDQDVVRFLDWLRQLVSRVVLEOH

41

Table 2 contd
)HWDOQHRQDWDOFRPSOLFDWLRQVLQIXWXUHSUHJQDQFLHV
6WLOOELUWK

&

3HULQDWDORUQHRQDWDOGHDWK

&

3UHWHUPELUWKRUORZELUWKZHLJKW

&

6PDOOIRUJHVWDWLRQDODJHLQIDQW

&

1HHGIRUYHQWLODWLRQDWELUWK

,QIDQWKRVSLWDOVWD\!GD\V

6WLOOELUWK

&

3HULQDWDORUQHRQDWDOGHDWK

&

3UHWHUPELUWKRUORZELUWKZHLJKW

&

6PDOOIRUJHVWDWLRQDODJHLQIDQW

&

3HOYLFIORRURXWFRPHV
6H[XDOG\VIXQFWLRQ

$QDOLQFRQWLQHQFH

8ULQDU\LQFRQWLQHQFHXUJH

&

8ULQDU\LQFRQWLQHQFHVWUHVV

6\PSWRPDWLFSHOYLFIORRUSURODSVH

'HOLYHU\LQMXU\WREDE\

%UDFKLDOSOH[XVLQMXU\

)DFLDOQHUYHLQMXU\

1HRQDWDOQHXURORJLFV\PSWRPV

&HUHEUDOSDOV\

HYLGHQFHLVVXIILFLHQW/ HYLGHQFHLVOLPLWHG& HYLGHQFHFRQIOLFWVEXWVXJJHVWVDQDVVRFLDWLRQLVSRVVLEOH

7KHVHILQGLQJVFRQWUDVWZLWKWKRVHRIWKH1DWLRQDO,QVWLWXWHVRI+HDOWK6WDWHRIWKH6FL
HQFH&RQIHUHQFH&HVDUHDQ'HOLYHU\RQ0DWHUQDO5HTXHVWZKLFKFRQFOXGHG>2@XUFRPSUH
KHQVLYHDVVHVVPHQWDFURVVPDQ\GLIIHUHQWRXWFRPHVVXJJHVWVWKDWQRPDMRUGLIIHUHQFHVH[LVW
EHWZHHQSULPDU\>HOHFWLYHFHVDUHDQGHOLYHU\@DQGSODQQHGYDJLQDOELUWKEXWWKHHYLGHQFHLVWRR
ZHDNWRFRQFOXGHGHILQLWLYHO\WKDWGLIIHUHQFHVDUHFRPSOHWHO\DEVHQW SY 7KHPDMRUGLIIHU
HQFHLQILQGLQJVVWHPVIURPWKHQDUURZVFRSHRIWKH1,+UHYLHZOLPLWDWLRQVLQWKHUHVXOWLQJERG\
RIOLWHUDWXUHDQGLQFOXVLRQRIUHVXOWVIURPLQDSSURSULDWHVWXGLHVVXFKDVYDJLQDOEUHHFKWULDOGDWD
DQGVWXGLHVWKDWZHUHXQGHUSRZHUHGIRUPHDVXULQJOHVVFRPPRQRXWFRPHV$XWKRUVRIWKHFRP
PLVVLRQHGHYLGHQFHUHSRUWXQGHUSLQQLQJWKHFRQIHUHQFHVHDUFKHGIRUUHVHDUFKFRPSDULQJPD
WHUQDOUHTXHVWFHVDUHDQZLWKSODQQHGYDJLQDOELUWK6LQFHQRWULDOVPDNHWKLVFRPSDULVRQWKH\
XVHGDVPDOODVVRUWPHQWRISUR[\VWXGLHVWRLGHQWLI\EHQHILWVDQGKDUPV7KHFXUUHQWEURDGHUUH
YLHZFRQVLGHUVDPRUHFRPSUHKHQVLYHOLVWRIUHOHYDQWRXWFRPHVDQGHQFRPSDVVHVERWKSODQQHG
DQGXQSODQQHGFHVDUHDQV,QDGGLWLRQXQOLNHWKH1,+UHSRUWWKHFXUUHQWDQDO\VLVH[FOXGHVVWXG
LHVRISODQQHGYDJLQDOEUHHFKELUWK DSRWHQWFRQIRXQGHUDVGLVFXVVHGSUHYLRXVO\ DQGEHQHILWV
IURPDGGLWLRQDOVWXGLHVDQGV\VWHPDWLFUHYLHZVSXEOLVKHGVLQFHWKH1,+UHYLHZ
42

Strengths and Limitations


7KLVUHYLHZDGGUHVVHVWKHEURDGHVWVHWRIRXWFRPHVRIDQ\UHYLHZRIFHVDUHDQYHUVXVYDJLQDO
ELUWKRIZKLFKZHDUHDZDUH7KHSXUSRVHRIWKHUHYLHZZDVWRSURYLGHWKHEHVWDYDLODEOHHYL
GHQFHWRLQIRUPDOOVWDNHKROGHUVFRQFHUQHGZLWKGHFLVLRQVDERXWPRGHRIELUWKDQGJXLGHSROLF\
PDNHUVFRQFHUQHGZLWKPDWHUQLW\FDUHTXDOLW\DQGYDOXH7RLPSURYHUHOHYDQFHWRGHFLVLRQPDN
LQJWKHUHYLHZLVFRQILQHGWRRXWFRPHVKDYLQJDVLJQLILFDQWLPSDFWRQWKHZRPDQRUKHUFKLOG
UDWKHUWKDQVXUURJDWHRXWFRPHVRURWKHUSUR[\PHDVXUHV:KHUHLQIRUPDWLRQZDVDYDLODEOHIURP
WKHVRXUFHVWXGLHVRUV\VWHPDWLFUHYLHZVWKHUHYLHZSURYLGHVDEVROXWHGLIIHUHQFHVLQRXWFRPHV
UDWKHUWKDQRGGVUDWLRVRUUHODWLYHULVNZKLFKDYRLGVLQIODWLQJSHUFHLYHGGLIIHUHQFHV7RIDFLOLWDWH
XQGHUVWDQGLQJRIULVNVZHUHSRUWHGULVNGLIIHUHQFHVZLWKDVWDQGDUGGHQRPLQDWRURIDQG
JURXSHGGLIIHUHQFHVE\RUGHUVRIPDJQLWXGH
7KHOLPLWDWLRQVRIWKLVUHYLHZSULPDULO\RULJLQDWHLQZHDNQHVVHVLQWKHERG\RIUHOHYDQWUH
VHDUFK,QPDQ\DUHDVRIFRQFHUQWKHHYLGHQFHLVFRQIOLFWLQJLQDGHTXDWHRUQRQH[LVWHQW,Q
SDUWLFXODUPRUHUHVHDUFKLVQHHGHGLQWRUDUHEXWVHULRXVRXWFRPHV HJGHDWK ORQJWHUP
RXWFRPHVLQERWKZRPHQDQGFKLOGUHQVXEVHTXHQWUHSURGXFWLYHFRPSOLFDWLRQVDIWHUSULPDU\
FHVDUHDQTXDOLW\RIOLIHLQWKHSRVWSDUWXPSHULRGEUHDVWIHHGLQJRXWFRPHVDQGSV\FKRORJLFDO
PRUELGLW\7KHUHYLHZDGGUHVVHVWKHVHOLPLWDWLRQVE\DSSO\LQJDIOH[LEOHKLHUDUFK\RIHYLGHQFHWR
LGHQWLI\WKHEHVWDYDLODEOHHYLGHQFHIRUHDFKRXWFRPH
$QRWKHUZHDNQHVVLVWKDWWKHUHVHDUFKGRHVQRWSHUPLWDQDO\VLVRIKDUPVLQWULQVLFWRPRGHRI
ELUWKYHUVXVWKRVHWKDWDUHPRGLILDEOHE\LPSURYHPHQWVLQREVWHWULFDQGPLGZLIHU\SUDFWLFHDQG
LQIDFWPDQ\VWXGLHVLQFOXGHGLQWKLVUHYLHZZHUHFRQGXFWHGLQWKHFRQWH[WRIVXERSWLPDOODERU
PDQDJHPHQW6WURQJFRQVLVWHQWHYLGHQFHLGHQWLILHVVLJQLILFDQWRYHUXVHRIKDUPIXORULQHIIHF
WLYHSUDFWLFHVDQGXQGHUXVHRIRWKHUSUDFWLFHVVKRZQWRLPSURYHRXWFRPHV3RRUTXDOLW\FDUH
IRUSODQQHGYDJLQDOELUWKUHVXOWVLQH[FHVVQHRQDWDOLQMXU\JHQLWDOWUDFWWUDXPDDQGSHOYLFIORRU
G\VIXQFWLRQDQGOHDGVWRDKLJKHUSURSRUWLRQRIODERUVWKDWHQGLQFHVDUHDQGHOLYHU\WKXVH[
SRVLQJZRPHQDQGEDELHVWRVXUJLFDOULVNV6XERSWLPDOSUDFWLFHVZLWKFHVDUHDQGHOLYHU\ HJ
LQDGHTXDWHSURSK\OD[LVDJDLQVWLQIHFWLRQRUEORRGFORWV DIIHFWUDWHVRIFHUWDLQDGYHUVHRXWFRPHV
DVZHOOEXWWKHSUREOHPLVPRUHSURQRXQFHGDQGDIIHFWVIDUPRUHRXWFRPHVZLWKSODQQHGYDJL
QDOELUWK7KXVDYDLODEOHVWXGLHVPD\ILQGDEHQHILWIRUFHVDUHDQWKDWFRXOGOHVVHQRUGLVDSSHDU
ZLWKPRUHRSWLPDOYDJLQDOELUWKFDUHQRGLIIHUHQFHWKDWPD\IDYRUYDJLQDOELUWKZLWKPRUHRSWLPDO
FDUHRUDEHQHILWIRUYDJLQDOELUWKWKDWPD\LQFUHDVHZLWKPRUHRSWLPDOFDUH7RPLWLJDWHWKLVOLPL
WDWLRQDQGSURYLGHFRQWH[WIRUUHDGHUVWKLVUHYLHZLQFOXGHVVWXGLHVRIERWKSODQQHGDQGDFWXDO
YDJLQDOELUWKUHSRUWVLQWUDSDUWXPFHVDUHDQUDWHVIRUVWXGLHVRISODQQHGYDJLQDOELUWKDQGUHSRUWV
LQIRUPDWLRQDERXWODERUFDUHSUDFWLFHVLQWKHVWXG\VHWWLQJVZKHUHUHOHYDQWDQGDYDLODEOH
7KLVUHYLHZLVDOVROLPLWHGE\WKHVFRSHDQGUHVRXUFHVRIWKHUHYLHZSURFHVV%HFDXVHRIWKH
ODUJHVFRSHDQGQXPEHURISRWHQWLDOO\HOLJLEOHVWXGLHVZHOLPLWHGRXUUHYLHZWRV\VWHPDWLFUH
YLHZVZKHUHDYDLODEOH+RZHYHUDVWKHUHDUHQRUDQGRPL]HGFRQWUROOHGWULDOVRISODQQHGYDJLQDO
ELUWKYHUVXVSODQQHGSULPDU\FHVDUHDQGHOLYHU\ RWKHUWKDQZLWKEUHHFKSUHVHQWDWLRQ V\VWHPDWLF
UHYLHZVZHUHOLPLWHGWRREVHUYDWLRQDORUGHVFULSWLYHVWXGLHVZKLFKLQPRVWFDVHVGLGQRWSHUPLW
PHWDDQDO\VLV:HGLGQRWKDYHWKHUHVRXUFHVWRDVVHVVLQGHSHQGHQWO\WKHVWXGLHVLQFOXGHGLQ
V\VWHPDWLFUHYLHZVRUWRVHDUFKIRUVXEVHTXHQWO\SXEOLVKHGVWXGLHVWKDWPLJKWKDYHDXJPHQWHG
RUFRQIOLFWHGZLWKV\VWHPDWLFUHYLHZILQGLQJV$VLQJOHUHYLHZHU +* FRQGXFWHGVHDUFKHVDQG
SUHSDUHGWKHUHVHDUFKVXPPDULHV$GGLWLRQDOUHYLHZHUV $5DQG&6 DVVLVWHGZLWKLGHQWLI\LQJ
VWXGLHVIURP&KLOGELUWK&RQQHFWLRQVGDWDEDVHVDQGUHYLHZHGVRXUFHVWXGLHVDVQHHGHGWRKHOS
SUHSDUHDQGHGLWUHVHDUFKVXPPDULHV7KXVLWLVSRVVLEOHWKDWHOLJLEOHVWXGLHVZHUHQRWLGHQWLILHG
RUZHUHDQDO\]HGLQDGHTXDWHO\

43

Priorities for Future Research


$VQRWHGDERYHPRUHUHVHDUFKLVQHHGHGLQWRPDQ\RIWKHRXWFRPHVDGGUHVVHGLQWKLVUHSRUW$
PRUHUREXVWHYLGHQFHEDVHIRUWKHVHRXWFRPHVZLOOKHOSFODULI\DQGTXDQWLI\WKHDVVRFLDWLRQEH
WZHHQFHVDUHDQGHOLYHU\DQGLQGLYLGXDODGYHUVHRXWFRPHVDQGIDFLOLWDWHLQIRUPHGGHFLVLRQPDNLQJ
7KHUHLVDOVRDQXUJHQWQHHGIRUPRUHDQGEHWWHUUHVHDUFKRQVWUDWHJLHVIRUVDIHO\SUHYHQWLQJ
FHVDUHDQGHOLYHU\$UHFHQWV\VWHPDWLFUHYLHZLVVXHGE\WKH(IIHFWLYH+HDOWK&DUH3URJUDPDWWKH
$JHQF\IRU+HDOWKFDUH5HVHDUFKDQG4XDOLW\HYDOXDWHGVWUDWHJLHVWRUHGXFHWKHXVHRIFHVDUHDQLQ
ORZULVNZRPHQ7KHUHYLHZHUVHYDOXDWHGWKHTXDOLW\RILQGLYLGXDOVWXGLHVDQGWKHVWUHQJWKRIWKH
ERG\RIHYLGHQFHIRUHDFKVWUDWHJ\2IWKHVWXGLHVLQFOXGHGZHUHJRRGTXDOLW\IDLUDQG
SRRUDQGWKHVWUHQJWKRIWKHHYLGHQFHZDVORZRULQVXIILFLHQWIRUDOOVWUDWHJLHVH[DPLQHG2IQRWH
WKHUHYLHZZDVOLPLWHGWRUDQGRPL]HGFRQWUROOHGWULDOVDQGIRUKHDOWKV\VWHPVWUDWHJLHVSUHSRVW
VWXGLHVRIFKDQJHVLQSROLFLHVRUSURFHGXUHV:KLOHWKHUHYLHZLGHQWLILHGQRVLQJOHVWUDWHJ\WKDWZDV
XQLIRUPO\VXFFHVVIXOLQUHGXFLQJFHVDUHDQGHOLYHU\GRFXPHQWHGYDULDWLRQLQFHVDUHDQUDWHVDFURVV
SURYLGHUVVHWWLQJVDQGJHRJUDSKLFUHJLRQVVXJJHVWVWKDWFHUWDLQDSSURDFKHVWRRUJDQL]LQJDQG
GHOLYHULQJPDWHUQLW\FDUH\LHOGPRUHFRQVHUYDWLYHXVHRIFHVDUHDQGHOLYHU\WKDQRWKHUV)XWXUHUH
VHDUFKVKRXOGH[DPLQHWKHFKDUDFWHULVWLFVRIVHWWLQJVDQGSURYLGHUVZLWKORZFHVDUHDQGHOLYHU\UDWHV
DQGJRRGPDWHUQDODQGQHZERUQRXWFRPHVWRLGHQWLI\DSSURDFKHVWRFDUHWKDWPD\EHHIIHFWLYH
2QHDSSURDFKWRFDUHWKDWVKRXOGEHFORVHO\H[DPLQHGLVFDUHWKDWSURPRWHVVXSSRUWVDQG
SURWHFWVSK\VLRORJLFODERUDQGELUWK(OHPHQWVRISK\VLRORJLFFDUHLQFKLOGELUWKLQFOXGHDZDLWLQJ
VSRQWDQHRXVRQVHWRIODERUXQOHVVWKHUHLVDPHGLFDOLQGLFDWLRQWRGRRWKHUZLVHHQFRXUDJLQJIUHH
GRPRIPRYHPHQWWKURXJKRXWODERULQFOXGLQJWKHVHFRQGVWDJHSURYLGLQJFRQWLQXRXVHPRWLRQDO
VXSSRUWDQGFRPIRUWFDUHWRWKHODERULQJZRPDQRIIHULQJWKHIXOOUDQJHRIQRQSKDUPDFRORJLFSDLQ
UHOLHIDQGFRPIRUWVWUDWHJLHVLQDGGLWLRQWRSKDUPDFRORJLFRSWLRQVDYRLGLQJDUWLILFLDOPHDQVRIKDV
WHQLQJODERUVXFKDVDUWLILFLDOR[\WRFLQRUUXSWXUHRIWKHPHPEUDQHVXQOHVVPHGLFDOO\LQGLFDWHG
XVLQJLQWHUPLWWHQWUDWKHUWKDQFRQWLQXRXVPRQLWRULQJRIWKHIHWDOKHDUWUDWHLQORZULVNZRPHQ
VXSSRUWLQJVSRQWDQHRXVPDWHUQDOEHDULQJGRZQHIIRUWVUDWKHUWKDQXVLQJGLUHFWHGSXVKLQJDQG
DYRLGLQJHSLVLRWRP\:KLOHVRPHRIWKHVHDSSURDFKHVKDYHEHHQLQGLYLGXDOO\DVVHVVHGIRUWKHLU
LPSDFWRQPRGHRIELUWKQRVWXG\KDVORRNHGDWDSDFNDJHRISK\VLRORJLFFDUHDVDVWUDWHJ\WR
UHGXFHFHVDUHDQGHOLYHU\6WXGLHVRIPLGZLIHU\FDUHHVSHFLDOO\WKRVHFRQGXFWHGLQKRPHOLNH
DOWHUQDWLYHKRVSLWDOVHWWLQJVIUHHVWDQGLQJELUWKFHQWHUVDQGWKHKRPHHQYLURQPHQWGHPRQVWUDWH
YHU\ORZXWLOL]DWLRQRIFHVDUHDQGHOLYHU\ZLWKSK\VLRORJLFFDUHVXJJHVWLQJWKDWVXFKDSDFNDJH
RIFDUHLVDSURPLVLQJVWUDWHJ\IRUUHGXFLQJFHVDUHDQGHOLYHU\DQGPD\EHDVVRFLDWHGZLWKRWKHU
EHQHILWVLQFOXGLQJKLJKHUEUHDVWIHHGLQJUDWHVDQGOHVVJHQLWDOWUDFWWUDXPDLQYDJLQDOELUWKV
$QRWKHUSULRULW\DUHDIRUIXWXUHUHVHDUFKLVWKHH[DPLQDWLRQRISUDFWLFHVWKDWPD\PLWLJDWH
KDUPVRIFHVDUHDQ5HFHQWUHVHDUFKKDVHYDOXDWHGWKHLPSDFWRIYDULRXVVXUJLFDOWHFKQLTXHVRQ
KHDOLQJDQGDGKHVLRQIRUPDWLRQDQGWKHLPSDFWRISURSK\ODFWLFPHDVXUHVDJDLQVWZRXQGLQIHF
WLRQDQGWKURPERHPEROLVPEXWPRUHUHVHDUFKLVQHHGHG,QDGGLWLRQHYLGHQFHVKRZV
WKDWSHUIRUPLQJSODQQHGFHVDUHDQVDIWHUZHHNVFDQSUHYHQWLDWURJHQLFQHRQDWDOKDUPIURP
HDUO\HOHFWLYHGHOLYHULHVDQGUHGXFHXWLOL]DWLRQRIQHRQDWDOLQWHQVLYHFDUH2WKHUSURPLVLQJ
OLQHVRILQTXLU\EDVHGRQSLORWVWXGLHVLQFOXGHSUDFWLFHVWKDWUHGXFHPDWHUQDOLQIDQWVHSDUDWLRQ
DIWHUVXUJHU\LQFOXGLQJVNLQWRVNLQFRQWDFWLQWKHRSHUDWLQJURRPWRLPSURYHEUHDVWIHHGLQJ
PDWHUQDOLQIDQWDWWDFKPHQWDQGQHRQDWDOWKHUPRUHJXODWLRQDQGRWKHULQQRYDWLRQVWRPDNH
FHVDUHDQGHOLYHU\PRUHZRPDQDQGIDPLO\FHQWHUHG
(PHUJLQJHYLGHQFHWKDWFHVDUHDQGHOLYHU\LQFUHDVHVWKHULVNRIFKLOGKRRGFKURQLFGLVHDVHV
DQGREHVLW\FUHDWHVDQLPSHUDWLYHWRFODULI\WKHSDWKRSK\VLRORJLFDOPHFKDQLVP V UHVSRQVLEOHIRU
WKHDVVRFLDWLRQ5HVHDUFKHUVK\SRWKHVL]HWKDWDSULPDU\PHFKDQLVPLVWKHGLVUXSWLRQRIQHRQDWDO
JXWIORUDZKLFKKDYHDNH\UROHLQHVWDEOLVKLQJKHDOWK\LPPXQLW\PHWDEROLVPDQGGLJHVWLRQ5H
VHDUFKLVXUJHQWO\QHHGHGWRH[SORUHWKLVDQGRWKHUK\SRWKHVHVDQGVHHNVWUDWHJLHVWRUHGXFHWKH
ULVNRIFKURQLFGLVHDVHDULVLQJIURPDOWHUDWLRQVLQSK\VLRORJLFSURFHVVHVDURXQGWKHWLPHRIELUWK
44

$OVRHIIHFWVRIFHVDUHDQGHOLYHU\PD\GLIIHUE\WKHWLPLQJDQGSODQQLQJVWDWXVRIWKHSUR
FHGXUHDQGFRLQWHUYHQWLRQVVXFKDVODERULQGXFWLRQGXHWRSK\VLRORJLFSV\FKRORJLFRURWKHU
PHFKDQLVPV)XWXUHUHVHDUFKVKRXOGHQGHDYRUWRXQGHUVWDQGZKHWKHUVXFKGLIIHUHQFHVH[LVW
DQGLIVRLPSOLFDWLRQVIRUPDWHUQLW\FDUHSUDFWLFH6XFKUHVHDUFKPD\KHOSWRGLVHQWDQJOHERG
LHVRIOLWHUDWXUHZLWKFRQIOLFWLQJUHVXOWV

Implications for Policy and Practice


7KHILQGLQJVRIWKLVUHSRUWRYHUZKHOPLQJO\VXSSRUWVWULYLQJIRUYDJLQDOELUWKLQJHQHUDODQGVSRQWD
QHRXVYDJLQDOELUWKLQSDUWLFXODULQWKHDEVHQFHRIDFRPSHOOLQJUHDVRQWRGRRWKHUZLVH+RZHYHU
WKHFXUUHQWFHVDUHDQGHOLYHU\UDWHLQWKH8QLWHG6WDWHVLVDQGKDVULVHQPRVWGUDPDWLFDOO\
LQWKHSDVWGHFDGHDPRQJZRPHQOHDVWOLNHO\WREHQHILWIURPVXUJLFDOGHOLYHU\$OWKRXJKFRVW
DQGUHVRXUFHXWLOL]DWLRQZHUHRXWVLGHRIWKHVFRSHRIWKLVUHYLHZWKHFRVWRIDFHVDUHDQGHOLYHU\
H[FHHGVWKDWRIDYDJLQDOELUWKE\DERXW7RLPSURYHERWKWKHTXDOLW\DQGYDOXHRIPDWHUQLW\
FDUHLQWKH8QLWHG6WDWHVDQGSURPRWHWKHRSWLPDOKHDOWKRIZRPHQDQGLQIDQWVFOLQLFLDQVSROLF\
PDNHUVDQGRWKHUVWDNHKROGHUVVKRXOGSULRULWL]HLGHQWLI\LQJDQGSURPXOJDWLQJSUDFWLFHVWKDWSUR
PRWHVDIHVSRQWDQHRXVYDJLQDOELUWKDQGUHGXFHWKHXVHRIFHVDUHDQGHOLYHU\


0HDVXULQJSHUIRUPDQFHDQGOHYHUDJLQJUHVXOWVWRLPSURYHTXDOLW\LQFOXGLQJEURDGHUXVH
RIHQGRUVHGSHUIRUPDQFHPHDVXUHVIRUIDFLOLWLHVDQGSURYLGHUV HJQXOOLSDURXVWHUP
VLQJOHWRQYHUWH[FHVDUHDQDQGKHDOWK\WHUPQHZERUQ DQGHYDOXDWLRQDQGHQGRUVHPHQW
RIDGGLWLRQDOUHOHYDQWPHDVXUHVWRILOOPHDVXUHJDSV HJVSRQWDQHRXVODERUDQGELUWK
SDWLHQWUHSRUWHGRXWFRPHPHDVXUHVGHFLVLRQTXDOLW\PHDVXUHV 
'HYHORSLQJDQGHYDOXDWLQJLQQRYDWLYHPRGHOVRIVHUYLFHGHOLYHU\DQGSD\PHQWWKDWIRVWHU
DQGUHZDUGKLJKTXDOLW\KLJKYDOXHFDUH
,QFUHDVLQJDFFHVVWRPLGZLYHVDQGIDPLO\SK\VLFLDQVZKRFDQSURYLGHSULPDU\PDWHUQLW\
FDUHLQFROODERUDWLRQZLWKREVWHWULFLDQVDQGRWKHUPHPEHUVRIWKHPDWHUQLW\FDUHWHDP
'HYHORSLQJSURPRWLQJDQGHYDOXDWLQJWKHXVHRIVKDUHGGHFLVLRQPDNLQJWRROVWRKHOS
ZRPHQDQGKHDOWKSURIHVVLRQDOVPDNHLQIRUPHGGHFLVLRQVDERXWPRGHRIELUWK
(QJDJLQJPDWHUQDODQGSHULQDWDOTXDOLW\FDUHFROODERUDWLYHVLQTXDOLW\LPSURYHPHQWLQLWLD
WLYHVUHODWHGWRLQWUDSDUWXPFDUHDQGPRGHRIELUWK
,PSOHPHQWLQJHIIHFWLYHVWUDWHJLHVWRLPSURYHWKHOLDELOLW\HQYLURQPHQWLQPDWHUQLW\FDUH
6XSSRUWLQJKHDOWKSURIHVVLRQDOVWKURXJKHGXFDWLRQDOSURJUDPVLPSDUWLQJQHHGHGNQRZO
HGJHDQGVNLOOVIRUSK\VLRORJLFELUWKDQGUHYHUVLQJORVVRIVNLOOVIRUYDJLQDOEUHHFKELUWK
YDJLQDOWZLQELUWKDQGDVVLVWHGYDJLQDOGHOLYHU\
,QFUHDVLQJDFFHVVWRSODQQHGYDJLQDOELUWKDIWHUFHVDUHDQDQGHYDOXDWLQJVWUDWHJLHVWR
LPSURYLQJYDJLQDOELUWKUDWHVDQGPDWHUQDODQGIHWDOQHZERUQVDIHW\LQ9%$&ODERUV

45


2IIHULQJH[WHUQDOFHSKDOLFYHUVLRQIRUZRPHQZLWKEUHHFKRUWUDQVYHUVHIHWXVHVFORVH
WRWHUP
)ROORZLQJHYLGHQFHEDVHGSROLFLHVIRULQGXFWLRQRIODERULQFOXGLQJDYRLGLQJXVHIRULQGLFD
WLRQVWKDWDUHQRWVXSSRUWHGE\UHVHDUFK HJVXVSHFWHGIHWDOPDFURVRPLD 
:RUNLQJZLWKZRPHQWRDZDLWDFWLYHODERUEHIRUHKRVSLWDODGPLVVLRQIRUSODQQHGYDJLQDOELUWK
3URYLGLQJLQWUDSDUWXPFDUHWRDSSURSULDWHO\VHOHFWHGZRPHQLQORZWHFKQRORJ\VHWWLQJV
VXFKDVPLGZLIHOHGKRVSLWDOXQLWVIUHHVWDQGLQJELUWKFHQWHUVDQGKRPHV
3URYLGLQJFRQWLQXRXVODERUVXSSRUWRSWLPDOO\IURPDGRXOD
$YRLGLQJWLPHOLPLWVRQODERUSURJUHVVHVSHFLDOO\LQHDUO\ODERUDQGGXULQJLQGXFHGODERU
8VLQJLQWHUPLWWHQWDXVFXOWDWLRQRIWKHIHWDOKHDUWUDWHGXULQJODERULQORZULVNZRPHQ
$YRLGLQJSUDFWLFHVWKDWPLJKWSUHFLSLWDWHQRQUHDVVXULQJIHWDOKHDUWUDWHSDWWHUQVLQFOXGLQJPD
WHUQDOVXSLQHSRVLWLRQLQJURXWLQHDPQLRWRP\DQGURXWLQHDGPLQLVWUDWLRQRIDUWLILFLDOR[\WRFLQ
DQGLPSOHPHQWLQJLQWUDXWHULQHUHVXVFLWDWLRQPHDVXUHVZKHQVXFKKHDUWUDWHSDWWHUQVRFFXU
-XGLFLRXVO\XVLQJVNLOOIXOLQVWUXPHQWDOYDJLQDOGHOLYHU\IRUSURORQJHGRUFRPSOLFDWHGVHFRQG
VWDJHODERU
0DQXDOO\URWDWLQJXOWUDVRXQGFRQILUPHGRFFLSXWSRVWHULRURURFFLSXWWUDQVYHUVHIHWXVHV
2IIHULQJSODQQHGYDJLQDOELUWKDIWHURQHRUWZRSULRUORZWUDQVYHUVHFHVDUHDQVDQGXVLQJ
HYLGHQFHEDVHGGHFLVLRQVXSSRUWWRROVWRHQDEOHVKDUHGGHFLVLRQPDNLQJ

46

Recommended Additional Resources



7UDQVIRUPLQJ0DWHUQLW\&DUH:HE6LWH KWWSWUDQVIRUPFKLOGELUWKFRQQHFWLRQRUJ SUR
YLGHVDFFHVVWRGLUHFWLRQVHWWLQJUHSRUWV9LVLRQIRUD+LJK4XDOLW\+LJK9DOXH0DWHUQLW\
&DUH6\VWHPDQG%OXHSULQWIRU$FWLRQ6WHSV7RZDUGD+LJK4XDOLW\+LJK9DOXH0DWHUQLW\&DUH
6\VWHPDVZHOODVDUHJXODUO\XSGDWHGLQYHQWRU\RIPDWHUQLW\FDUHTXDOLW\LPSURYHPHQWWRROV
&RQVXPHUUHVRXUFHV KWWSZZZFKLOGELUWKFRQQHFWLRQRUJFHVDUHDQ LQFOXGHVFRQVXPHU
IULHQGO\VXPPDU\RIWKHVHUHSRUWILQGLQJVDQGRWKHUWLSVDQGWRROVLQFOXGLQJGRZQORDGDEOHERRN
OHW:KDW(YHU\3UHJQDQW:RPDQ1HHGVWR.QRZ$ERXW&HVDUHDQ6HFWLRQ


7KHIROORZLQJZLOOEHDYDLODEOHLQDWKWWSWUDQVIRUPFKLOGELUWKFRQQHFWLRQRUJUHSRUWV
7KH&RVWRI+DYLQJD%DE\LQWKH8QLWHG6WDWHV 'HFHPEHU
0DWHUQLW\&DUHDQG/LDELOLW\3UHVVLQJ3UREOHPV6XEVWDQWLYH6ROXWLRQV -DQXDU\
/LVWHQLQJWR0RWKHUV,,,3UHJQDQF\DQG&KLOGELUWK )HEUXDU\
/LVWHQLQJWR0RWKHUV,,,1HZ0RWKHUV6SHDN2XW 0D\
+RUPRQDO3K\VLRORJ\RI&KLOGEHDULQJ 


+DUWPDQQ.($QGUHZV-&-HURPH51/HZLV50/LNLV)(0F.R\-16XUDZLF]76:DONHU
6+6WUDWHJLHV7R5HGXFH&HVDUHDQ%LUWKLQ/RZ5LVN:RPHQ&RPSDUDWLYH(IIHFWLYHQHVV5H
YLHZ1R$+543XEOLFDWLRQ1R  (+&()5RFNYLOOH0'$JHQF\IRU+HDOWKFDUH
5HVHDUFKDQG4XDOLW\2FWREHU $YDLODEOHDWKWWSZZZHIIHFWLYHKHDOWKFDUHDKUTJRY
UHSRUWVILQDOFIP
1DWLRQDO3ULRULWLHV3DUWQHUVKLS,PSURYLQJ0DWHUQLW\&DUH:DVKLQJWRQ'&1DWLRQDO4XDOLW\
)RUXP $YDLODEOHDWKWWSZZZTXDOLW\IRUXPRUJ:RUN$UHDOLQNLWDVS["/LQN,GHQWLIL
HU LG ,WHP,' 
1DWLRQDO4XDOLW\)RUXP$FWLRQ5HJLVWU\ $YDLODEOHDWKWWSSXEOLFTXDOLW\IRUXPRUJDFWLRQ
UHJLVWU\6LWH3DJHV+RPHDVS[ 
0DLQ(.0RUWRQ&++RSNLQV'*LXOLDQL*0HOVRS.DQG*RXOG-%&HVDUHDQ'HOLYHULHV2XW
FRPHVDQG2SSRUWXQLWLHVIRU&KDQJHLQ&DOLIRUQLD7RZDUGD3XEOLF$JHQGDIRU0DWHUQLW\&DUH
6DIHW\DQG4XDOLW\3DOR$OWR&$&04&& $YDLODEOHDWKWWSZZZFPTFFRUJ
&KDLOOHW1'XPRQW$(YLGHQFHEDVHGVWUDWHJLHVIRUUHGXFLQJFHVDUHDQVHFWLRQUDWHVDPHWD
DQDO\VLV%LUWK  

47

References
1RWH$QDVWHULVN GHQRWHVVWXGLHVLQFOXGHGLQUHVHDUFKVXPPDULHV2WKHUVDUHFLWHGLQWKH
LQWURGXFWLRQEDFNJURXQGPHWKRGVFRQFOXVLRQDQGH[SODQDWRU\QRWHVZLWKLQWKHUHVXOWV

0DWHUQLW\&HQWHU$VVRFLDWLRQ:KDWHYHU\SUHJQDQWZRP
DQQHHGVWRNQRZDERXWFHVDUHDQVHFWLRQ1HZ<RUN0DWHU
QLW\&HQWHU$VVRFLDWLRQ-XO\
+DQQDK0(+DQQDK:-+HZVRQ6$+RGQHWW('6DLJDO
6:LOODQ$53ODQQHGFDHVDUHDQVHFWLRQYHUVXVSODQQHGYDJL
QDO ELUWK IRU EUHHFK SUHVHQWDWLRQ DW WHUP D UDQGRPLVHG PXO
WLFHQWUH WULDO 7HUP %UHHFK 7ULDO &ROODERUDWLYH *URXS /DQFHW

 *ULPHV '$ 6FKXO] .) 6XUURJDWH HQG SRLQWV LQ FOLQL
FDO UHVHDUFK KD]DUGRXV WR \RXU KHDOWK 2EVWHW *\QHFRO

 +DUSHU 0$ %\LQJWRQ 53 (VSHODQG 0$ 1DXJKWRQ 0
0H\HU 5 /DQH . 3UHJQDQF\UHODWHG GHDWK DQG KHDOWK FDUH
VHUYLFHV2EVWHW*\QHFRO
 'HQHX[7KDUDX[ & &DUPRQD ( %RXYLHU&ROOH 0+
%UHDUW*3RVWSDUWXPPDWHUQDOPRUWDOLW\DQGFHVDUHDQGHOLY
HU\2EVWHW*\QHFRO
&ODUN6/%HOIRUW0$'LOG\*$+HUEVW0$0H\HUV-$
+DQNLQV*'0DWHUQDOGHDWKLQWKHVWFHQWXU\FDXVHVSUH
YHQWLRQ DQG UHODWLRQVKLS WR FHVDUHDQ GHOLYHU\ $P - 2EVWHW
*\QHFROHGLVFXVVLRQH
 /LX 6 /LVWRQ 50 -RVHSK .6 +HDPDQ 0 6DXYH 5
.UDPHU060DWHUQDOPRUWDOLW\DQGVHYHUHPRUELGLW\DVVRFL
DWHGZLWKORZULVNSODQQHGFHVDUHDQGHOLYHU\YHUVXVSODQQHG
YDJLQDOGHOLYHU\DWWHUP&0$-
.DFPDU-%KLPDQL/%R\G06KDK+RVVHLQL53HLSHUW-
5RXWHRIGHOLYHU\DVDULVNIDFWRUIRUHPHUJHQWSHULSDUWXPK\VWHU
HFWRP\DFDVHFRQWUROVWXG\2EVWHW*\QHFRO
6WLYDQHOOR(.QLJKW0'DOOROLR/)UDPPDUWLQR%5L]]R1)DQ
WLQL033HULSDUWXPK\VWHUHFWRP\DQGFHVDUHDQGHOLYHU\DSRS
XODWLRQEDVHGVWXG\$FWD2EVWHW*\QHFRO6FDQG
 &ODUN 6/ 0H\HUV -$ )U\H '. 3HUOLQ -$ 3DWLHQW VDIHW\
LQREVWHWULFVWKH+RVSLWDO&RUSRUDWLRQRI$PHULFDH[SHULHQFH
$P-2EVWHW*\QHFRO
.RURXNLDQ605HODWLYHULVNRISRVWSDUWXPFRPSOLFDWLRQV
LQWKH2KLR0HGLFDLGSRSXODWLRQYDJLQDOYHUVXVFHVDUHDQGH
OLYHU\0HG&DUH5HV5HY
 7LWD $7 5RXVH '- %ODFNZHOO 6 6DDGH *5 6SRQJ &<
$QGUHZV :: (PHUJLQJ FRQFHSWV LQ DQWLELRWLF SURSK\OD[LV
IRU FHVDUHDQ GHOLYHU\ D V\VWHPDWLF UHYLHZ 2EVWHW *\QHFRO

&RVWDQWLQH005DKPDQ0*KXOPL\DK/HWDO7LPLQJRI
SHULRSHUDWLYH DQWLELRWLFV IRU FHVDUHDQ GHOLYHU\ D PHWDDQDO\
VLV$P-2EVWHW*\QHFROH
.QLJKW07XIIQHOO'%URFNOHKXUVW36SDUN3.XULQF]XN
--,QFLGHQFHDQGULVNIDFWRUVIRUDPQLRWLFIOXLGHPEROLVP2E
VWHW*\QHFRO
,VRQR:7VXWVXPL5:DGD+LUDLNH2HWDO8WHULQHDU
WHU\SVHXGRDQHXU\VPDIWHUFHVDUHDQVHFWLRQFDVHUHSRUWDQG
OLWHUDWXUHUHYLHZ-0LQLP,QYDVLYH*\QHFRO
$OEHUV//6HGOHU.'%HGULFN(-7HDI'3HUDOWD30LG
ZLIHU\FDUHPHDVXUHVLQWKHVHFRQGVWDJHRIODERUDQGUHGXF
WLRQRIJHQLWDOWUDFWWUDXPDDWELUWKDUDQGRPL]HGWULDO-0LG
ZLIHU\:RPHQV+HDOWK

0HQDFNHU)'HFOHUFT(0DFGRUPDQ0)&HVDUHDQGHOLY
HU\ EDFNJURXQG WUHQGV DQG HSLGHPLRORJ\ 6HPLQ 3HULQDWRO

%R\OH$5HGG\80(SLGHPLRORJ\RIFHVDUHDQGHOLYHU\WKH
VFRSHRIWKHSUREOHP6HPLQ3HULQDWRO
 %DUEHU (/ /XQGVEHUJ /6 %HODQJHU . 3HWWNHU &0 )XQDL
(),OOX]]L-/,QGLFDWLRQVFRQWULEXWLQJWRWKHLQFUHDVLQJFHVDU
HDQGHOLYHU\UDWH2EVWHW*\QHFRO
%DLFNHU.%XFNOHV.6&KDQGUD$*HRJUDSKLFYDULDWLRQLQ
WKHDSSURSULDWHXVHRIFHVDUHDQGHOLYHU\+HDOWK$II 0LOOZRRG 
Z
1DWLRQDO3ULRULWLHV3DUWQHUVKLS0DWHUQLW\$FWLRQ7HDP&RQ
YHQLQJ1333DUWQHUVDQGYDULHGRUJDQL]DWLRQVLQDVSHFLDOL]HG
HIIRUWWRGHYHORSDQGH[HFXWHVWUDWHJLHVWRUHGXFHHOHFWLYHGH
OLYHULHVDQGFVHFWLRQVLQORZULVNZRPHQ2FW $F
FHVVHG1RYDWKWWSQTIFRPPSDUWQHUVFRPVH
0HHWLQJV3OD\EDFNDVS["PHHWLQJLG 
:RUOG%DQNOLVWRIHFRQRPLHV:RUOG%DQN-XO\ $F
FHVVHG -XO   DW KWWSVLWHUHVRXUFHVZRUOGEDQN
RUJGDWDVWDWLVWLFVUHVRXUFHVFODVV[OV
3DOLQJ-6WUDWHJLHVWRKHOSSDWLHQWVXQGHUVWDQGULVNV%0-

:RUOG+HDOWK2UJDQL]DWLRQ0RQLWRULQJHPHUJHQF\REVWHWULF
FDUHDKDQGERRN)UDQFH:RUOG+HDOWK2UJDQL]DWLRQ
0DLQ(.0RRUH')DUUHOO%HWDO,VWKHUHDXVHIXOFHVDUHDQ
ELUWKPHDVXUH"$VVHVVPHQWRIWKHQXOOLSDURXVWHUPVLQJOHWRQ
YHUWH[ FHVDUHDQ ELUWK UDWH DV D WRRO IRU REVWHWULF TXDOLW\ LP
SURYHPHQW $P - 2EVWHW *\QHFRO  GLVFXV
VLRQ
-RKDQWJHQ0)RXQWDLQ/=DQJDUR*1HZKRXVH56WDQ
LN+XWW-:KLWH.&RPSDULVRQRIODERUDQGGHOLYHU\FDUHSUR
YLGHGE\FHUWLILHGQXUVHPLGZLYHVDQGSK\VLFLDQVDV\VWHPDWLF
UHYLHZWR:RPHQV+HDOWK,VVXHVH
/XWK\'$0DOPJUHQ-$=LQJKHLP5:/HLQLQJHU&-3K\
VLFLDQFRQWULEXWLRQWRDFHVDUHDQGHOLYHU\ULVNPRGHO$P-2E
VWHW*\QHFROGLVFXVVLRQ
0DUWLQ-$+DPLOWRQ%(9HQWXUD6-2VWHUPDQ0-.:LO
VRQ(&0DWKHZV7-%LUWKVILQDOGDWDIRU1DWO9LWDO6WDW
5HS
6RFRO0/7KHLQIOXHQFHRISUDFWLFHPDQDJHPHQWRQSUL
PDU\FHVDUHDQELUWK6HPLQ3HULQDWRO
 0DLQ ( 0RUWRQ & +RSNLQV ' *LXOLDQL * 0HOVRS .
*RXOG - &HVDUHDQ GHOLYHULHV RXWFRPHV DQG RSSRUWXQLWLHV
IRUFKDQJHLQ&DOLIRUQLD7RZDUGDSXEOLFDJHQGDIRUPDWHUQLW\
FDUHVDIHW\DQGTXDOLW\&DOLIRUQLD0DWHUQDO4XDOLW\&DUH&RO
ODERUDWLYH
.RUVW/0*UHJRU\.')ULGPDQ03KHODQ-31RQFOLQLFDO
IDFWRUVDIIHFWLQJZRPHQVDFFHVVWRWULDORIODERUDIWHUFHVDU
HDQGHOLYHU\&OLQ3HULQDWRO
 0DLQ (. 0RUWRQ &+ 0HOVRS . +RSNLQV ' *LXOLDQL *
*RXOG-%&UHDWLQJDSXEOLFDJHQGDIRUPDWHUQLW\VDIHW\DQG
TXDOLW\LQFHVDUHDQGHOLYHU\2EVWHW*\QHFRO
 4XHHQDQ -7 +RZ WR VWRS WKH UHOHQWOHVV ULVH LQ FHVDUHDQ
GHOLYHULHV2EVWHW*\QHFRO

48

 7KDYDJQDQDP 6 )OHPLQJ - %URPOH\ $ 6KLHOGV 0'


&DUGZHOO &5 $ PHWDDQDO\VLV RI WKH DVVRFLDWLRQ EHWZHHQ
&DHVDUHDQ VHFWLRQ DQG FKLOGKRRG DVWKPD &OLQ ([S $OOHUJ\

+XK6<5LIDV6KLPDQ6/=HUD&$HWDO'HOLYHU\E\FDH
VDUHDQVHFWLRQDQGULVNRIREHVLW\LQSUHVFKRRODJHFKLOGUHQD
SURVSHFWLYHFRKRUWVWXG\$UFK'LV&KLOG
 0DNRKD ): )HOLPEDQ +0 )DWKXGGLHQ 0$ 5RRPL )
*KDEUD70XOWLSOHFHVDUHDQVHFWLRQPRUELGLW\,QW-*\QDHFRO
2EVWHW
 1LVHQEODW 9 %DUDN 6 *ULQHVV 2% 'HJDQL 6 2KHO *
*RQHQ50DWHUQDOFRPSOLFDWLRQVDVVRFLDWHGZLWKPXOWLSOHFH
VDUHDQGHOLYHULHV2EVWHW*\QHFRO
6LOYHU50/DQGRQ0%5RXVH'-HWDO0DWHUQDOPRUELG
LW\DVVRFLDWHGZLWKPXOWLSOHUHSHDWFHVDUHDQGHOLYHULHV2EVWHW
*\QHFRO
$OH[DQGHU-0/HYHQR.-+DXWK-HWDO)HWDOLQMXU\DVVRFL
DWHGZLWKFHVDUHDQGHOLYHU\2EVWHW*\QHFRO
'HVVROH6&RVPL(%DODWD$HWDO$FFLGHQWDOIHWDOODFHU
DWLRQVGXULQJFHVDUHDQGHOLYHU\H[SHULHQFHLQDQ,WDOLDQOHYHO
,,,XQLYHUVLW\KRVSLWDO$P-2EVWHW*\QHFRO
+DDV'0$\UHV$:/DFHUDWLRQLQMXU\DWFHVDUHDQVHF
WLRQ-0DWHUQ)HWDO1HRQDWDO0HG
/XULH66DGDQ2*RODQ$5HODSDURWRP\DIWHUFHVDUHDQ
VHFWLRQ(XU-2EVWHW*\QHFRO5HSURG%LRO
+RUWRQ-''H]HH.-$KQIHOGW(3:DJQHU0$EGRPLQDO
ZDOOHQGRPHWULRVLVDVXUJHRQVSHUVSHFWLYHDQGUHYLHZRI
FDVHV$P-6XUJ
 7LPRU7ULWVFK ,( 0RQWHDJXGR $ 8QIRUHVHHQ FRQVH
TXHQFHV RI WKH LQFUHDVLQJ UDWH RI FHVDUHDQ GHOLYHULHV HDUO\
SODFHQWDDFFUHWDDQGFHVDUHDQVFDUSUHJQDQF\$UHYLHZ$P
-2EVWHW*\QHFRO
 /\HOO '- &DXJKH\ $% +X ( 'DQLHOV . 3HULWRQHDO FOR
VXUHDWSULPDU\FHVDUHDQGHOLYHU\DQGDGKHVLRQV2EVWHW*\
QHFRO
 :KHHOHU 7/ QG 5LFKWHU +( 'HOLYHU\ PHWKRG DQDO
VSKLQFWHUWHDUVDQGIHFDOLQFRQWLQHQFHQHZLQIRUPDWLRQRQD
SHUVLVWHQWSUREOHP&XUU2SLQ2EVWHW*\QHFRO
0DFDUWKXU$-0DFDUWKXU&,QFLGHQFHVHYHULW\DQGGHWHU
PLQDQWVRISHULQHDOSDLQDIWHUYDJLQDOGHOLYHU\DSURVSHFWLYH
FRKRUWVWXG\$P-2EVWHW*\QHFRO
*RHU+5RPDQR$2SWLPDO&DUHLQ&KLOGELUWK7KH&DVHIRU
D3K\VLRORJLF$SSURDFK6HDWWOH&ODVVLF'D\3XEOLVKLQJ
$QGHUVHQ/%0HOYDHU/%9LGHEHFK3/DPRQW5)-RHU
JHQVHQ -6 5LVN IDFWRUV IRU GHYHORSLQJ SRVWWUDXPDWLFVWUHVV
GLVRUGHUIROORZLQJFKLOGELUWK$V\VWHPDWLFUHYLHZ$FWD2EVWHW
*\QHFRO6FDQG
/REHO0'H/XFD563V\FKRVRFLDOVHTXHODHRIFHVDUHDQ
GHOLYHU\UHYLHZDQGDQDO\VLVRIWKHLUFDXVHVDQGLPSOLFDWLRQV
6RF6FL0HG
 &DUWHU )$ )UDPSWRQ &0 0XOGHU 57 &HVDUHDQ VHFWLRQ
DQGSRVWSDUWXPGHSUHVVLRQDUHYLHZRIWKHHYLGHQFHH[DPLQ
LQJWKHOLQN3V\FKRVRP0HG
 2OGH ( YDQ GHU +DUW 2 .OHEHU 5 YDQ 6RQ 0 3RVWWUDX
PDWLF VWUHVV IROORZLQJ FKLOGELUWK D UHYLHZ &OLQ 3V\FKRO 5HY

0DUWLQH]*'DQLHOV.&KDQGUD$)HUWLOLW\RIPHQDQGZRP
HQ DJHG  \HDUV LQ WKH 8QLWHG 6WDWHV 1DWLRQDO 6XUYH\ RI
)DPLO\*URZWK1DWO+HDOWK6WDW5HSRUW
 *XLVH -0 (GHQ . (PHLV & HW DO 9DJLQDO ELUWK DIWHU
FHVDUHDQ QHZ LQVLJKWV (YLG 5HS 7HFKQRO $VVHVV )XOO5HS 

%DKO56WUDFKDQ%0XUSK\'-2XWFRPHRIVXEVHTXHQW
SUHJQDQF\WKUHH\HDUVDIWHUSUHYLRXVRSHUDWLYHGHOLYHU\LQWKH
VHFRQGVWDJHRIODERXUFRKRUWVWXG\%0-

 %RGQHU . :LHUUDQL ) *UXQEHUJHU : %RGQHU$GOHU %


,QIOXHQFH RI WKH PRGH RI GHOLYHU\ RQ PDWHUQDO DQG QHRQDWDO
RXWFRPHV D FRPSDULVRQ EHWZHHQ HOHFWLYH FHVDUHDQ VHFWLRQ
DQGSODQQHGYDJLQDOGHOLYHU\LQDORZULVNREVWHWULFSRSXODWLRQ
$UFK*\QHFRO2EVWHW
/HWK5$0ROOHU-.7KRPVHQ5:8OGEMHUJ11RUJDDUG
05LVNRIVHOHFWHGSRVWSDUWXPLQIHFWLRQVDIWHUFHVDUHDQVHF
WLRQ FRPSDUHG ZLWK YDJLQDO ELUWK D ILYH\HDU FRKRUW VWXG\ RI
ZRPHQ$FWD2EVWHW*\QHFRO6FDQG
6DQFKH]5DPRV/:HOOV7/$GDLU&'$UFHOLQ*.DXQLW]
$0:HOOV'65RXWHRIEUHHFKGHOLYHU\DQGPDWHUQDODQGQHR
QDWDORXWFRPHV,QW-*\QDHFRO2EVWHW
*HOOHU(-:X-0-DQQHOOL0/1JX\HQ799LVFR$*0DWHU
QDORXWFRPHVDVVRFLDWHGZLWKSODQQHGYDJLQDOYHUVXVSODQQHG
SULPDU\FHVDUHDQGHOLYHU\$P-3HULQDWRO
/\GRQ5RFKHOOH0+ROW9/0DUWLQ'3(DVWHUOLQJ75$V
VRFLDWLRQEHWZHHQPHWKRGRIGHOLYHU\DQGPDWHUQDOUHKRVSLWDO
L]DWLRQ-$0$
'HFOHUFT(%DUJHU0&DEUDO+-HWDO0DWHUQDORXWFRPHV
DVVRFLDWHG ZLWK SODQQHG SULPDU\ FHVDUHDQ ELUWKV FRPSDUHG
ZLWKSODQQHGYDJLQDOELUWKV2EVWHW*\QHFRO
7KRPSVRQ-)5REHUWV&/&XUULH0(OOZRRG'$3UHYD
OHQFHDQGSHUVLVWHQFHRIKHDOWKSUREOHPVDIWHUFKLOGELUWKDV
VRFLDWLRQVZLWKSDULW\DQGPHWKRGRIELUWK%LUWK
/\GRQ5RFKHOOH07+ROW9/0DUWLQ'3'HOLYHU\PHWKRG
DQGVHOIUHSRUWHGSRVWSDUWXPJHQHUDOKHDOWKVWDWXVDPRQJSUL
PLSDURXVZRPHQ3DHGLDWU3HULQDW(SLGHPLRO
:RROKRXVH+3HUOHQ6*DUODQG6-%URZQ6-3K\VLFDO
KHDOWK DQG UHFRYHU\ LQ WKH ILUVW  PRQWKV SRVWSDUWXP GRHV
FHVDUHDQVHFWLRQUHGXFHORQJWHUPPRUELGLW\"%LUWK
 'HFOHUFT ( &XQQLQJKDP '. -RKQVRQ & 6DNDOD &
0RWKHUV UHSRUWV RI SRVWSDUWXP SDLQ DVVRFLDWHG ZLWK YDJLQDO
DQG FHVDUHDQ GHOLYHULHV UHVXOWV RI D QDWLRQDO VXUYH\ %LUWK

/DWWKH30LJQLQL/*UD\5+LOOV5.KDQ.)DFWRUVSUH
GLVSRVLQJ ZRPHQ WR FKURQLF SHOYLF SDLQ V\VWHPDWLF UHYLHZ
%0-
 0DF'RUPDQ 0) 'HFOHUFT ( 0HQDFNHU ) 0DOOR\ 0+
1HRQDWDOPRUWDOLW\IRUSULPDU\FHVDUHDQDQGYDJLQDOELUWKVWR
ORZULVN ZRPHQ DSSOLFDWLRQ RI DQ LQWHQWLRQWRWUHDW PRGHO
%LUWK
+DQVHQ$.:LVERUJ.8OGEMHUJ1+HQULNVHQ7%(OHFWLYH
FDHVDUHDQVHFWLRQDQGUHVSLUDWRU\PRUELGLW\LQWKHWHUPDQGQHDU
WHUPQHRQDWH$FWD2EVWHW*\QHFRO6FDQG
3ULRU(6DQWKDNXPDUDQ6*DOH&3KLOLSSV/+0RGL1
+\GH0-%UHDVWIHHGLQJDIWHUFHVDUHDQGHOLYHU\DV\VWHPDWLF
UHYLHZ DQG PHWDDQDO\VLV RI ZRUOG OLWHUDWXUH $P - &OLQ 1XWU

%DJHU3:RKOIDKUW-:HVWHUJDDUG7&DHVDUHDQGHOLYHU\
DQGULVNRIDWRS\DQGDOOHUJLFGLVHDVHPHWDDQDO\VHV&OLQ([S
$OOHUJ\
&DUGZHOO&56WHQH/&-RQHU*HWDO&DHVDUHDQVHFWLRQ
LV DVVRFLDWHG ZLWK DQ LQFUHDVHG ULVN RI FKLOGKRRGRQVHW W\SH
GLDEHWHVPHOOLWXVDPHWDDQDO\VLVRIREVHUYDWLRQDOVWXGLHV
'LDEHWRORJLD
'HFNHU((QJHOPDQQ*)LQGHLVHQ$HWDO&HVDUHDQGH
OLYHU\ LV DVVRFLDWHG ZLWK FHOLDF GLVHDVH EXW QRW LQIODPPDWRU\
ERZHOGLVHDVHLQFKLOGUHQ3HGLDWULFVH
-RIIH7+6LPSVRQ1$&HVDUHDQVHFWLRQDQGULVNRIDVWK
PD7KHUROHRILQWUDSDUWXPDQWLELRWLFVDPLVVLQJSLHFH"-3H
GLDWU
.RSOLQ-$OOHQ.*XUULQ/2VERUQH17DQJ0/'KDU
PDJH 6 ,V FDHVDUHDQ GHOLYHU\ DVVRFLDWHG ZLWK VHQVLWL]DWLRQ
WRIRRGDOOHUJHQVDQG,J(PHGLDWHGIRRGDOOHUJ\DV\VWHPDWLF
UHYLHZ3HGLDWU$OOHUJ\,PPXQRO

49

 6PLWK *& 3HOO -3 'REELH 5 &DHVDUHDQ VHFWLRQ DQG
ULVNRIXQH[SODLQHGVWLOOELUWKLQVXEVHTXHQWSUHJQDQF\/DQFHW

.HQQDUH57XFNHU*+HDUG$&KDQ$5LVNVRIDGYHUVH
RXWFRPHVLQWKHQH[WELUWKDIWHUDILUVWFHVDUHDQGHOLYHU\2E
VWHW*\QHFRO
7D\ORU/.6LPSVRQ-05REHUWV&/2OLYH(&+HQGHU
VRQ6PDUW '- 5LVN RI FRPSOLFDWLRQV LQ D VHFRQG SUHJQDQF\
IROORZLQJFDHVDUHDQVHFWLRQLQWKHILUVWSUHJQDQF\DSRSXOD
WLRQEDVHGVWXG\0HG-$XVW
*UD\54XLJOH\0+RFNOH\&.XULQF]XN-*ROGDFUH0
%URFNOHKXUVW3&DHVDUHDQGHOLYHU\DQGULVNRIVWLOOELUWKLQVXE
VHTXHQWSUHJQDQF\DUHWURVSHFWLYHFRKRUWVWXG\LQDQ(QJOLVK
SRSXODWLRQ%-2*
 5LFKWHU 5 %HUJPDQQ 5/ 'XGHQKDXVHQ -: 3UHYLRXV
FDHVDUHDQRUYDJLQDOGHOLYHU\:KLFKPRGHLVDJUHDWHUULVNRI
SHULQDWDOGHDWKDWWKHVHFRQGGHOLYHU\"(XU-2EVWHW*\QHFRO
5HSURG%LRO
 :RRG 6/ &KHQ 6 5RVV 6 6DXYH 5 7KH ULVN RI XQ
H[SODLQHG DQWHSDUWXP VWLOOELUWK LQ VHFRQG SUHJQDQFLHV IRO
ORZLQJ FDHVDUHDQ VHFWLRQ LQ WKH ILUVW SUHJQDQF\ %-2*

%DKWL\DU02-XOLHQ65RELQVRQ-1HWDO3ULRUFHVDU
HDQGHOLYHU\LVQRWDVVRFLDWHGZLWKDQLQFUHDVHGULVNRIVWLOOELUWK
LQDVXEVHTXHQWSUHJQDQF\$QDO\VLVRI86SHULQDWDOPRUWDO
LW\GDWD$P-2EVWHW*\QHFRO
6DOLKX+06KDUPD33.ULVWHQVHQ6HWDO5LVNRIVWLOO
ELUWKIROORZLQJDFHVDUHDQGHOLYHU\EODFNZKLWHGLVSDULW\2E
VWHW*\QHFRO
 2VERUQH & (FNHU -/ *DXYUHDX . /LHEHUPDQ()LUVW
ELUWKFHVDUHDQDQGULVNRIDQWHSDUWXPIHWDOGHDWKLQDVXEVH
TXHQWSUHJQDQF\-0LGZLIHU\:RPHQV+HDOWK
5HGG\80/DXJKRQ6.6XQ/7URHQGOH-:LOOLQJHU0
=KDQJ-3UHSUHJQDQF\ULVNIDFWRUVIRUDQWHSDUWXPVWLOOELUWKLQ
WKH8QLWHG6WDWHV2EVWHW*\QHFRO
&DUOVVRQ:DOOLQ0(NVWURP30DUVDO..DOOHQ.$SJDU
VFRUHDQGSHULQDWDOGHDWKDIWHURQHSUHYLRXVFDHVDUHDQGHOLY
HU\%-2*
+HPPLQNL(6KHOOH\-*LVVOHU00RGHRIGHOLYHU\DQG
SUREOHPV LQ VXEVHTXHQW ELUWKV D UHJLVWHUEDVHG VWXG\ IURP
)LQODQG$P-2EVWHW*\QHFRO
 6HUDWL 0 6DOYDWRUH 6 6LHVWR * HW DO )HPDOH VH[XDO
IXQFWLRQ GXULQJ SUHJQDQF\ DQG DIWHU FKLOGELUWK - 6H[ 0HG

 'XPRXOLQ & +D\6PLWK - 3HOYLF IORRU PXVFOH WUDLQLQJ
YHUVXV QR WUHDWPHQW RU LQDFWLYH FRQWURO WUHDWPHQWV IRU XUL
QDU\ LQFRQWLQHQFH LQ ZRPHQ &RFKUDQH 'DWDEDVH 6\VW 5HY
&'
:LQJ55:HVW'6*UDG\'HWDO(IIHFWRIZHLJKWORVV
RQXULQDU\LQFRQWLQHQFHLQRYHUZHLJKWDQGREHVHZRPHQUH
VXOWVDWDQGPRQWKV-8URO
1HOVRQ5/)XUQHU6(:HVWHUFDPS0)DUTXKDU&&H
VDUHDQ GHOLYHU\ IRU WKH SUHYHQWLRQ RI DQDO LQFRQWLQHQFH &R
FKUDQH'DWDEDVH6\VW5HY&'
0DFDUWKXU&*OD]HQHU&/DQFDVKLUH5+HUELVRQ3:LO
VRQ'([FOXVLYHFDHVDUHDQVHFWLRQGHOLYHU\DQGVXEVHTXHQW
XULQDU\DQGIDHFDOLQFRQWLQHQFHD\HDUORQJLWXGLQDOVWXG\
%-2*
 3UHVV -= .OHLQ 0& .DF]RURZVNL - /LVWRQ 50 YRQ
'DGHOV]HQ 3 'RHV FHVDUHDQ VHFWLRQ UHGXFH SRVWSDUWXP
XULQDU\ LQFRQWLQHQFH" $ V\VWHPDWLF UHYLHZ %LUWK 

 /DUVVRQ & .DOOHQ . $QGROI ( &HVDUHDQ VHFWLRQ DQG
ULVNRISHOYLFRUJDQSURODSVHDQHVWHGFDVHFRQWUROVWXG\$P
-2EVWHW*\QHFROH

 %KDWWDFKDU\D 6 3RUWHU 0 +DUULOG . HW DO $EVHQFH RI
FRQFHSWLRQDIWHUFDHVDUHDQVHFWLRQYROXQWDU\RULQYROXQWDU\"
%-2*
 7ROODQHV 0& 0HOYH .. ,UJHQV /0 6NMDHUYHQ 5 5H
GXFHGIHUWLOLW\DIWHUFHVDUHDQGHOLYHU\DPDWHUQDOFKRLFH2E
VWHW*\QHFRO
3DULHQWH*:L]QLW]HU$6HUJLHQNR50D]RU0+ROFEHUJ
*6KHLQHU(3ODFHQWDODEUXSWLRQFULWLFDODQDO\VLVRIULVNIDF
WRUV DQG SHULQDWDO RXWFRPHV - 0DWHUQ )HWDO 1HRQDWDO 0HG

7LNNDQHQ03ODFHQWDODEUXSWLRQHSLGHPLRORJ\ULVNIDFWRUV
DQGFRQVHTXHQFHV$FWD2EVWHW*\QHFRO6FDQG
 *UREPDQ :$ *HUVQRYLH] 5 /DQGRQ 0% HW DO 3UHJ
QDQF\ RXWFRPHV IRU ZRPHQ ZLWK SODFHQWD SUHYLD LQ UHODWLRQ
WR WKH QXPEHU RI SULRU FHVDUHDQ GHOLYHULHV 2EVWHW *\QHFRO

.QLJKW0.XULQF]XN--6SDUN3%URFNOHKXUVW3&HVDU
HDQ GHOLYHU\ DQG SHULSDUWXP K\VWHUHFWRP\ 2EVWHW *\QHFRO

 )ORRG .0 6DLG 6 *HDU\ 0 5REVRQ 0 )LW]SDWULFN &
0DORQH)'&KDQJLQJWUHQGVLQSHULSDUWXPK\VWHUHFWRP\RYHU
WKHODVWGHFDGHV$P-2EVWHW*\QHFROH
*XURO8UJDQFL,&URPZHOO'$(GR]LHQ/&HWDO5LVNRI
SODFHQWDSUHYLDLQVHFRQGELUWKDIWHUILUVWELUWKFHVDUHDQVHF
WLRQDSRSXODWLRQEDVHGVWXG\DQGPHWDDQDO\VLV%0&3UHJ
QDQF\&KLOGELUWK
 'DOWYHLW $. 7ROODQHV 0& 3LKOVWURP + ,UJHQV /0 &H
VDUHDQGHOLYHU\DQGVXEVHTXHQWSUHJQDQFLHV2EVWHW*\QHFRO

 <DQJ 4 :HQ 6: 2SSHQKHLPHU / HW DO $VVRFLDWLRQ
RI FDHVDUHDQ GHOLYHU\ IRU ILUVW ELUWK ZLWK SODFHQWD SUDH
YLD DQG SODFHQWDO DEUXSWLRQ LQ VHFRQG SUHJQDQF\ %-2*

 /\GRQ5RFKHOOH 0 +ROW 9/ (DVWHUOLQJ 75 0DUWLQ '3
)LUVWELUWKFHVDUHDQDQGSODFHQWDODEUXSWLRQRUSUHYLDDWVHF
RQGELUWK2EVWHW*\QHFRO
 6WDQFR /0 6FKULPPHU '% 3DXO 5+ 0LVKHOO '5 -U
(PHUJHQF\SHULSDUWXPK\VWHUHFWRP\DQGDVVRFLDWHGULVNIDF
WRUV$P-2EVWHW*\QHFRO
:KLWHPDQ0..XNOLQD(+LOOLV6'HWDO,QFLGHQFHDQG
GHWHUPLQDQWV RI SHULSDUWXP K\VWHUHFWRP\ 2EVWHW *\QHFRO

 %DNVKL 6 0H\HU %$ ,QGLFDWLRQV IRU DQG RXWFRPHV RI
HPHUJHQF\SHULSDUWXPK\VWHUHFWRP\$ILYH\HDUUHYLHZ-5H
SURG0HG
)RUQD)0LOHV$0-DPLHVRQ'-(PHUJHQF\SHULSDUWXP
K\VWHUHFWRP\DFRPSDULVRQRIFHVDUHDQDQGSRVWSDUWXPK\V
WHUHFWRP\$P-2EVWHW*\QHFRO
6HOR2MHPH'2%KDWWDFKDUMHH3,]XZD1MRNX1).DGLU
5$(PHUJHQF\SHULSDUWXPK\VWHUHFWRP\LQDWHUWLDU\/RQGRQ
KRVSLWDO$UFK*\QHFRO2EVWHW
5RQHO':L]QLW]HU$6HUJLHQNR5=ORWQLN$6KHLQHU(
7UHQGV ULVN IDFWRUV DQG SUHJQDQF\ RXWFRPH LQ ZRPHQ ZLWK
XWHULQHUXSWXUH$UFK*\QHFRO2EVWHW
 *DO\HDQ $0 /DJUHZ '& %XVK 0& .XUW]PDQ -7 3UH
YLRXV FHVDUHDQ VHFWLRQ DQG WKH ULVN RI SRVWSDUWXP PDWHUQDO
FRPSOLFDWLRQVDQGDGYHUVHQHRQDWDORXWFRPHVLQIXWXUHSUHJ
QDQFLHV-3HULQDWRO
 6SRQJ &< /DQGRQ 0% *LOEHUW 6 HW DO 5LVN RI XWHULQH
UXSWXUHDQGDGYHUVHSHULQDWDORXWFRPHDWWHUPDIWHUFHVDUHDQ
GHOLYHU\2EVWHW*\QHFRO
+XDQJ;/HL-7DQ+:DONHU0=KRX-:HQ6:&H
VDUHDQGHOLYHU\IRUILUVWSUHJQDQF\DQGQHRQDWDOPRUELGLW\DQG
PRUWDOLW\LQVHFRQGSUHJQDQF\(XU-2EVWHW*\QHFRO5HSURG
%LRO

50

(QFDUQDFLRQ%=ODWQLN0*&HVDUHDQGHOLYHU\WHFKQLTXH
HYLGHQFHRUWUDGLWLRQ"$UHYLHZRIWKHHYLGHQFHEDVHGFHVDU
HDQGHOLYHU\2EVWHW*\QHFRO6XUY
1LU91DGLU()HOGPDQ0/DWHEHWWHUWKDQHDUO\HOHFWLYH
WHUP&HVDUHDQVHFWLRQ$FWD3DHGLDWU
 +XQJ .- %HUJ 2 (DUO\ VNLQWRVNLQ DIWHU FHVDUHDQ
WR LPSURYH EUHDVWIHHGLQJ 0&1 $P - 0DWHUQ &KLOG 1XUV
TXL]
 6PLWK - 3ODDW ) )LVN 10 7KH QDWXUDO FDHVDUHDQ D
ZRPDQFHQWUHG WHFKQLTXH %-2*  GLVFXV
VLRQ
+\GH0-0RVW\Q$0RGL1.HPS357KHKHDOWKLPSOL
FDWLRQVRIELUWKE\&DHVDUHDQVHFWLRQ%LRO5HY&DPE3KLORV
6RF
7UXYHQ+HDOWK$QDO\WLFV7KHFRVWRIKDYLQJDEDE\LQWKH
8QLWHG6WDWHV&KLOGELUWK&RQQHFWLRQ'HF""
 6DNDOD & <DQJ < 7 &RUU\ 0 3 0DWHUQLW\ FDUH DQG OL
DELOLW\ PRVW SURPLVLQJ VWUDWHJLHV IRU LPSURYHPHQW :RPHQV
+HDOWK,VVXHVLQSUHVV
 +RIPH\U *- .XOLHU 5 ([WHUQDO FHSKDOLF YHUVLRQ IRU
EUHHFK SUHVHQWDWLRQ DW WHUP &RFKUDQH 'DWDEDVH 6\VW 5HY
&'
0R]XUNHZLFK(&KLOLPLJUDV-.RHSNH(.HHWRQ..LQJ
9-,QGLFDWLRQVIRULQGXFWLRQRIODERXUDEHVWHYLGHQFHUHYLHZ
%-2*
 -DFNVRQ '- /DQJ -0 (FNHU - 6ZDUW] :+ +HHUHQ 7
,PSDFW RI FROODERUDWLYH PDQDJHPHQW DQG HDUO\ DGPLVVLRQ LQ
ODERURQPHWKRGRIGHOLYHU\-2EVWHW*\QHFRO1HRQDWDO1XUV
GLVFXVVLRQ
+RGQHWW('*DWHV6+RIPH\U*-6DNDOD&&RQWLQXRXV
VXSSRUWIRUZRPHQGXULQJFKLOGELUWK&RFKUDQH'DWDEDVH6\VW
5HY&'
1HDO-//RZH1.3DWULFN7(&DEEDJH/$&RUZLQ(-
:KDW LV WKH VORZHVW\HWQRUPDO FHUYLFDO GLODWLRQ UDWH DPRQJ
QXOOLSDURXV ZRPHQ ZLWK VSRQWDQHRXV ODERU RQVHW" - 2EVWHW
*\QHFRO1HRQDWDO1XUV
 =KDQJ - 7URHQGOH - 5HGG\ 80 HW DO &RQWHPSRUDU\
FHVDUHDQGHOLYHU\SUDFWLFHLQWKH8QLWHG6WDWHV$P-2EVWHW
*\QHFROHH
'HYDQH'/DORU-*'DO\60F*XLUH:6PLWK9&DU
GLRWRFRJUDSK\YHUVXVLQWHUPLWWHQWDXVFXOWDWLRQRIIHWDOKHDUWRQ
DGPLVVLRQ WR ODERXU ZDUG IRU DVVHVVPHQW RI IHWDO ZHOOEHLQJ
&RFKUDQH'DWDEDVH6\VW5HY&'
*DULWH7-6LPSVRQ.5,QWUDXWHULQHUHVXVFLWDWLRQGXULQJ
ODERU&OLQ2EVWHW*\QHFRO
6SRQJ&<%HUJKHOOD9:HQVWURP.'0HUFHU%06DDGH
*5 3UHYHQWLQJ WKH )LUVW &HVDUHDQ 'HOLYHU\ 6XPPDU\ RI D
-RLQW(XQLFH.HQQHG\6KULYHU1DWLRQDO,QVWLWXWHRI&KLOG+HDOWK
DQG +XPDQ 'HYHORSPHQW 6RFLHW\ IRU 0DWHUQDO)HWDO 0HGL
FLQH DQG $PHULFDQ &ROOHJH RI 2EVWHWULFLDQV DQG *\QHFROR
JLVWV:RUNVKRS2EVWHW*\QHFRO
6KDIIHU%/&KHQJ<:9DUJDV-(&DXJKH\$%0DQXDO
URWDWLRQ WR UHGXFH FDHVDUHDQ GHOLYHU\ LQ SHUVLVWHQW RFFLSXW
SRVWHULRURUWUDQVYHUVHSRVLWLRQ-0DWHUQ)HWDO1HRQDWDO0HG


 5RUWYHLW * %URZQ -6 7KRP '+ 9DQ 'HQ (HGHQ 6.
&UHDVPDQ-06XEDN//6\PSWRPDWLFSHOYLFRUJDQSURODSVH
SUHYDOHQFHDQGULVNIDFWRUVLQDSRSXODWLRQEDVHGUDFLDOO\GL
YHUVHFRKRUW2EVWHW*\QHFRO
/HLMRQKXIYXG$/XQGKROP&&QDWWLQJLXV6*UDQDWK)
$QGROI($OWPDQ'5LVNVRIVWUHVVXULQDU\LQFRQWLQHQFHDQG
SHOYLFRUJDQSURODSVHVXUJHU\LQUHODWLRQWRPRGHRIFKLOGELUWK
$P-2EVWHW*\QHFROH
+DQGD9/%ORPTXLVW-/.QRHSS/5+RVNH\.$0F'HU
PRWW.&0XQR]$3HOYLFIORRUGLVRUGHUV\HDUVDIWHUYDJL
QDORUFHVDUHDQFKLOGELUWK2EVWHW*\QHFRO
$QLP6RPXDK06P\WK5+RZHOO&$QLP6RPXDK0
(SLGXUDO YHUVXV QRQHSLGXUDO RU QR DQDOJHVLD LQ ODERXU &R
FKUDQH'DWDEDVH6\VW5HY&'
$OILUHYLF='HYDQH'*\WH*0&RQWLQXRXVFDUGLRWRFRJ
UDSK\ &7* DVDIRUPRIHOHFWURQLFIHWDOPRQLWRULQJ ()0 IRU
IHWDODVVHVVPHQWGXULQJODERXU&RFKUDQH'DWDEDVH6\VW5HY
&'
 &ODUN 6/ 9LQHV 9/ %HOIRUW 0$ )HWDO LQMXU\ DVVRFLDWHG
ZLWKURXWLQHYDFXXPXVHGXULQJFHVDUHDQGHOLYHU\$P-2E
VWHW*\QHFROH
 /DJHUNYLVW $/ -RKDQVVRQ 8 -RKDQVVRQ $ %DJHU %
8YHEUDQW 3 2EVWHWULF EUDFKLDO SOH[XV SDOV\ D SURVSHFWLYH
SRSXODWLRQEDVHG VWXG\ RI LQFLGHQFH UHFRYHU\ DQG UHVLG
XDO LPSDLUPHQW DW  PRQWKV RI DJH 'HY 0HG &KLOG 1HXURO

0RF]\JHPED&.3DUDPVRWK\30HLNOH6HWDO5RXWH
RI GHOLYHU\ DQG QHRQDWDO ELUWK WUDXPD $P - 2EVWHW *\QHFRO
H
.RODV76DXJVWDG2''DOWYHLW$.1LOVHQ672LDQ3
3ODQQHG FHVDUHDQ YHUVXV SODQQHG YDJLQDO GHOLYHU\ DW WHUP
&RPSDULVRQRIQHZERUQLQIDQWRXWFRPHV$P-2EVWHW*\QH
FRO
6FKHOOHU-01HOVRQ.%'RHVFHVDUHDQGHOLYHU\SUHYHQW
FHUHEUDOSDOV\RURWKHUQHXURORJLFSUREOHPVRIFKLOGKRRG"2E
VWHW*\QHFRO
9LVZDQDWKDQ09LVFR$*+DUWPDQQ.HWDO&HVDUHDQ
'HOLYHU\ RQ 0DWHUQDO 5HTXHVW (YLGHQFH 5HSRUW7HFKQRORJ\
$VVHVVPHQW 1R  5RFNYLOOH 0' $JHQF\ IRU +HDOWKFDUH
5HVHDUFK DQG 4XDOLW\  5HSRUW 1R $+54 3XEOLFDWLRQ
1R(
 6DNDOD & &RUU\ 03 (YLGHQFH%DVHG 0DWHUQLW\ &DUH
:KDW,W,VDQG:KDW,W&DQ$FKLHYH1HZ<RUN0LOEDQN0HPR
ULDO)XQG
+DUWPDQQ.($QGUHZV-&-HURPH51HWDO6WUDWHJLHV7R
5HGXFH&HVDUHDQ%LUWKLQ/RZ5LVN:RPHQ&RPSDUDWLYH(IIHF
WLYHQHVV5HYLHZ1R 3UHSDUHGE\WKH9DQGHUELOW(YLGHQFH
EDVHG 3UDFWLFH &HQWHU XQGHU &RQWUDFW 1R , 
$+543XEOLFDWLRQ1R  (+&()5RFNYLOOH0'
 $PHULFDQ &ROOHJH RI 1XUVH0LGZLYHV 0LGZLYHV $OOLDQFH
1RUWK $PHULFD 1DWLRQDO $VVRFLDWLRQ RI &HUWLILHG 3URIHVVLRQDO
0LGZLYHV6XSSRUWLQJKHDOWK\DQGQRUPDOSK\VLRORJLFFKLOGELUWK
DFRQVHQVXVVWDWHPHQWE\$&100$1$DQG1$&30
 +RGQHWW (' 'RZQH 6 :DOVK ' :HVWRQ - $OWHUQDWLYH
YHUVXV FRQYHQWLRQDO LQVWLWXWLRQDO VHWWLQJV IRU ELUWK &RFKUDQH
'DWDEDVH6\VW5HY&'
 :DOVK ' 'RZQH 60 2XWFRPHV RI IUHHVWDQGLQJ PLG
ZLIHOHGELUWKFHQWHUVDVWUXFWXUHGUHYLHZ%LUWK
 %LUWKSODFH LQ (QJODQG &ROODERUDWLYH *URXS 3HULQDWDO
DQGPDWHUQDORXWFRPHVE\SODQQHGSODFHRIELUWKIRUKHDOWK\
ZRPHQ ZLWK ORZ ULVN SUHJQDQFLHV WKH %LUWKSODFH LQ (QJODQG
QDWLRQDOSURVSHFWLYHFRKRUWVWXG\%0-G
6KL=0D/<DQJ<HWDO$GKHVLRQIRUPDWLRQDIWHUSUH
YLRXV FDHVDUHDQ VHFWLRQD PHWDDQDO\VLV DQG V\VWHPDWLF UH
YLHZ%-2*

51

Childbirth Connection
260 Madison Avenue, 8th Floor
New York, NY 10016 USA
T 1 212 - 777 - 5000, F 1 212 - 777 - 9320
info@childbirthconnection.org
www.childbirthconnection.org

You might also like