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Sir,

We discussed with great interest this study published in BJOG at our journal club attended by various medical professionals, including consultants, registrars, senior house officers and medical students. We acknowledge the effort taken in the design, analysis of the data and presentation of this ‘first of its kind’ prospective cohort study in the UK on multiple repeat caesarean sections (MRCS).[1]

We compared the findings of this article with similar studies. Interestingly, a study by Rashid and Rashid,[2] published in BJOG, involving nearly 600 women, concluded that higher order (five to nine) repeat caesarean sections carry no specific additional risk for the mother or the baby when compared with lower order (three or four) repeat caesarean sections. Nevertheless, the results of increased maternal and fetal morbidity for MRCS were confirmed by several other studies, although they compared less frequent caesarean sections (more than three).

On critical appraisal of the study, there were very interesting results which might alert clinicians with regard to the potential risks of MRCS; however, we noted that the study did not illustrate why, specifically, the fourth repeated caesarean section or beyond was used as a cut-off point for increased maternal and fetal morbidity.

The majority of the comparison group (72%) were having their second caesarean section and, in theory, would have relatively lower surgical morbidity, thus making the comparison with previous ‘four and beyond’ caesarean sections biased. We noted that another potential bias could result from the fact that the comparison groups were not matched or adjusted for many factors, e.g. age, smoking, current as well as previous surgical obstetric and nonobstetric complications.

In our opinion, the skills and experience of the surgeons performing MRCS – whether registrars or consultants – were not uniform, meaning that the increased intraoperative surgical morbidity in general and the hysterectomy rate (50%) in the placenta praevia and accreta subgroups might also be biased.

We were hoping that the study could shed light on why MRCS is associated with more emergency caesarean sections and premature births, resulting in a potential increase in maternal and fetal morbidity.

Finally, we thank you for your interesting study and we are looking forward to your response so that we can discuss it at our next journal club.

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