Vaginal or Cesarean Birth:
What Is at Stake for Women and Babies?
A Best Evidence Review
Contributors
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Table of Contents
Executive Summary 4
Introduction and Background 12
Methods 13
Results 15
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Discussion 40
References 48
3
Executive Summary
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References
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Introduction and Background
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2. What physical effects occur in babies
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3. What role may cesarean delivery play in the
development of childhood chronic disease?
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5. What complications are unique to vaginal birth?
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6. What are potential psychosocial
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7. What are potential effects of cesareans on
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