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Author's Reply re: Maternal outcomes at 3 months after planned caesarean section versus planned vaginal birth for twin pregnancies in the Twin Birth Study: a randomised controlled trial

Sir, We would like to thank Professor Salvesen for his commentary in response to our recent article and we concur that counselling pregnant women about mode of delivery can be challenging. However, we would like the opportunity to clarify the issue regarding the validity of the intent-to-treat analysis. The intent-to-treat analysis is the only analysis that provides unbiased estimates of the relative risk and benefits when counselling women with twins who are faced with the choice between planned caesarean section (PCS) and planned vaginal birth (PVB). The fact that the benefits and risks depend on actual mode of delivery, while obviously true, is not relevant to the choice between PVB and PCS. What can make counselling difficult are the comparisons of actual mode of delivery. These conditional comparisons cannot inform the choice, and that is what makes the counselling difficult. So, as they are not relevant and create difficulties, why bring them up in the counselling discussion? Analyses based on actual mode of delivery can only inform women about risks and benefits post-delivery and although this may be informative after delivery, they are not relevant regarding the choice between PCS and PVB, a priori.& Reference