Cesarean Cachet or Status Symbol for Brazil Women?

An NPR report this past week, C-Sections Deliver Cachet For Wealthy Brazilian Women, by Lourdes Garcia-Navarro, is available to listen to here, and a few days later, this report by Nicole Stevens was published: Elective Cesarean Sections Seen as a Status Symbol [in Brazil]. I posted the following comment on the NPR news article:

I'd firstly like to agree with the OBGYN below, that it is very important that women are advised of planned cesarean risks, and in particular, the risks of repeat surgeries. This is precisely why CDMR (cesarean on maternal request) is only advised for women planning small families. Additionally, CDMR is recommended at 39+ gestational weeks. However, the fertility rate in Brazil (as in many countries) is now less than 2, so it understandable that many obstetricians there may not be as concerned about repeat surgeries.

I'd also like to note that if comparisons are being made about birth outcomes - specifically the health and well being of mothers and babies - it is important to compare the right data. For example, perinatal mortality is more relevant than infant mortality in the context of birth. Also, Brazil's overall country rates of mortality and morbidity will be affected by different levels of maternity care and different socio-economic access to health care throughout the country (the same is true in the U.S., where wealth and poverty can often have the greatest impact on health outcomes rather than chosen birth plan). The Netherlands for example, has a very low cesarean rate but also one of the highest perinatal mortality rates in Europe. Meanwhile Greece has a comparatively high cesarean rate but ranks among the very lowest for stillbirth and maternal mortality.

While I absolutely agree that women should not be pressured or forced to 'choose' a cesarean, the exact same should hold true for women being forced to have a trial of labor - when their birth plan preference is a cesarean. The pendulum swings both ways, and I find it very disappointing that whenever countries with high cesarean rates are discussed, the knee jerk reaction is that 'these women can't be choosing CS; it must be their lazy or greedy doctors recommending it' - or worse, insulting comments along the lines of, 'well these poor disillusioned women can only be making this choice because they're not properly educated about birth'. Yet countries with low cesarean rates are automatically placed on a pedestal as how birth 'should be'.

Personally, I planned and chose a cesarean for both of my births, and don't have a single regret about that choice. However, I don't criticize other women who make a different birth plan choice than my own, and I have no ideological bias towards increasing CS rates - but the same cannot always be said about advocates of birth with as little intervention as possible. I suggest we listen to all women - properly - and not always assume that we know what's best for everyone. Many, many women happily choose a cesarean birth, and it's about time people everywhere got used to the idea and stop trying to vilify this legitimate choice.

Finally, reproductive choice has evolved on so many levels in recent decades, and yet whereas no one would ever dream of asking me what birth control I'm using or if/when I started using it or whether my baby's conception was planned/unplanned, natural or assisted (and socially, people don't seem to mind what the answers to these questions are anyway), when it comes to my birth plan, reactions to my cesarean choice have ranged from shock and disbelief to outright anger and disgust. But as the woman in the NPR interview says, "In the end, it's my choice", and I couldn't agree more.

Two things strike me about this umbilical cord cesarean story

On Sunday, the following story appeared in the Daily Mail: The baby who cheated death by 30 minutes: Doctors spot umbilical cord strangling foetus during routine scan and carry out emergency caesarian at 32 weeks, and two things jumped out at me.

Reporter Lucy Laing refers to the 32-week scan mother Melissa Tooke was given during her pregnancy as "a routine scan", but in fact there was nothing routine about it; Melissa had been diagnosed with pre-eclampsia and was having extra scans as a result.

The charity Pyramid of Antenatal Change (POAC) has been campaigning for some time now for pregnant women to be advised about the risks of nuchal complications and offered late term scans as standard maternity care.

Ironically, this little baby was very lucky that her mother was ill during pregnancy; had her mother been healthy, then it is highly likely that the outcome would have been very, very different.

Date of birth

Completely separate to the issue of maternity care, the second thing that struck me is that this little girl, Imogen, is a summer born baby, born prematurely and weighing just 2lb 8oz.

As some readers already know, I am now also campaigning on another website, summerbornchildren.org, for summer born children to be able to start school - in Reception Class - at compulsory school age (age 5) if this is what their parents choose.

The charity BLISS is also campaigning for this to happen for children born prematurely, and we can only hope that by the time Imogen reaches school age, her parents will be granted this legitimate choice by their school and/or local authority.

Intervention in childbirth: What’s wrong with letting women choose?

On Tuesday 11th June, Bournemouth University is hosting a DEBATE with free entry, which promises to be interesting.

Intervention in childbirth: What’s wrong with letting women choose? is scheduled to take place between 10am and 12.30pm, and the organisers have told me that a summary will be published afterwards.

 

Details are as follows:
 

The publication of the National Institute of Health & Clinical Effectiveness guidelines on caesarean section (Nov 2011) sparked a media frenzy with newspapers reporting that women could now choose ‘caesarean section on demand’. While opportunity for greater choice is welcomed by some consumer groups, others have expressed concern about the rising rate of intervention in childbirth. This session will debate the pros and cons of allowing women free choice with regard to major medical interventions, such as caesarean section. Attendees will have the opportunity to vote for or against the motion.

 

Convened by Vanora Hundley and Edwin van Teijlingen

Hospitals 'are ignoring advice on caesarean sections'

This was the headline in last week's Guardian article in which the Royal College of Obstetricians and Gynaecologists (RCOG) and the NCT criticised hospitals for not following NICE guidance on elective cesareans.

Absolutely! I agreed with them.

Just this past week I have been trying to help the latest of many women who have contacted me over the years to say their maternal request cesarean is being blatantly refused.

Not based on an individual risk and benefit, not having followed the appropriate recommendations contained in the November 2011 NICE guidance, but simply because of arbitrary or ideological reasons to reduce cesarean rates and increase 'normal' births.

Unfortunately, neither RCOG nor the NCT referred to this ongoing issue, and while the article focus on the risks of early elective cesarean delivery is a very important one, the Guardian reports that "the overall proportion of elective C-sections performed before 39 completed weeks has fallen from 61% in 2000-01 [to] 30.3% (20,674 babies) in 2011-12."

It is recommended that elective cesareans are performed at 39+ weeks in order to reduce the risks of neonatal respiratory morbidity, but evidently, there will always be cases where a doctor feels it would be safer, on the balance of individual risks and benefits, to bring that date forward.

These early elective deliveries are certainly worth our attention, but so too are the women who request a cesarean and denied support for no good reason; it would be wonderful to see the headline above in the context of tokophobic women's mental health and general birth plan autonomy.

Maybe one day soon...
 

 

New ACOG Committee Opinion on Maternal Request

ACOG has just published a new Committee Opinion on Cesarean Delivery on Maternal Request (Number 559, April 2013), and says, "In the absence of maternal or fetal indications for cesarean delivery, a plan for vaginal delivery is safe and appropriate and should be recommended."

 

However, the accompanying press release says ACOG "recommends that pregnant women plan for vaginal birth unless there is a medical reason for a cesarean."

It's subtle, but look again and you'll see that the two statements do differ.

The first one informs us that vaginal delivery is the birth mode that should be recommended when there are no indications, but the second one - especially taken out of context - could be interpreted by some that ACOG is recommending against CDMR, which is not the case.

This is potentially further exacerbated by the PR statement, "Cesareans involve risks and require longer hospital stays than uncomplicated vaginal births."

Of course they do - no one is disputing this fact - but the Committee was supposed to be comparing planned birth modes, which makes the statement irrelevant in this context.

The PR presentation of any recommendation is crucial, given that the majority of media reports will never refer to the original full text, and as such, I hope that ACOG's PR here is not misinterpreted.

Controversy and Politics

We discussed the role of controversy and birth politics in obstetrics in our book, and how these can adversely affect discussions on CDMR.

The words of two Australian doctors in 2003, for example: "What a disaster it would be if it was found elective cesarean was safer than vaginal birth." (Robson and Ellwood, 2003)

For years and years, the CDMR debate has been desperate for research, called for again by ACOG here today:

"This includes surveys on cesarean delivery on maternal request, modification of birth certificates and coding to facilitate tracking, prospective cohort studies, database studies, and studies of modifiable risk factors for cesarean delivery on maternal request versus planned vaginal delivery. Short-term and long-term maternal and neonatal outcomes as well as cost need further study."

I wholeheartedly agree with this, but when will it happen?

Important to note

The Committee Opinion refers to birth plans "in the absence of maternal or fetal indication", and we know that individual women and indivudual health professionals can have very different opinions on what constitutes these indications. For example, a previous stillbirth at 40.5 weeks' gestation, a family history of long labor with emergency surgery or suspected macrosomia (large baby).

There are also prophylactic considerations around the mother and baby's wellbeing that are not adequately addressed in ACOG's new Committee Opinion -- the publication only cites 11 references, four of which date from the 1990s, the rest ranging between 2002 and 2007.

It's literally incredible for the Committee to conclude that the maternal risks fistula, anorectal function or pelvic organ prolapse "seemed to favor neither delivery route".

In due course, and when time permits, I plan to publish a list of studies that do not appear to have been considered by the Committee -- some of which appeared in our book, and some which have been published in the last 12-18 months.

Remember - when there are no direct comparisons between CDMR/PCD and PVD, then the way researchers select and interpret available research can lead to some very diverging opinions.

ACOG's new recommendations for CDMR

First, ACOG does not state that CDMR should not be allowed in the absence of maternal or fetal indication.

Second, ACOG does not state that CDMR in the absence of maternal or fetal indication is unethical.

In fact, ACOG provides recommendations for CDMR when it is planned:

*Cesarean delivery on maternal request should not be performed before a gestational age of 39 weeks.

*Cesarean delivery on maternal request should not be motivated by the unavailability of effective pain management.

*Cesarean delivery on maternal request particularly is not recommended for women desiring several children, given that the risks of placenta previa, placenta accreta, and gravid hysterectomy increase with each cesarean delivery.

Cesarean rates UP since the 70s and 80s... AND...?

Countless articles, news reports and media interviews begin with an introduction along these lines... "Back in the 1980, the CS rate was just X but today it's risen to Y. Evidently, this is bad."

But surely the CS rate is not all that readers and listeners need or want to know? For example, why not inform them that over the same period, rates of infant deaths have decreased significantly.

The neonatal mortality rate fell by 62%, from 7.7 deaths per 1,000 live births in 1980 to 2.9 in 2010, and the perinatal mortality rate (which includes stillbirths)* fell by 44% from 13.3 deaths per 1,000 total births in 1980 to 7.4 in 2010.

*in October 1992, the legal definition of a stillbirth was changed to include deaths after 24 completed weeks of gestation or more, instead of after 28 completed weeks of gestation or more. Therefore improvements in perinatal mortality outcomes may be even greater than that shown above.

Other birth outcomes

Pregnant women may also like to know that in the last year alone, rates of complications such as perineal laceration (39.9%), long labour (10.3%) obstructed labour, fetal distress and umbilical cord-related complications (30.5%), episiotomies (15.2%) and instrumental vaginal deliveries (13%) have all increased.

All of these outcomes can be directly associated with serious infant and maternal morbidity, so to assume that the caesarean rate - high or low - can somehow be the most important indicator of marternity health outcomes over a given period, is a very limited view in my opinion.

Antibiotic risk for all births, but especially planned CS

On Monday, the Chief Medical Officer in England, Professor Dame Sally Davies, warned that unless we "tackle the catastrophic threat of antimicrobial resistance", we could see more people dying following even minor surgery.

The Department for Health press release reports that an infectious disease has been discovered nearly every year over the past 30 years, very few new antibiotics have been developed, leading to concerns that as diseases evolve, they can become resistant to existing drugs.

Dr. Magnus and I wrote about this issue in our chapter on 'Planned Cesarean Risks', since without effective antibiotics (remember that today, most women are given prophylactic antibiotics just before their planned cesarean in order to reduce the risk of infection), the risks of surgery are increased.

Therefore it is very good news to learn that the government is setting out a five-year UK Antimicrobial Resistance Strategy and Action Plan (read more here) and is calling on the WHO and others to act now in tackling this potential threat.

It's also worth highlighting of course, as we wrote in our book, that whatever happens, the risk surrounding the future of antibiotics is not exclusive to women planning cesarean surgery because prophylactic antibiotics are common in vaginal births too (for example, where Strep B is present), and of course where a vaginal birth plan has an emergency cesarean outcome.

Are women who choose a cesarean LAZY?

Yesterday, Australian radio presenter Jason Morrison hosted a discussion on whether women who choose a cesarean are 'too posh to push'.

His co-host, pregnant and planning a natural birth in a few weeks' time, agrees with some of her friends - that women who choose a cesarean are 'lazy'.

But what I find most interesting about the discussion is this: Jason is very understanding and balanced on the subject - largely because his own wife had a cesarean birth.

I've always said that what will help discussions on this issue is when the journalists and presenters talking or writing about cesareans have some personal experience of women who choose cesareans - and know that their reasons for doing have nothing to do with being posh.

Now this clip is only a few minutes long, but try and imagine how very different it might have sounded had the presenter's wife given birth naurally, and had the same feelings about cesarean birth as his co-host...

Two letters to BMJ editor published today

In response to the publication of a new research paper on the Maternal and fetal risk factors for stillbirth, I wrote two Rapid Responses, and they were published today.

In the first, I ask the researchers whether there is any other data available (in addition to that published) on the gestational ages of the stillbirths that were analyzed in their study, as this information is very useful for women deciding on delivery mode:

Gestational ages at which stillbirths occur and maternal or fetal risk factors observed at term

And in the second, I talk about the caesareans, stillbirth and maternal mortality in Greece and the Netherlands, and question whether the push for 'normal' birth and minimal intervention is the best approach in maternity care:

Reducing mortality is not as simple as low cesarean rate good, high cesarean rate bad

Photo: wales.nhs.uk

This is  a very quick post to reassure readers who may have read the story making worldwide headlines yesterday: Caesarean deliveries and formula feeding linked to lifelong diseases: research

Incredibly, and despite the fact that it only involved 24 infants, 6 of whom were delivered by cesarean (and we don't know what type of cesarean), one Canadian paper (The Edmonton Sun) even went as far as to call it "the first large study of its kind in North America."

Thankfully, the NHS choices website has produced an excellent 'Behind the headlines' appraisal of the study: Caesarean birth link to asthma lacks proof.

It concludes, "The study does not provide any evidence that the mode of delivery or feeding pattern was the cause of the bacterial levels measured. Neither does the study provide any evidence that being born by caesarean delivery leads to developing asthma later on in life."

Busy blogger

I'm conscious that I haven't blogged for more than a month now, and I have a number of saved drafts that have accumulated here in recent weeks, but I'd like to assure readers that this is only because I have been inundated with birth research and other deadlines throughout January.

As just one example, NICE is currently writing Quality Standards on numerous areas of healthcare, and my organisation recently submitted feedback on the 'Caesarean' Quality Standard draft and there are two others ongoing this month. Each one requires vast amounts of reading and research, and together with other ongoing projects, my blog often ends up taking a temporary back seat.

Apologies for this, but rest assured that I am working hard to ensure that there is greater balance in both the delivery of maternity care, and the information that is provided to pregnant women.

Petition for Ultrasound Scan in Third Trimester

I'd like to highlight the work being done by Rachel Buckley (@rachelbuckley88), who (along with others, including Robbie Devine at POAC) is trying to raise awareness about the benefits of a late term scan in terms of assessing potential problems for your baby or for you.

 

I've just signed her petition below, and if you'd like to do the same, please click here.

 

"In the NHS, pregnant women will be scanned at 12 and 20 weeks gestation. ( First and second trimester). A simple ultrasound scan in a woman's third trimester could save their babies life. This scan should be done as a precaution to check the baby's amniotic fluid is not falling low. The scan can check the baby's growth and can check what position the baby is in! My baby's life could have been saved if I had had an ultrasound scan late on into my third trimester. Women need to be monitored more closely near the end of their pregnancies as this is where things can go wrong and stillbirth could be the devastating result."

Does the NCT tell women the truth about birth?

This is the question posed by New Scientist journalist Linda Geddes, author of the new book, Bumpology, in her new blog, and below is my response: 

The impression I have of the NCT recently is that it has had to respond to the huge amount of criticism it's received (whether at the end of news articles, on sites such as Mumsnet or elsewhere), and ensure that its public message is one of support and choice for ALL women -- and not concentrated on the importance of natural or 'normal' birth (or breastfeeding for that matter) for as many women as possible. But while I welcome this change in attitude, my concern lies in how genuine the organisation's assurances really are.  Here's why:

1) In 2010, in the midst of lengthy and ongoing correspondence between myself and the NCT, I was requesting its help to support my campaign for support for women who request a cesarean, and I supplied some of the same evidence I submitted to the NICE caesarean guideline development group.
I was told in no uncertain terms that I would not be receiving its support. Instead, the NCT maintained that maternal request (MR) would likely increase rates of maternal and infant mortality and morbidity, and compared it to someone demanding a hip replacement with no medical need.
Of course in the following year, NICE published its updated CS guidance recommending that a MR should be supported within the NHS -- a recommendation that could never have been made had there been insufficient evidence to support its comparable safety and cost (with a planned vaginal delivery). To my knowledge, there was no public outcry from the NCT that NICE had made a dangerous or unethical mistake and on the contrary, it seemed to support the guidance.

2) In August 2012, there were was an outcry following the publication of a collaborative document from RCOG, the RCM and the NCT, which contained guidance on the importance of increasing 'normal birth' birth, even if it leads to more ventouse or forceps deliveries (i.e. no epidurals, no cesareans, and defined health outcomes that are NOT considered a gold standard to pursue in many doctors’ and women’s view).
Information on its contents was criticised by a number of maternity charities, organisations and medical professionals (here).
Further, responses (in comments) from news reports of this story were overwhelmingly AGAINST the document's recommendations (here).
And two separate Mumsnet threads expressed overall anger (here).
But yet... although initially removed from RCOG’s website, the document was later reinstated.

 

*******

My point is that the content of the NCT's antenatal classes may be the least of women's worries. Obviously, it should be of a high quality and presented in a balanced way, but what's far more important is what happens in the labour wards throughout this country and in hospital antenatal consultations where decisions are being made about each woman's birth plan.

This is because you can attend the most informative and balanced antenatal class in the world, but if your request for an epidural or cesarean is ultimately denied (for example), or your pregnancy or labour are allowed to continue for a longer time than you feel comfortable with, or believe to be safe (e.g. late gestation or prolonged labour with warning signs of potential problems), then this will ultimately have a far greater impact on your birth experience and satisfaction.

We need to make sure that the NCT is speaking up for ALL women and ALL choices 'outside' the antenatal classroom too - i.e. when it comes to influencing maternity policy and strategies, hospital targets and political decision-making. Currently, the NCT is relied on far too heavily by the government (and organisations such as the RCOG and RCM) as being the 'representative voice' of women in this country, and there clearly needs to be far greater communication with the many smaller charities and organisations whose members provide them with equally legitimate (and sometimes different) information about what women want from their maternity care.

Debate on TOKOPHOBIA broadcast Jan 2

On December 7, 2012 I was fortunate to be a guest at the Voice of Russia broadcast studios to pre-record a five-strong panel debate on the issue of tokophobia. An edited 28 minutes of this discussion aired on January 2, 2013 and can be listened to here, and here is a summary of who was on the panel and what we were asked about:

Too posh to push or too scared to give birth? Latest figures from the Health and Social Care Information Centre reveal that last year 25 per cent of mothers in England had a caesarean. Why so many? Are these mums-to-be squeamish, scared, or sensible? Listen in as VoR discusses the question with midwives and other birth experts. So, does pushing for normal birth always give the best psychological outcome for mothers and babies?

 

VoR's Juliet Spare is joined by Pauline Hull, co-author of ‘Choosing Caesarean: A Natural Birth Plan; Toni Harman, co-creator of the One World Birth film; Virginia Howes, an independent midwife; Zara Chamberlain, who is an NHS midwife counsellor in Kent; and Maureen Treadwell, co-founder of the Birth Trauma Association.

NEWS: Northern Ireland endorses NICE guidance

On December 31, I received this reply from the DHSSPS, in answer to my question about whether its new Maternity Strategy would include the evidence-based NICE recommendations on maternal request cesareans, as published in November 2011:

"Following a Departmental process, the guidance was endorsed for the HSC in November 2012. As set out in Circular HSC (SQSD) 04/11, the Health and Social Care Board are currently considering how best to commission services in line with this NICE guideline.

The Strategy for Maternity Care in Northern Ireland 2012-2018 was launched by the Minister in 2012. The strategy recognised that interventions, such as caesarean sections, can and do save lives. As such, it does not set targets for the rate of caesarean sections in Northern Ireland. However, as the variation in practice between units within Northern Ireland is not adequately explained, the Strategy does recommend that inappropriate varation should be reduced by examining all intervention rates and benchmarking against comparable units across Northern Ireland, the rest of the UK and Ireland."

On the face of it, this is very good news, not least for women like the severely tokophobic woman who contacted me in November 2012 (and prompted my December 3 DHSSPS email) after her cesarean request was repeatedly denied - even by an obstetrician who personally believed it would be the best birth option for her.

But while this endorsement is undoubtedly a very welcome step in the right direction, I remain concerned about how it will be commissioned in practice...

As I've written about many times, even in England and Wales women have contacted me to say that the NICE guidance is being ignored, and in previous correspondence I've received from the DHSSPS (October 24, 2011) it said its Strategy "promotes normalising birth through midwives taking the lead" and that "health care uses its limited resources wisely".

Therefore, given some of the language contained in the second paragraph above (i.e. cesareans may need to be "adequately explained", and "inappropriate varation" "reduced", and the "examining" and "benchmarking" of "all intervention rates" carried out), and in the context of my original (September 29, 2011) blog on Northern Ireland's maternity care proposals (Pay (Not) To Push, says Northern Ireland's health minister Edwin Poots), I can only hope that the NICE guidance will be implemented there in full - and assure readers that I will continue to correspond with the DHSSPS to find out what specifically is being done to ensure that the November 2012 endorsement prevents this November 2012 antenatal conersation from being repeated throughout hospitals in Northern Ireland in 2013 and beyond:

"I spoke to my consulant about NHS/NICE guidelines but he just said this doesn't cover Northern Ireland and sent me on my way."

Is this the cutest cesarean pic ever?





 

A Classic Pin-Up Photography,
Glendale, Phoenix

(...our own babies' aside of course!). As reported by LifeNews.com, this "Photo of Baby Reaching Out From Womb During C-Section Goes Viral".
 

I just love this photo of a baby gripping a doctor’s finger during a cesarean, and it's reported that the parents of baby Nevaeh are delighted with it to.

In this age of photography at everyone's fingertips (even our 5-year-old daughter has been busy snapping away on her new pink camera this Christmas!), it's easy to forget how little generations past really knew about what happens during birth - vaginal or cesarean.

I remember a family member being moved to tears when he saw the videos of our children's births, and realising that this is truly an incredible memento that so many of us are now able to enjoy.

A happy news story to begin what I hope will be a Happy New Year to you all!



 

Would you wear one of these t-shirts?

I've just been shown these t-shirts being sold by Asda - one with the slogan 'Too Posh to Push' written above a picture of Miss Piggy and the other with the words 'Keep Calm and Push'.

And mmmm... I must admit that I'm in two minds about how I feel about them.

On the one hand, having come from a starting point in 2004 when it was considered almost sacrilege to even mention the idea of 'choosing a cesarean', I welcome the idea of women who do prefer a cesarean birth plan being able to express their choice freely and confidently. And in some ways, it helps keep the spotlight on this birth choice as a women's rights issue, by literally saying to the world, "It's my baby, my body, my choice - you do things your way, I'll do things mine".

But on the other hand, I'm very uncomfortable about the slogans too.

Firstly, I really dislike the phrase 'too posh to push'; it misses the whole point about wanting to avoid the very real risks of a trial of labor, and is so often used in such a disparaging and ignorant way that I just couldn't bring myself to give it any credibility by wearing it in public or adopting it as something I want to say about myself.

Secondly, I don't like the insinuation that women who choose a cesarean are any less 'calm' than anyone else; or that somehow the ability to give birth vaginally is dependent on a person's mood or temperament. They aren't, and it isn't.

Thirdly, I'm concerned that these slogans could promote further division and even conflict between women; and for pregnant women especially, I'm not sure that it's a good idea to invite any confrontation or subsequent stress that these t-shirts might cause.

But ultimately, I guess it's each to their own; I've never been a fan of wearing words across my body, whatever the words say (and I consciously avoid slogans on our toddlers' t-shirts too!), so it may be that it's simply not 'my thing'.

And who knows, maybe one day in the future, when choosing a PROPHYLACTIC (as opposed to POSH) cesarean has attained the worldwide understanding, respect and legitimacy that it deserves, I'll be ready to call myself too posh to push too - albeit it in an ironic rather than literal sense, and within the context of what being 'too posh' really meant for real women during this very controversial period in maternity history.

Baby dies in NHS Trust with 'normal birth' targets

DO NOT INTERVENE

Another day, another story of a baby dying because a supposedly 'low risk' pregnancy became high risk without appropriate action being taken - but this was at an NHS Trust that has been praised for its success in increasing normal births.

Just when are hospital staff and politicians going to understand that a normal outcome is NOT more important than a healthy outcome??

When are we going to see a shift in policy that focusses on birth outcomes and NOT the birth process??

The BBC reports today of a Warwick Hospital apology over death of newborn baby who was starved of oxygen during labour in May 2012. It says, "hospital staff did not monitor the baby's heart rate properly and failed to recognise he was in distress"; Lucas suffered brain damage and died a few days later.

According to the Daily Mail, Lucas' mother, Natasha Fermor, is 40 years old and now has advanced breast cancer). It says she was induced, and that while in labor she "was told that everything was fine." There is no mention of whether a planned cesarean was ever discussed as an option...

TARGETS IN PLACE

I have repeatedly expressed grave concerns about the push for 'normal births' at any cost, and when I did a little research this evening into South Warwickshire NHS Foundation Trust (SWFT), I discovered that it is one of the 19 Trusts in England where the NHS Institute for Innovation and Improvement's controversial Toolkit for reducing Caesarean section rates was first implemented.

The Institute stated in 2009 that "Normal birth is both cheaper and safer than Caesarean section" (note the complete lack of distinction between planned and emergency surgery here).

As such, in SWFT's Quality Accounts 2009/10, you can read how the Trust is seeking "to promote normal birth and reduce caesarean section rates... [with] an evidence based guideline for Care of Women in Labour, which empowers midwives to avoid unnecessary interventions which may lead to a cascade of further intervention, [as well as] updates for every midwife in the skills and art of facilitating normal birth".
It says, "In the coming year we have set a target of increasing our normal birth rate from a consistent 61% to 65%, and will focus on retraining midwives in skills that facilitate normal birth. We will also work... to ensure safe outcomes for both mothers and babies."

Interestingly, in February 2012 Minutes of the SWFT's Clinical Governance Committee Meeting, it says, "The high caesarean rate was noted and it was suspected that this might increase further due to the NICE guidance on elective caesarean sections."

No specific 'Action' is then noted, but in a July 2012 report to its Board of Directors (two months after baby Lucas' death), Promoting normal birth is listed as a High Impact Action - with "Continued emphasis on promoting normal birth". Cesarean rates for 2011/12 are highlighted as being at 26%, "slightly above standard of 25%... due to increased numbers of higher risk births", --- yet nowhere do I read any mention of what the hospital's perinatal mortality or stillbirth rates are, or what percentage of women are left with debilitating pelvic floor damage or psychological trauma following their births.

And this is despite SWFT's March 2011 report to its Board of Directors reporting that its instrumental deliveries are 14.4%, "the highest in the region (average 9.7%)" or that its stillbirth rate of 5.7 per 1000 births "is greater than previous years where traditionally SWFT had always one of the lowest rates in the region."

PRIORITIES WRONG

Finally, I read that the Trust's Maternity Forum 2011 Annual Report concludes, "Labour Ward staff are to be congratulated on real progress this year in reducing the caesarean section rate for first timers. This must continue to be a key focus of work."

No, no, no, no, no!!!!

Reduce unwanted cesareans where safely possible, YES.
Reduce emergency cesareans where possible, YES (but while including 'planned cesareans' as a viable alternative for women deemed at risk for an instrumental or surgical delivery).
Consider alternatives to induction as the default for late gestational age, YES.
Put individuals' best physical and psychological outcomes ahead of flawed cost-saving strategies, YES (NHS Litigation Authority data shows just how much delayed or absent cesareans cost).
Make 'reducing stillbirth and perinatal mortality' a key focus of work - not cesarean rates, YES.
Make 'positive psychological outcomes' another key focus, YES (an epidural isn't 'normal' according to these targets, but many women WANT one and are very UNHAPPY and even TRAUMATIZED when they don't get one).

*     *     *     *

Lucas' parents, like countless parents before them, have said they want to "ensure the hospital has indeed learnt lessons from what happened to Lucas so that no other couple has to suffer the heartache we have endured."

But it is my belief that until we get away from arbitrary targets to reduce cesarean rates and increase 'normal birth' rates, I will be returning to this blog - all too soon - to write about the next reported case of death or injury following a trial of labor that went unforgivably wrong.

The unpredictable, understaffed and unofficial birth risk

In discussions about different birth plan risks - comparing the likelihood of maternal and perinatal mortality and morbidity outcomes - you won't often hear the risk that is 'your maternity ward care'.

And yet this is a risk I've talked about in the past - because when you plan a vaginal birth in the UK, you don't know what the staffing levels will be like in the maternity ward you enter, how many other women will be there with you, or what level of experience your carers (midwives or doctors) will have. It's an unpredictable risk that is all too often unrecognized.

 

I raise it again tonight because, published anonymously in the Daily Mail this weekend, a London midwife has written, 'The secret midwife: Psychotic mothers, exhausted doctors and nurses asleep on the job: A whistleblower reveals the desperate truth behind those rose-tinted TV shows'.

There are many worrying issues and stories, but the one that struck me is this:

"In the next bed, I have Claire, a 38-year-old woman who has been on the ward for six days. She’s already been on the ward far too long. It turns out she’s a lawyer, and no, she can’t possibly leave.
She says she felt frightened and confused by her birth experience, no one had explained what was happening, and she ended up having emergency caesarean section. She’s physically well, but emotionally shaky. No one has given her the time and attention she needs. She’s angry, upset and wants to complain. I do what I can, and she goes home with the promise of a referral to our counsellors. The significant few who need more time and help to come to terms with their birth experience are often bypassed – because we need the  bed space."

Clearly, 'Claire' feels that she has not received an acceptable level of care, and while obviously I have no way of knowing what birth plan she wanted from the outset, I can't help but notice a very familiar scenario:

Advanced maternal age. Likely first time mother. Emergency cesarean outcome.

Now, IF this woman had asked for - or wouldn't have minded - a planned cesarean birth, the cost of her birth to the NHS would definitely have been lower, her experience might have been better, and the workload of the midwife in this story might have been lighter. But my guess is that a planned cesarean didn't come up in antenatal discussion, and the woman was left confused because she'd been led to believe her birth would be completely 'normal'.

And ironically, the frightening thing is that her experience is all too normal for women in England: 15% end up needing an emergency cesarean. It's just that Claire, together with another >97,000 women, was expecting a very different normal to the one that was she experienced...

Instrumental deliveries ↑ but c-sections headline

This week saw the annual publication of England's maternity data by the Health and Social Care Information Centre, and as always, the cesarean rate made headlines - for example, Caesarean sections now account for a QUARTER of all births - and older mothers are the reason why.

But for anyone interested in maternity care outcomes beyond the 'controversial c-section', there were far more concerning rate increases to be found in the HSCIC's NHS Maternity Statistics, 2011-12.

Yes, the cesarean rate saw an increase of 0.1% to 25% in total (10.2% elective and 14.8% emergency), but the INSTRUMENTAL DELIVERY rate (that's forceps and ventouse - both of which are associated with increased risks for adverse outcomes) had an increase of 0.4%, to 13% of all births.

Also, EPISIOTOMIES showed an increase of 0.4% to 15.2% of all 668,936 births.

Did these 'normal' adverse outcomes receive anywhere near the interest that cesareans did? Yet these are outcomes that many women want to AVOID and some women FEAR.

I think that by focussing on what's most controversial and newsworthy, we're in danger of completely missing the real issue - the health and safety of mothers and babies.

Filmmaker asks, 'Can anyone argue with this?'

This evening, I came across the article, Freedom for Birth - Can Anyone Argue Against Respecting Women's Rights in Childbirth?, written by "filmmaker turned birth warrior" Toni Harman.

 

This was my reponse:

"I have not watched the film in full, but I have watched the trailer and associated video clips on the One World Birth website, and I think one of the problems is its emphasis on just one end of the spectrum of birth choices - that is, home birth and birth with minimal medical intervention.

My personal birth choice was a planned cesarean, and I was lucky in that I found a supportive obstetrician. Too many other women are not as lucky, and either have to fight to have their birth plan preference respected and supported or are forced to have a trial of labor against their will.

Hopefully a future film will include the voices and rights of these women too because, as it stands, I'm afraid it represents a rather limited call for 'all' birth choices."

Is the obsession with doctor-free births risking lives?

This is the question posed in the Daily Mail this morning, as Carol Sarler asks, Is the NHS’s obsession with doctor-free births putting babies at risk?

Here is the response I've just posted beneath it:

"Considering the DM has published some of the most vociferous criticisms of planned caesareans in the past (including reference to the outdated 1985 WHO recommendation), incl. articles like those of Jenni Murray (Sep.2012 Get real, girls! Pain is part of childbirth, and Nov.2011 The madness of Caesareans on demand), it's about time that the balance is being redressed. Thank you.

And while I don't agree with some aspects of the article above, the most important messages are that we need more calls for more obstetricians in the UK, and that midwife-led birth units should not be forced on women - or recommended based on biased ideology.

Choice is a good thing, but choice is NOT what's been happening in our maternity wards. Let's hope things will change from here on, and the RCM, NCT and RCOG will realise that a 'normal birth' means different things to different women - but for the vast majority, a healthy physical and psychological outcome is more important than mode or place of delivery."

A normal birth and a baby's death

Yesterday I posted the comment below in the Daily Mail article, 'Mother-to-be lost baby after staff at midwife-led birthing centre failed to spot rare pregnancy condition', and you can scroll down further to read a comment posted by another reader, who also lost her baby during labor in a midwife-led birth unit.

Please note that I am not against birth units as a birth choice, but I do not agree that they be encouraged as standard maternity care and policy for all women deemed 'low risk' in the UK.

 

My comment

 

NO ONE can judge any pregnancy or birth to be "low risk" without the benefit of hindsight. Low risk can become high risk in a heartbeat, and yet maternity care in the UK is decidedly focused on making sure as many women as possible achieve a "normal birth" - with the lowest rates of medical intervention (read: 'New RCOG guidance urges CCGs to increase births without epidurals and reduce caesarean rates to 20%' for more info).

 

Well this mother's birth experience was 'normal' according to mode of delivery definitions, but it resulted in irreparable physical and psychological damage for this devastated family. Worse still, Rhiannon Davies had known risk factors, plus she was 38 years old (i.e. advanced maternal age). Too many women are being advised to give birth in a midwife-led unit (which is very different to providing choice), and there are too many cases like this one where death or serious injury are the result.

Women need unbiased information - not ideology.

Roz , London, 19/11/2012 12:52

"I too lost my full term baby in similar circumstances. She died during labour. I too was booked in as low risk into a midwife led unit. For all those who advocate birthing centres, and natural births, that's great but once something goes wrong it's too late isn't it. Sadly I've learnt this the hard way. Giving birth might be natural but it's a time in your life when you need the most experienced medical professionals around you, because the slightest thing going wrong can result in a death, even worse, two deaths. Why would anyone want to take the chance? Parents need to be made aware of all risks and possibilities - sadly there's too much politics involved. Just so sad xx"

Support for tokophobic women

Following yesterday's blog on tokophobia, I came across another article today, this time by the BBC, with some positive news for women.

Dr. Malcolm Dickson, a consultant obstetrician at Rochdale Infirmary, is quoted as agreeing that cesareans "are often the best option for women who are terrified of delivering their baby for months beforehand.

"Birth phobia is a dreadful thing. You can't quantify it but I see women physically change and relax when I agree to a section.

"Lots of anxiety in the patient can lead to an emergency section during labour anyway."

And the Birth Trauma Association, which says many tokophobic women contact them after being told that they can't have a cesarean, insists that "whatever the cause of a woman's fear, it is vitally important they choose how the baby is delivered."

Furthermore, in light of pressure to reduce cesarean rates in the NHS, Maureen Treadwell, a founder of the BTA's, insists that "there are no grounds for argument" with this issue.

"Caesareans don't cost much more than a vaginal birth - only £84. It's not a bad hit if a woman who is really afraid doesn't want to give birth vaginally."

As others have commented on this blog, given the costs associated with antenatal counselling and postnatal counseling for birth trauma, it's entirely feasible that in fact a planned cesarean - if desperately wanted - is likely more cost effective than a trial of labor.

Tokophobia support - am I right to be concerned?

"More needs to be done to help women who have a morbid dread of childbirth...", says expert.

I am trying very, very hard not to be cynical about this call for midwives to recognize tokophobia as a legitimate issue affecting as many as 10% of women. Firstly, why has it taken so long and why have so many educated health professionals never even heard of it? But secondly - and more importantly, - why the concern NOW?

Could it be that this call is a direct response to the November 2011 NICE Caesarean section guideline update, which recommended that all women who request a caesarean should ultimately be offered one (once informed of the risks and benefits), and which specifically cited tokophobia as a reason some women might prefer surgery? And note, NICE says that tokophobic women should be 'offered' counseling, but not that it should be a requirement prior to offering a c-section.

Here are some of the reasons for my concern:

1) Expert Zara Chamberlain is quoted as saying, "This could result in the women deciding to have an abortion or to seek an elective C section", as though these two options are an equally terrible consequence. I know of three cases where abortion was sought by tokophobic women, and in all three, had their cesarean maternal request been granted, they would have happily taken that option – and a live baby - but surgery was refused.

2) Zara talks about "a robust birth plan" for tokophobic women, as though they can somehow be guaranteed a more predictable trial of labor than anyone else – but they can't, and this is one of their legitimate fears. Women and babies CAN die or suffer injuries during the birth process, and this is why tokophobia is not wholly irrational.

3) Zara concludes, "Other women have an elective Caesarian section - which is also a very scary option". This demonstrates to me that even this midwife counselor, who is trying to educate midwives, may not have fully understood that for many tokophobic women, the very opposite is true. They do not perceive planned surgery as particularly "scary" at all, and in fact, once surgery is scheduled, their anxiety is vastly reduced (even though fears such as premature labor or their doctor being unavailable on the day may remain).

4) The "offer" of counseling to vulnerable and scared women can too often mean a thinly veiled attempt to pressure or convince them into having a trial of labor; labor risks are completely downplayed and cesarean risks are overemphasized. And this is more to do with an ideological desire to reduce cesarean rates and increase 'normal' births than anything else.

Norway study

For evidence, just look at this article today on a recent Norwegian study, which begins, "Group therapy can help women avoid risky and costly cesarean sections":

Lead study author Dr. Hanna Rouhe, from the Helsinki University Centralö Hospital, is quoted as saying (about tokophobia), "Symptoms of the intense fear included panic that affected daily life, nightmares about delivery and a strong desire for a C-section."

"A number of initiatives aim to reduce the first cesarean section by waiting longer to induce labor and by allowing longer delivery times before C-sections are offered, she noted. But… I am not aware of initiatives surrounding childbirth fear - maybe there should be."

With all this in mind, I'm left wondering whether some midwives are developing a new concern for tokophobic women with purely altruistic intentions, or actually because these women - with their "strong desire" for a cesarean now supported by national clinical guidance - are a danger to the RCM (and others)’s ideological goal of reducing cesarean rates.

After all, 6-10% tokophobia is a very big number when you're trying to hit low CS targets...