cesarean debate

The challenge of new mothers being older and older

2012-03-01T23:21:00.001Z

ONS figures reported in the Daily Mail yesterday show that not only is there something of a baby boom going on, but the average age of new mothers is now almost 30, and there are more and more women giving birth at older ages.

This is creating unprecdented obstetric challenges for doctors and midwives, and these are compounded by the fact that pregnant women in general are heavier weights than ever before, and giving birth to bigger term babies too.

I'm not for one minute suggesting that all of these women might want to consider a planned cesarean birth, but I do think it's important that they are fully informed of the specific risks associated with giving birth at an older age so that (if they want to) they can make their own decision between choosing surgery or a trial of labor.

2012-03-01T22:46:00.001Z

Photo: Press Association

Amanda Holden has been talking to The Sun newspaper about her recent birth experience during which she almost died.

Thankfully, both Amanda and her new baby Hollie are safe and healthy, but their experience demonstrates the very real risks associated with repeat c-sections - and in particular, placental problems.

Amanda told The Sun, "I had something called placenta previa - a low-lying placenta that prevents you from giving birth naturally. I also had placenta accreta - which meant my placenta was stuck to the C-section scar from the two previous births."

We write about placental complications in our book, and of course individual women will balance these risks with the risks associated with planned vaginal birth too, but I decided to blog about them here to highlight that no birth plan - no matter how 'safe' it seems - is inherently risk-free.

Call the Midwife but Celebrate the C-section too

2012-02-22T01:00:00.003Z

The dedicated midwives depicted in this BBC drama undoubtedly deserve our praise.

But so far at least, there seems to have been a dearth of recognition (in reviews) for another praiseworthy life saver: the c-section.

The often untold stories of babies and mothers who died or were seriously injured during natural births in the 1950s are touched on in this series, and it's evident that the technology available to us today, including ultrasound and emergency or planned cesareans, would have prevented so much grief and heartache.

We marvel at how far we've come (e.g. contraception, IVF, pain relief and hygiene), and yet advances in the comparative safety of cesarean surgery can sometimes be overlooked, taken for granted or even maligned.

Let's celebrate the call to midwifery, yes, but we should celebrate the cesarean too; it's just as deserving.

Australian Hospital says NO to C-section (Same Story in UK and Canada)

2012-02-21T23:54:00.001Z

According to this Northern Star article, "under the Towards Normal Birth policy, the [NSW] state is aiming to reduce the cesarean rate to 20% before 2015."

Remember - there is NO EVIDENCE for ANY ideal cesarean rate - yet (as is happening in the UK and Canada too), an ideological focus on achieving normality is deemed more important than best physical and psychological outcomes for babies and mothers.

Lismore pediatrician Dr. Chris Ingall is quoted here as saying that 'the rights of the both babies and mothers have to be balanced out'... "It's not just the mum's choice. It's also the baby's choice as to how the delivery transpires."

You may disagree, but having read this mother's very genuine and legitimate reason for wanting to schedule a c-section, I don't believe for one minute that - if such a consultation was even possible - her macrosomic baby would make a different choice. Do you?
Extract taken from Northern Star article, Hospital says No to cesarean, by Jem Wilson (February 22, 2012):

Sylvia Leveridge, 38, said she was told by an obstetrician at the hospital she could only have a C-section (cesarean section operation) in an emergency.

"I just had tears streaming down my face - I couldn't believe it," Ms Leveridge said.

"I feel so powerless and betrayed by the medical system that my choice has been taken away."

Ms Leveridge, who is 28 weeks pregnant, wants to avoid the 20-hour labour she experienced before undergoing an emergency cesarean to deliver her first child.

Her first baby was a whopping 4.240kg and Ms Leveridge understands this baby will be just as big.

"Chances are I will be having a C-section again but it will just be as traumatic as it was the last time," Ms Leveridge said.

Why are cesarean rates rising in India?

2012-02-21T23:30:00.000Z

Photo: iloveindia.com

In response to a recent article in The Economist, journalist Sriram Vadlamani has written a very interesting rebuttal titled, "Auspicious C-Sections in India? Not really".
I've just commented on his blog, but for brevity here, I would have to agree with Vadlamani that when it comes to discussing c-sections, "context is paramount".

I also think it's likely that, as is the similar case in China, when it comes to birth choices, "Astrology is a probable side-effect of this new found awareness and risk averseness".

Latest news from Portland hospital makes interesting reading

2012-02-21T22:45:00.000Z

The statistic most likely to hit the headlines soon is this London private hospital's c-section rate - 53%.

I don't know the elective/emergency breakdown yet, and will endeavor to find out, but given that the rate of emergency cesareans in public hospitals is around 15%, it's very likely that the elective number is very high.

The other interesting statistic is The Portland's 89% normal delivery (standard vaginal delivery) rate.

This is only for second time or subsequent mothers, and I'm not sure why this Private Maternity News report doesn't mention the first-time mothers rate too, but on the face of it, it looks as though this hospital, with its 2,230+ deliveries in 2011, deserves credit for striving to provide mothers with their preferred birth outcomes.

How to restore your sex life after having a baby

2012-02-21T22:19:00.000Z

Not every woman who has a vaginal birth has sexual health issues months or even years later.

But some do.

Articles like this one, 'How to restore your sex life after having a baby' are helpful for at least getting the subject out in the open and informing women that there are risks with vaginal birth and they shouldn't be kept in the dark about the truth.

The French Government Wants To Tone My Vagina

2012-02-21T21:13:00.000Z

This Slate article by Claire Lunberg is worth reading alone, but just as importantly, read the comments posted below, and in the Huffington Post version of the article, posted a few days later.

It's all about French postnatal care for the damage to a woman's pelvic floor that can happen during vaginal birth, something Pamela Druckerman also wrote about in the New York Times back in 2007.

We don't have anything like this in the UK or the U.S., at least not for the average woman (private medical care may differ), and what resonates most with me are the comments from women who, like so many others, echo the words, "No one told me this could happen."

Comment extract:

"I was so scared that at the age of only 21 I would now be wearing adult diapers and would do so for the rest of my life. Despite all the books I'd read during my pregnancy about the birth and delivery and the recovery, none of them mentioned the loss of sensation I experienced, let alone the lack of control. The doctor chuckled at my predicament, smiled, and said, "Not to worry. That's perfectly normal. You'll be able to feel when you have to urinate soon." How is it normal if I'd never read about it in any of those books, in any of the experiential anecdotes? Six weeks later, my brief incontinence was not mentioned, was not noted, and I was certainly not told that I could strengthen those muscles. I've peed when I sneeze ever since. It's been 21 years of sneezing and peeing."

Latest £3.35m NHS settlement for 1985 birth - Millions more still to be paid

2012-01-25T01:19:00.005Z

No one knows how any birth will turn out, and no one knows how much more money the NHS (tax-payers) will have to pay when mistakes are made. But what we do know is that NHS litigation bills are already at unaffordable levels (and millions of pounds are yet to paid for claims already made), and that when it comes to birth (in the eyes of the law), the delay or absence of cesarean surgery is the most costly mistake of all. Perhaps if maternity budgets were directly affected by these litigation costs, then more hospitals might remove their target driven pressure to 'reduce cesarean rates'. The NHS can't afford it, and more importantly, mothers and babies deserve better care (you can read the BBC story about 24-year-old Adam Spinks here).

NHS bailed out of litigation black hole - Obstetrics Claims Cost the Most

2012-01-23T00:53:00.001Z

Photo: pdb.blogspot.com

And things can only get worse...

As the British Medical Journal reports that the NHS compensation fund gets £185m bailout as claims rise by 30% in a year, it's important to remind readers that the largest litigation costs for the NHS arise from OBGYN claims.

When planned vaginal birth goes wrong, and especially when a baby is injured, the financial costs are substantial - and the backlog of these claims is huge.

When will maternity care policy makers understand that it's not a focus on "normal" birth that's most important (or cost-effective), but rather a focus on best health outcomes?!

Perhaps it'll take cash-strapped MPs to understand this first.

As reported in the Law Society Gazette, "Peter Walsh, chief executive of the charity Action against Medical Accidents, said most of the increased costs came from a judgment that injured children are entitled to more compensation."

While Mr. Walsh doesn't specifically talk about birth injuries, we do know that the cost of compensation when birth injuries occur (the vast majority following planned vaginal birth) is massive.

Why do I keep writing this blog? Because of emails like this...

2012-01-22T23:58:00.000Z

Photo: allaboutincontinence.co.uk

I receive many emails from women, and especially from those who are facing difficulty in having their cesarean birth choice understood, respected or supported.

But there are other emails too, telling of the devastating consequences of a cesarean birth request that was ultimately denied.

Here are just two of the most recent I've received - from courageous women who are willing to speak out about the often downplayed risks of vaginal birth, and who don't want other women to suffer in the way they have.
I found your campaign online and totally agree with the sentiments.

I would have choosen a c-section if it had been an option. In the later stages [of pregnancy] I requested one when I had gone overdue, but was point blank refused.

Intially I had a fear of childbirth and tried hypnobirthing to help. I went 10 days overdue and was taken into hospital but was waiting around in distress for 6 days.

When I was eventually induced I had an 18 hour induction. I was totally exhausted when it came to pushing and made no progress. I ended up with a forceps delivery to a 9lb 2 baby, a 3rd degree tear and massive blood loss.

I was in hospital for 5 days and told there was a chance I would be doubly incontinent. I noticed the c-sections were up and about long before I was. Additionally, the terror and horror I felt will stay with me.

I think the natural birth fanatics are putting women and babies at risk. An elective c section would have spared an instumental delivery but we all know these are cheaper.

[I'd] like to share my experience with you as I am sure many women do.

I recently had a baby and after a hard vaginal delivery, I ended up with a condition that I had never heard about called bowel incontinence (losing the ability to control gas or bowel).

After suffering this, I started to read about it and about the many women who experience this after a childbirth, especially after a vaginal delivery. It is interesting to me that you are told so much about the risks associated with a c-section or cesarean but are never told what can happen as a result of a vaginal delivery.

As you argue as well, pushing for many hours and/or vacuum or forceps used to pull out the baby are common practices and can result in bowel incontinence. Women it seems, have been experiencing these horrible consequences of the vaginal delivery in silence as no one talks about these even when you are pregnant, not your doctor, not other women, no one.

I think the unusual insistence on a vaginal delivery here in the US, even for women who should be delivered via c-section, maybe due to the insurance companies penalizing the doctors who have more cesarean cases than they like to see as cesarean delivery costs more.

In my case, I had discussed my delivery with my doctor during my office visits throughout my pregnancy. The fact that I like to avoid being torn or cut (Episiotomy) and vacuum or forceps be used to pull out my baby. I had told him that I am quite fine with having a c-section rather than a difficult delivery that would involve these methods.

However, he insisted (and convinced me) that I should have a vaginal delivery even though I am over 40 and had prior surgeries that would have qualified me for a c-section. During my delivery, my doctor was not even there and I ended up pushing for many hours before he finally came over to proceed with cutting extensively (4th degree Episiotomy) and using forceps, the very methods that I had asked him not to use, to pull out my baby.

The day after my delivery, I had the most painful spasms in my colon, the kind of pain that when arrived I screamed loudly and uncontrollably. I ended up with very large hemorrhoids and for the next 2 weeks, I could not function without several pain killers a day. I could not stand or walk without pain or have a bowel or gas movement without excruciating pain and I could not control my bowel or gas movement.

Now after over 5 months, I am still suffering from hemorrhoids and bowel incontinence. I have become isolated and afraid to be around people and have had to reject a job offer with great benefits (that we very much need now) for the fear of being around people and have an embarrassing accident.

Thank you for your time to read this and for the great work you do.

Transfer risk from midwifery-led birth centers is real

2012-01-18T01:29:00.002Z

A wait of just under two hours for an emergency cesarean transfer, and now brain damage is suspected.

The Braintree & Witham Times reports that a full internal investigation has been launched by the East of England Ambulance Service NHS Trust, and that parents Sarah Jenkins and Jamie Murray say "they have been “failed” by the NHS after what should have been a straight-forward birth in Braintree ended with baby Riley Murray being starved of oxygen and eventually being taken to intensive care at Addenbrookes Hospital, Cambridge."

Last April, my criticism of current thinking to encourage all 'low risk' woman to give birth in midwife-led birth centers' was published in the BMJ, as it's a policy I am wholeheartedly against.

By all means, allow women the choice to give birth in these centers - after all, the vast majority do not result in death or injury - but the NHS should not be prescribing or forcing this option on women in general, simply because they're deemed 'low risk'.

And especially not if (in addition to natural birth risks) there is the risk that no ambulance will appear when the situation becomes high risk.

Mother and baby would have died if VBAC was attempted elsewhere

2012-01-18T01:00:00.000Z

Photo by Simon Finlay

This birth story was quite rightly reported as a good news story in last week's Norwich Evening News: 'Our little boy is just cool after 72 hour fight for life'

But there's also something very troubling about the story if you consider the fact that had this VBAC been attempted in a different hospital - one without the specialist life-saving equipment that was needed - both mother and baby would have died (according to the report).

Baby Adam's mother, Marie Jermy, is quoted as saying, “I wanted a natural delivery with Adam, as my other two kids were born by C section, and the hospital were very supportive.".

Yet despite being considered 'low risk' enough to attempt labor, Marie's experience emphasizes just how quickly problems can escalate during labor, leading to possible death or disability.

She says, “If they hadn’t done the tests on Adam when I was in labour, we would have both died... We owe them our lives, I just can’t thank them enough."

“The results came back as I was about to push, saying I would bleed to death if I tried it. It was that close... I was minutes away from dying.”

“I don’t think they’ve ever done a C section that fast before, their speed saved his life."

She continues, “It was going OK until last thirty minutes. Blood tests were all normal, wasn’t until in theatre that problems started.”

Marie's surgery reportedly took 17 minutes, breaking all previous records for the unit, and baby Adam needed to stay in a special unit for seven days.

Complications in labor

Dr. Mark Dyke, a consultant in paediatrics, explained, “The condition that we treated in this case is perinatal hypoxia-ischaemia, where the baby suffers a reduced blood and oxygen supply from the placenta via the umbilical cord often due to complications in labour.

“The result is a baby who may suffer severe shock, which can be fatal in some cases, and/or organ failure.

“Where infants survive the early problems the risk of brain damage in the longer term is high – that’s where the ‘cooling mat’ comes in. By reducing the body temperature (by 3-4 degrees C) for 72 hours we can reduce the risk of cerebral palsy or learning problems."

“We were the only unit in the East of England to be involved in the major trial in this country (ToBY Study) and have been offering this treatment for 4 years now. We cool 1-2 babies per month overall, many of whom come from other parts of the region specifically for this treatment.”

Informed choice

Please note that I don't write this blog in order to criticize anyone's decision to attempt VBAC, but rather it is to demonstrate that there are risks, just as there are risks with cesarean surgery, and I hope that all women are being advised of these risks before being encouraged to have a normal birth experience 'because that's best'.

Sometimes it isn't - only hindsight knows for sure - and that's why women need to be fully informed and allowed to make a choice.

Cesarean delayed and denied. Baby dies.

2012-01-18T00:03:00.003Z

Baby Lilly-Mai (and parents, below)

These photographs are just heartbreaking, and while the investigation into the death of baby Lilly-Mai, at just 2 days-old, remains ongoing, anyone involved with maternity care in the UK needs to read this report by Alison Sanders.

South Wales Argus photos

In it, we read how the baby's mother, Trish Noonan, alleges that "when, fearing her baby was distressed, she kept asking for a Caesarian, she was called “impatient.”"

As readers of this blog will know, this is not the first time a mother has requested a cesarean in order to save her baby's life, only to have her request ignored or refused, with the same tragic outcome.

The circumstances surrounding Baby Lilly-Mai's birth was reported in Gwent News just two days before the birth of Blue Ivy Carter - and of course it was the latter that captured the world's attention, as is so often the way.

Why are people so quick to judge and vilify obstetricians?

2012-01-16T21:39:00.000Z

It's an issue I could write more about if time allowed, but in Viv Groskop's article, Welcome to modern motherhood, Beyoncé..., I've just posted the following comment:

Why are so many commentators so quick to judge and vilify obstetricians, the absolute majority of whom should be applauded for the amazing work they do, while simultaneously placing midwives on a pedestal when it comes the antenatal advice they give to women? Do we really, as a society, distrust our doctors SO much?

It’s also worth remembering that celebrities are all individual women with their own perception of birth risks and benefits - so regardless of what advice their money can buy, they may also have their own personal preference for one birth plan over another, and this would be exactly the same even if they weren’t famous.

[Viv Groskop wrote: "If you seek out the best advice money can buy, you are unlikely to find someone who will say, "If there are no complications, why not start out with the usual exit and see how you get on? No charge for this consultation, by the way. It's just common sense." Having sought the counsel of the best-qualified private obstetricians in the land – as opposed to your average, practically minded midwife with little interest in furnishing hotel suites with Cristal on tap – it's hardly surprising these women make the choices they do."]

Call the Midwife: 'There isn’t much comedy delivering a baby'

2012-01-16T01:11:00.000Z

I just had to post this comment on Morwenna Ferrier's article in The Telegraph today, especially given the way NHS maternity policy seems to be heading:

Let me start by saying that I think that the majority of midwives do a great job and I agree that there is evidence to show that midwife-led care can enhance the experience of women who would like to have a natural birth.

However, I would not describe midwifery-led care as categorically "uncontroversial", as it appears to be represented in this article's conclusion.

Listening to and reading the stories of women who have experienced birth trauma, it is very clear that the "care" provided by some midwives is extremely poor. They do not always respect women's feelings or birth choices, and their treatment of women, both physically and psychologically is sometimes described as dismissive and even cruel.

The Netherlands has a very long history of midwifery-led care, and was found to have one of the highest perinatal mortality rates in Europe, while another study there found better health outcomes with high risk pregnancies (cared for by obstetricians) than with low risk pregnancies (cared for by midwives).

Midwives tend to place a greater trust in Mother Nature than doctors do when it comes to the physiological nature of childbirth, and while this makes them the perfect care-givers for women who want to have a natural birth experience, and whose trust in the birthing process matches that of midwives, it does not make them the best care-givers for women like myself, who place a greater trust in medical intervention, fetal monitoring and obstetrician-led care.

Different women should be allowed to receive care from the maternity care provider that best suits their own perception of birth risks and benefits - rather than trying to create NHS maternity policies that prescribe one type of care (midwifery-led) as being the best option for all (supposedly) low risk women.

None of us know which pregnancies can truly be described as “low risk” until after the birth is over, and as too many birth stories can attest, for some, by then, it's simply too late.

IMPORTANT INFORMATION: The NICE c-section handout for pregnant women

2012-01-13T00:38:00.006Z

Are you thinking about choosing a c-section? Are you worried that you will not be taken seriously when you attend your antenatal meetings? Have you already tried to discuss a cesarean birth plan and been refused point blank? Are you unsure of your rights as a patient in the NHS?

If so, please read the NICE (National Institute for Clinical Excellence) NHS patient leaflet: Understanding NICE guidance

Also see: NEW GUIDELINES YOU SHOULD BE AWARE OF

For example, on page 6 of the patient leaflet it reads:

If you request a caesarean section

*Your doctor or midwife should explore and discuss your reasons with you and make a note of this discussion.

*If your request is not for medical reasons, your doctor or midwife should explain the overall risks and benefits of caesarean section compared with vaginal birth. You should also be able to talk to other members of your healthcare team, such as the obstetrician or anaesthetist, to make sure you have accurate information.

*If you ask for a caesarean section because you have anxiety about giving birth, your midwife or doctor should offer you the chance to discuss your anxiety with a healthcare professional who can offer you support during your pregnancy and labour.

*If after discussion and support you still feel that you do not want a vaginal birth, you should be offered a caesarean section.

*If your obstetrician is unwilling to carry out a caesarean section, they should refer you to another obstetrician who will carry out the caesarean section.

REMEMBER

The new guidance from NICE is a result of a lengthy evidence-based review, so if your hospital is refusing to follow the guidance, this is a concern.

Please contact me if this is your experience.

Thank you.

First-time moms' unrealistic views about having uncomplicated births

2012-01-11T23:36:00.001Z

An Australian report by Evelyn Yamine in the Daily Telegraph discusses a new study showing an increased risk of post-natal depression in first-time mothers with "unrealistic views about having uncomplicated births".

This does not surprise me in the least, and I think that women are often not being helped in forming realistic expectations during their antenatal care.

Unfortunately, I haven't been able to locate the study just now, nor indeed email or twitter contact for Ms. Yamine, but in the report above, she writes:

"The survey of 195 expectant mothers revealed they believe there is a 56.2 per cent chance of an uncomplicated birth, which means a baby being born without the use of forceps, suction cups, caesarean section or induced labour.

Pain relief is considered part of an uncomplicated birth.

The figure is more than double that of Victorian data, which shows the chance of having a medically uncomplicated birth is 21 per cent.

A further 30.7 per cent said they believed women would have uncomplicated births without needing sutures. The actual figure is 8 per cent.

"We believe that many women and their carers have overly optimistic views," the report states.
"In this study, we have found that pregnant women, staff and students all overestimate the chance of first time mothers having an uncomplicated labour and delivery.

"The finding is important because unrealistic expectations of the likelihood of intervention may lead to increased feelings of distress in the postpartum period.""

Beyonce Gives Birth to Blue Ivy and Colorful Debate

2012-01-11T00:06:00.001Z

Jim Spellman/ Wire image (TIME Healthland)

I've posted this comment on TIME article, Beyoncé's Baby: C-Section? Natural Childbirth? Why We Care So Much:

Bonnie Rochman picks up on some interesting points in this article - namely the hierarchy of c-sections, and indeed the perceived hierarchy of all birth types.

Unfortunately, birth plans and birth outcomes are often discussed within a context of mixed data and anecdotal evidence, and when a celebrity has a baby - however she has it - this provides a fresh opportunity to discuss and debate issues surrounding the birth choices women make (or want to make).

What has proved particularly interesting in the case of Beyonce's birth experience is the way different people have reacted to different information about whether it was natural or surgical.

Personally, I believe that choosing a cesarean is as natural a birth plan in the 21st century as planning a vaginal birth - as long as the woman is fully informed of both sets of risks, is planning a small family, and schedules surgery at 39+ gestational weeks (assuming no medical indication for earlier delivery). Of course, not everyone agrees with this, which is why there is so much debate on the subject.

What I would say is this: It's not celebrities that have been leading the way with cesarean birth choices. Rather, it is doctors, as demonstrated in a number of research studies on their birth choices, and the choices of their wives and partners.

Finally, however Beyonce gave birth, it is her business (unless she chooses to discuss it) and she should be neither condemned nor put on a pedestal because of it. What matters most is that this mother and daughter are healthy, and that as a society we do everything we can to give other mothers and babies the same chance of healthy outcomes too.

November and December 2011

2012-01-04T21:19:00.001Z

A very busy few months, filled with completing the final stages of our new book and ongoing cesarean campaign work.

I've highlighted some of the main activities below, but plan to post more details about many of these as soon as possible.

December 09, 2011
Contacted BBC Complaints and Woman's Hour programme makers in response to Jenni Murray's November 23 report on the NICE Caesarean section guideline (update), in light of her Daily Mail article, published just weeks earlier.

November 30, 2011
Attended the NHS Alliance Conference in Manchester, speaking with many representatives from many healthcare organizations on the subject of cesarean rate targets and maternal request. Request made for information (incl. DoH letter, below) to be handed to Health Secretary Andrew Lansley; response was affirmative by NHSA staff but no confirmation yet that it was received.

November 24, 2011
Interviewed on BBC Scotland's Call Kaye programme on the subject of the NICE Caesarean (update) guideline

November 23, 2011
Interviewed on ITV Daybreak, Sky News, BBC London 94.9, BBC Radio Leeds and BBC Radio Hull on the subject of the NICE Caesarean (update) guideline recommendation on Maternal Request, published today

November 22, 2011
Interviewee for BBC 1 The One Show's cesarean request film, presented by Angellica Bell.

November 18, 2011
Submitted an open letter to the Department of Health outlining my concerns with target cesarean rates that are in place in many hospitals throughout the UK. Both Jeremy Hunt MP and Daniel Poulter MP have agreed to forward my concerns to the DoH. On November 22, Jeremy Hunt MP contacted me to confirm that my letter has been forwarded to Anne Milton, Minister for Public Health. As at December 11th, no confirmation yet from Daniel Poulter. MP.

November 04, 2011
Together with co-author Dr. M Murphy, submitted a formal request to FIGO for a review of its 1998 statement regarding Ethical Aspects Regarding Caesarian Delivery For Non Medical Reasons: “At present, because hard evidence of net benefit does not exist, performing Caesarean section for non-medical reasons is ethically not justified.”

November 04, 2011
Interview (and pictures) by Associated Press journalist Maria Cheng, "Too posh to push? More C-sections on demand in UK", published online.

November 03, 2011
Research published in the British Journal of Midwifery: Why do some women prefer birth by caesarean? An internet survey. By Pauline Hull, Carol Bedwell, Tina Lavender (BJM, Vol. 19, Iss. 11, 02 Nov 2011, pp 708-716)

November 01, 2011
The NHS Litigation Authority formally confirmed that in response to my request for claims data to be separated into births relating to an emergency or a planned cesarean, it will "introduce a system for recording this information on new claims in future."

U.S. cesarean rate is down from 32.9% to 32.8%

2011-11-17T22:02:00.000Z

According to this report by USA Today, the latest figures from the United States show that the country's overall cesarean rate fell from 32.9% in 2009 to 32.8% in 2010.

Why do some women prefer birth by caesarean? New research published

2011-11-04T01:18:00.002Z

It's taken a few years to publish but it's finally here - my website survey results formally published in the British Journal of Midwifery:

Why do some women prefer birth by caesarean? An internet survey by Pauline Hull, Carol Bedwell, Tina Lavender

BJM, Vol. 19, Iss. 11, 02 Nov 2011, pp 708 - 716

Abstract: Caesarean section at maternal request remains a contentious issue, fuelled by reports of associated morbidity. To explore the motivations behind women's expression of preference for a planned caesarean birth, an internet survey was conducted using semi-structured questionnaires available via a UK-based international website, www.electivecesarean.com, over a 9-month period. A convenience sample of 359 pregnant women who stated that their preferred delivery method was 'elective caesarean section through my own choice' was included.
Data were analyzed descriptively and thematically. Women from 16 countries were included. Two main themes were identified: 1) anti-vaginal birth; and 2) physical and psychological validation. Women who were anti-vaginal birth had a fear of morbidity (maternal and neonatal) and of the birth experience. They viewed vaginal birth as unpredictable and saw planned caesarean birth as a safer alternative. Some women justified their decision of birth mode by referring to either a physical or psychological issue that related to a previous birth or an existing medical complication. Respondents had similar views regardless of country of residence. We concluded that women have multiple reasons for wanting a caesarean birth. These reasons are usually considered, and motivated by a genuine desire to avoid the potential problems of vaginal birth. Individualized birth consultations should include discussion of the risks and benefits of vaginal and caesarean birth as they relate to individual women.

Thank you to everyone involved, and in particular, Tina, Carol and Alice (BJM editor)!

More NICE cesarean media coverage

2011-11-04T00:52:00.001Z

Media coverage of the NICE draft guideline on caesarean section continues, and in the last few days, I have commented on the following:

Telegraph: Cruel cuts to midwives have made Caeasarean sections a cheaper option for NHS (3rd Nov)

Practical Ethics: The moral case for elective caesarean section (2nd Nov)

Marie Claire: All women will have the right to a caesarean, Hannah Thomas (31 Oct)

Huffington Post: Midwives are Able to Help Women Make the Right Choice About Their Childbirth, Cathy Warwick, Chief Executive of the Royal College of Midwives (31 Oct)

Huffington Post: Why didn't I have the right to a Caesarean, Sue Hedges (31 Oct)

Interview on BBC Breakfast Television

2011-11-01T00:48:00.002Z

I was interviewed this morning on BBC Breakfast television, and for a short while at least, a shortened version of the discussion can be viewed here.

Sian Williams and Bill Turnball interviewed me and made the whole experience a very enjoyable one.

I must also thank

the make-up lady - having ran to and arrived at the studio barely four minutes before I was due to appear on the sofa (for which I can thank the wonderful M3 and M4 Monday motorway traffic), she provided an oasis of calm before I was taken on set.

RCOG's response to the NICE guideline media reports

2011-11-01T00:29:00.001Z

This is what the Royal College of Obstetricians and Gynaecologists (RCOG) has to say about the past few day's media headlines and stories:

"The RCOG does not comment on draft consultation documents since the content and recommendations are subject to change.

However,
in light of the misleading headlines on the availability of c-sections on the NHS, the RCOG would like to state that:

•C-sections are a safe medical procedure but as with any intervention, there are risks involved. All doctors must ensure that women are informed about the risks and/or benefits of procedures undertaken and the alternative options. Women must have access to good quality information so that they can make informed decisions

•Tokophobia, or the morbid fear of childbirth, may lead to maternal request for c-section. Tokophobia is a complex rare condition and women need to be supported by a range of healthcare professionals, including midwives, obstetricians and occasionally perinatal mental health specialists, so that the most appropriate choice of delivery can be made.

The headlines ‘Now all women have the right to NHS caesareans in hugely expensive move’ and ‘All women get right to caesarean birth on the NHS... even if they don't need it’ are inaccurate. There is no proposal in the current NICE guidelines which state that women should have the automatic right to a caesarean section. Indeed, the current Hospital Episode Statistics show that the c-section rate over 2009-10 was 24.8%. This shows that the majority of women currently deliver normally or by assisted vaginal delivery depending on their circumstances.

There are well defined indications for caesarean section for both elective and emergency and these should form the basis of clinical practice.

Healthcare providers have the responsibility to ensure the safest, most cost-effective method of delivery for women and babies accepting that very occasionally women will request an elective c-section in the absence of conventional obstetric indications."

Comment posted on media NICE guideline stories today

2011-11-01T00:22:00.003Z

So many stories, so many views.

The news that the draft NICE caesarean guideline supports maternal request for all informed women who want one has undoubtedly caused a media storm.

Here are a selection of links where I have registered (variations of) my comment below:

Express: Folly of caesarean births for everyone, Vanessa Feltz
Guardian: Caesarean sections should be life-saving, not a lifestyle choice, Louise Foxcroft
Telegraph: Childbirth finally leaves the Stone Age, Cristina Odone
Daily Mail: Now all women have the right to NHS caesareans in hugely expensive move, Tamara Cohen
AOL: All women to get the right to a caesarean birth on the NHS, Ceri Roberts

My Comment

The most important things here are
safety and choice, and the understanding that planned cesarean choice does not come at a necessarily higher financial cost than planned vaginal birth once all 'downstream' costs (as the NICE guideline refers to them) are factored in.

Beyond that, arguing back and forth about which birth plan is 'best' is so subjective and open to people's own personal perceptions of natural birth (e.g. its inherently safe versus its inherently risky) that it's very similar to when people argue about religion or politics.

As I understand it, all that the (draft) NICE guideline is trying to do is to ensure that the very small percentage of women who want a cesarean birth are actually able to arrange one because presently, this is not categorically the case throughout the country - not even for women with severe tokophobia.

I also think that for today's controversial debate to have more depth and meaning, it is imperative that more people actually read the guideline draft - in full - before passing judgment.

Finally, readers might be interested in an article written in The Guardian in July 2008: 'We know the reality of childbirth'. It's worth remembering that it's not just lay women who are choosing cesarean birth plans - it's doctors too - and this is certainly something worth thinking about as part of this whole debate.

Media reports on NICE guideline ahead of publication

2011-10-30T20:47:00.001Z

The Sunday Times' front page today reads "All women get right to caesareans" - a story that's been followed up by many other newspapers, radio and television news* programmes.

And athough I was surprised to read the article ahead of the NICE final publication date, I have not been surprised by some of the negative reactions to the news.

Unfortunately, many of the comments being made highlight the desperate need for education about planned cesarean births, and particularly those on maternal request, but even so, it is absolutely incredible to think that as of November 2011, cesarean autonomy may finally be a reality for all women, and not just those who are lucky enough to meet with a supportive obstetrician or live in an area with a supportive hospital.

*I was interviewed live on Sky News at lunchtime today and am scheduled to talk on BBC Breakfast tomorrow morning.

Where have I been? I've been to London to visit the Queen

2011-10-30T02:03:00.003Z

That's not actually true of course, but it rhymes a whole lot better than 'the MP Dr. Daniel Poulter'!

On Tuesday 25 October, I attended the APPG meeting on Maternity and Population, Development and Reproductive Health in Portcullis House, House of Commons, London.

Afterwards, I spoke briefly with Dr. Poulter, who is the APPG chair, and he agreed to present a letter containing my concerns about caesarean rate targets to the Department of Health.

At the moment, my workload is such that I am not finding time to blog (the final proof-reading stages of our book, Choosing Cesarean: A Natural Birth Plan, are upon us), but also I'm busy preparing the above letter, corresponding with the BBC concerning my complaint about The One Show in August 2011, emailing and talking with women who are trying to have their birth choice understood and respected, and working on other campaign research and letters - news of which I will post here as soon as possible.

In the News

There has also been a great deal of news and information on cesarean birth in the last few weeks, all of which I have saved as drafts and plan to post when I can, but one of the most noteworthy is this, published yesterday in The Independent (Inspectors find culture of abuse in NHS trust's maternity services) and Daily Mail. I posted this comment on both:

Part of the problem here is that too much attention is given to the cry of needing 'more midwives' in the UK. What we need to hear more is the cry for 'more obstetricians', who have the specialist knowledge and experience to identify some of the problems listed above. We critically need more obstetricians on our maternity wards.

Moreover, we need to move away from our ideological obsession with 'normalising' birth and arbitrarily reducing caesarean rates at all costs. This puts targets and 'normal' outcomes ahead of ensuring that each individual woman gets the best, safest and most appropriate care for her individual birth. Positive, healthy outcomes should be viewed as more important than anything else, but currently they're not.

Creators of maternity policy would do well to remember that death in childbirth (for mother and/or baby) is one of the most natural consequences of normal birth. Most women want a safe, satisfactory birth, not necessarily a normal one.

Is an obsession with natural birth putting mothers and babies in danger?

2011-10-05T21:59:00.001+01:00

This was the question posed yesterday, by reporter Jane Feinmann, in an article that is certainly worth reading.

I commented: "There is nothing wrong with supporting women to have a natural birth if this is their preference, but we should not put maternity policies in place that set out to encourage (and even force) natural birth for ALL women who have been labeled 'low risk'. It is impossible to be sure which pregnancies and births are low risk until the birth is over, and women should be fully informed of this. The fact is that no birth plan is inherently "safe" or risk-free, and it's about time we started measuring good practice based on the actual physical and psychological health outcomes of babies and women - and not a hospital or area's caesarean rate."

Fair Play FIGO

2011-09-30T00:06:00.002+01:00

I'll be honest, I am not the biggest fan of FIGO's 1998 statement on the ethics of cesarean birth with no medical indication (a subject I will return to later).

However, just recently, the International Federation of Gynecology and Obstetrics handled a situation (regarding a news story on its website) so professionally and courteously that I felt compelled to write about it.

On September 2, 2011, I noticed that the story "Caesarean section 'doubles blood clot risk'", on FIGO's website (which related to this ACOG press release) contained inaccuracies.

I contacted the press office, and explained, providing reasons, that the reference to maternal request cesareans in the opening paragraph may be misleading, and that the U.S. cesarean rate quoted was incorrect.

Benefit of the doubt

The first thing that FIGO did was to give me the benefit of the doubt and removed the story while it investigated my concerns.

This in itself was commendable.

And then, on September 6, I received an apology via email, with an explanation about how some of the figures and information were confused, and an assurance that it would not happen again.

Simple, Fair and Effective

I can't stress enough how impressed I was with the attitude of FIGO's staff.

I spend a great deal of my time reading articles, research papers and opinions on cesarean birth, and understandably, I am frustrated when I see statements or comments about maternal request cesareans that are either untrue or unfair.

To have an issue dealt with so quickly and reasonably was a breath of fresh air.

Thank you FIGO.

Should women get to choose c-sections?

2011-09-29T23:35:00.001+01:00

Jezebel Birth Pains blog

I liked this blog quote so much that I just had to mention it.

Written by Anna North in her review of this BBC news story, she wrote:

"So basically, women and their doctors should discuss birth options and come up with a plan that takes into account both a patient's wishes and her medical needs. Sounds so crazy it just might work."

You just have to ask yourself - who can argue with that?

Can I choose to plan a cesarean birth in the NHS?

2011-09-29T23:22:00.000+01:00

This is one of the most common questions I am asked by women who visit my websites.

And up until recently, the answer was very much, "Not officially, but there are supportive doctors out there, if you can also find a supportive midwife who's willing to refer you to one."

However, finally, there may now be better news for women - whether you have a fear of labor and birth, or you've been considering a cesarean for prophylactic reasons and want to discuss your individual risks and benefits further with an obstetrician, or you have another personal reason.

This month, NICE published its draft guideline on Caesarean section (update) and in it, recommends the following:

Maternal request for CS (page 12)*
36. When a woman requests a CS because she has anxiety about childbirth, offer referral to a healthcare professional with expertise in providing perinatal mental health support to help her address her anxiety in a supportive manner.
38. For all women requesting a CS, if after discussion and offer of support (including perinatal mental health support for women with anxiety about childbirth), a vaginal birth is still not an acceptable option, offer a planned CS.
39. An obstetrician has the right to decline a woman’s request for a CS. If this happens, they should refer the woman to an NHS obstetrician in the same unit who will carry out the CS.

*Now remember that this is only draft guidance, and therefore subject to change, but NICE has stated that changes to the guideline prior to its final publication later this year will concentrate on errors and inaccuracies in the text only - thereby giving hope to hundreds and potentially thousands of women.

Women don’t have to push so much, says U.S. doctor

2011-09-29T23:05:00.000+01:00

This is a very interesting article with advice for women who want to achieve a vaginal birth outcome, and is essentially a Q&A with Dr. Aaron Caughey on the subject of "delayed pushing" techniques.

But what caught my attention was the poorer outcomes for babies in the research group of women who did wait before finally pushing...

Because while Dr. Caughey, chairman of the Department of Obstetrics and Gynecology at Oregon Health and Sciences University and director of its Center for Women’s Health, advocates "letting women stall even after they’re fully dilated, [with] no big rush to push", when asked whether these women's babies were just as healthy, he answered:

"The vast majority of babies are just fine. However, in the delayed arm, in a very small percentage of cases, there was more maternal fever, and it does seem that the babies of women who have maternal fever are at risk for some bad long-term outcomes. The second thing is that a very small percentage of the babies of women who delayed pushing had slightly lower pH or acid levels. When pH is low, you start worrying about injuries to the baby’s brain."

I happen to think that efforts to help women experience a vaginal birth outcome (where this is their preferred choice) are praiseworthy, and that this type of research is certainly very helpful.

What it also provides however, is further evidence that vaginal birth, and the pursuit of vaginal birth at all costs, can introduce an increased level of risk to the unborn child.

And I don't write this in order to criticize vaginal birth or the women who might follow Dr. Caughey's advice (after all, according to his research, the vast majority will have positive experiences and healthy outcomes), but rather to highlight the risks to babies that many women who choose a cesarean are seeking to avoid.

Pay (Not) To Push, says Northern Ireland's health minister Edwin Poots

2011-09-29T21:47:00.005+01:00

I am not going to criticize the Northern Ireland's health minister Edwin Poots here just yet - despite the fact that yesterday he said that cesarean births should be paid for by women who choose them (see BBC and Belfast Telegraph reports).

This is because I am not convinced that he has heard all sides of this debate, and as such, have contacted his office and am awaiting his response.

Northern Ireland has the highest rate of cesarean births in the UK, at 29.8%, and this is one of the reasons why
Mr. Poots is launching a consultation on a review of maternity services (ending December 23, 2011).

Low Risk and Natural

According to the BBC report, "Women at low risk will be encouraged to consider having their baby in a midwife-led unit or at home, if appropriate."

And Mr. Poots insists, "This isn't about saving money per se, what we want to encourage, is more people to give birth naturally because it has better outcomes for the mother and the baby.

Controversial

I have a number of concerns about Mr. Poots' ideas, and it will be very interesting to see how the gauntlet he appears to have set down will play out over the coming few months.

Especially given NICE's publication of its Caesarean section (update) guideline...

But also the fact that women are already asking (e.g. on BBC Radio Ulster's Talkback programme 'Maternity Shake-up' yesterday, with Wendy Austin) whether "non-medical" epiduarals will be next in the firing line for maternity cost savings...?

Choice is Choice is Choice

I just wonder, when will some MPs, maternity care professionals and birth commentators realize that if you're going to advocate genuine choice in childbirth, then they cannot be prescriptive about limiting women to a menu of choices that support their own ideology or experience.

Remember - most women choose a cesarean birth for prophylactic reasons.

That is - they choose to avoid the known risks associated with vaginal birth plans (for their babies and themselves), and are more tolerant of the risks associated with planned surgery.

I think it's dangerous, naive and irresponsible to keep referring to planned vaginal birth as categorically "safe" in the context of birth choices.

It isn't - and it never has been.

Interestingly...

According to the Belfast Telegraph*:

"A spokeswoman from the Department of Health, Social Services and Public Safety stressed the possibility of being charged for an elective C-section is not in the current consultation document.

She said this is an option the minister may consider in future and any move to introduce a charge would be subject to normal consultation."

*I have posted two comments at the end of this article.

The Biggest Change in Women's Rights since they got to Vote

2011-09-08T00:39:00.003+01:00

www.herstoria.com

One of the many supportive doctors I've worked with over the years sent me an email today that got me thinking.

He (yes - a male doctor) had written, "it's a major breakthrough. The biggest change in women's rights since they got to vote" (in response to the NICE Guideline news).

I realized that just because we take the vote for granted as a good thing now, this doesn't mean that the women who campaigned had much support at the time - and least of all from other women.

Which is precisely what I've been finding over the past few days.

Many women (and particularly those who've already had their babies) are blogging, tweeting and phoning into radio shows to voice their disapproval of maternal request cesareans.

Education is Key

And perhaps this is not so shocking, especially when you consider what a massive change in public knowledge, understanding and awareness of the facts now needs to occur in order for some people to better understand why NICE has revised its recommendation.

It has been accepted for so long that vaginal delivery is the norm, and that when it comes to childbirth, natural is next to Godliness, some see women who choose a cesarean as being rather closer to the devil incarnate (e.g. selfish, posh, wasting NHS resources).

Women - Their Own Worst Enemies

This view is of course disconcerting at times, but I am comforted by the fact that at the time of the Suffragettes' campaign to ensure women were given the right to vote, not only was there strong opposition from men, but moreover, some of the most vehement condemnation of their ideas came from women.

For example, some said that they didn't even want the right to vote and would never choose to use it if they had it; others felt that it might upset the established balance of things - a woman's natural place was in the home.

And then there was the argument that I think matches particularly well with the view that pregnant women shouldn't be involved in cesarean decision-making at all - this should be the sole charge of medical professionals:

"The vast mass of women are too ignorant of politics to be able to use their vote properly."(*)

Sovereign Criticism

Even Queen Victoria herself was not at all enamored by the campaign.

According to Lytton Strachey's biography 'Queen Victoria' (cited here), "In 1870, her eye having fallen upon the report of a meeting in favour of Women's Suffrage, she wrote to Mr. Martin in royal rage--

"The Queen is most anxious to enlist everyone who can speak or write to join in checking this mad, wicked folly of 'Woman's Rights,' with all its attendant horrors, on which her poor feeble sex is bent, forgetting every sense of womanly feeling and propriety.

"Lady--ought to get a GOOD WHIPPING. It is a subject which makes the Queen so furious that she cannot contain herself. God created men and women different--then let them remain each in their own position.

"Tennyson has some beautiful lines on the difference of men and women in 'The Princess.' Woman would become the most hateful, heartless, and disgusting of human beings were she allowed to unsex herself; and where would be the protection which man was intended to give the weaker sex? The Queen is sure that Mrs. Martin agrees with her.""

Social Change

Also, as I've written about before, there are many, many people who fear the consequences of NICE's draft recommendation - what will the world do if more women decide to choose surgery?

What will happen if we empower women, provide them with all the facts and allow them to make an informed choice about how they want to give birth (at least those who want to make a choice - remember that many women are content with a more paternalistic approach in maternity care)?

The Future

No one can know for sure, and only in the future will we be able to look back and make a judgment call on whether NICE has done the right thing this week.

But personally, having communicated with the women that I have, I'm convinced that there is no other ethical way forward than to support maternal request, and I commend NICE for taking this historical step forward.

NICE News - ALL Women to be Offered a Cesarean if they Request one

2011-09-05T17:29:00.001+01:00

Fantastic News.

If women make the informed decision to choose a cesarean birth, following individualized discussion and support, the new NICE Caesarean Guideline (Update) Draft, says that this should be made available to them on the NHS.

More on this later!

NICE Admits "Extra £800 Cost" Doesn't Add Up

2011-08-31T01:11:00.002+01:00

A great deal is being made of maternal request cesareans (principle of choice aside) being a waste of tax-payers money and an unaffordable luxury in the current economic climate.

But, and it's a BIG BUT, the reported estimated £800 extra cost is flawed.

Even NICE admits this in its 2011 Guideline Update (Draft), as indeed it did in its 2004 Guideline too (even though it was dismissed).

When both PLANNED modes of delivery (cesarean and vaginal) plus their subsequent intrapartum AND longer term health consequences are assessed, a "different cost-effectiveness result" could be produced, says NICE.
Here is an extract from the 2011 NICE Update Draft on the subject of Health Economics:

"However, there may be other outcomes, such as urinary incontinence, which were not reported in the studies that were included in the clinical review which make the findings reported above more uncertain. Sensitivity analysis suggested that this could, under certain assumptions, produce a different cost-effectiveness result.

An economic model developed for this guideline suggested that planned vaginal birth was cost- effective compared to a maternal request CS. However, this finding was limited to outcomes that were reported in the included studies for the clinical review undertaken for this guideline (see section 4.2). A sensitivity analysis suggested that the inclusion of adverse outcomes not reported, such as urinary incontinence, could make the cost-effectiveness conclusion less certain.

On balance this model does not provide strong evidence to refuse a woman’s request for CS on cost-effectiveness grounds."

Women are Willing to Pay

One last point on this subject.

Regardless of whether NICE's figures are correct or not, I've heard from numerous women in the UK who say they would be perfectly willing to pay £800 in order to plan a cesarean birth in the NHS - in order to avoid the stress of fighting for their birth choice, spending their entire pregnancy waiting to hear if their request will be granted, and being faced with a private hospital bill running into £1000s as their only other alternative.

(Bold highlighting above is mine)

Maternal Anarchy or Human Evolution?

2011-08-31T00:14:00.001+01:00

Quite by chance this evening, I came across this fascinating bioethics blog on the history of anesthesia, and it really struck a chord with me regarding birth choices.

Religion and ideology have historically hampered women's access to pain relief during labor (from chloroform through to modern-day epidurals), but I had no idea that such obstacles stood in the way of the very first surgical pain relief relief too.

According to the blog (based on a Boston Globe report on 7 June 2009), Prior to October 16, 1846 (the date of the first operations conducted under anesthesia) our view of the person seemed inseparable from the concept of pain: “the vast majority of religious and medical opinion held that pain was inseparable from sensation in general, and thus from life itself”. Thus, while the technology was available, the doctors and the patients were not ready for medicine: less painful medical care “required not simply new science, but a radical change in how we saw ourselves”.

When I think about the language used by many birth advocates (and I've talked about this before), I often feel as though they might easily be talking about some form of religious experience when they describe the birth process.

And I have heard some say that the way we are medically tampering with our bodies natural physiological processes during birth, we might have a lasting negative affect on mankind.

But while I don't dismiss these comments out of hand (I actually agree that rising rates of cesarean birth can have negative as well as positive repercussions), I can't help but draw a parallel between the instinctive resistance to women like me choosing prohylactic surgery that's out there, and the instinctive resistance to pain relief prior to the mid-19th Century.

We often hear the words, "women have been giving birth since the beginning of time", so what's so different now?

I'll tell you what's different now - Everything is different.

I honestly think that we're sometimes in danger of living in this little bubble of complacency, in an age where we take medical advances for granted, and like to pretend that that 'we're not so different from our ancestors really'.

Well perhaps we're not so different in some ways (our pelvic floors haven't improved any in terms of withstanding a fetus' often clumsy passage through), but advances in modern medicine - and in particular, cesarean surgery - have meant that our exposure to insufferable pain, grief and loss has been markedly reduced.

I sympathize with every woman who has an unwanted cesarean birth, and I respect every woman who chooses to give birth naturally - I only ask that these same women do not campaign against a choice that embraces medical intervention, and is forever grateful for it.

Pivotal Moment in Obstetrical History - the NICE Caesarean Update

2011-08-30T23:38:00.003+01:00

The 2011 NICE Guideline Update will ALLOW maternal request cesareans in NHS hospitals.

There are those who fear its coming, and there are those who welcome it, but in a few months' time (barring a complete U-turn), the blanket refusal of maternal request cesareans will no longer be considered acceptable maternity care.

"If a vaginal birth is still not an acceptable option to the woman, her request for a CS should be supported within the health service." (quote from May 2011 Update Draft)

In May 2011, NICE published its Draft Update, and Stakeholder organizations like my own were asked to provide comments on the content.

Here is an extract of what the new NICE Caesarean Update (draft) says about Maternal Request:

*Explore, discuss, and record specific reasons for the request.
*Where there is no identifiable reason, discuss the overall benefits and risks of CS and vaginal birth. *Facilitate a discussion with other members of the obstetric team
*For women with fear of childbirth, offer referral to a healthcare professional with expertise in providing perinatal mental health support.
*The healthcare professional providing perinatal mental health support should have access to the planned place of birth
*If a vaginal birth is still not an acceptable option to the woman, her request for a CS should be supported within the health service
*An obstetrician has the right to decline a woman’s request for a CS. If this happens, they should refer the woman to an obstetrician who will carry out the CS.

What's the Real Story Behind the Cesarean 'Ban' News?

2011-08-30T23:03:00.001+01:00

I found last week's 'news' that a number of PCTs are banning maternal request cesareans very strange.

After all, the 2004 NICE Guideline already states that the request is not "on its own an indication" for surgery.

So why are PCTs suddenly re-iterating their long-established rule in such a public way?

Could it have anything to do with the fact that this autumn, NICE is changing its Guideline statement on maternal request in what promises to be a potentially controversial Update (read the full Draft here)?

Could the PCTs be trying to gain public support and put pressure on NICE ahead of this 2011 publication?

I have no evidence of any of these theories, but I do have my suspicions.

I can only hope that NICE decides to do the right thing, and pushes forward with its planned Caesarean Update, regardless of the ongoing push towards a more natural birth ideology 'for all women' that is coming from some individuals and groups.

I've joined The Mom Pledge Community

2011-08-27T01:15:00.003+01:00

I came across this rather intriguing website recently, and decided to sign up. Its founder, Elizabeth Flora Ross, has written a book called 'Cease Fire', which she describes as a "call to end the war between women", and The Mom Pledge aims to eradicate cyber bullying among moms. Here's what she writes:

"The so-called “Mommy Wars” are going stronger than ever.

Blogging and social media have added a new dimension to the conflict, and competition among moms has spread far beyond the traditional work or stay at home debate.

Today, every parenting decision a mother makes is open to attack, and there are no winners.

There seems to be no end to the topics that can generate controversy.

A recent poll of Mom bloggers revealed 76% had experienced or witnessed cyber bullying between moms on online."

Why Did I Join?

One of the reasons I joined today is because I've certainly witnessed cyber bullying by some women who are so determined to impose their own views and ideas on others that they resort to typing insensitive, frenzied attacks.

For example, I've read tentative, frightened posts by tokophobic women looking for support, and responses akin to telling them to shut up, put up and stop whining about it.

I agree with Elizabeth when I say that some women in this world (real and cyber) really need to work harder on respecting each other's life choices.

A Rare but True Risk of Planned Cesareans

2011-08-27T01:00:00.000+01:00

War, Hurricanes and any other Disruptive Force.

I read two things this week that made me decide to write about this risk.

That is - if you want or need to have a cesarean birth, you really are reliant on the availability of your obstetrician, other supporting medical staff, and a hospital with a functioning OR.

Obviously, as a statistical risk, this is likely a very small one
for the vast majority of women and I'm not suggesting it's a risk that should be discussed during every antenatal discussion.

However, in the interests of balance, and ensuring that I highlight all cesarean risks, I do believe that this deserves at least some attention.

Firstly, on Wednesday, the Reuters report Libyan capital faces health disaster as aid held up quoted Rosa Crestani of MSF, who said, "There are clearly shortages of life-saving medication and equipment. There are no antibiotics and instruments for life-saving surgery."

She continued, 'the most urgent cases included not just those wounded in the fighting, but also civilians such as women needing caesarian sections.'

And then tonight, I noticed the following Tweet from (I believe) a reporter at ABC News:
Mikaela.A.Conley.-ND@abc.com needs women who have planned cesarean sections this wkd in areas where the hurricane is expected.

This made me remember seeing pregnant women in some of the Hurricane Katrina footage and thinking how especially frightened they must be, and although the Tweet below illustrates that it's not just planned cesarean births that are put in jeopardy when disaster strikes (since any woman planning a vaginal birth may need emergency surgery), I still feel that the point is worth making here on my blog.

Katie.A.Moisse@abc.com needs pregnant woman on the East Coast due to give birth during Hurricane Irene.

I can only hope that help reaches the women and babies who are affected by world events such as these - and that it reaches them in time.

My Interview with My Baby Radio is Now Live

2011-08-25T21:37:00.000+01:00

You can listen to this 30 minute 'Planned Caesarean' interview with MyBabyRadio.com here.

This was a great opportunity to talk through the many issues surrounding planned cesarean birth, and I really appreciated the professionalism of the team who invited me on.

Thank you!

Interview on BBC Tees - Maternal Request Cesarean 'Ban'

2011-08-25T21:26:00.001+01:00

I was interviewed by Ali Brownlee on his Breakfast Show (at 2hr 10min), with a second guest, Dr Michael Dixon, Chairman of NHS Alliance.

In all honesty, I was shocked by some of the answers Dr Dixon provided, and was very concerned that someone
at such a high level should be so ill-informed about the facts surrounding cesarean birth.

I have contacted his office and plan to amicably communicate with him following the BBC Tee's experience because I think that part of the solution to this cesarean debate controversy just has to be politely providing people with links to evidence they may simply not be aware of.

Also talking on the BBC Tee's programme yesterday was Leigh East, of csections.org (1hr 40min), and she specifically highlighted the issue of tokophobia, which can sometimes be overlooked and even dismissed during cesarean debates.

Leigh was first quoted in the The Sunday Times article (link to Daily Mail version) last weekend, and you can read her blog about the cesarean ban here.

Complaint to BBC's The One Show re: its Cesarean Coverage

2011-08-24T22:37:00.000+01:00

Last night, I contacted BBC Complaints, and also the programme itself, to ask why 'news' of NHS Trusts banning maternal request cesareans was presented in such an unbalanced and one-sided way.

The guest being interviewed on Monday's show was Dr. Sarah Jarvis, someone who clearly had her own personal views about maternal request, and whose views went completely unchallenged during the live chat.

The programme will only be available on BBC iPlayer (20 mins in) for a few more days, so I have typed up the transcript of what was said below:

You can draw your own conclusions about what was said:

Alex Jones: But some news today that the NHS Trusts are restricting cesarean births, aren’t they?

Dr Sarah Jarvis: They are, but that does not, absolutely does not, mean if you need one, you’re going to have problems getting one. This is about women who make a choice. They say, I want, not I need, I want to have a cesarean. And NICE, the National Institute says, 'Actually, it’s got to be done on clinical grounds.'

Now, to put it into perspective, the World Health Organization says, ‘No way should more than 15% of women in a country be having cesareans.' In our country, it’s 25%, so they can’t all need them. There has to be a yummy-mummy, a too-posh-to-push effect out there. I have to say. And that’s what…

Alex Jones: And the too posh to push – that’s pushing up that percentage is it?

Dr Sarah Jarvis: Well, I don’t think it’s all to do with that.

Alex Jones: Come on Sarah… (smiles)

Dr Sarah Jarvis: Well I don’t think it’s all to do with that, but I do think that there is…(trails off) People forget - cause, you think of cesareans, you think of having a baby, and you think, 'Oh I’m going to come out of it with a wonderful baby at the end.' Actually, this is really major surgery. If it was any other operation, and you weren’t having a baby, you know, you’d have taken to your bed for a couple of weeks, you wouldn’t have lifted anything for three months. This is big stuff, don’t take it lightly.

(Dr Jarvis then turns to Luol Deng, who is seated next to her)

Dr Sarah Jarvis: You would never take a cesarean section lightly, would you? (laughter)

In my opinion, this was one of the most unprofessional examples of maternal request cesarean news coverage I've ever seen, and that's saying something.

The Labor Ward 'Care' I Chose to Avoid

2011-08-23T23:24:00.001+01:00

I may have chosen to avoid the unpredictability of Mother Nature and a trial of labor when I planned my cesarean births, but I know that many women are choosing to avoid the unpredictability of care in NHS labor wards too.

These poor families lost their babies, quite unnecessarily, and all because the care they received was utterly atrocious.

And while I try not to blog about my own birth choice too much (since my anecdotal story is not necessarily relevant in the context of wider debate), when I read a stories like these, I find myself thinking, 'I feel so lucky that this, or something even close to this, was not my birth experience.'

(Much Needed) Call for More Maternity Doctors

2011-08-23T23:08:00.000+01:00

On August 10, the BBC reported on a Call for more maternity doctors in order to prevent mothers dying due to "substandard care".

Six obstetricians have written an editorial in the British Medical Journal, pointing out that "most maternal deaths are now caused by treatable medical conditions."

But while this editorial focuses on maternal deaths, it is also true that babies' lives are endangered too when sufficient experienced doctors are not available on maternity wards.

It's all very well hearing constant cry for more midwives - but we should not ignore the lesser publicized call for more doctors either.

When labor and birth complications occur, women need the skill and attention of doctors, and it makes sense that with birth rates going up, so too should the number of obstetricians.

NHS Controversial Cesarean Cost Clampdown

2011-08-23T22:55:00.002+01:00

Yesterday, I commented on this, one of many reports following up on The Sunday Times story this week: NHS in clampdown on Too-Posh-To-Push mums.

I wrote: Firstly, there is actually evidence that a planned cesarean is no more costly than a planned vaginal birth - when comparisons include costs beyond the immediate intrapartum period (e.g. treating infant and maternal birth injuries, but also litigation).

In terms of choice however,

the report states that women "will only be allowed to opt for the procedure at some hospitals if a natural delivery would endanger them or their baby."

That is precisely the point. Just as many doctors believe this to be true, there are women who evaluate the risks of natural birth and make the informed decision that a prophylactic cesarean at 39+ gestational weeks is the best option.

They want to avoid the unpredictable nature of a trial of labor, and feel more at ease in the operating theatre with an obstetrician than they do with Mother Nature and a midwife.

Eventually these NHS Trusts will be exposed by the truth - it is just a matter of time. And incidentally, perhaps if these Trusts had to pay a greater share of the litigation costs when things go wrong during planned vaginal births in their hospital maternity wards, they'd take a very different view on what constitutes 'cost-effective' care.

Remember that in some countries, where doctors and hospitals are directly responsible for litigation costs, there are accusations that women are not being allowed the choice of a vaginal birth plan.

Read this GP's experience of "Brutal" NHS maternity wards

2011-08-23T22:44:00.000+01:00

This is a fascinating comment by GP Partner Katharine Morrison, which I saw posted on the Pulse report, PCTs impose restrictions on caesarean sections.

Perhaps this will help some readers understand just one of the meanings of PROPHYLACTIC in the context of planned cesareans.

Morrison writes: I chose to have two caesarian sections after witnessing the brutality of "normal vaginal deliveries" that are the culture of the NHS.

At the time, the hospital was a training hospital for midwives. If they hadn't done a certain number of episiotomies by the end of their labour placement they had to repeat it and get left behind compared to their colleagues.

The rule was, if a woman had not had an episiotomy, she needed one. If she had not had an episiotomy she needed one. No escape.

These episiotomies were sometimes done with local but frequently they were not. The idea was that at the height of a contraction the woman didn't feel it.

From the screaming and jumping about the bed, and from direct questionning of these poor women, it was obvious that they suffered up to three hacks with scissors and this was extremely painful. Some midwives refused to accept this but others did.

I was sick of seeing well motivated, brave women completely lose it in the second stage of labour due to the pain and anxiety involved.

Midwives shouted at women to push as if it was a football match.

Forceps deliveries are brutal and not without risk to the baby and the woman's perineum.

I also did a neonatal paediatrics. I would go along and ask who was in labour and I would take note of the room numbers were difficult deliveries were anticipated.

When my bleep went off I would go straight to the problem room.

Sometimes the birth had not happened, sometimes the baby was out fine.

More frequently it was "Mrs Normal" whose birth had gone badly and I needed to resuscitate a floppy, navy blue baby.

It is a medical joke that the first three minutes of your life comes only second to the last three minutes when danger is concerned.

If these babies get brain damage their entire lives and that of their parents is severely blighted.

I want to see caesarian sections on request for everyone.

Women need to know the risks and what can go wrong at sections and for other types of delivery.

By word of mouth from other mothers they should be able to find out which hospitals practice humanely and those that don't.

There is a conspiracy of silence in the NHS about the bad and brutal practices that go on in labour wards.

Interview on BBC WM - Maternal Request Cesarean 'Ban'

2011-08-23T22:08:00.000+01:00

This morning I was an invited guest on BBC WM's Phil Upton's Breakfast Show.

News of NHS Trust 'bans'* on maternal request cesareans has been receiving a great deal of media attention, and it was my job to explain why I think the NHS should be supportive of this legitimate and prophylactic birth choice.

It was certainly a heated debate, and for the next week at least, you can listen to it here on BBCiplayer (scroll through to about 1hr 50min duration).

*In fact, until the NICE Caesarean Guideline Update is published later this year (which I hope will include much needed changes on this subject), it remains the case in England and Wales that a maternal request cesarean "is not on its own an indication" for surgery.

Therefore it strikes me as odd that this news is being reported as though maternal request cesareans have been permitted in the NHS up until now.

My guess is that these Trusts are trying to clamp down on doctors who support maternal request and have been quietly supporting this choice on an individualized basis.

BBC London's Vanessa Feltz phone interview with me on RCOG

2011-08-23T21:50:00.000+01:00

On the morning of RCOG's publication of its maternity "proposal for change", I was listening to Vanessa Feltz on BBC London and decided to call the producers with my comments.

They took my number and then a few minutes later, called me back and put me live on air with Vanessa - fantastic.

To hear our discussion on Thursday 14th July, just click here.

Private hospitals in Iraq say women are requesting c-sections

2011-08-22T01:33:00.001+01:00

If you only read the headlines last week, on the Rise in Iraqi C-sections, with rates reaching 79% in private hospitals, you may not have seen this:

"Officials at private hospital say it is not greed that's driving the C-section boom but the patients themselves."

The Associated Press report continues: "Dr. Aseel Ahmed Salman

from the al-Jarrah private hospital in Baghdad acknowledged the higher risks of C-sections but said many patients are uneducated, don't know the risks and just want the process over with. "They cannot endure pain. They want the easy way. They are not even encouraged by their own families or mothers," to have a vaginal childbirth, she said. "The mothers of these wives, most of the time, come to us crying and requesting Cesareans for their daughters because they cannot endure seeing their daughters in pain.""

That's not to say that there isn't a problem with the country's c-section practice, if doctor Ulfat al-Nakkash's description of events is representative of what's going on:

Controversy

"When I accompany my own patients to private hospitals, I see disastrous things there... "The gang-like medical staff there fight each other over patients to do C-sections and get the money."

As always, it's very difficult to get at the truth of what's happening inside any hospital maternity ward, and to know for sure just how many women wanted their cesarean birth and how many did not.

Other countries are not very good at keeping an accurate tally of wanted and unwanted c-sections in their own hospitals either, so in that sense at least, perhaps we shouldn't be so shocked that there's controversy in Iraq too.

Not just Too Posh to Push says Australian doctor

2011-08-21T23:45:00.003+01:00

This article about an upcoming study being carried out in Australia is well worth a read, and this is the comment I've written:

I'm curious. Is the author of this (most welcome) article about the need for greater clarity, in the comparison of risks and benefits of planned maternal request cesareans versus planned vaginal births, the same Stephen Robson that co-authored this in 2003?

Should obstetricians support a 'term cephalic trial'?
Aust N Z J Obstet Gynaecol. 2003 Oct;43(5):341-3.
I am co-author of an upcoming book on the very subject of "Choosing a Cesarean", and while Dr. Magnus Murphy and I believe that there is already sufficient evidence to support the legitimacy of prophylactic surgery, we agree that further studies, which SPECIFICALLY compare maternal request surgery with other birth plans and outcomes, without bias, can only help to inform the ongoing debate and controversy that surrounds this birth choice.

New study on how to reduce post-cesarean infection

2011-08-21T23:03:00.005+01:00

U.S. researchers claim to have found a way to reduce the likelihood of women having complications such as endometritis and wound infections after cesarean surgery.

A reported study from the University of Pennsylvania used a "preoperative skin prep protocol that combines a 3-minute povidone iodine scrub with povidone iodine paint", and it was discovered that this application is better for preventing wound infections than povidone iodine paint alone.

The study only relates to infections that are diagnosed during the "initial hospital admission or a readmission during the first 30 postoperative days and not infections diagnosed at an outpatient clinic, emergency room, or other hospital", but even so, if this protocol could improve women's health outcomes, it's will be interesting to see whether it is implemented in hospitals beyond this particular study's reach.

Review ordered into baby death at Victoria hospital

2011-08-21T22:30:00.002+01:00

Could a cesarean delivery delay - because an anesthetist was not readily available - have led to a baby's death this month?

This is what the Vancouver Island Coastal Health Authority will investigate in a review of the events that took place in a public hospital in Canada on August 9.

According to a doctor quoted in the Globe and Mail this week, “B.C. is the only province in the country that doesn’t have, in high-risk units, a dedicated anesthesiologist just working in obstetrics and nowhere else... “Everywhere else in the country, there is one available at a moment’s notice. “And things happen fast in obstetrics...”

I personally know of women for whom a planned cesarean birth was delayed
(and even denied altogether) because of anesthetist staffing issues, and while I hope that this is not the case here, if it does turn out to be true, I will not be shocked that this can happen - because I already know it does.

In sorrow thou shalt bring forth children? (Genesis: 111,16)

2011-07-31T10:04:00.001+01:00

This is how Dr Han Dong-up, who works at a Christian hospital in Korea, has described the bonding benefits of vaginal birth, in an article criticizing the high rate (36.8%) of Korean women choosing c-section births:

"We persuade the mothers to endure the pain and see the baby in a more natural state."

"The more painful the whole experience was, the more attached you would feel to the child," he said.

This point of view has been around for centuries, and as anyone who knows their birth history, pain relief in labor (from chloroform through to modern epidurals) has been frowned upon by many health professionals for being "unnecessary".

Perhaps it's only natural that the criticism would extend to prophylactic cesareans too.

The article continues:

"There are several options mothers-to-be can take in giving birth in a natural way: water birth, swing birth and family birth.

Water birth was once favored by many women because the pain was lessened inside the water.

However, it takes longer because the muscles are much looser. Also, the possibility of contamination from excrement during birth now sees many doctors to not recommend it.

The swing birth has similar effect in lessening the pain but it also takes longer time and the possibility of injury in the vulva."

Family birth
And so family birth that is now the most "preferred method" for labor and birth.

"It raises intimacy between the couple and stronger family ties after birth,"Dr Han said, and 'the practice is common in many other countries.'

I actually think that the process of labor and birth can indeed be a very strong bonding experience for families, and so I am certainly not going to disagree with the doctor on this point.

But sometimes, natural birth advocates seek to warn women that a cesarean birth experience lacks the ingredients necessary for family bonding, and this is certainly not true.

[Photo copyright mimsyweretheborogroves blog]

TV documentaries Sing from the Same Song Sheet

2011-07-29T21:32:00.003+01:00

Barely more than a month after ITV broadcast its programme, "Maternity in Crisis", this week saw BBC Panorama air "One Born Every 40 Seconds".

The message in each programme was the same - maternity care in the UK is failing too many women and babies - but the question is, what can be done about it?

The shocking and horrific stories described in each programme speak for themselves, but what concerns me is the over-riding message (i.e. lyric) that the only way forward is to employ MORE MIDWIVES throughout the NHS.

In my view (and others), what we also need is MORE OBSTETRICIANS - many more obstetricians.

This is the media message we need to be communicating more effectively - please.

I didn't tear, so you won't tear - if you do it properly

2011-07-23T23:37:00.000+01:00

At least this seems to be the advice of Rikki Lake, while talking about her new doc, More Business of Being Born.

When asked her reaction to women who choose cesareans 'to protect their “vaginal integrity”', Rikki is reported to have said,

"It’s a joke! I didn’t tear with either of my children and they were both over 8 pounds. In fact, my midwife came back to my apartment the next day and she looked down there and said that it didn’t even look like I’d had a baby. My body recovered so quickly. That’s what happens when you’re not given a drug that numbs you from the waist down. You can feel what you’re doing."

This type of anecdotal 'informing' women is at best, naive and at worst, irresponsible - perineal and pelvic floor damage caused by vaginal birth is a REALITY for some women.

Certainly, it doesn't happen to every woman, but one of the biggest problems with this associated risk of vaginal birth is that no one can predict precisely who it will (or won't) happen to.

Therefore, if some women choose to plan a prophylactic c-section - just in case - I don't think it demonstrates much respect for their informed decision to describe a very legitimate reason as a "joke".

Nor does it illustrate a knowledge or understanding of these potential risks.

Birth Choices

Rikki Lake says, "I want to be clear: I am promoting choice, not home birth."

And yet the interview continues: "I don’t judge any woman for making the choice that she makes. But I think major abdominal surgery should be a last resort."

(Perhaps she feels the same way about epidurals, given what she says about her experience of not tearing?)

For me, surgery was my first choice, not my last resort, but I sometimes wonder whether some birth advocates will ever be able to truly understand or accept that fact.

Going Up... 34% U.S. C-Section Rate reported in HealthGrades study

2011-07-20T22:45:00.002+01:00

More accurate and relevant information on c-sections is needed - begins my comment on the HealthDay News article, C-Section Rate in U.S. Climbs to All-Time High: Report:

Year after year, we see the same report - cesarean rates hit all-time high. And year after year, the very simplest action is not taken in the USA, which would help us to better understand exactly what's going on and where - so more can be done to target and reduce the most dangerous surgeries, and leave the others well alone.

What am I referring to? Compiling data that is more relevant and precise to different birth plans and outcomes.

Why, when many other developed world countries have been doing this for years, do U.S. hospitals not separate emergency and elective cesarean data as standard

(although they do at least separate primary and repeat cesareans, which is good)? And within the elective cesarean group, why not monitor gestational age at birth - together with an indication (medical, obstetrical, maternal request or a combination of more than one indication) - as standard?

If we then look at the national data and see that prophylactic maternal request cesareans (for example) are being carried prior to the ACOG and NIH guidelines of 39+ gestational weeks, then they can be targeted and improved. Similarly, we can identify where the highest rates of emergency cesareans are occurring, and try to better assess what is leading to these and what can be done to reduce them (since emergency surgeries are associated with the greatest risks).

Also, the cesarean data should include the mothers' BMI and maternal age, for example (this will help analysis of maternal deaths, for example).

This comment does not purport to be a comprehensive outline of everything we need to know, but I hope that it at least illustrates that any general discussion or debate about 'cesarean rates' in a country the size of America, without more specific data informing it, is just an exercise in floundering around in the dark, going round and round in circles.

Ask two different doctors and you'll get two different opinions on c-section rates - what the country needs is more facts. Who, what, where, why, when and how. This will equip us to improve maternity services for more effectively than a league table of percentages that simply pit individual State 'c-section versus vaginal' birth rates against each other.

As a final point, I would remind readers of another Healthgrades report, which was published 8 years ago. It reported significantly higher than expected vaginal complication rates in hospitals with lower than expected cesarean rates, and lower than expected vaginal complication rates in hospitals with higher than expected cesarean rates: "suggestive of, but not definitive of, inappropriate under-utilisation of preplanned first time" cesareans.

The lives, and quality of lives, of babies and mothers are at stake if we target the wrong cesareans in an arbitrary rate reduction drive. Let's get the right information and move forward from there.

My interview with the Western Mail newspaper

2011-07-19T14:19:00.003+01:00

Are you too posh to push? asked reporter Rachel Mainwaring, in her article on Sunday.

She was exploring the reasons why some women choose to plan a cesarean birth, and put together her list of cesarean pros and cons.

I was invited to answer some questions about the topic of choosing a cesarean, and you can read the article in full and comment on it here.

Dr Miriam Stoppard, you disappoint me

2011-07-17T01:42:00.002+01:00

Click on Dr Miriam Stoppard's website and you'll read: "I have always aimed to give people the confidence to follow their instincts - whether planning for a healthy and happy pregnancy..."

Well, choosing to plan my two prophylactic cesarean births was a completely natural and instinctive choice for me. My babies arrived safely and I was satisfied with my choice.

And yet during her article, Victoria Beckham had a caesarean - is it the right choice for you? (Daily Mirror 14 July), Dr Stoppard not only strongly criticizes maternal request cesareans, saying they're not natural, but appears uncharacteristically determined not to even entertain the possibility that this choice is a legitimate one.

To her mind, "the natural way is the way to go", and that's the end of it.

Perhaps she's the type of woman that thinks, 'well, if I had to / managed to go through it all naturally, then so should you', or perhaps she genuinely isn't aware of the emerging research and opinion on the prophylactic nature of c-sections.

I don't know her reasons, but I struggle to respect ideological criticism of an informed birth plan.

Incredibly, she writes, "...call me old-fashioned, I’m in favour of a woman giving birth to her baby naturally, where possible. Even though an eminent obstetrician has said that caesareans are no more dangerous than natural births, to me, that dodges the question."

How does that statement (and similar statements from the likes of a previous President and current exec-vice President of ACOG, and the editor-in-chief of BJOG) 'dodge the question'?

I guess it depends what question is being asked...?

Finally, I'm disappointed that Dr Stoppard wrote this article without making sure that her "old-fashioned" views were being expressed in the context of contenporary clinical guidance.

She writes that for women with a fear childbirth, the National Institute for Clinical Excellence (NICE) "hasn’t recommended they have a caesarean".

And yet in its Caesarean Guideline Draft Update (published in May this year), NICE does just that. It states:

"When a woman requests a CS because she has a fear of childbirth, offer referral to a healthcare professional with expertise in providing perinatal mental health support to help her address her fears in a supportive manner. If after providing support, a vaginal birth is still not an acceptable option to the woman, offer a planned CS."

Please, Dr Stoppard, take another look at c-sections with an open mind and perhaps a more 21st century persepctive.

You may still feel you'd never make this choice, but you might begin to understand and respect those of us who do.

Critics round on Turkey's 45% c-section rate but are they justified?

2011-07-17T00:47:00.001+01:00

A report in Istanbul's Today's Zaman begins: Caesarean births in Turkey at 3 times WHO limit, and has been re-tweeted by critics of c-section surgery.

But aside from the fact that we now know the WHO has admitted it has no empirical evidence for ever having recommended a 15% cesarean rate threshold, this report is sadly lacking in its provision of a more balanced description of what's going on in Turkey.

For starters, there is no mention of the perinatal or neonatal mortality rates in the country, which from my reading of UNICEF and WHO data, have been falling during the last 20 years.

That's perhaps worthy of mention, no?

"How Many?" is not the only question

The report does provide detail about which regions of Turkey have a greater number of c-section births than others, and it also describes how "the Social Security Institution (SGK) reduced state support for Caesarean sections from TL 675 to TL 475 and increased state support for normal births from TL 250 to TL 400."

And yet: "For the time being, however, the high rate of C-sections persists."

It would be useful to know what women's attitudes are towards their cesarean births, and how many surgeries are emergency versus planned / primary versus repeat.

What are the views of the doctors who are evidently carrying out these surgeries?

Is any research being carried out to determine which groups of women are more likely to need and/or choose a cesarean - or indeed whether they are satisfied or unsatisfied with their birth experiences?

The story is NOT the headline % rate.

Unless cesarean rate stories are furnished with relevant background data and information, it's arguably pointless to criticize an average % number alone.

Media headlines misinterpret RCOG but make good point on Home Birth

2011-07-16T19:06:00.001+01:00

The Daily Mail has gone with the headline "Big push for home births: Too many babies are being born in hospital, say doctors", and The Guardian, We need a cultural shift on homebirth - If women are to opt for homebirth over hospital-based care, we must teach them about the benefits of choosing to stay at home.

Unfortunately, according to RCOG's president Dr Anthony Falconer, some media reports may be getting the wrong end of the stick following its maternity "shake-up" proposals yesterday.

I heard Dr Falconer stress on BBC radio yesterday that the RCOG is NOT suggesting more home births, but rather, more births in midwife-led centers.

But what RCOG may have failed to recognize is the fact that women perceive the SAME risks (see below) with both, which is why its proposals are not feasible.

Speaking to Vanessa Feltz on July 14, Dr Falconer said: "I should stress that we’re not, we’re not advocating going back to a huge increase in homebirths...

That is certainly not our line at all, and some of the media publicity today is misquoting us in terms of saying homebirth. I think they’re interpreting that we support midwifery-led care units, saying that that is analogous to a homebirth, which it isn’t."
The fact is, that whether they're deemed low risk or high risk, the overwhelming majority of women WANT to give birth in hospitals, where emergency care is IMMEDIATELY available should they (or their babies) need it.

It is an insult to the intelligence and preferences of these women to try to convince them that staying away from doctors is the 'safest' way to give birth.

Indeed it's a national disgrace.

Stop lying to women in a flawed attempt to save a few pounds, and stop wasting time and money on proposals and schemes that will risk the lives of mothers and babies.

Yes - the majority of low risk pregnancies can have a spontaneous vaginal birth outcomes - but until RCOG, the RCM or the NCT can produce evidence of a fail-safe method of identifying (before labor) which women will fall into this 'low risk' category, let women give birth where they want to.

In hospital.

Choice and Risk

In its report introduction, RCOG states:

"The services should not only improve women’s experience by including them more in decision making (‘no decisions about me without me’1) but also improve services for all, based on some already excellent good practice. Services must also be cost-effective."

It then states that its proposals are underpinned by principles and values, including:
"women should be at the centre of their own care"
"care should be provided closer to home (accepting this principle may require women to travel to access very specialist care)"

I might be wrong, but given the fact that so few women currently choose to give birth any distance from hospital, I don't foresee a huge increase in the number of women who are willing to accept the possibility of travelling to access specialist care.

Cesarean Infearmation is Unnecessarily Frightening

2011-07-15T14:27:00.002+01:00

Is it really necessary to instill SUCH levels of cesarean fear in women?

During the last two episodes of 'One Born Every Minute' that I have watched, I have seen women writhing in agony, labor not progressing, baby's heart rate decelerating, and they cry out, "I don't want to be cut. I don't want a cesarean. Please."

Surely this is a sign that we are failing in antenatal care?

I KNOW that many cesareans are unwanted, but shouldn't we still prepare women sensibly for the possibility that they may NEED a cesarean, for their own and for their baby's safety?

Cesarean's are life-saving procedures.

If you don't want to have one, then you should work with a maternity care provider that can advise you on how best to optimize your chances of a successful spontaneous delivery - but every woman should also try and mentally and physically prepare for the possibility that surgery may be needed.

In fact, Leigh East of c-sections.org has just published a book called "Caesarean Birth: A Positive Approach to Preparation and Recovery", which helps women to do just that.

Shaken, Not Stirred: RCOG's proposed maternity shake-up hard to swallow

2011-07-14T23:20:00.002+01:00

It's been reported right across the media today (e.g. BBC news online) that the Royal College of Obstetricians and Gynaecologists wants to shake-up UK maternity wards.

But as far as I can tell, the proposed new model mirrors the maternity care system in The Netherlands rather too much for my taste - where the perinatal mortality rate is NOT something I think we should aspire to.

The problem is this (as outlined in my letter to the BMJ, which was published earlier this year): who is capable of identifying - without the benefit of hindsight - low risk pregnant women?

The Good News

Today, I took a look at RCOG's Expert Advisory Group Report, "High Quality Women’s Health Care: A proposal for change", and I also asked the press office a few questions about the report, and it seems that there MAY WELL BE an element of choice involved here.

For example, in response to my question about where women with maternal request cesareans fit into this model, RCOG said:

"The RCOG supports clinically appropriate choice. If a woman is going to have a caesarean section, then under our proposals, she will be cared for in an obstetric unit. Likewise, if she requests for pain relief, then she should have her delivery in a hospital."

And in its press release, Chair of the Expert Advisory Group, Dame Joan Higgins, says:
“Women will still have ready access to hospital-based care but this will be when clinical need dictates or the woman chooses to have her care delivered in this setting.”

How Many Women Will Choose Midwife-Led Units?

This is one of the key questions here in my opinion - how on earth will this shake-up be managed?

Women will be labeled low and high risk, but they'll also have autonomy (we hope - in practice) to choose the current hospital birth model in preference to a midwifery-led unit.

I've asked the question of RCOG, and now await the answer, but has anyone calculated just how many women will CHOOSE to go down the midwife-only route?

And how many women will still prefer to give birth in traditional hospital environment (with all its faults), with immediate access (ideally) to consultant care and 24-hour emergency services?

Top Down versus Bottom Up

(an accidental birth metaphor I'm afraid)

I get the feeling that this proposal has been designed with finding a solution to the 'birth rate increase / midwifery shortage' situation that the UK's hospitals are facing - instead of deciding first what would be BEST for and WANTED by mothers.

So let's listen to women, and make sure that ANY changes we make in our maternity services are for the benefit of positive physical and psychological outcomes for our mothers and babies - and not for any other reason.

Researchers want to know Reasons why women Choose Cesareans

2011-07-06T13:29:00.001+01:00

Sign up to volunteer information on the reasons YOU decided to request a cesarean birth here.

Australia's Herald Sun has reported today that: James Cook University and Australian National University researchers are trying to recruit 1000 women planning their first vaginal birth or planning an elective caesarean birth.

Women who are planning caesareans will be asked the reasons for their decisions.

Researchers will also follow up with questions after the babies' births.

Women interested in the study can sign up at: caesareanstudy.net

You are eligible to participate if:

This is your first baby
The baby is head-down (not breech!)
The placenta is not low
You are 18 years of age or older
There are no other complications with the pregnancy (such as pre-eclampsia or diabetes)

Read medical studies - but Beware Bias

2011-07-06T12:54:00.002+01:00

I came across this article yesterday, which offers a wonderfully simple explanation of how bias can creep into the medical studies you might read about. Interestingly, the author mentions the WHO's heavily criticized survey on cesarean births,

published last year, so in the context of your birth research, this is something I would recommend you read.

Oxfam, John Wayne and The Da Vinci Code - statistically wonderful or rubbish? is written by Julian Champkin, and here is the WHO extract:

"White Hat research tends to prove what the researcher wants to prove, or (which is often the same thing) what the people paying for it want to have proved. An example from last year was a survey which ‘proved’ that elective Caesarean births in third-world Asian countries were more dangerous than normal births. It was paid for by a UN organisation which was politically heavily biased against unnecessary medical interventions. When its numbers were looked at by anyone who was at all impartial, the figures showed very obviously the exact reverse."

Old School versus New Science - Birth Advice

2011-07-04T14:14:00.001+01:00

There is no getting away from the fact that different medical professionals hold very different views about what constitutes optimum maternity care for women and babies.

Women need to understand this fact - your information will almost always come from someone with a personal and professional view of birth risks and benefits, and so it's important to do your own homework too.

Just yesterday, I came across this post on a nursing website: "C-section vs. letting Mom go naturally", in which a nurse (I believe) criticizes a doctor's offer of a planned cesarean to her friend, whose baby might be macrosomic at birth (large).

I skim read through about half of the answers, and in amongst all the responding criticisms of this doctor (making more money from c-sections; fearing litigation etc.), nowhere did I see anyone talking objectively about the very real increased risks with macrosomia - for mothers and babies.

Nor did they seem to think for one moment that the doctor may have the woman's best interests at heart in his cesarean offer - nothing to do with money and/or litigation.

Here's what some of the post read:

"I have a friend that is pregnant for the first time, isn't due for a few more weeks, has a very healthy pregnancy, no problems with her or the baby except that at last U/S, they guesstimated the baby is almost 9 lbs and has still not descended any and her cervix is still closed and thick. He offered her a c-section in a few days and she took the offer! Ugh! Ok, I may be old-school here in my thinking but I just don't see why any Dr. would offer that (besides they see it as easy money in their pocket) or why any woman would want that!! C-sections are major surgery to the body, as we all know. They are relatively easy in uncomplicated pregnancies but there is still more room for post-op infections, bleeding problems, etc...why can't Dr.'s just leave well-enough alone and let nature take it's course and let the woman's body do what it was made to do and has been doing for centuries...the baby will come out when it's good and ready, her body will tell her it's time to deliver that baby. She's not even at her due date yet, and it's her first baby, of course the baby hasn't descended yet and there's no dilation! Duh! Give it a few weeks, tell her to go walking, have sex, etc...geez!"

She continues later in the discussion:

"I'm an advocate for natural birth, as natural as medically possible of course and I'm all for women making decisions and all but to me, this is just ridiculous that a Dr. would suggest this to a first-time mom who will never even know if her body can deliver a baby naturally, and more than likely, she never will be able to experience that... As I said before, I'm old-school...I'm an advocate of letting that baby simmer until done, and barring no health issues of either mom or baby, waiting for mom's body to give birth as it was made to do."

Unfortunately, we do not live in a perfect world, and therefore making an informed decision about your birth plan means you must navigate your way through the subjective views and opinions of those working in maternity care.

If you desperately want a vaginal birth, you might find a doctor's offer of a cesarean quite offensive, whereas if you desperately want a cesarean birth, you might find a midwife's insistence that birth is a safe, physiological process quite irrelevant.

Be Educated, but Educate Yourself too

And then there is the biggest group of women right in the middle - who don't have a preference of birth type either way; they prefer to rely on professional guidance.

All I'm saying is that whoever you are, and whatever your views, understand that in the 21st Century, it is incredible difficult to find maternity advice that is not (even slightly) subjective, and you might need to decide for yourself which education YOU prefer:

Old school or New Science.

Job satisfaction for midwives - should it matter?

2011-07-03T23:59:00.002+01:00

I understand why people are drawn to working in the maternity services, and I understand how welcoming a new life into the world as part of your regular day's work must be very rewarding.

But a question that comes up in my mind again and again, is whether some midwives (and indeed some OBGYNs) are focusing too much on their own personal job satisfaction - and not enough on the birth satisfaction of the mothers in their care?

Here's just one example:

I came across this post in an online discussion, from a woman in Switzerland, talking about her German friend who was traumatized by her hospital midwife while giving birth.

According to the post, "The midwife on duty berated her when she asked for an epidural, berated her for not progressing, and finally yelled at her that she had mental problems when she tried to tell the midwife that something didn't feel right after she was induced, and her contractions never stopped. (the midwife actually had a resident walk in and tell her that she needed mental counseling)... Finally, there was a shift change, and the new midwife treated her like a human being, had the epidural moved (t wasn't placed properly), and as soon as the pain stopped, she progressed and delivered."

She continues: "As a result of this, she went with a midwife practice for her second child -- just to avoid winding up with the midwife from hell when in labour... Then, she had to fight back the midwife pushing a home birth on her, and telling her that "she considers it a personal and professional failing when one of her patients requests an epidural"."

Who's birth is it anyway?

I read about and hear this kind of attitude altogether too much.

Surely what matters MOST in any birth is that the baby and mother are healthy and happy at the end of it?

And if that means the midwife or doctor on duty goes home feeling like they've somehow failed professionally, then so be it.

Birth satisfaction is not about them - it's about you and your baby - and in my humble opinion, it's the best medical professionals in the world who recognize that fact.

Has AIMS misunderstood what women in labor want? You decide...

2011-07-03T23:17:00.002+01:00

While listening to a recent episode of Woman’s Hour last week, it struck me how even the most basic research can be misunderstood by its interpreters - and in this case, Beverley Beech, the Chair of AIMS.

Beverley was talking about the subject of 'Birthing Buddies' (which is where a supportive, trained carer stays with a woman throughout her labor), and wanted to emphasize that in this role, the 'buddy' does not necessarily need to take an active support role in the birth - it is merely their presence in the room that is of importance.

However, the research example that Beverley provided as proof of this assertion communicated something completely different to me.

I interpreted as demonstrating that women feel secure in the knowledge that there is a DOCTOR in the room (in case anything should go wrong during their labor), and this is what made them feel more relaxed and supported - not just anyone's presence.

Here's what Beverley describes:

"In 1960, an AIMS member, a man, wanted to find out what was happening in labor wards and he suggested to a hospital that perhaps he could come in and do a short study and observe, and they said, ‘Fine. Go sit in the corner and don’t you dare say a word. We’ll give you a white coat and just sit there and observe.'

And what they found was that his presence resulted in women having shorter labors. And he didn’t ever say anything. But after the birth, the women would go to him and say “So thank you doctor, for being there all the time.” And in fact he wasn’t a doctor. He was just an observer.

So, the presence of someone, whom the woman feels is supportive, has a really important effect. And I think it’s helpful for women to have this kind of care. But this is what a midwife should be doing, and this is what midwives have not been enabled to do, in our centralized obstetrics system."

(BBC programme broadcast on Radio 4, 22 June 2011)

What do you think?

Safe is a Dangerous Word

2011-06-27T08:38:00.007+01:00

I've been reading a blog post by Rikki Lake this morning, and while a great deal of what she writes is to be applauded - providing birth plan choices that reflect each individual woman's preference and caring about a woman's postnatal mental health for example - as with many voices on the subject of natural birth, her repeated use of the word "safe" concerns me.

Don't get me wrong - I have used the word safe to describe a planned cesarean too, but in the context of surgery in 2011 being 'comparatively safe' or 'statistically safer' in some respects, than other birth plans.

I would never categorically state that any birth plan is categorically safe.

Why?

Because it dangerously raises expectations of what a woman's birth might be (or have been), when the truth is that birth has never been safe.

And while I understand and sympathize with women who feel that medical intervention destroyed their birthing experience, and while I agree that where women want to do things more naturally, they should be supported wherever possible, I think it's important that they are not promised that Mother Nature and/or their own bodies will guarantee perfectly safe outcomes.

Yes, women are designed to have babies, but like it or not, it's a flawed design.

Yes, the majority of babies can be born safely via natural means, but a significant number will require medical intervention in order to optimize safety. And that's before considering the balance of risks and benefits in terms of the woman's own morbidity.

Choice

In many ways, Rikki and I are campaigning for very similar birth choices - but at opposite ends of the birth spectrum.

She lives in a country where women are able to request a planned cesarean birth and for the most part, have their informed choice discussed and supported in a respectful way (medical insurance coverage allowing of course - the big sticking point in the U.S.), whereas I live in a country where women will be supported 100% in their decision to have a home birth or intervention-free birth in a birth center or hospital.

And ironically, while women fight to get a VBAC in the U.S., we have cases of women here who are actively encouraged to have a VBAC, and then left to get on with the most intervention-free birth possible - at the cost of human life (read more here).

Perception

Believe me, it is as distressing for women in this country, who desire a surgical birth, to be refused their birth choice too. Not because surgery is the 'experience' they want, but for most, quite the opposite.

They don't perceive birth as a personal experience in and of itself; it's simply a means to an end - the birth of their baby. Their requirements for post-birth satisfaction are made up of a different set of criteria to women who desire natural birth (and both should be respected).

And most importantly, many believe that a planned cesarean is the safest way for their baby to be born and for their own bodies to be protected.

And there it is - that word safe again. And I tried so hard not to use it.

You see, I told you - it's a very dangerous word...

(On a serious note, I repeat - I do not advocate that a planned cesarean is a 'safe' birth choice. There are undoubtedly serious risks involved that each woman must be informed about. However, I maintain that the exact same statement is true of a planned vaginal birth, wherever and however it takes place.)

NICE Stakeholder Caesarean Comments Submitted - Back to Blog

2011-06-26T17:02:00.002+01:00

As always, I seem to have a backlog of stories and medical studies to report on here. On this occasion, my time has been largely consumed with reading around 600 pages of the NICE Caesarean Guideline Update Draft, and preparing detailed feedback for the Guideline Development Group before they agree the final text.

This is such an important Guideline Update for maternity care in the UK - not only in terms of maternal request, but for the health and welfare of ALL mothers and babies who enter hospitals here.

I will update this blog with latest cesarean news shortly.

C-section Caps Cost Lives and Money

2011-06-12T21:32:00.001+01:00

I was appalled to read this story in the Express this morning, "Op Cutbacks Put Mothers At Risk".

In it, Lucy Johnston writes: "The Sunday Express has learned a growing number of health authorities have said they will not cover the cost of caesareans if they exceed the national average of 23 per cent. They will instead pay only the rate for a normal delivery, which means hospitals could lose up to £1,300 each time."

And I couldn't agree more with some of the comments quoted in the report:

"Nick Morris, a top consultant obstetrician, said: “This could put the lives of mothers and babies at risk. Financial considerations should not be allowed to interfere with clinical judgment.”

"Professor Sabaratnam Arulkumaran, former president of the Royal College Obstetricians and Gynaecologists said: “It is wrong to set these targets without recognising that one reason caesarean sections are on the increase is because we are dealing with more complex cases such as obese women who develop problems and then need an op to deliver their child."

This is the comment I added to the article:

"This is exactly what I've been warning for years - there is an unhealthy obsession with 'cesarean rates', and it is endangering the lives of mothers and babies. In terms of cost, you only need to look at the NHS Litigation Authority figures to see how much we end up spending (hundreds of millions of pounds) trying to avoid and delay life-saving c-sections. This 'national average' 23% target is a disgrace."

Where is it happening?

According to the report, this target of achieving a 23% cesarean rate in its hospitals (despite there being NO evidence-based research that indicates 23% as an optimum rate) has already been announced by primary care trusts in Surrey, Kent and Sussex, and now NHS South West London is adopting the same approach.

When, oh when, will this obsession with the ''cesarean rate'' number be eclipsed by a more healthy obsession with gathering high quality data on different cesarean types, and ensuring that women have healthy and satisfactory (read: live, healthy baby and mother) birth outcomes?

Breech Birth Choice or Pressure?

2011-06-12T15:02:00.002+01:00

Many women have complained that when they wanted to try to deliver their breech babies vaginally (e.g. using ECV), they have been pressured into having a planned cesarean by their doctors.

Obviously, a percentage of these women would have been successful in their trial of labor, and therefore it's good that the SOGC has published guidelines that may help women like this in the future.

In an article that was originally published in 2009, but updated this year (C-section not best option for breech birth), André Lalonde, executive vice-president of the SOGC, said: “Our primary purpose is to offer choice to women”.

But let's hope that the pendulum hasn't swung too far the other way now, and that women who would be more confident having a planned cesarean for breech presentation (as I was) are not being denied this entirely legitimate choice.

Why am I worried?

Because in the same article, while talking about birth plans more generally, Dr Lalonde says: “The safest way to deliver has always been the natural way,” and “Vaginal birth is the preferred method of having a baby because a C-section in itself has complications.”

And the report continues: "The SOGC believes that if a woman is well-prepared during pregnancy, she has the innate ability to deliver vaginally."

This doesn't say 'choice' to me, and given that it was a recent Canadian study (comparing breech babies born via planned cesarean with cephalic babies born following planned vaginal birth) that found better outcomes with babies born via cesarean, it will be interesting to see what happens if women are actively discouraged from planning cesareans for breech births.

Devastating story in BMJ today: 'Living with obstetric fistula'

2011-06-10T23:40:00.002+01:00

This is why I often say that there are TOO FEW cesareans in many parts of the world. Published in the BMJ on 9th June, 2011, 'Living with obstetric fistula' is a must-read for anyone who doubts the need for more obstetric care in the developing world.

And for those doubters who refuse to believe or accept that natural birth can have a devastating impact on the pelvic floor - remember that while this level of injury is the most rare, there is a whole sliding scale of damage that occur in women.

If we don't inform women of this potential risk when they are planning their births, then they are not equipped to make a truly informed decision.

Maternal Request Children LEAST Likely to Develop Psychopathological Problems

2011-06-07T01:41:00.006+01:00

"The likelihood of childhood psychopathological problems may be the lowest in children born by CDMR (cesarean delivery on maternal request), followed by those born by SVD (spontaneous vaginal delivery), whereas the highest probability was observed in those born by AVD (assisted vaginal delivery)."

This conclusion appeared in a Chinese study published in November 2010, when at the time (frustratingly), I was too busy finishing my book (with Dr Magnus Murphy) to write about it.

As is so often the case with 'positive' cesarean news stories, it didn't get the same level of media attention that 'negative' stories usually receive, yet "Caesarean delivery on maternal request and childhood psychopathology: a retrospective cohort study in China" (by authors: Li H-T, Ye R, Achenbach T, Ren A, Pei L, Zheng X, Liu J-M) certainly makes for very interesting reading.

It covered 18 counties and 3 cities in China, and included a total of 4,190 preschool children whose emotional (internalising) and behavioural (externalising) problems were assessed.

Differences were Significant

The authors concluded that: "The likelihood of childhood psychopathological problems may be the lowest in children born by CDMR, followed by those born by SVD, whereas the highest probability was observed in those born by AVD."

Why should you care?

Cesarean rates in China have been reported as 46%, with a quarter of these being on maternal request; and so this makes the study important. In many other countries, maternal request is so infrequently cited as an indication for cesarean surgery that it's very difficult to properly analyze this birth type.

Now, before anyone suggests that I'm suggesting this - I am NOT suggesting that this study is a reason for all pregnant women to run out and schedule a cesarean.

Firstly, this is a relatively small study, but secondly, it's also only a small part of a whole range of risks and benefits that you might want to consider when planning the birth of your child. Your perception of each risk and benefit will differ from the next person's.

But what the study DOES SUGGEST, is that the traditional data analysis we've seen in past research (that used mixed cesarean birth type outcomes) - where (all) 'cesarean births' were associated with various health problems later in life - may not be as reliable as once thought, and is certainly not a reason to criticize maternal request surgery.

School asks parents how child was born - cesarean or vaginal?

2011-06-07T00:20:00.001+01:00

Yes - as part of its elementary school application process, Dry Creek School District in California is reported to have asked parents how their child was born.

You can read the story in full at CBS' School Application Criticized For Birth Questions, but as the reporter says, unfortunately there is no word yet from the school district.

What I'd like to know is this - does the application only differentiate between vaginal and cesarean - or does it separate the birth types into (e.g.) planned versus emergency cesareams, and spontaneous versus assisted vaginal?

I doubt it, given that even many hospital records and birth research papers often fail to do this - but whatever the rights and wrongs may be about this school disctrict's methods of screening pupils, and whatever it is they may or may not be trying to determine by asking this question, its completely pointless if 'cesarean' and 'vaginal' are the only two options for parents to tick.

Frederick Leboyer on Natural Birth - A Must Listen

2011-06-03T00:39:00.003+01:00

BBC Radio 4's Woman's Hour: "The French obstretician, now aged 92, discusses the influence of his landmark 1975 book Birth Without Violence."

This is just a short interview that played on Woman's Hour on 31 May, 2011, and well worth a listen - just prepare for your mouth to drop open wide very early on and probably stay like that way right the way through to the end.

Why I Chose To Have An Elective C-Section

2011-06-03T00:29:00.004+01:00

I just had to comment on this article by canadian author Rebecca Eckler. Here's what I wrote:

This is a great post, thank you.

May I just add that there are also women who choose to plan a cesarean birth because they've made an informed decision - and not just out of fear.

There are risks and benefits with every birth plan, and what more and more studies are showing now is that a planned cesarean birth plan is not actually more risky - or costly - than a planned vaginal birth (given that many of the latter end up as emergency cesareans and instrumental deliveries - not to mention court cases).

Like you say, this 'too posh to push' tag is completely overused, and misses the point about informed decision making. Also, women are not so much posh as they are rich enough to pay privately when the state health system says 'no' to their maternal request.

I've always described my decision to plan cesarean births for our two children as having genuinely believed it to be the safest option for our babies. As for fear, I've also said that had I been pregnant a century earlier - or even just 50 years earlier - I most probably would have feared labor, but for the whole of my adult life, I've known that cesarean surgery was available, and I had no doubt in my mind that this was what I would have (barring my baby being born in less than an hour of course, which is how long I had to hotfoot it to my OBGYN in the event of premature labor).

Tokophobia is a genuine fear, and one that should be recognized, respected and supported. Just please (UK and Canada), don't waste tax-payers' money forcing women like me to go through antenatal counseling and therapy when our mental state has nothing to do with our cesarean birth plan decision - rather, it is our educated and informed preference.

Forgotten Cost of NHS Birth Litigation

2011-05-30T16:22:00.002+01:00

This is the comment I've just posted on an article in The Sun today: NHS pays out for 750 £1m blunders.

"Litigation is a cost of childbirth that is rarely included in cost comparisons between different birth plans.

It's so easy to state that a planned cesarean birth is more costly than a spontaneous vaginal birth, but the truth is that when you take into account the real cost (financial and psychological) of all PLANNED vaginal births (and all their actual outcomes - good and bad), a planned cesarean birth is not necessarily more costly for the NHS.

In addition to litigation, there are also costs of trauma counselling, pelvic floor repair and treatment for other (infant and mother) birth injuries, which should be attributed to the cost of planning vaginal births."

Study: Exclusive Cesarean Birth Reduces Incontinence Risk

2011-05-14T22:39:00.001+01:00

This latest study has been reported on Reuters under a rather different headline: "Choosing C-section may not prevent incontinence"... Hence my comment below:

It's incredible that even this research, which clearly adds to the body of evidence demonstrating prophylactic benefits with planned cesarean birth, should be presented in as negative a way as possible.

"Having a Cesarean section may not lower a woman's chance of incontinence later in life -- unless she delivers all of her children that way."

I chose a cesarean birth with both of my children, and the potential protection of my pelvic floor was certainly a factor in making my informed decision. So many birth advocates persistently downplay the risk of pelvic floor damage (including incontinence but also pelvic organ prolapse) when informing women about the risks of planning a vaginal birth, and yet this study adds to an existing body of evidence - highlighting an increased risk.

It is very interesting to me that this undeniably 'good cesarean news' should be presented here in the style of a back-handed compliment, and I would suggest this as an alternative headline:

"Giving birth exclusively by cesarean may lower a woman's chance of incontinence later in life".

Finally - it would be useful to report on the difference in this study (if the information is available) between women whose cesareans were planned and those who had emergency surgery, as this is likely to make a difference in health outcomes too.

Knee-Jerk Comments Criticize Cesarean Cost

2011-05-11T14:12:00.002+01:00

I praised the Baltimore Sun's article on cesarean satisfaction rates (May 7, 2011), but others have been roundly criticizing it. The latest comment, titled "Before praising C-sections, consider the cost" (Rosalind Ellis, Baltimore) concludes that if women choose a cesarean, then they should jolly well pay for it themselves.

This was my response:

A prophylactic, planned cesarean birth (on maternal request with no medical or obstetrical reason) at 39+ weeks' gestation has been shown in studies to be no more costly that a planned vaginal birth.

Unfortunately, this fact has not been widely publicized. Traditionally, cost comparisons of different birth types have only compared actual (not planned) outcomes, and costs in the immediate intrapartum period. But in fact this does not provide us with a true comparison.

As you know, planned vaginal delivery requires the availability of 24-hour emergency surgery in case a cesarean is required. A significant number of births are not spontaneous deliveries - they require assistance (e.g. ventouse, forceps and/or surgery), and there are costs attached to these that are often simply ignored when we examine how much vaginal birth truly costs.

Also, there are long term costs that should not be ignored. Litigation bills, paid for by the tax-payer, are an enormous cost, and usually occur as a result of mistakes made during a trial of labor. How many times have you read in the news about multi-million dollar settlements because a cesarean was not carried out on time or not carried out at all?

Similarly, the cost of repairing injuries that occur during planned vaginal births should not be ignored. When a child is injured (e.g. Erb's Palsy), these costs are attributable to the vaginal birth, and when perineal or pelvic floor damage occurs in the mother, which requires further surgery/hospitalization - again, these costs should be properly attributed.

I planned my cesarean because I felt that it was safest for my baby and less damaging to my own body. This birth choice may be perceived by some as an 'unnecessary' lifestyle choice because they do not understand, appreciate or respect the prophylactic benefits behind my decision, but I believe that it should be funded by the tax-payer - in exactly the same way that medical support for other birth choices (and indeed other lifestyle choices - smoking, drinking, over-eating etc.) is given.

Tougher Nuts to Crack than Cesarean Rates

2011-05-09T22:54:00.006+01:00

The irony in this article (Obesity, elective cesarean contribute to U.S. maternal mortality rate, by Robyn Carlisle, MSN, CNM, WHNP, May 9, 2011) is astonishing, and its headline does little else but feed the anti-cesarean frenzy that it is taking place amongst many birth advocates around the world.

Irony no.1:

In the developing world,
women are dying in childbirth because there are too few cesareans being carried out, in areas where women have little or no access to emergency obstetric care (and indeed planned obstetric care, in cases where this would be beneficial too). Meanwhile, in the U.S., the maternal mortality rate is not declining to a level comparable with many other developed world nations, and therefore, as so often happens, it’s the rising rate of cesareans being blamed.

Irony no.2
So very often, articles that juxtapose rising cesarean rates with low maternal mortality ranking in the U.S. fail to acknowledge or even mention obesity as a significant contributing factor. This article DOES concede that obesity is an issue – but then couples it with the cesarean type that has consistently been shown in research to be much safer than its emergency counterpart.

If indeed maternal mortality in the U.S. has been found to be most attributable to ELECTIVE cesareans - as opposed to emergency cesareans (you cite the CDC as listing elective cesareans specifically as a "possible" contributing factor but no reference is provided), then I wonder whether these might include elective cesareans for medical or obstetrical reasons, or repeat cesareans following primary surgery for medical or obstetrical reasons?

In fact, - and we know this from studies in countries that more effectively separate their cesarean data (i.e. elective versus emergency) - maternal mortality occurs more frequently following emergency surgery, not planned. Furthermore, we must not forget that emergency cesareans are an outcome of PLANNED vaginal deliveries.

Finally, and interestingly, one thing this article does not mention at all - but what I would suggest is the more obvious and ominous challenge facing maternal mortality reduction in BOTH the United States and the developing world – is the number of women dying who are poor and less educated. It really doesn’t matter what a whole nation spends on its healthcare if those dollars are not fairly distributed.

In my opinion, the prevention of maternal mortality will NOT be effectively tackled by the arbitrary reduction of cesarean rates, and certainly not by targeting elective cesarean rates in particular (which are rising in part due to maternal request of course). Cesarean rates are a politically soft target. In contrast, evolutionary conditions, – big(ger) babies, small pelvis, heavier and older mothers – and sociological challenges are the far tougher nuts to crack.

Moms who planned C-sections report high satisfaction, study says

2011-05-07T21:13:00.003+01:00

I have just posted the following comment on this article, "Moms who planned C-sections report high satisfaction, study says" in the The Baltimore Sun (dated May 8, 2011), which begins: "Research adds a new perspective to complex view of Cesareans...".

Firstly, thank you to Meredith Cohn for being one of the first journalists to cover this
new research. There is actually a growing number of studies demonstrating very positive outcomes (for babies and mothers) with planned cesarean birth, but unfortunately, it is often negative cesarean news that receives the widest coverage.

This U.S. research is in fact the latest in a series of studies that have shown the same result with planned cesareans (and more specifically, maternal request cesareans). And that is:- these mothers report a greater level of satisfaction and psychological wellbeing than mothers who planned a vaginal birth.

(This is in fact the research that I referred to in my letter to the British Medical Journal, which was published in its weekly magazine in April, 2011)

Cutting Planned C-Sections Cuts Choices, not Costs

2011-05-06T22:48:00.002+01:00

It's the same story on cesareans in Canada as we have here in the UK - full of misunderstanding about the very different risks of planned and emergency surgery, and a determination to reduce the numbers of the safest (and often WANTED) kind while doing little or nothing to address the riskiest (and naturally unwanted) kind.

On top of which, these experts think they're going to save money like this - of course they completely ignore costs like litigation and birth injuries in their calculations...

Read more at the Vancouver Sun article - Cutting C-sections cuts costs, medical risks: article (Kim Covert, May 6, 2011)

You Are What You Eat or How You Were Born?

2011-04-30T16:23:00.007+01:00

Could the way you were born REALLY influence your BMI?

Let me first caveat this post with the fact that I have not read the full text of this new study from Brazil, which states in its conclusion that: "We hypothesize that increasing rates of cesarean delivery may play a role in the obesity epidemic worldwide."

It reminds me of an American study reported by the BBC back in August 2005 - "C-section 'baby teeth decay risk'", in which a connection was made between children with tooth decay and being born by cesarean. Lead researcher Dr Yihong Li was quoted as saying, "C-section babies have less bacterial exposure at birth, and therefore less resistance."

However, "he also pointed out that the C-section mothers in the study also had higher levels of tooth decay, a history of sexually transmitted infections and low family income, all of which could have contributed to the findings."

The Real Risk Factors

So the children worst affected by tooth decay also had mothers with tooth decay, and came from low income homes, where - in a country with an ever-increasing rate of obesity - we know that high fat and high sugar meals are often given to children.

And now we have a new study from Brazil (lead researcher Helena AS Goldani) that begins, "Obesity is epidemic worldwide, and increases in cesarean delivery rates have occurred in parallel", and then sets out its objective to "determine whether cesarean delivery is a risk factor for obesity in adulthood".

It's incredible - I mean, what will researchers try and blame the cesarean for next?

Cesareans Are Not Born Equal

As I say, I haven't read the full details of this study, so perhaps the fact that the obesity rate in adults born by cesarean was 15.2% compared with the 10.4% of those born by vaginal delivery IS conclusive of such a connection. But I genuinely doubt it.

Aside form anything else, there seems to be no distinction (as is often the case in cesarean studies) between different cesarean TYPES - planned versus emergency for example.

This type of research and the headlines it creates can often prove rather unhelpful in the cesarean debate.

A Convenient Cesarean?

2011-04-26T23:48:00.003+01:00

Scheduling your cesarean

Today I came across a question that had been posted on a website for birth doulas to answer 'yes or no' to, and it struck me (as it always does when I see maternal request cesareans being discussed in this context) how irrelevant and uninformed it is:

"Should women be able to choose elective cesarean for convenience?"

Of course they shouldn't.

But the vast majority of women who request a planned cesarean birth are NOT doing so out of convenience, and even those who do cite convenience when asked, it's usually only as a secondary or associated benefit of surgery - not the primary one. Concern for their baby's health and protection against possible damage to their own bodies are far more important to them than convenience - as is an aversion to or fear of the natural birth process.

Furthermore, this focus on debating 'cesarean convenience' insults the intelligence and ethical standing of the many doctors who support maternal request. Certainly, there will be cases of women and doctors who schedule cesarean surgery in and around busy diaries, but it is very well established in medical studies that cesareans should not be carried out before 39+ weeks' gestation unless there is a specific medical or obstetrical reason for doing so, and again, the vast majority of doctors will abide by this.

Therefore, if you're going to vote on or discuss the clearly controversial issue of maternal request cesareans, at least word the question in a way that doesn't leave the author of this blog wanting to vote 'no' to something that - if worded correctly - I would normally find myself answering 'absolutely, yes!' to.

For example:

"Should a woman planing a small family be able to make an informed decision to choose a prophylactic elective cesarean at 39+ weeks' gestation?"

P YES

BMJ letter printed: Midwife led care may not be appropriate or cost-effective

2011-04-18T13:58:00.001+01:00

Following on from the publication of The King's Fund report in March, my letter to the British Medical Journal: "Positive birth experience: Midwife led care may not be appropriate or cost-effective" has been published in this week's print edition (April 18, 2011) and also online.

This was my original (longer version) letter,
which was published online only on March 7, 2011:
"Midwife led care is not appropriate for all low risk women, and its cost-effectiveness is not proven".

Concern Over "The Big Push" in Liverpool

2011-04-15T15:58:00.009+01:00

The Liverpool Echo has reported on "a £10m vision to transform maternity care on Merseyside", with Liverpool Women’s Hospital in Toxteth calling it “The Big Push”.

According to the report, "Trish Dunmore, general manager for maternity at the Women’s, said: “The Big Push is about reviewing our model of maternity care to make the best use of our resources and to give a better quality of service to mum’s”."

My Concern

Apparently, "women who have had a caesarean section can now access a special clinic which will help they weigh up the benefits and risks to delivering naturally."

I could be wrong (and clearly have no evidence of this), but given what I already know about the way risks and benefits of primary planned cesarean birth (versus planned vaginal delivery) are presented to women, I am concerned that this clinic might 'push' women down the VBAC route.

I trust that this will not be the case, and maybe it's just the English Literature graduate in me, but I still can't help thinking how unbiased an information clinic might appear if it was borne of an initiative called "The Big Slice"...?

The Big Irony

Just two days earlier, another Liverpool Echo report told the story of a mother who gave birth to a "giant baby girl weighing 12lb 5oz", which the mother describes as "painful towards the end, she got stuck and they had to get help".

Nothing shocking about that you might think. But then you read on:

"Staff said Darcy was a very lucky baby, because she had already taken all the nutrients from the placenta and may not have survived if the labour had come any later."

So what thankfully turned out to be an interesting little news story - with the accompanying picture of smiling mum and baby - could have been an entirely different news story altogether... and one likely to have included quotes from their lawyer.

Bigger mothers, Bigger Babies - A Bigger Push?

I've written about this many times on this blog and on my website, but the fact is that pregnant women are getting heavier and older, while their babies are getting bigger. This is causing a well-documented challenge in obstetrics.

And yet so many professionals seem to think that the solution to this maternity crisis is simply to increase numbers of midwives and reduce cesarean deliveries. Maybe you're not concerned that maternity hospitals around Britain are in danger of sailing too close to the wind - and potentially putting the lives of women and babies at risk - in their efforts to reduce cesarean rates, but I am.

Yes, I want perfectly healthy pregnant women to have access to a prophylactic cesarean birth plan if that is their informed decision, but I'm just as concerned about women who have no such preference but who may be being misinformed about the true risks and benefits of different birth plans, and pushed in entirely the wrong direction.

Incidentally, last October, the Liverpool Echo also reported on the "Huge rise in Liverpool obesity rates". It said that the "amount of obese people in Liverpool rocketed during the past year [the fifth highest increase in England]", rising to 45,843 adults.

Cesarean Rates Up, Stillbirth and Neonatality Mortality Rates Down

2011-04-04T15:45:00.003+01:00

And that's a headline you're unlikely to read anywhere else today...

CMACE (Centre for Maternal and Child Enquiries) has published its latest report: Perinatal Mortality 2009, and reported that since 2000, stillbirth and neonatal mortality rates in the United Kingdom have shown a downward trend.

Now, although we also know that cesarean rates during this time have shown an upward trend, I'm not going to sit here and make an absolute connection between the two - but I guarantee that had the CMACE report reported the opposite news today (i.e. increasing stillbirth and neonatality mortality rates), virtually all commentary in the news would have mentioned the fact that cesarean rates are also rising.

The Data: In 2009 there were 790,781 live births in the UK.
There were 4,125 stillbirths, 6,070 perinatal deaths and 2,511 neonatal deaths.

RCOG press release: Dr Tony Falconer, President of the Royal College of Obstetricians and Gynaecologists said, “Every stillbirth is a tragic event. This report highlights a promising downward trend of perinatal mortality over the last ten years. However, worryingly, the numbers of perinatal deaths linked to rising obesity is high.

“Maternal obesity is a key public health concern and pregnant women who are obese need to know about the possible risks to them and their baby. The ideal situation of course would be for women to maintain a healthy weight before they fall pregnant to ensure the best outcome for them and their babies. Therefore, it is vitally important for women to be encouraged to lead healthy lifestyles throughout their lives and they can get good information from their GPs on diet, nutrition and exercise.”

I have more confidence in doctors and machines than in midwives

2011-04-03T15:25:00.003+01:00

My son's birth in 2009

The statement above is undoubtedly controversial, but speaking personally, it is nevertheless true.
Many midwives do a great job, and if I had no access to hospitals or medical intervention, then absolutely, I would not have wanted to give birth alone, and would have been eternally grateful for the knowledge and expertise of a midwife by my side.

But in the 21st Century, with all its medical advances,
I simply felt more comfortable placing my trust - and the health of my unborn babies - in the information that ultrasound scans could provide, and the hands of my obstetrician who would ultimately carry out my cesarean delivery. I didn't trust Mother Nature in the slightest, and I wasn't interested in doing everything naturally, which is essentially what midwives specialize in.

BMJ response

Therefore, I am very concerned that the recently published King's Fund report in the UK: 'Staffing In Maternity Units' has recommended that midwife-led models of care should be deployed across the NHS for low- and medium-risk women. As such, I have just published a Rapid Response in the British Medical Journal, titled: "Midwife led care is not appropriate for all low risk women, and its cost-effectiveness is not proven".

I don't wish to be interpreted as someone who is "anti-midwife" - I'm not.

But I was a "low risk" woman (up until late in pregnancy when breech presentation was discovered) and personally, I felt no desire or need to meet with a midwife - and because I was in the U.S. at the time, I didn't have to). But had I been pregnant in the UK, I would have had a battle on my hands - a battle to choose an obstetrician-led model of care, which would have far better suited my informed birth plan:

An elective, prophylactic cesarean.

This is the situation that women who contact me at my wesbite are increasingly coming up against, and it makes no logical, ethical or financial sense. Please sign this petition if you agree.

I am finishing writing a book on cesarean birth - hence recent blog silence

2010-11-09T21:42:00.004Z

Apologies to all for my blogging absence, but please rest assured that I have been saving recent cesarean stories and medical research to blog about, which I plan to post once the book is finished.

I am writing this book together with Dr. Magnus Murphy, and our publisher is Prometheus Books. Further information to follow...

Maternal request is not a myth

2010-10-09T22:03:00.003+01:00

There have been a number of media reports in response to the publication this week of the study, 'Variation in rates of caesarean section among English NHS trusts after accounting for maternal and clinical risk: cross sectional study' by Bragg et al.

Below are a few examples of these stories, plus the comment I have posted in most of them:

*Who's Too Posh to Push? High Cesarean Section Rates Aren't Moms' Fault, TIME.com
*Too posh to push mums 'a myth', nhs.uk
*High caesarean rates are not down to women being 'too posh to push', The Telegraph
*Wide variation in Caesarean rates in UK, hc2d.co.uk

My comment

Aside from the fact that persistent use of the derogatory term ‘too posh to push’ is both irrelevant and unhelpful in discussions about whether women are choosing a caesarean birth plan, the idea that this study has exposed it as a myth is flawed.

The authors write: “It seems unlikely that maternal request in the absence of any clinical indication contributes substantially to the rates.” This is not the same as saying that maternal request is not contributing to the rates ‘at all’ or that women choosing caesareans is a myth. As far as I am aware, no media report as yet has actually cited the number (or percentage) of non-medically indicated caesareans found in this study, and I have contacted the authors for further clarification of this precise figure.

As it stands, the current estimate of rates of caesarean delivery on maternal request is around 5% of all births. This is clearly a very small number. However, it is more than double the number of women who request a homebirth, and yet these women and their birth choice are afforded greater support and respect by many birth support groups and the Department of Health.

As a final point, here are some other reasons why this study (which analysed routinely collected hospital episode statistics and did not involve any interviews with women or doctors) does not provide categorical proof that women are not choosing caesareans themselves or that caesareans in the absence of any clinical indication are not contributing to overall caesarean rates:

1) A medical indication and maternal request are not mutually exclusive. Anecdotally, I chose to plan a caesarean for both my births but my hospital data reads ‘breech presentation’ for the 1st (as this was discovered in the 8th month of pregnancy) and ‘repeat caesarean’ for the 2nd. I have also been contacted by other women via my website whose situation is the same.

2) It is not unknown for a medical indication to be cited by doctors on a woman’s records rather than draw attention to the more controversial indication of maternal request.

Please note that this comment is not in any way a criticism of the study itself or its authors; only the wider interpretation of maternal request caesareans that is being reported. In fact, the study itself presents extremely useful data and suggestions for NHS trusts going forward.

WHO non-medical cesarean study under spotlight again

2010-08-21T08:39:00.002+01:00

Nigel Hawkes has written an opinion piece in The Independent today, 'Peer-reviewed journals aren't worth the paper they're written on', in which he refers to the WHO's cesarean study that I wrote about back in January.

He writes: "A few months ago, I wrote in this column about a study in The Lancet of which I took a dim view. It claimed that Caesarean operations undertaken without medical cause were nearly three times as likely to cause death or complications to the mother as a normal birth. The evidence fell miles short of proving this claim.

Others shared my view, and one of them, Penny Christensen of Birth Trauma Canada, complained to The Lancet. Rebuffed, she sent them my analysis to support her claim. In reply, an editor wrote to her with the disparaging remark: "We are a scientific journal, and as such prefer to see the scientific debate continued by reference to other academic articles that have been peer-reviewed."

Ms Christensen's complaint has now gone to The Lancet's ombudsman, and we'll see if he shares the attitude that only the peer-reviewed are entitled to have their opinions properly considered."

I have just submitted this comment:

"I have also complained to the Lancet Ombudsman about the cesarean delivery study Nigel mentions above, and together with other references, cited his statistical analysis (and criticism) of it in my letter.

As a journalist, my confidence in the peer review process was knocked after the publication of "Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007-08, Lumbiganon et al", since I struggled to understand how such inconsistency between actual data gathered and final interpretation drawn could be accepted by reviewers for publication. I wrote about it on my blog in January this year.

I still believe peer review is a good thing, but I agree that criticism and open debate of a particular study or collection of studies should not be stifled by a requirement that all references referred to in any argument be peer reviewed first too."

Pauline McDonagh Hull
Editor, electivecesarean.com

It's not just an issue of Maternal Request

2010-08-10T20:55:00.003+01:00

I probably spend most of my time writing about maternal request cesareans, and have certainly dedicated the last six years of my life to helping make the decision to request surgery a more widely respected and accepted birth plan.

However, more and more I'm just as concerned for the health and safety of women (and their babies) to whom the thought of requesting a cesarean would never occur, but who are not being properly advised of the risks and benefits of surgery versus a trial of labor as they relate to their personal circumstances.

There are numerous cases (most often highlighted in litigious court cases after the birth) when risk factors for vaginal birth problems that surface during pregnancy and/or labor are ignored or downplayed.

Birth involves risk
Stillbirth, severe injuries for the baby, debilitating pelvic floor injuries for the mother and post traumatic stress are just some of the outcomes that can result when an ideological natural birth plan is prioritized over and above timely medical intervention.

And it's one thing if the woman WANTS a natural birth plan - in other words, vaginal delivery was her maternal request - but quite another when the woman is ambivalent about the birth plan. She just wants a healthy baby and to feel satisfied at the end of it, and relies on her midwife or doctor to arrive at that outcome.

I know that I'm on record as saying that I believe a planned cesarean delivery at 39+ weeks is the safest way for a baby to enter the world, and that's the main reason I had cesareans for my two children, but as I've also said, I completely respect the choice of women who believe that a trial of labor is the best way to go.

What concerns me now is that in an attempt to protect the interests of women who WANT a vaginal delivery, the interests of women who WANT a cesarean and women whose best interest it would be to schedule one for medical reasons (and they don't mind either way) are being put at risk.

For example, we know that studies exist that show better outcomes with elective cesarean delivery in cases of breech, twin, macrosomia (big baby) and repeat cesarean versus VBAC. But there are some women who feel confident about their chances to labor naturally and who want to have that option but feel like they are being forced to have a cesarean. They feel very much wronged and campaign against what they perceive as unnecessary surgery.

Well, two wrongs don't make a right. Forcing a woman to attempt labor when she clearly wants a cesarean or advising a trial of labor in cases where a cesarean has been shown to have better outcomes (and then not reacting properly if/when things begin to go wrong) is dangerous. The law courts agree with this, and that's why usually, when serious problems arise, somebody is made to pay.

But there are thousands and thousands of cases that never even make it to litigation, where women are left physically abandoned and psychologically destroyed by a birth experience that in the event, didn't live up to its entirely unpredictable expectations.

My advice to women?

DO YOUR HOMEWORK.
EDUCATE YOURSELF.
PREPARE QUESTIONS.
DEMAND ANSWERS.
TRUST YOUR INSTINCT.

...whatever your birth plan...

BMJ Letter published: ACOG wants to allow, not urge, more VBACs

2010-08-04T21:04:00.002+01:00

My letter, published in the British Medical Journal on 4th August 2010, was in response to the publication: 'Urge more women who have previously had a caesarean section to have vaginal delivery, experts say', by Bob Roehr.

It says:

The title of this article reads, ‘Urge more women who have previously had a caesarean section to have vaginal delivery, experts say’.

But this is not what the American College of Obstetricians and Gynecologists' July 2010 press release says.

Rather, ACOG says that ‘restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will’.

These two statements are entirely different, and it is important that we recognize this. Patient/maternal autonomy is not about urging a group of women to have one particular birth plan; it is about allowing them to make their own informed decision.

Also, the opening sentence of this article is not entirely accurate.

Like so many reports of ACOG’s updated VBAC guidelines, Roehr’s choice of words, ‘Doctors in the United States have emphasised the safety of vaginal delivery for women who have had one or two previous caesarean sections’, omits the crucial word ‘most’, and this dangerously changes the message intended.

In fact, ACOG says, ‘Attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans.’

That’s ‘most’ and ‘some’ women. Not by any means ‘all’.

Unfortunately, some of the confusion has arisen from ACOG's decision to talk about the ‘importance of patient autonomy’ in the same context as the desire ‘to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate’. But who and/or what will decide when this ‘reasonable’ rate has been reached?

Certainly, if ACOG's decision to change the wording in its VBAC guidelines (to reflect that ‘quickly gathered’ rather than ‘immediate’ emergency care should be available in case uterine rupture occurs) helps more women who desperately ‘want’ a VBAC, then this is a good thing.

But it's equally important to remember that many women will prefer to have a repeat cesarean, and will be completely happy with their choice. This is because although ‘approximately 60-80% of appropriate candidates who attempt VBAC will be successful’, this means that 20-40% of women with the BEST chance of success will STILL be unsuccessful.

Therefore, women’s birth plan decision to have a repeat cesarean should not be refused or disrespected in a misplaced attempt to ‘swing the pendulum back’.

Perhaps if, instead of target rates, we let patient autonomy take a greater role in maternity care... if we provide women with the risks and benefits and let them decide which birth plan they prefer... if assessment of birth outcomes includes maternal satisfaction... then the rates will fall where they will, and more women and babies will be happier and healthier for it.

Worrying mahurat cesarean trend in India

2010-07-29T13:30:00.003+01:00

'Are you planning a mahurat C-section?' asks Zeenia Baria in The Times of India today.

Baria reports on a worrying trend for some planned cesareans in India, and that is the decision by couples to insist on a particular time and date for the birth of their babies. It's unclear from the report whether parents are being influenced within days or weeks of their advised delivery date, but if it's the latter, this can mean serious health consequences for a newborn baby (e.g. respiratory distress).

"Obstetrician, Gynaecologist and infertility specialist Dr Faram Irani says... “Unlike the West where women request for a c-section because of the pain associated with vaginal birth or fear of damage to the pelvic floor; in India many c-sections are performed on the basis of mahurat..."

What do they hope to achieve?
"Longevity, health, marital harmony, career prospects, eclipses and domestic peace of the offspring are the biggest motivators for such couples. The astrologer formulates the most auspicious time for delivery after asking the would-be parents for the tentative delivery dates, place, time zone and DST (daylight saving time). Due to the astrological factors involved, the mahurat differs for every couple. Although they cost more than double, deliveries at sunrise are among the most auspicious."

"Gynaecologist Dr Rishma Pai Dhillon says that the trend of having mahurat babies or a planned caesarean section on an auspicious date, is getting increasingly popular among patients and is giving doctors a headache because it comes with its share of complications.

“I recently had to rush to the hospital at an unearthly hour to deliver a mahurat baby. If one refuses, one is flooded with phone calls from senior politicians and affluent bureaucrats to oblige. Mahurat babies or mahurat c-section is a controversial trend that middle and upper class women across the country are increasingly opting for. It involves planned deliveries and surgical caesarean sections in the hopes of having babies on a specific date and time predicted lucky by their astrologers. Families are so particular about the exact time of delivery that they create a ruckus if the previous surgeon is delayed in the operation theatre. This puts tremendous stress on doctors. It isn’t fair to hurry up such a delicate procedure,” she says.

“The reasons for having a mahurat baby are often credulous. One patient’s astrologer said that if her child was delivered at the right time, it would be a fair-skinned boy, who would look after his parents in their old age. How can the time of delivery change a baby’s gender, which is decided at conception itself!” asks Dr Pai.

ACOG's motivation for new VBAC guidelines disappoints

2010-07-24T21:46:00.011+01:00

The news that obstetricians at ACOG have published less restrictive guidelines for VBAC is good news for women that desperately want to avoid repeat cesarean surgery and who feel that their decision to plan a trial of labor is neither respected - or in many cases, and particularly in American hospitals, allowed.

But now for the not so good news...

First of all, I suggest that you read ACOG's press release for yourself, and then come back to read my thoughts on some of its contents, below.

ACOG PR: "Attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans..."

*Just a small observation I've made while perusing much of the media and blog reporting of this story - the number of headlines and bylines that have dropped the crucial word "most" from the sentence above. This is a very dangerous interpretation of what ACOG has said.

ACOG PR: "The cesarean delivery rate in the US increased dramatically over the past four decades, from 5% in 1970 to over 31% in 2007. Before 1970, the standard practice was to perform a repeat cesarean after a prior cesarean birth. During the 1970s, as women achieved successful VBACs, it became viewed as a reasonable option for some women. Over time, the VBAC rate increased from just over 5% in 1985 to 28% by 1996, but then began a steady decline. By 2006, the VBAC rate fell to 8.5%, a decrease that reflects the restrictions that some hospitals and insurers placed on trial of labor after cesarean (TOLAC) as well as decisions by patients when presented with the risks and benefits."

*It is important to remember that many women prefer to have a repeat cesarean, and are more than happy not to plan a VBAC, and their birth plan decision should not be refused or disrespected in this attempt to "swing the pendulum back".

ACOG PR: "The current cesarean rate is undeniably high and absolutely concerns us as ob-gyns," said Richard N. Waldman, MD, president of The College. "These VBAC guidelines emphasize the need for thorough counseling of benefits and risks, shared patient-doctor decision making, and the importance of patient autonomy. Moving forward, we need to work collaboratively with our patients and our colleagues, hospitals, and insurers to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate."

*I find it disappointing and indeed disconcerting that 'more reasonable rates' has even been mentioned in the context of patient autonomy here. What is a 'more reasonable' rate of VBAC? And perhaps more importantly, what is considered a reasonable rate of TOLAC? A 25-year-old argument over the optimum percentage rate of cesarean deliveries came to a head last year when the WHO admitted that there is no evidence for one, so who's got the answer to the 'right number' of VBACs and TOLACs?

I think that if, instead of target rates, we let patient autonomy (where patient autonomy is requested - remember, there are many women who are more than happy to be guided and advised by their doctor or midwife, with no personal delivery preference either way) take a greater role in maternity care... if we provide women with the risks and benefits and let them decide which birth plan they prefer... if assessment of birth outcomes includes maternal satisfaction... then the rates will fall where they will, and more women and babies will be happier and healthier for it.

ACOG PR: "In making plans for delivery, physicians and patients should consider a woman's chance of a successful VBAC as well as the risk of complications from a trial of labor, all viewed in the context of her future reproductive plans," said Dr. Ecker. Approximately 60-80% of appropriate candidates who attempt VBAC will be successful."

*This is important to understand. Approximately 60-80% of appropriate candidates will have a successful VBAC. This means that approximately 20-40% will be unsuccessful - a risk many women are not comfortable with.

And when ACOG's statement is misinterpreted by stating that VBAC might be safe for all women, it completely ignores the fact that the cited 60-80% success rate is ONLY for women firstly established as appropriate candidates. The success rate if all women with previous cesareans were included is much lower.

ACOG PR: "The risk of uterine rupture during a TOLAC is low - between 0.5% and 0.9% - but if it occurs, it is an emergency situation. A uterine rupture can cause serious injury to a mother and her baby. The College maintains that a TOLAC is most safely undertaken where staff can immediately provide an emergency cesarean, but recognizes that such resources may not be universally available.

"Given the onerous medical liability climate for ob-gyns, interpretation of The College's earlier guidelines led many hospitals to refuse allowing VBACs altogether," said Dr. Waldman. "Our primary goal is to promote the safest environment for labor and delivery, not to restrict women's access to VBAC."

Women and their physicians may still make a plan for a TOLAC in situations where there may not be "immediately available" staff to handle emergencies, but it requires a thorough discussion of the local health care system, the available resources, and the potential for incremental risk. "It is absolutely critical that a woman and her physician discuss VBAC early in the prenatal care period so that logistical plans can be made well in advance," said Dr. Grobman. And those hospitals that lack "immediately available" staff should develop a clear process for gathering them quickly and all hospitals should have a plan in place for managing emergency uterine ruptures, however rarely they may occur, Dr. Grobman added.

*In summary, it appears that the criteria for a TOLAC/VBAC birth plan has changed from requiring the availability of "immediate" emergency care for the laboring women, to that which is "quickly gathered".

The change of wording here is worthy of a blog post all of its own, but I mention it here because what happens in the inevitable cases of uterine rupture emergencies is crucial, and I think that while ACOG has done well to address the fundamental issues of insurance and litigation, questions remain.

How do we remove doctors' fears of being sued when a TOLAC fails? Do insurers now agree with ACOG that 'quickly gathered' emergency care is sufficient duty of care? Will women be asked to sign a waiver stating that they are fully aware of the risks of uterine rupture and its possible consequences? There are no easy answers to all this, and again, while helping women gain access to wanted VBACs is commendable, ACOG's statement might have provided more in the way of broadening discussion of these, and other, continuing challenges.

ACOG PR: The College says that restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC. On the other hand, if, during prenatal care, a physician is uncomfortable with a patient's desire to undergo VBAC, it is appropriate to refer her to another physician or center."

*As mentioned above, I applaud ACOG's efforts to help women who feel they are being given no choice when it comes to VBAC versus a repeat cesarean, but I just wish that this was the sole focus of its statement, with nothing said about the shared desire to swing the pendulum back on percentage rates. Has it occurred to anyone that when women are informed about the risks and benefits of VBAC, the number of women that actually choose VBAC may not swing the pendulum back as far as some may imagine? I guess only time will tell.

BMJ Letter published: Planned Cesarean Delivery Benefit

2010-07-22T23:01:00.003+01:00

My letter, published in the British Medical Journal on 22nd July 2010, was in response to the publication: 'Time of birth and risk of neonatal death at term: retrospective cohort study', by Dharmintra Pasupathy, Angela M Wood, Jill P Pell, Michael Fleming and Gordon C S Smith.

It says:

"The unpredictability of planned vaginal delivery or a trial of labor (i.e. the possibility of assisted delivery and/or emergency surgery) is one of the reasons often cited by women who decide to deliver their babies by planned cesarean.

This study illustrates that the unpredictable nature of the delivery outcome itself (and any associated morbidity or mortality) is not the only risk these women seek to avoid. The unpredictability of the quality of care available at different hours of the day and night when women arrive at hospital in labor is another risk they do not wish to take, especially when this might impede the safe and healthy arrival of their baby.

The 'convenience' of scheduling a time and date for maternal request cesarean delivery is sometimes criticized as an irresponsible benefit of surgery, but when looked at from the perspective of this study (and others like it), there is clearly a legitimate benefit involved in knowing exactly who will deliver your baby and when, and it has nothing whatsoever to do with convenience."

NICE decides to review Maternal Request Cesareans

2010-07-10T11:41:00.006+01:00

As you know, NICE (The National Institute for Health and Clinical Excellence) is currently reviewing its 2004 Clinical Guideline on Caesarean Delivery, and on Thursday 8th July, it published the Final Scope of what will be reviewed.

GOOD NEWS!

The NICE guideline on Maternal Request Cesareans is to be reviewed.
The draft scope, published earlier this year, had excluded Maternal Request as an area requiring review, but a number of Stakeholder organizations (including electivecesarean.com) urged NICE to reconsider at a meeting in London, and followed up with the submission of reasons and evidence to support their position.

The Final Scope reads:

"c) The original caesarean section guideline addressed issues relating to maternal request including the prevalence of request, fear of childbirth and how obstetricians should respond to such requests. In the light of new evidence and a strong concern amongst stakeholders that this area needs to be re-examined this topic will be addressed in the update."

Also now being included is a much-needed update of a table in the 2004 guideline that compared the risks of vaginal and cesarean delivery:

"d) A great deal of support has been expressed by stakeholders for the usefulness of Table 3.1 in the original guideline summarising risks and benefits of caesarean section vs. vaginal birth. Given that this table is often used as the basis of information given to women and underpins informed consent there is a need to ensure this information is as accurate and up to date as possible and therefore it will be included in the update."

Unfortunately, I was not successful in my application to be one of the Guideline Development Group (they will now review all the latest evidence and prepare the new guideline for publication), but I genuinely hope that it takes this opportunity to look at maternal request cesarean delivery with the Stakeholders' comments and concerns in mind.

Again, you can read these in detail here.