The great Caesarean section debate

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PARENTING: WHAT IS IT with Irish women and obstetricians? Most of us feel so much safer putting our pregnancy in their care. That makes absolute sense for the minority of expectant mothers who have complications. But why do the rest of us not see midwives as the experts on normal birth? It is abnormal births that are the business of consultants, ...

... “Sometimes the idea of ‘my obstetrician’ is flaunted like a Prada bag. ... I have never seen it in any other country to that degree, except in America,” says Krysia Lynch, press officer for the Association of Improvements in Maternity Services (AIMS) – Ireland.

“They feel if they get an obstetrician, somehow it is going to be safer. What a lot of women don’t realise is that what you’re doing with an obstetrician is you are getting continuity of care, that is the only thing that is different; when you are going for antenatal visits you are seeing the same person.

However, when women are in labour, they are cared for by midwives they have not met before, so there's not true continuity of care.

“But when you have your baby it is the same midwives that will deliver your baby as are delivering the public patient in the next room and I think a lot of woman feel very taken aback by this,” Lynch suggests. (Although I would have thought that at that point in labour, you should be glad that you don’t need the services of your consultant.)

There is plenty of evidence to suggest that the “medicalisation” of straightforward births increases the risk of complications, with one intervention leading to another, until an emergency Caesarean section is the best option. Some pregnant women, terrified of the pain and unpredictable nature of labour, see a planned Caesarean as the best choice from the start.

A planned caesarean can almost be guaranteed, whereas a planned vaginal birth is not a certainty. Women planning vaginal births are sometimes encouraged to also consider the possibility of a caesarean, whereas women planning caesareans are not encouraged to consider the possibility of a fast labour and natural birth. Women who plan caesareans generally want the certainty that a caesarean brings.

This ultimate intervention into the natural birth process has risen dramatically in the past 15 years.

Australia's CS rate is most likely around 35% now. It was 31% in 2006 and CS rates increase every year. Our low VBAC rate suggests that most women who have a primary caesarean will have an elective repeat caesarean for their next birth. This is contrary to the best evidence around VBAC.

According to the World Health Organisation, Caesarean sections should account for no more than 15 per cent of all births. It found there were no additional health benefits associated with a higher rate.

... There is no doubt that a Caesarean section increases the risk to both mothers and babies, when compared with spontaneous vaginal birth, and it is also significantly more expensive for the health service.

... the reasons behind this increase are much more opaque ...

... known risk factors, such as older maternal age at birth and the earlier gestational age of the child, only explained half of the increase in the rate among first-time mothers ...

... “If we are saying the section rate is too high, we have to come up with logical reasons as to how we can decrease it.”

I have a few suggestions: 1. Increase the numbers of women who receive primary midwifery care. Encourage midwifery care for all low risk and healthy women. 2. Encourage home as the normal place for birth to occur for all healthy and low risk women. 3. Provide continuity of midwifery care for all high risk women (in conjunction with obstetric care). 4. Ensure that all women having their first babies, all VBAC women and all women who have previously been traumatised by their birth, have continuity of midwifery care.

... Our maternity services certainly have an excellent safety record ... Ireland had the lowest rate in the world of women dying during or just after pregnancy – one out of 47,600 women, compared with one in 4,800 in the US ...

... the factors at play in driving up the rate of Caesarean births seem to range from medical and health policy issues to cultural and social influences.

The huge variation in rates from hospital to hospital indicates the complexities of the situation ...

... Caesarean rates range ... from a low of 18 per cent ... to 37 per cent ...

... we have no national guidelines on Caesarean section ... “If we did, and they were applied across the board, we would have possibly lower C-section rates.”

Secondly ... "We have a high birth rate, too few midwives; we have quite inadequate circumstances for dealing in proper one-to-one care for women in labour.”

She sees a third major factor being the “inappropriate” use of routine foetal heartbeat monitoring, known as CTG. Research shows that continuous monitoring of the heartbeat leads to a substantial increase in the risk of a woman having a Caesarean section.

... “More C-sections will be performed for abnormal foetal heart rates, but they may not really be abnormal foetal heart rates.”

Fourthly, there is a perception that Caesarean section is a safe and trouble-free intervention – that is a view held not only by the public but also by the consultants, she argues. “Women are not informed of complications.”

... "sometimes come to classes with the notion that maybe they would go for an elective section ... It has become sort of accepted that this would be an option. I think some women would be very glad if there was a reason an elective section had to be performed.”

She attributes much of that to fear: “They are not hearing that many good stories from their friends, their sisters and their cousins about birth – particularly birth in the current maternity services. It doesn’t really allow women to build up any degree of confidence.”

What Healy describes as “my precious baby syndrome” among older mothers is also a factor. “They have either waited a long time to have their first baby, or perhaps in some instances unfortunately it took a long time to conceive their first baby.

“People are acutely aware that they don’t have too many shots at this and they need to be taken better care of. In actual fact, Caesarean isn’t safer at all, but the general population thinks that it is.”

When she hears back from clients who have had an emergency Caesarean section, they typically talk about feeling very grateful that their baby was saved and that nothing terrible went wrong.

“That is great, except what I would often question is what went before it? Was there a cascade of intervention that is a well-known phenomenon in the medicalised birth?”

Research shows that continuity of care, typically provided in midwife-led units, and lack of time pressures, increases the chances of a normal birth.

Mothers are not caught in the following cycle: induction causing greater pain, leading to the need for epidurals, which slow down labour, that is speeded up with synthetic hormones, which result in faster and harder contractions, that may distress the baby and require a surgeon to come to the rescue.

... the way to cut the rate of Caesareans is to look at more low-tech solutions and to get more midwives in there.

“Conceiving your baby for most people is not a high-tech activity; birthing your baby also shouldn’t be,” she adds. “If we supported women, they would have a more enjoyable experience, which is a better start to motherhood.”

... the philosophy of any given maternity unit is also influential. “If you have a high section rate, you have a high instrumental delivery rate, you have a high intervention rate.”

The fear of litigation is there, he agrees, but not a significant factor ...

... In Dublin’s three public maternity hospitals, the principal increase has been among women who have had previous Caesareans ...

... “... Obstetric care doesn’t make sense, unless a woman has complications.”

She believes changes are imminent as policymakers focus on normal birth and the cost of intervention. Positive findings are coming through in research on the few midwifery-led schemes.

“In 10 years’ time I think we will be looking at a very different maternity system,” Donegan says. “But while consultants are seen to be the experts on maternity care, I think Mary Harney is going to have her work cut out for her.”

Melissa Maimann, Essential Birth Consulting 0400 418 448