The Labor Market

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Expectant parents, spare a thought for Mrs. Jacob Nufer, who in 1500 found herself in agonizing labor. More than a dozen midwives ... tended to her for days, with no sign of the baby. Facing the likelihood of losing mother and child, and in the absence of any surgeons, Mrs. Nufer's husband, a swine gelder, decided to cut her open and extricate his offspring. Because there had, at this time, been no known incidence of a woman surviving such a procedure, the couple would have said what were assumed to be their last goodbyes before Jacob Nufer made the first incision.

As it turned out, mother and baby lived. While it would be nice to say that this had something to do with Mrs. Nufer's constitution or her husband's skills with a knife, it was almost certainly because Mrs. Nufer's pregnancy was extrauterine — a freakishly rare form of gestation in which the baby grows outside the womb, in this case probably in the abdomen. Had the baby been inside the uterus ... Mrs. Nufer would have bled to death when the uterine wall was breached ... Mrs. Nufer's is generally accepted as the world's first completely successful cesarean, or C-section.

Five hundred years later, surgical delivery seems as trifling as tooth extraction. In Chile ... 40% of all births are in the operating theater. But larger populations in Asia mean that greater numbers of C-sections are performed in this region, particularly in South Korea (36.4% of all births in the first half of 2006), Taiwan (with a rate of roughly 33%) ... "I've seen statistics from Bangkok General Hospital that suggest the national rate is as high as 65% of all births." ...

Because cesarean delivery is associated with higher maternal mortality and other health issues, these figures are alarming to some medical practitioners and natural-childbirth advocates ... Their concern has been exacerbated by statistics recently released in the U.S., showing an increase in the cesarean rate ... coinciding with a rise in maternal mortality ... For every 100,000 births in the U.S. in 2003, 12.1 women died — the first time the figure exceeded 10 in 26 years. The number rose to 14 in 2004. Figures for 2005 and 2006 are being compiled. After a decade's study of cesarean birth, Professor Eugene Declercq ... cautions against giving too much weight to the cesarean-mortality connection, but concedes that "there is some evidence of higher maternal mortality rates in cases of cesareans to low-risk mothers," and suggests that a woman contemplating a C-section should ask herself why she should undergo major surgery "when she and her baby are healthy."

Nobody questions the rightness of cesareans performed in a medical emergency (which account for up to 20% of the total), but those made simply at the request of the mother, known as "elective cesareans," are associated with a number of pitfalls. Before these are addressed, however, it is worth remembering that vaginal delivery is not always an appealing alternative.

Utter the phrase "natural childbirth" and the mind envisages a stoic and earnest woman, surrounded by murmuring midwives in a softly lit room, where ambient music plays and tea lights flicker. Upon the elapse of some decent, manageable labor, she pushes out her baby with honest grunts. While that may be true for some, for most women natural childbirth is one of the most violent physical traumas they will ever experience ... it can easily be 20 hours or more. During that time, she is wracked by contractions — ... violent spasms that take hold when the body reflexively tries to squeeze a baby through a narrow vaginal opening. The forces involved are such that when the baby's head emerges, it can do so with sufficient pressure to rip the mother's perineum ... the act of giving birth resembles a medical emergency — in fact, if no medical intervention of any kind were made, up to 1 in 67 women would die in labor. Fear of birth pain is thus legitimate and it is no wonder that many women elect to have C-sections — especially when the procedure is over in about 40 minutes and feels no more uncomfortable, in the words of an anesthetist in one of Hong Kong's top maternity hospitals, "than someone rummaging around in your tummy." ...

Wow, what can I say?? How can birth ever be considered to be violent when it is a natural process? Perineal tearing is not necessarily a part of natural labour when the woman is encouraged to choose the position that is right for her, and to push or breathe as her body tells her to. I agree that tearing is a common occurence when women are directed to push thewir babies out while lysing on their backs in bed, with directed pushing and breath-holding, buw when this process is managed naturally, perhaps with the aid of water birth, tears are not a normal finding.

A caesarean is not no more uncomfortable than having someone rumaging around in ones abdomen: women who have caesareans do have epidural or spinal or general anaesthetic. Without this, the surgery would be excruciating.

"You often hear people express the wish to have a less painful delivery," ... "They may also want some predictability in the time and day the baby is born" ...

Granted, but life is not predictable and we do not opt out of living!

Cesareans are not without drawbacks however, and they begin the moment the last stitches are made in the stupefied patient's lower belly. The WHO recommends that babies be breastfed within an hour of birth, because vital antibodies and protective proteins — in effect, the baby's first immunizations — are delivered through those precious early drops of milk. But, as Dr. Atwood points out, breastfeeding "is difficult to do if you are coming out of anesthesia ...

In the days following a C-section, a woman will be at an elevated risk of potentially fatal blood clots or infections ... more women die as a result of cesarean section than in natural childbirth ... 12.1 maternal deaths per 100,000 births ... becomes 36 if only cesareans are considered — and the difference ... is "attributable to the surgery itself, not any complications that might have led to the need for surgery."

... as a woman contemplates future children, she may face the possibility of reduced fertility ... women who had cesareans were almost four times more likely to have problems conceiving again, compared to women who gave birth naturally. The former will also experience increased risks of ectopic pregnancy and placenta previa or accreta ... And because many doctors will not permit a woman to undergo natural childbirth once she has had a cesarean ... it is likely that her subsequent children will also be surgically delivered, multiplying all of these risk factors each time. "If there is no medical reason to have a C-section, we would advise [women] to have a vaginal delivery," ...

In Thailand, the pleas of natural-birth advocates do not find a large audience. "It's like pushing a stone uphill," ... "... It's very easy to get a C-section in Thailand ..." ... "If you use the term 'natural birth' here, people think it means you have to go sit in a paddy field to have your baby." Cesareans, she says, "have become very fashionable, especially among middle-class women" A third of the babies at Bangkok's private Samitivej Hospital ... are delivered by C-sections, even though its birth unit was set up ... to promote natural childbirth ...

... "I blame the obstetricians," ... "They don't give women confidence in their bodies ... They create an environment of fear around birth ..." ... C-sections are common because "doctors have no patience. Most doctors want to end the birth quickly."

... It may become something akin to a rite of passage ... When ... patients choose to give birth naturally, even to the extent of refusing painkillers, "it's like they're climbing Everest without oxygen," ... "They feel very powerful." And so they should — even if the real climb begins after the baby is born, naturally or not.

Melissa Maimann, Essential Birth Consulting 0400 418 448