Tuesday, August 27, 2013

It's about knowledge and empowerment

I plan to write about Piper Newton again - she's written a courageous book called, 'And Then My Uterus Fell Out', which is due out on October 1st - but for now I'd like to share the blog post she published a few days ago:

"It's about knowledge and empowerment"

She describes how her vaginal delivery has left her "with permanent disabilities, an inability to return to the workforce (at 30 years old) and... facing many high risk surgeries as [she tries to] cope with my disabilities."

She is very honest, and says that she really isn't sure what decision she would have made if her doctor had done a risk assessment and said that she was high risk for prolapse and other birth complications, but now, given what she's lived through over the past eight years, she is sure: "if I could go back in time with the knowledge I have now, I would have absolutely gone with an elective C-section. In my case, that procedure would have been the more sound and safe birth option... A planned C-section could have prevented most, if not all, of my current disability. And what I am facing is surprisingly common. "

Piper doesn't advocate caesareans as the best choice for all women; not at all. But she does have serious concerns about the information women are given about different birth plans:

"Where I have issue is when women are not being assessed for risk factors and not being informed of all risks factors, for all the options. Once assessed women should be educated and empowered to make an informed and knowledgeable choice based on what they want for their own body...

"Each woman is different, living a different lifestyle, with different desires and needs. For some women a large family is highly desirable, for others doing everything possible to preserve their pelvic floor due to work or athletics is desirable.

"What bothers me most about these arguments is that elective surgeries are done all the time. I can get my boobs inflated, my nose streamlined, my fat sucked out, but if I want a C-section to help mitigate my risks of a lifetime of complications due to a damaged pelvic floor, the choice is attacked and in many cases denied by the medical community."

Piper also comments on Dr. Silvio's excellent blog post.

Saturday, August 24, 2013

Obstetrician changes his mind about Maternal Request

Admiration and respect. These are the words I would use to describe my feelings towards Dr. Silvio Aladje, an OBGYN and maternal fetal medicine specialist at Michigan State University in the U.S.

In his blog posted yesterday, 'Caesareans Section On Demand', he describes how, after reading our book, he has changed his position in the debate over maternal request caesareans.

I don't admire and respect him because he has changed his mind, but rather because he is willing to say so publicly (which not everyone would be brave enough or gracious enough to do) and because his actions are one step closer towards wider recognition that maternal request caesarean is a legitimate birth plan.

Dr. Silvio writes that his position used to be, "there are two modes of delivery: 'vaginal' and 'cesarean section'. When needed, cesarean sections should be performed without hesitation, and, when not, they shouldn’t." He also says, "until very recently I was in the group of physicians who would have been hard pressed to perform a cesarean section without a medical indication."

But he concludes thus:

"I was once told that politicians change their positions because it may be convenient; we, physicians, change our ideas because our learning never stops. Yes, I have now changed my mind. The time has come for us to support women making an informed decision regarding how they want to be delivered. They have their choice for a vaginal delivery experience or a birth by cesarean section, without medical indications. It should be a decision between the pregnant woman and her physician, after a thorough evaluation of the patient’s intrinsic risks based on her medical history or circumstances, and not based on our own bias on the subject."

Thank you, Dr. Silvio.

Wednesday, August 21, 2013

Birthrights organisation highlights maternal request refusal

Birthrights website reads: "We believe that all women are entitled to respectful maternity care that protects their fundamental rights to dignity, autonomy, privacy and equality."

And on August 9, 2013, in its response to the Care Quality Commission consultation on changes to the ways the CQC regulates, inspects and monitors care services, Birthrights included the issue of maternal request caesareans being misunderstood and refused, alongside the issues being faced by women with various other birth choices (e.g. epidural and home birth).

The document is certainly well worth reading; and I can only hope that the CQC takes serious note of Birthrights' comments, and that its response leads us one step closer towards true autonomy and respect for the woefully misunderstood prophylactic caesarean.

Monday, August 12, 2013

Why women often don't get the birth they want

The answer to why women often don't get the caesarean birth they want is this: Their requests are blatantly refused.

The answer to why women often don't get the vaginal birth is more complicated, but there was an interesting debate today on BBC Radio 4's Woman's Hour, hosted by Kirstie Allsopp.

I have much to write about it, but due to other more immediate commitments tonight, I will leave any comments for another day, and simply post the programme link here and encourage you to have a listen.

Feedback welcome!

Wednesday, August 7, 2013

NICE says a planned caesarean section SHOULD be offered to women who request it

My letter (title above) was published in the British Medical Journal today; I wrote it in response to another letter, NICE says caesarean section is not available on demand unless clinically indicated, sent in by Mandie Scamell, a lecturer in midwifery, Alison Macfarlane, a professor in women’s and child health, Christine McCourt, a professor in women’s and child health, Juliet Rayment, a research fellow, Judith Sunderland, a lecturer and programme lead in midwifery, and Mary Stewart, a research midwife.

It reads:

"I am equally “alarmed" by Scamell et al’s letter (“NICE says caesarean section is not available on demand unless clinically indicated”).[1] Mainly because of the inaccuracies it reveals in maternity professionals’ knowledge and understanding of current NICE guidance (CG132) on caesareans, but also because of the potential dissemination to a wider body of student midwives and the subsequent effect on pregnant women.

Refusal to follow NICE caesarean guidance is unjustified

My letter (with the title above) was published in the British Medical Journal today; I wrote it in response to another letter, NICE promises on infertility and caesarean section are unmet, sent in by Lawrence Mascarenhas, a consultant obstetrician and gynaecologist, Zachary Nash, a medical student, and Bassem Nathan, a consultant surgeon.

It reads:

"Firstly, I’d like to commend Mascarenhas et al[1] for their efforts in highlighting the lack of implementation of NICE caesarean guidance in many hospitals.

Wednesday, July 31, 2013

Midwives worth their weight in gold

Every now and then, I meet or read comments by a midwife who is completely and utterly supportive of women who request cesareans, who understands and respects their motivations, and who is willing to speak up about the very real risks associated with a vaginal birth.
 
This is what one midwife wrote on one Australian blog
 
"I have worked as a midwife, and now in general practice.
I have been quietly more and more concerned as I near my retirement, at these discussions.
I do Pap smears as part of my work now.
I see increasingly women, young to old, who have such damage to their pelvic floor that they wear pads constantly because they are incontinent of urine and faeces.
We push 'natural, when women are having bigger babies than ever before, and women are taller than ever before, both of which contribute to obstructed labour, and the heroics to deliver vaginally, which leaves huge, long acting damage.
I am ashamed to be 'midwife' who focuses on the 6 days of the life continuum, and believe that we are right.
I believe we have a duty to support women to have the birth of their choice.
I also believe we are trained to also protect them and their babies from damage.
The social pressure to have vaginal birth is immense. It is not CS vs vaginal birth, it is holistic care. If I encourage this woman to deliver this woman of her 4kg baby with intact peri, I am proud. Never mind that she has major surgery every 15 years to repair undetected prolapsed and anal sphincter damage.
Please can we look at the whole?"

Read more comments at: January 23, 2013 The rise of Caesarean births in Australia by Sarah Vogel

Sunday, July 28, 2013

The wrong debate about cesarean sections

Following a comment I left on his article this week, What Is A Normal Pregnancy?, Dr. Silvio Aladjem invited me to comment on an article he'd written in May 2012, titled, The wrong debate about cesarean sections.
 
Here is what I wrote:
 
I am always very pleased when I read criticism of the obsessive focus on caesarean rates, and of national and global efforts to reduce these rates to arbitrary levels. In 2009, the WHO admitted it had no empirical evidence (and still doesn't) for recommending a 15% threshold in 1985, and that there is no known optimum rate; yet countries and hospitals are still rated according to their overall number of caesarean surgeries as though this absolutely reflects the health outcomes of mothers and babies.
One example of the problem with these international 'league tables' can be read in my letter to the BMJ earlier this year: Reducing mortality is not as simple as low cesarean rate good, high cesarean rate bad
 
Another problem is that focussing on the "overall CS rate" ignores the fact that it's emergency caesareans that are associated with the greatest risks, and planned caesareans have comparatively better outcomes (and costs). Yet instead of strategies to reduce the worse types of CS, very often planned CS are refused or avoided - only to end up as an emergency CS anyway.
 
My instinct is that we probably agree on the above, but I am not so sure about your views on maternal request caesareans. You write that "there is no good medicine where extraneous and non medical forces intervene", so it would be interesting to read what you think about a CS that is not medically indicated (though of course someone like myself would describe such surgery as prophylactic; i.e. there is no immediate medical indication, but there is knowledge of and desire to avoid known morbidities with a trial of labour).
 
In this context, if I may, I'd like to highlight concerns I have with some of the statements in your article, particularly in the context of what's happening in UK maternity care (as opposed to U.S.).
 
Extract: "a new trend is evolving: cesarean section on demand...In the USA this is not yet a serious problem.  But in other countries, this is a problem. Cesarean sections rate has reached 90% levels, like in Brazil for example."
 
This is usually referred to as caesarean on maternal request, but whether demanded or requested, you refer to what I believe is a legitimate prophylactic request (given the known potential risks associated with a trial of labour - both in the intrapartum period and longer term) as "a problem". Yet there is evidence of very high maternal satisfaction following CDMR, and very good health outcomes too (for women planning small families and with delivery at 39+ weeks' gestation).
 
Extract: "The movement to reverse the trend is facing great obstacles."
 
Unfortunately, maternal request caesareans are viewed as an easy target in efforts to reduce CS rates, and I am frequently contacted by women whose legitimate request is being refused and denied. Forced trials of labour (that often end up as emergency CS or instrumental VD) for women who WANT a CS is, in my opinion, an unethical and ineffective method of 'reversing CS trends'.
 
Extract: "Third, there is a need for tort reform, so that medical decisions should not, even remotely, have to take into account the possibility of legal consequences of  a medical decisions."
I agree that medical liability is a factor in driving up CS rates but I disagree that tort reform should go this far. Already in the UK, we have a HUGE litigation bill for obstetrics (both current and estimated future payments), and this is a country where there is a very strong drive to reduce CS rates and increase "normal" birth rates. In countries where maternity care is cost-driven, and litigation is taken out of the equation, there ends up being too many cases where efforts to get the baby out vaginally (and avoid a CS) leads to mortality and severe morbidity. The MODE of birth should never be the driving focus, but rather health outcomes and maternal satisfaction.
 
Extract: "Fourth, we need to educate the public that there are going to be complications and poor outcomes, no matter who cares for the patient. The occurrence of obstetrical complications is a reality we should stop denying."
 
I agree with your perspective that birth is inherently risky (while accepting others' views that it is inherently safe - with intervention only as a last resort). However, this is where maternal choice is vital. Women need to be informed of the risks and benefits of BOTH birth PLANS (PVD and PCD), and allowed to choose which they prefer (e.g. some may choose VBAC, others may choose repeat CS). Maternity policies dictating one birth plan or another is a real problem.
 
Extract: "Neonatal morbidity was high, much of it the result of obstetrical maneuvers and manipulations intended to deliver the infant vaginally at all costs, because of fear of performing a cesarean section. Those times are gone  for ever.  Thank God."
 
Unfortunately, this is simply not true in countries like the UK. A quick google search (or look on my blog) will provide you with numerous examples of cases where this exact scenario has resulted in the death or injury of mothers and babies.
 
Extract: "“Good medicine” will take care of itself and the rate of cesarean section will find its own level. But it will not be the rate of the 50s or 60s, nor should it be."
 
Good medicine in the context of obstetrics is extremely subjective, and this is one of the ongoing problems in the whole caesarean debate. There are some who hold very strong ideological beliefs that vaginal delivery should always be attempted in the absence of immediate medical indications, while there are others who believe that a caesarean delivery is advisable with even the slightest risk factor. Personally, I don't propose any appropriate caesarean level, so I am not going to say that a range of 50 or 60% is either right or wrong. However, I would repeat that in some countries/hospitals with high CS rates, the rates of perinatal mortality (incl. stillbirth) and maternal mortality are very low - and also the very opposite is true. So again, I would like to see discourse moving away from the criticism of caesarean rates alone - whatever the number - and only talk about CS alongside rates such as stillbirth, perinatal mortality, maternal mortality, infant birth injuries and maternal morbidity (short- and long-term). The CS rate alone actually tells us very little.
 
On maternal request:
I genuinely believe that where women ARE allowed to choose CS freely, there are more women choosing it than some may be comfortable with... but this doesn't make it 'wrong', nor categorically 'unsafe'. Absolutely, surgery is not risk-free, but increasing numbers of women are realising that natural birth (or rather, a trial of labour) is not risk-free either, and the rates of CS that are seen in private hospitals - where women have greater CHOICE - demonstrate that maternal request CS is a reality; albeit one that some have chosen in turn to ignore, deny, criticise, discourage and (if all else fails) refuse.
 
One final comment.
This month, ACOG published the article (written by W.Lawrence Warner, MD), "Arriving at the appropriate cesarean delivery rate". Again, I'm glad that Warner is not advocating simply "lowering" the CS rate, but I have concerns about some of his comments.
 
He writes about an increase in maternal mortality in the U.S., linking it with a rise in the caesarean rate, but of course there are numerous other factors at play. For example, obesity levels in the U.S. and socio-economic differences in quality of health care to name just two. Also, other countries with higher CS rates than the U.S. have lower maternal mortality rates, but American women are unlikely to hear about that.
 
I commend Warner for seeking to reach an "appropriate" CS rate "rather than just lowering [it]", but his conclusion, that doctors "educate our patients about the immediate and future consequences of a cesarean delivery" is concerning. Surely they should be educating patients about the consequences of BOTH birth plans, and then measuring HEALTH outcomes (physical and psychological)? Perhaps this is what he means, but it's not completely clear.
 
Something tells me we haven't moved far enough away from the focus on caesarean rates as we need to... It's as though it's finally been agreed that yes, a 15% CS rate is unrealistic and unachievable, but if we can get down to 'let's say the mid-20s%', then that would be about right.
 
I disagree with this view. There is no more evidence for rates of these suggested percentages than there ever was for 15%, and with more women having (bigger) babies later in life, with very high expectations of a good outcome, obstetric challenges have never been greater.
 
Dr. Murphy and myself talk about this, and much more, in our book, "Choosing Cesarean: A Natural Birth Plan" (Prometheus Books, New York), and if interested, readers can browse some of the chapter pages here for more information.

Monday, July 22, 2013

Royal Congratulations to William and Kate!

It's great news today that the Duke and Duchess of Cambridge have become new parents to a baby boy.

No news on the name yet - only that he was born at 4.24pm at St Mary's Hospital in London, weighing 8lb 6oz.

Now, I haven't been particularly enamoured by many of the political and ideological debates about what Kate may or may not have wanted in her (private) birth plan, but I thought I'd share a very short anecdote from my experience of talking with other mums this morning.

Like most people, we were chatting about the media circus surrounding the impending Royal birth, and the cameramen who have been standing outside in this unbearable heat for days.

Then someone said, "I thought she might have chosen a cesarean", to which another mum replied, "No, I don't think she's the type to do that." There was nothing malicious in the way she said it; the mum in question is a truly lovely person, and I didn't pick up on what she said.

It's just that in a somewhat Carrie-esque manner, I couldn't help but wonder... what "type" of woman do others perceive as being the type to choose a cesarean?

I'm certainly one, and if you're reading this blog, you might be one too - so I wonder what it is that typifies us in the eyes of others?

My guess is - the perception of others and our personal reality are very likely two different things.

Saturday, June 15, 2013

Australian Royal Birth debate this month


I'm not keen on the title of this debate (it's not for anyone to say how a woman "should" give birth), but in the context of talking about the risks and benefits of different birth plans, the debate below (more information here) may be of interest.


Tuesday, June 11, 2013

New NICE Quality Standard Reinforces Support for Maternal Request

electivecesarean.com  2013 NICE Quality Standard Reinforces Support for Maternal Request Caesareans and Mothers’ Satisfaction with Maternity Care
PRESS RELEASE
Embargoed until 00:01 Tuesday 11th June 2013 (GMT)
Published by electivecesarean.com

Following the National Institute for Health and Care Excellence (NICE)’s publication of its Caesarean Section Guideline (update) in November 2011, which recommended ultimate support for women who choose to plan a caesarean birth without any clinical indication, and highlighted a cost difference of just £84 with planned vaginal birth when the adverse outcome of urinary incontinence was considered,[1] electivecesarean.com welcomes NICE’s Quality Standard for Caesarean Section, and hopes that it results in greater adherence by hospitals and health professionals to its 2011 caesarean recommendations.
 
It is this organisation’s experience, through communication with parents, midwives, doctors and hospital trusts, that arbitrary refusal of maternal request planned (primary and repeat) caesareans continues to occur, and more widely, that women without a personal preference for any particular birth plan are being encouraged to focus on the benefits of planned vaginal delivery and the risks of planned caesarean – with the emphasis on reducing overall caesarean rates and increasing rates of ‘normal birth’ – rather than being provided with balanced information and an evidence-based assessment of their individual risk factors associated with a trial of labour.
 
 
WHAT IS MOST WELCOME FROM THE QUALITY STATEMENTS (with emphasis)

 ·         Overview: “A person-centred approach to provision of services is fundamental…”

 ·         QS 2 Maternal request for a caesarean section: maternity team involvement: “The purpose of this statement is to inform decisions about the planned mode of birth. It is important that the woman can talk to the most relevant member of the maternity team… It is important that access to members of the maternity team is possible at any point during the woman’s pregnancy and promptly arranged following a request. Outcome measure: “Women’s satisfaction with the process of discussing options with the maternity team.” Definitions: “The core membership of the maternity team should include a midwife, an obstetrician and an anaesthetist.”

 ·         QS 1 VBAC: “Pregnant women who have had 1 or more previous caesarean section have a documented discussion of the option to plan a vaginal birth.” i.e. it is not compulsory.

 ·         Q 4 Definitions. Pregnant women who may require a planned caesarean section have consultant involvement in decision-making: “This includes both women who have clinical indications… and women who request a caesarean section when there are no clinical indications.

 ·         QS 3 Pregnant women who request a caesarean section because of anxiety about childbirth are offered a referral to a healthcare professional with expertise in perinatal mental health support

·         QS 5 Timing of planned caesarean section: The woman should be given a specific day and time at which the caesarean section will be performed. A model for delivering planned caesarean section is for services to have dedicated planned caesarean section lists. The lists should have protected surgical and anaesthetic time and appropriate staffing to ensure that planned caesarean section are not delayed because of surgical time being prioritised for emergency cases.

·         NICE press release: She should also be able to talk to the most relevant member of the maternity team depending on her question or concern at any time during her pregnancy. A consultant should be involved in decisions surrounding caesarean sections because they are best placed to advise about the potential benefits and risks. Quote from Dr Malcolm Griffiths, Consultant Obstetrician and Gynaecologist, Luton and Dunstable Hospital and chair of this QS expert group: “…Most women want to avoid the major surgery of a caesarean section. However, it is important that the NHS ensures all women can give birth in the most appropriate way for them, and for some women, this will mean having a caesarean section... 

 
 
WHAT WOULD ALSO HAVE BEEN WELCOME IN THE QUALITY STANDARD
 
 
·         NICE press release: While the number of caesareans “has gone up dramatically” in the last 30 years from 9% in 1980 to around 20-25% in 2013, in 2011, NICE made clear that “Many of the factors contributing to CS rates are often poorly understood. This guideline has not sought to define acceptable CS rates.”[1]
 
Over the same period, rates of infant deaths have decreased significantly. The neonatal mortality rate fell by 62%, from 7.7 deaths per 1,000 live births in 1980 to 2.9 in 2010, and the perinatal mortality rate (which includes stillbirths) fell by 44% from 13.3 deaths per 1,000 total births in 1980 to 7.4 in 2010 (and in October 1992, the legal definition of a stillbirth was changed to include deaths after 24 completed weeks of gestation or more, instead of after 28 completed weeks of gestation or more; therefore improvements in perinatal mortality outcomes may be even greater.)

·         QS 9 Outcome: “Rates of complications in women who have had a caesarean section.” For this information to be useful, it’s essential that type of caesarean is recorded here.

·         QS 2 Outcome: “Women’s satisfaction with the process of discussing options with the maternity team.” Women’s satisfaction with actual birth outcome is crucial to record here too (whether she has her maternal request CS or is persuaded to plan a vaginal birth), as is the actual number of maternal request births (so that we finally know this % rate).


“For 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.
“An obstetrician unwilling to perform a CS should refer the woman to an obstetrician who will carry out the CS.”
“On balance, this model does not provide strong evidence to refuse a woman's request for CS on cost effectiveness grounds.” (Health Economics p.100-1 & see p.220 for £84 figure)


Contact for Further Information
Pauline Hull              
Co-author of ‘Choosing Cesarean, A Natural Birth Plan’ (Prometheus Books, New York. 2012), and founder of electivecesarean.com and cesareandebate.blogspot.com

Telephone 07780 308 455

Monday, June 3, 2013

Guess which makes headlines - Birth Orgasm 0.3% or Perineal Tears 39.9%?

The fact that some women experience an orgasm during birth is not a new concept, as one midwife commented at the bottom of yesterday's Daily Mail article:

"Can I please state in 1984 when I became a midwife this was well known so its not a new study, but in 30 years I have never seen it NOT ONCE." (lizzy2511 Swansea, United Kingdom, 2/6/2013 23:41)

But a new study by Thierry Postel has highlighted the possibility once again. The French psychologist contacted 956 French midwives, of which 109 online responses were completed, and concluded that there was a 0.3% rate of women who experience an orgasm while giving birth.

Informing women

I don't have a problem with Postel's survey per se, but I do have concerns about how its results might be used by some maternity health professionals, in the context of emphasising that birth need not be viewed as inherently painful or fearful, but rather an experience to be embraced and enjoyed - with the 'right' mental attitude.

I also think it might pile on pressure for some new mothers, who may already feel like they've somehow 'failed' if their labor didn't go according to plan, and now they discover there are women who enjoyed their labor in more ways than they might ordinarily divulge.

Now I don't write this blog in order to scare women, but I do think it's important to inject a little balance to the 'orgasmic' headlines that I've seen over he last few days, and remind women that in England at least, maternity data includes the following percentage outcomes too:

Perineal laceration (39.9%)
Long labour (10.3%)
Obstructed labour, fetal distress and umbilical cord-related complications (30.5%)
Episiotomies (15.2%)
Emergency cesareans (14.8%)

So if birth isn't orgasmic for you, you're really not alone.

I think it's a shame we don't see more news headlines and discussions about how to reduce some of the big numbers above - and have a little less focus on the titillating topic of orgasms in a context that most people are really not interested in at all.






Thursday, May 23, 2013

Prolapse surgery unsuccessful for almost one third of women

A new study from the University of Utah School of Medicine (lead author Ingrid Nygaard, M.D), which followed the experiences of 215 women following reconstructive surgery for pelvic organ prolase, has concluded:

"Results after seven years of follow-up suggest that women considering abdominal sacrocolpopexy (surgery for pelvic organ prolapse [POP]) should be counseled that this procedure effectively provides relief from POP symptoms; however, the anatomic support deteriorates over time; and that adding an anti-incontinence procedure decreases, but does not eliminate the risk of stress urinary incontinence, and mesh erosion can be a problem..."

The May 14, 2013 press release also reminds readers that POP "occurs when the uterus or vaginal walls bulge into or beyond the vaginal introitus [vaginal opening]. It is a common occurrence and 7% to 19% of women receive surgical repair...

More than 225,000 surgeries are performed annually in the United States for POP."


Wednesday, May 22, 2013

Hooray for the c-section vacation!

Above is the title of a recently posted blog on the U.S. babycenter website by mum of two Kristina Sauerwein.

Kristina's post begins by asking, "Dare I admit that I enjoyed my c-section birth experiences?" and she goes on to describe with relish what she enjoyed about her hospital stay.

Some of what she writes will certainly be controversial for some tastes, but I really felt it was a blog post worth highlighting here as it's a perspective I haven't really seen anywhere else.

Of course, see what you think.

Tuesday, May 21, 2013

Midwives in Switzerland want greater influence over women's birth choices



Julie Hunt, swissinfo.ch May 13, 2013

Pregnant women are faced with a whole range of birthing options, which can make choosing how to have their babies pretty difficult. An increasing number of Swiss women are opting for caesarians, mostly on the advice of their doctors.
 
The Federal Office of Public Health recently published a report that neither criticised nor supported C-sections. But health care professionals in Stans, canton Nidwalden, are clearly against them. At the cantonal hospital, 29% of births are C-sections, around the national average. Birthing staff want to reduce that number. And at the nearby privately run birthing house, ‘caesarian’ is almost a dirty word. 

Saturday, May 18, 2013

Cesarean Cachet or Status Symbol for Brazil Women?

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

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

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

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

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

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

Tuesday, May 14, 2013

Two things strike me about this umbilical cord cesarean story

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

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

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

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

Date of birth

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

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

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

Friday, May 10, 2013

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

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

Intervention in childbirth: What’s wrong with letting women choose? is scheduled to take place between 10am and 12.30pm, and the organisers have told me that a summary will be published afterwards.
 
Details are as follows:
 
The publication of the National Institute of Health & Clinical Effectiveness guidelines on caesarean section (Nov 2011) sparked a media frenzy with newspapers reporting that women could now choose ‘caesarean section on demand’. While opportunity for greater choice is welcomed by some consumer groups, others have expressed concern about the rising rate of intervention in childbirth. This session will debate the pros and cons of allowing women free choice with regard to major medical interventions, such as caesarean section. Attendees will have the opportunity to vote for or against the motion.
 
Convened by Vanora Hundley and Edwin van Teijlingen

Hospitals 'are ignoring advice on caesarean sections'

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

Absolutely! I agreed with them.

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

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

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

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

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

Maybe one day soon...
 
 

Friday, March 22, 2013

New ACOG Committee Opinion on Maternal Request

ACOG has just published a new Committee Opinion on Cesarean Delivery on Maternal Request (Number 559, April 2013), and says, "In the absence of maternal or fetal indications for cesarean delivery, a plan for vaginal delivery is safe and appropriate and should be recommended."
 
However, the accompanying press release says ACOG "recommends that pregnant women plan for vaginal birth unless there is a medical reason for a cesarean."

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

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

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

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

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

Controversy and Politics

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

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

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

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

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

Important to note

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

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

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

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

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

ACOG's new recommendations for CDMR

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

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

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

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

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

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

Wednesday, March 13, 2013

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

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

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

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

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

Other birth outcomes

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

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

Antibiotic risk for all births, but especially planned CS

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

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

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

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

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

Friday, March 8, 2013

Are women who choose a cesarean LAZY?

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

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

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

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

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