Call the Midwife but Celebrate the C-section too

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)

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?

Why are cesarean rates rising in India?

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

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

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

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."

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

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

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.

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

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.

Transfer risk from midwifery-led birth centers is real

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.

Mother and baby would have died if VBAC was attempted elsewhere

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.

Cesarean delayed and denied. Baby dies.

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?

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.

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

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.

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

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

First-time moms' unrealistic views about having uncomplicated births

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.

Beyonce Gives Birth to Blue Ivy and Colorful Debate

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

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%

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

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.

More NICE cesarean media coverage

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

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

RCOG's response to the NICE guideline media reports

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,

Comment posted on media NICE guideline stories today

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

Media reports on NICE guideline ahead of publication

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

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.

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

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

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.

Should women get to choose c-sections?

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?

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:

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

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...

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

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

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

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.

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

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

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.

Maternal Anarchy or Human Evolution?

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”.