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

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”.

Pivotal Moment in Obstetrical History - the NICE Caesarean Update

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)

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

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?

I've joined The Mom Pledge Community

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:

A Rare but True Risk of Planned Cesareans

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

My Interview with My Baby Radio is Now Live

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'

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

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

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:

The Labor Ward 'Care' I Chose to Avoid

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.

(Much Needed) Call for More Maternity Doctors

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."

NHS Controversial Cesarean Cost Clampdown

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,

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

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.

Interview on BBC WM - Maternal Request Cesarean 'Ban'

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).

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

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

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

Not just Too Posh to Push says Australian doctor

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

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.

Review ordered into baby death at Victoria hospital

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

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

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.

TV documentaries Sing from the Same Song Sheet

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

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.

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

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

My interview with the Western Mail newspaper

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

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.

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

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.

Media headlines misinterpret RCOG but make good point on Home Birth

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.

Cesarean Infearmation is Unnecessarily Frightening

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?

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

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?

Researchers want to know Reasons why women Choose Cesareans

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.

Read medical studies - but Beware Bias

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,

Old School versus New Science - Birth Advice

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).

Job satisfaction for midwives - should it matter?

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?