RCOG removes controversial guidance from website

Following vehement opposition from maternity organisations and doctors, the Royal College of Obstetricians and Gynaecologists has today removed its guidance for CCGs ('Making sense of commissioning Maternity Services in England', published August 14) from the RCOG website.

 

I don't know yet whether revised guidance will be published, and if so, whether RCOG will collaborate with organisations other than the RCM and the NCT, but in the opinion of many, this would be the appropriate action to take.

Meanwhile, in the Sun newspaper today, Emma Little and Martyn Halle report:

'Cathy Warwick, of the Royal College of Midwives, defended the proposals, insisting: “There are women who do not want to have caesareans or epidurals who are having them at the moment.”' 

Lowest scalp injury risk with planned cesarean

Scalp injury during birth is a risk commonly associated with all cesarean deliveries, and therefore good reason to discourage women from choosing surgery, when in fact the vast majority occur following a planned vaginal delivery.

I explained this in the comments section of today's Daily Mail article, Caesarean 'superknife' that could spare thousands of babies from injury when surgeons cut through the mother's womb:

"Although the article talks about this being a risk with caesarean births, it's important to understand that the risk for babies is actually greatest with a planned natural birth than with a planned caesarean birth. Here's why:

The 2004-05 NHS Maternity Statistics, England, state, "Birth injury to scalp accounted for 0.9% (est. 5,400) births but none related to elective caesarean.”

The 2005-06 NHS Maternity Statistics, England states, "There were very few such cases where delivery was spontaneous, or where the baby was delivered by caesarean section; but scalp injury was reported in about 5% of instrumental deliveries.

The 2010-11 NHS Maternity Statistics, England has a table that reads, "Birth injury to scalp, 1% (n.6,659). This increased risk with planned natural birth is evident in published research too."

(Note: I have to write 'natural' in comments because the word 'vaginal' isn't accepted.)

Mumsnet users angry at maternity guidance

Picture: Wikipedia.org (Zoney)

Women posting on Mumsnet have quite rightly got their knickers in a twist after reading Friday's press release on RCOG's (and the RM and NCT) guidance proposing increased rates of 'normal birth' and cesarean rates of 20%.

There are two threads - one in Childbirth and the other in Feminism/ Women's Rights - and here are just few examples of what's being said:

"...I'm utterly appalled by this. It seems to be in direct opposition to what NICE, NHSLA and others are saying. And the trouble with targets is they completely neglect individual care, and create a conflict of interests for doctors & midwifes - and ultimately put woman last."

"You are right about targets. Once you set targets, the target becomes the focus not the woman and baby."

"I think this is one of the most shocking documents I have seen."

"If a male doctor went on TV or radio and said he planned to reduce epidurals he would probably need police protection. But the midwives and NCT get away with it. I think people don't associate these dry boring documents with what is going to happen in practice."

"[I] am almost speechless with anger at the condescension."

"I will certainly write to my MP about this (first time I've ever been moved to do so)."

PR response to RCOG's 20% cesarean rate guidance

"New RCOG guidance urges CCGs to increase births without epidurals and reduce caesarean rates to 20%"

Controversial guidance contained in a new document published by the Royal College of Obstetricians (RCOG) could result in worse health outcomes for mothers and babies, and greater costs for the NHS, say maternity campaigners (left) and doctors (below).

You can read the press release in full HERE.

Perception of risk is everything...

and birth is no different. Most women perceive greater risks either with a trial of labor or surgery.

This struck me again today while at our local gym play session, and where a sign reads, 'one child at a time on the trampoline'.

It's no exaggeration to say that every single time we go, parents do not adhere to this rule, allowing children to all jump randomly around the trampoline together. As one mother said to me today as our son waited his turn, "Don't worry. Everyone just piles on."

I thanked her, but said we'd rather wait in case of a head clash or similar...

As parents, we all make choices about all sorts of things related to our own and our children's wellbeing, and the chances are, whichever choices we make, things will probably turn out ok. I don't allow our children on a trampoline with other children, but I'm sure there are other things I allow that other parents might not.

And it's often this very individual perception of risk, our belief in the likelihood of catastrophe, and our tolerance of a 'worse case scenario', that help us to make these choices - which leads me to wonder why then, when parents are expecting a new baby, they are often treated as a homogenous group whose risk choices for the birth of their baby should all be the same?

The sexual revolution continues...

Photo: wikipedia.org

...in the battle for reproductive choice.

The death of Helen Gurley Brown, long-time editor of Cosmopolitan magazine and advocate of women's sexual freedom, reminded me of these words, which I wrote in one of the first ever pages of my website.

While (in many countries) women now have greater freedom than ever before in terms of sex, their own bodies and their reproductive choices, until planned cesarean delivery is widely accepted as a legitimate birth plan, this journey will not be complete - as we discuss in Choosing Cesarean, A Natural Birth Plan.

And as Dr. W Benson Harer, Jr, a retired obstetrician and former president of the American College of Obstetricians and Gynecologists, wrote after reading our book:

"A woman's right to choose how she will deliver her baby is the last bastion to overcome in women's long struggle to control their reproduction and sexuality—indeed, to control their lives. Choosing Cesarean is a powerful weapon to help women to finally win this battle."

Maternal request study: women are satisfied and educated

The main focus of this new U.S. research was on which nonmedical factors might be addressed in order to reduce record-high rates of cesarean delivery.

As such, the research is presented in terms of which factors affected the risk of having a cesarean most (e.g. "higher educational attainment was associated with an increased risk").

But look again at the study of 1308 Californian mothers; it shows that a cesarean was more likely with women who:

*reported higher scores for "empowerment and self-care"
*reported high English proficiency
*were of greater maternal age
*had a higher educational attainment

In most other areas of healthcare, the type of woman described above has access to the best medical care, and is most satisfied with it - and yet because the subject is cesarean birth, this situation is being viewed as a problem that needs fixing.

Most likely, it will be your own personal perception of how birth 'should' be that will dictate your reaction to this post, but my own view is that we should be more concerned about the women who reported lower scores for empowerment and self-care in this study - perhaps they might have preferred a cesarean birth!?

Maybe not - but I bet they were never asked that question...

Diabetes could bankrupt the NHS - and maternity care?

The Health and Social Care Information Centre have released a report showing that "Diabetes prescriptions have for the first time topped 40 million in year, a rise of nearly 50% on six years ago."

And in an interview with the Daily Mail, Barbara Young, Chief Executive of Diabetes UK, warns: "About 2.5 million people in England have been diagnosed with the condition and the number of people with diabetes is expected to reach 4.2 million in England by 2025.

"We face the real possibility of diabetes bankrupting the NHS within a generation."

What does this have to do with maternity care?

Diabetes in pregnancy (gestational diabetes), and the fact that more than 50% of women of childbearing age are overweight or obese, is a serious issue.

Obstetricians in the U.S. have been coping with this very situation for many years now, and it's no coincidence that its cesarean rates have climbed alongside maternal weight gain.

So while hospitals and midwives in the UK may desire a lower cesarean rate, I remain very concerned that their desire to encourage a "normal, physiological process" ignores the reality that many women's bodies are outside a normal physiological range.   

Brazilian women rebel against c-section births

Source: photobucket.com

Some, but not all.

The Associated Press article published this weekend, Rebelling against Brazil’s record C-section rate, women rediscover virtues of natural birth, makes for very interesting reading.

I'd like to draw attention to the reported information about how obstetetricians are paid - i.e. THE SAME for a cesarean as for a natural birth (and in fact the article provides an example of doctors being paid R$10 more for a natural birth).

Why is this important?

Because in other countries, high cesarean rates are blamed on the fact that obstetricians are paid MORE for surgery, which provides an unethical financial incentive to encourage more cesareans.

In Brazil, the accusation is different: AP reports that it's more an issue of time management, with a cesarean "taking 30-40 minutes" compared with "a natural birth that can last an entire day".

And in order to support women to have a better natural birth experience and to help reduce the country's cesarean rate, Brazil is said to be investing more than R$4.5 billion.

So while I support those women who are trying to gain access to quality care during a trial of labor, I think that this example demonstrates that natural birth in the 21st century - where women want to have it all (a natural experience but with a guaranteed safe outcome) - doesn't come cheap.

Israel: greater risk of PTSD with natural birth

This postpartum study of 89 women will not come as a surprise to organizations such as The Birth Trauma Association and Birth Trauma Canada, but more generally, the sometimes very traumatic experiences of mothers can be lost in descriptions of 'empowering and beautiful' births.

In Postpartum Post-Traumatic Stress Disorder symptoms: The Uninvited Birth Companion (IMAJ Vol 14, June 2012), Inbal Shlomi Polachek et al conclude that "although childbirth is a natural and widespread experience, it is a challenging event that often has longterm emotional repercussions. While PTSD is diagnosed in only a few percent of postpartum women, there are significant partial symptoms in a quarter of women, and over 50% of women define at least one of their childbirth experiences as difficult. These high percentages indicate a population at risk and the importance of early detection, diagnosis and management if necessary."
The abstract is available here, or you can read this article in The Times of India: Childbirth causes post-traumatic stress to many, which begins:

"Prof. Rael Strous of Tel Aviv University has found that approximately one third of all post-partum women exhibit some symptoms of PTSD, and a smaller percentage develop full-blown PTSD following the ordeal of labor."

  

Study questions cesarean 'financial incentive' role

A frequent accusation in the cesarean debate is that doctors are carrying out more cesareans because they can earn more money this way than with a natural birth.

But a new study from Michigan State University in the U.S., which asked, Does medical insurance type (private vs public) influence the physician's decision to perform Caesarean delivery? has concluded that no, it doesn't.

Tammy Z Movsas et al found that from 2004 to 2008 in Michigan hospitals, 33% of privately insured patients had a cesarean, compared with 29% of Medicaid patients.

However, after adjusting for risk factors (e.g. maternal age, maternal medical conditions, multiple births and prematurity), "no significant disparity was found".

The researchers intend to continue their study of this issue, looking at hospitals on a national level. 

10% risk of cesarean infection

There have been a number of articles reporting on the BJOG study today, and this is the comment I've posted on many of them:

Firstly, the study has shown a 9.6% rate of infection for ALL caesareans, the vast majority of which were emergencies and/or medically indicated. Of these, 88% were minor infections; which leaves us with a 1% total caesarean risk for serious infections.

Compare this with the risk of pelvic floor trauma in women who deliver vaginally: 15% of women have an episiotomy, 36.6% of women tear (including very serious injuries with 3^rd and 4^th degree tears). The repercussions of these (i.e. a significantly increased risk of incontinence and pelvic organ prolapse) will “seriously affect a woman’s quality of life” too, and yet this does not receive the same level of media attention.

For the RCM to conclude that this study “further supports the need to ensure that any caesarean section is performed only where clinically indicated” demonstrates its true opinion of the NICE guideline on maternal request; especially since this study (except for overweight and obese women) demonstrates no specific additional risk for women choosing to plan a caesarean compared to those planning a natural birth. Surely it actually supports the need to help women achieve and maintain a healthy weight before and during pregnancy?

Also remember that infection control is a performance indicator for hospitals whereas pelvic floor trauma is considered a “normal” outcome of natural birth, and therefore it is not given the due attention it deserves. Yes, women choosing a caesarean should be made aware of the risk of infection, but ALL pregnant women should be fully informed of the true risks of a natural (or attempted natural) birth too.

Finally, in terms of the “substantial burden” of caesarean infections, NICE reported in the Health Economics section of its caesarean guideline that the difference in cost between a planned caesarean and a planned vaginal delivery is reduced from £710 to just £84 when the cost of treating postpartum urinary incontinence is included in cost comparisons. It’s simply not factually correct to state that planned caesareans are categorically more expensive or burdensome for the NHS than a trial of labour.