I came across news of two new campaigns in the United States that aim to reduce their local hospital cesarean rates to between 10 and 15%. I've described this as frightening news because that's exactly what it is.
Not that I believe the campaigners have any hope of achieving such low rates; I don't. But I am concerned that in their efforts to make such drastic reductions, it will be at the cost of numerous mothers' and babies' health.
20% by 2020
The first is in Sarasota, where '20% by 2020' describes itself as "an initiative to encourage elected officials, hospital staff, maternity care practitioners and consumers to reduce Sarasota's epidemic cesarean section rates to 20% by the year 2020."
Worst to First 2010
The second is in New Jersey (where both of my children were born - by elective cesarean), which is called 'Worst to First 2010'. Evidently, the State's current cesarean rate is deemed too high, and this campaign aims to reverse the situation.
It states that all but two hospitals have agreed to re-educate their staff to achieve cesarean rates of 10%-15% and episiotomy rates of 5%. But as you'll see from the figures posted, they have a long way to go...
Fact:
A 10-15% cesarean rate is unachievable, undesirable and dangerous
The World Health Organization recommended this rate back in 1985, but in 2009, it finally admitted that there is no empirical evidence for such a range of numbers, and that in fact, there is no known optimum rate for cesarean delivery.
The campaign organizers above are most likely unaware of the 2009 update by the WHO, and therefore believe that they are helping women by trying to reduce cesarean rates to this level. However, they are in real danger of doing more harm that good if they're not careful; while I agree that there probably are cases where an unwanted cesarean delivery may be avoided (although I would add that hindsight is usually the most beneficial tool in deciding what was and wasn't medically necessary - obviously not available during labor), there are undeniably grave risks at stake when cesareans are delayed or avoided 'at all costs'.
Finally, I would urge these campaigners to focus on trying to reduce unwanted cesarean rates, and leaving those of us who want our cesareans well alone. After all, it should be positive, happy and healthy birth outcomes that matter - and not simply a % figure at each year end.
Friday, April 30, 2010
Mother Nature's Way versus The Easy Way
This is the title of an article (my capitalization) in the Shanghai Daily today, which you might be interested in reading here.
There's nothing particularly new to say in the article, which discusses the reasons for China's particularly high rate of cesarean births, and especially those arranged on maternal request, but I found the title itself quite interesting.
Easy?
What do you think? When you read 'Mother Nature's way versus the easy way', what do you make of the words 'the easy way' in reference to a cesarean delivery?
*Is the author inferring that it is actually the easiest way to give birth? In which case, why wouldn't so many Chinese women choose to have one?
*Is it meant sarcastically/ironically (i.e. 'a cesarean is thought of as 'easy' but it is in fact the very opposite)?
*Or does it infer that women are not living up to their natural born responsibility to endure the pain of labor - an essential moral and physical rite of passage into motherhood?
I don't purport to have the answer this evening, but I wanted to write about it because it's an accusation/comment/idea I've seen written about before - that a cesarean is the 'easy' option.
A cop-out almost
Personally, I've even found at some of the mother and baby groups I attend that because I chose and enjoyed a cesarean birth, I'm ineligible for membership in the birth story 'club'. Although luckily, I make the cut for the 'my babies don't sleep through the night - ever' club, so I'm not left out in the cold completely!
It makes me wonder if perhaps there's something about women/mothers that makes us bond better when we can be joined via an empathetic shared suffering of one kind or another.
And what I find fascinating is that while in China, women are choosing cesareans to avoid the potential trauma of vaginal birth or an emergency cesarean that they've heard or read about, in Western culture, we criticize and even condemn women who make the very same decision. Here, we think its natural and normal for women to want to put themselves in the hands of Mother Nature and utilize surgery only when the likely alternative is death or serious injury.
Mmm...
There's nothing particularly new to say in the article, which discusses the reasons for China's particularly high rate of cesarean births, and especially those arranged on maternal request, but I found the title itself quite interesting.
Easy?
What do you think? When you read 'Mother Nature's way versus the easy way', what do you make of the words 'the easy way' in reference to a cesarean delivery?
*Is the author inferring that it is actually the easiest way to give birth? In which case, why wouldn't so many Chinese women choose to have one?
*Is it meant sarcastically/ironically (i.e. 'a cesarean is thought of as 'easy' but it is in fact the very opposite)?
*Or does it infer that women are not living up to their natural born responsibility to endure the pain of labor - an essential moral and physical rite of passage into motherhood?
I don't purport to have the answer this evening, but I wanted to write about it because it's an accusation/comment/idea I've seen written about before - that a cesarean is the 'easy' option.
A cop-out almost
Personally, I've even found at some of the mother and baby groups I attend that because I chose and enjoyed a cesarean birth, I'm ineligible for membership in the birth story 'club'. Although luckily, I make the cut for the 'my babies don't sleep through the night - ever' club, so I'm not left out in the cold completely!
It makes me wonder if perhaps there's something about women/mothers that makes us bond better when we can be joined via an empathetic shared suffering of one kind or another.
And what I find fascinating is that while in China, women are choosing cesareans to avoid the potential trauma of vaginal birth or an emergency cesarean that they've heard or read about, in Western culture, we criticize and even condemn women who make the very same decision. Here, we think its natural and normal for women to want to put themselves in the hands of Mother Nature and utilize surgery only when the likely alternative is death or serious injury.
Mmm...
Wednesday, April 28, 2010
Worse outcomes when fewer than expected cesareans
In a study that has echoes of the 2003 Healthgrades survey of U.S. hospitals, this month, researchers Srinivas SK et al have published: 'Evaluating risk-adjusted cesarean delivery rate as a measure of obstetric quality'.
In it, they report that when cesarean rates are lower than expected, adverse maternal or neonatal outcomes are higher.
However, as Michael Smith reports in MedPage Today, "the converse isn't true". Higher-than-expected cesareans rates "aren't associated with a protective effect".
IMPORTANT - The study was carried out in the U.S. where emergency and elective cesarean deliveries are not separated in birth records; therefore, it is highly likely, and indeed comparable with what other studies have found, that the protective effect with planned, elective cesareans is higher in these hospitals but they are being tarnished by the inclusion of emergency cesarean outcomes in the data.
MedPage Today report
In his report, Smith explains how: "the researchers constructed a population-based cohort of 845,651 patients from 401 hospitals in California and Pennsylvania. They excluded premature births and those in which C-sections were standard of care (such as for malpresentation and cord prolapse).
As well as analyzing the overall cohort, the researchers looked separately at the 274,371 primiparous patients with full-term singleton pregnancies.
For both groups, they linked birth certificate and hospital admission records to estimate the correlation between risk-adjusted cesarean delivery and a composite of adverse maternal outcomes, adverse neonatal outcomes, and four obstetric patient safety indicators from the Agency for Healthcare Research and Quality (AHRQ).
The composite maternal outcome included such events as wound infection and postdelivery hemorrhage, and the composite neonatal outcome included such things as death and birth injury. The AHRQ indicators included such things as birth trauma and injury with cesarean delivery.
The researchers used logistic regression to calculate an expected rate of C-section for each hospital and compared that with the observed rate.
In both cohorts, there was a negative correlation between the C-section rate and each of the outcomes, which was significant except for one -- AHRQ patient safety indicator 19 (injury with non-instrumented vaginal delivery).
Comparing C-section and adverse events rates showed that, in the general cohort:
•59.8% of the 107 hospitals with lower-than-expected risk-adjusted C-section rates had a higher-than-expected rate of at least one of the six adverse outcomes.
•Only 19.6% of the 102 hospitals with higher-than-expected risk-adjusted C-section rates had a higher-than-expected rate of any of the six adverse outcomes.
•The comparable figure was 36.1% for the hospitals with the as-expected risk-adjusted C-section rates, which was statistically similar to the higher-than-expected group."
In it, they report that when cesarean rates are lower than expected, adverse maternal or neonatal outcomes are higher.
However, as Michael Smith reports in MedPage Today, "the converse isn't true". Higher-than-expected cesareans rates "aren't associated with a protective effect".
IMPORTANT - The study was carried out in the U.S. where emergency and elective cesarean deliveries are not separated in birth records; therefore, it is highly likely, and indeed comparable with what other studies have found, that the protective effect with planned, elective cesareans is higher in these hospitals but they are being tarnished by the inclusion of emergency cesarean outcomes in the data.
MedPage Today report
In his report, Smith explains how: "the researchers constructed a population-based cohort of 845,651 patients from 401 hospitals in California and Pennsylvania. They excluded premature births and those in which C-sections were standard of care (such as for malpresentation and cord prolapse).
As well as analyzing the overall cohort, the researchers looked separately at the 274,371 primiparous patients with full-term singleton pregnancies.
For both groups, they linked birth certificate and hospital admission records to estimate the correlation between risk-adjusted cesarean delivery and a composite of adverse maternal outcomes, adverse neonatal outcomes, and four obstetric patient safety indicators from the Agency for Healthcare Research and Quality (AHRQ).
The composite maternal outcome included such events as wound infection and postdelivery hemorrhage, and the composite neonatal outcome included such things as death and birth injury. The AHRQ indicators included such things as birth trauma and injury with cesarean delivery.
The researchers used logistic regression to calculate an expected rate of C-section for each hospital and compared that with the observed rate.
In both cohorts, there was a negative correlation between the C-section rate and each of the outcomes, which was significant except for one -- AHRQ patient safety indicator 19 (injury with non-instrumented vaginal delivery).
Comparing C-section and adverse events rates showed that, in the general cohort:
•59.8% of the 107 hospitals with lower-than-expected risk-adjusted C-section rates had a higher-than-expected rate of at least one of the six adverse outcomes.
•Only 19.6% of the 102 hospitals with higher-than-expected risk-adjusted C-section rates had a higher-than-expected rate of any of the six adverse outcomes.
•The comparable figure was 36.1% for the hospitals with the as-expected risk-adjusted C-section rates, which was statistically similar to the higher-than-expected group."
£5.6 million for girl injured in ill-advised VBAC
I met a woman just the other day at a toddler group whose first baby was born by cesarean and whose second baby had arrived 7 weeks earlier via VBAC. She was happy that she had the chance to deliver vaginally. I also know there are numerous women out there who would choose a VBAC instead of a repeat cesarean, and feel that their informed decision is being unfairly denied.
However, the case below (reported by Darbys Solicitors LLP on Webwire in February) illustrates the reason why many doctors do favor repeat surgery over VBAC - because when it goes wrong, it can seriously injure a baby, distress an entire family and ensure a huge litigation bill at the end. My sympathy lies with the parents, who, like so many families, have to wait years before receiving their compensation, and who feel that they were not informed about all the risks associated with a VBAC.
Choice, not VBAC for all, is crucial
It's one thing if YOU personally want to have a VBAC and are willing to accept the risks, but I would urge caution - particularly in light of what is happening in some Trusts in the NHS currently - that VBAC is not a delivery method that should be encouraged for every woman who has had a previous cesarean. Most importantly, if a woman wants to have a repeat cesarean, she should not be forced to have a VBAC trial of labor first.
This is an extract from the report:
"A 13 year old girl who was severely injured during birth has been awarded £5.6 million in compensation, payable by South Buckinghamshire Hospitals NHS Trust.
Alice Joyce was born on 23 March 1996 at Wycombe General Hospital with breathing difficulties, and later developed fits whilst in the Special Care Baby Unit. Her development was delayed and she was later diagnosed as having spastic quadriplegic cerebral palsy. As a result Alice suffers from severely delayed mental development and learning difficulties.
Were it not for medical negligence on the part of the doctors responsible for Alice’s mother’s care, all this could have been avoided. Doctors failed to inform Mrs Joyce that, due to a previous birth which involved caesarean delivery, there was a risk of rupture of the womb should she have a subsequent labour and vaginal delivery. If she had been warned of this risk she would have chosen to have a second caesarean delivery, thus avoiding the risk of labour."
However, the case below (reported by Darbys Solicitors LLP on Webwire in February) illustrates the reason why many doctors do favor repeat surgery over VBAC - because when it goes wrong, it can seriously injure a baby, distress an entire family and ensure a huge litigation bill at the end. My sympathy lies with the parents, who, like so many families, have to wait years before receiving their compensation, and who feel that they were not informed about all the risks associated with a VBAC.
Choice, not VBAC for all, is crucial
It's one thing if YOU personally want to have a VBAC and are willing to accept the risks, but I would urge caution - particularly in light of what is happening in some Trusts in the NHS currently - that VBAC is not a delivery method that should be encouraged for every woman who has had a previous cesarean. Most importantly, if a woman wants to have a repeat cesarean, she should not be forced to have a VBAC trial of labor first.
This is an extract from the report:
"A 13 year old girl who was severely injured during birth has been awarded £5.6 million in compensation, payable by South Buckinghamshire Hospitals NHS Trust.
Alice Joyce was born on 23 March 1996 at Wycombe General Hospital with breathing difficulties, and later developed fits whilst in the Special Care Baby Unit. Her development was delayed and she was later diagnosed as having spastic quadriplegic cerebral palsy. As a result Alice suffers from severely delayed mental development and learning difficulties.
Were it not for medical negligence on the part of the doctors responsible for Alice’s mother’s care, all this could have been avoided. Doctors failed to inform Mrs Joyce that, due to a previous birth which involved caesarean delivery, there was a risk of rupture of the womb should she have a subsequent labour and vaginal delivery. If she had been warned of this risk she would have chosen to have a second caesarean delivery, thus avoiding the risk of labour."
More Dutch women have epidurals - now that they can
Radio Netherlands Worldwide has reported that a growing number of Dutch women are opting to have an epidural during childbirth, according to a survey of teaching hospitals by free daily newspaper Spits.
It says that since January 2009, "All hospitals have been obliged to make the procedure available 24 hours a day – a new development in Dutch obstetrics."
Can you imagine - up until just a few months ago, in a developed European country, an epidural was not readily available as a standard of care for all laboring women?? Obviously, there are plenty of cases in other developed countries where resources are so stretched or disorganized that an epidural is not necessarily available for all women either (the anesthetist is busy with other patients for example), but in The Netherlands, an epidural has been traditionally viewed as an "unnecessary" medical intervention.
Pandora's Box
As the report states, even with a rate increase from 25% at a Maastricht teaching hospital in 2008 to 30% just one year later, "the Dutch epidural rate has a long way to go before it matches that of many other countries" (e.g. the United States, which can be as high as 85% in some hospitals).
But my guess is that the rate is only going to climb further in the coming years. Some might say that Pandora's box may well have been opened in Holland by 'allowing' women access to epidurals; after all, if more women are going to choose epidurals, it's surely a slippery slope to that other infamous medical intervention - the cesarean delivery on maternal request...
I, on the other hand, would say that access to this perfectly legitimate pain relief should be available for every laboring woman, and likewise, legitimate cesarean surgery should be available for every pregnant woman too.
It says that since January 2009, "All hospitals have been obliged to make the procedure available 24 hours a day – a new development in Dutch obstetrics."
Can you imagine - up until just a few months ago, in a developed European country, an epidural was not readily available as a standard of care for all laboring women?? Obviously, there are plenty of cases in other developed countries where resources are so stretched or disorganized that an epidural is not necessarily available for all women either (the anesthetist is busy with other patients for example), but in The Netherlands, an epidural has been traditionally viewed as an "unnecessary" medical intervention.
Pandora's Box
As the report states, even with a rate increase from 25% at a Maastricht teaching hospital in 2008 to 30% just one year later, "the Dutch epidural rate has a long way to go before it matches that of many other countries" (e.g. the United States, which can be as high as 85% in some hospitals).
But my guess is that the rate is only going to climb further in the coming years. Some might say that Pandora's box may well have been opened in Holland by 'allowing' women access to epidurals; after all, if more women are going to choose epidurals, it's surely a slippery slope to that other infamous medical intervention - the cesarean delivery on maternal request...
I, on the other hand, would say that access to this perfectly legitimate pain relief should be available for every laboring woman, and likewise, legitimate cesarean surgery should be available for every pregnant woman too.
Monday, April 26, 2010
April is Cesarean Awareness Month
I have some catching up to do on the blogging front as I have been unusually busy over the last six weeks, but I want to start back on the keyboard by making a plea to everyone that is involved with 'Cesarean Awareness' during the month of April.
Could you please be equally aware of these facts:
*There are women for whom a planned cesarean delivery is their number 1 preferred birth choice - we do exist, and we are capable of making independent, informed decisions about our births.
*For many women, a cesarean birth is a fulfilling, exciting and satisfying experience.
*Many cesareans are very much WANTED by mothers - so while it may be relevant to talk in terms of necessary or unnecessary cesareans for women whose cesareans are unwanted, it is entirely irrelevant to apply these labels to all cesarean births.
*There is still a great deal of confusion and misinformation about the specific risks involved with emergency cesareans, planned cesareans for medical reasons and planned cesareans on maternal request. Mixed data provides unreliable information.
*As long as a cesarean birth takes place after the start of the 39th gestational week and the mother is planning a small family, then she should not be bombarded with risks that are associated with surgery following a prolonged trial of labor or surgery carried out prematurely for medical reasons unrelated to the surgery itself. It is neither helpful nor ethical to confuse the very different degrees of risk that are applicable to each.
Could you please be equally aware of these facts:
*There are women for whom a planned cesarean delivery is their number 1 preferred birth choice - we do exist, and we are capable of making independent, informed decisions about our births.
*For many women, a cesarean birth is a fulfilling, exciting and satisfying experience.
*Many cesareans are very much WANTED by mothers - so while it may be relevant to talk in terms of necessary or unnecessary cesareans for women whose cesareans are unwanted, it is entirely irrelevant to apply these labels to all cesarean births.
*There is still a great deal of confusion and misinformation about the specific risks involved with emergency cesareans, planned cesareans for medical reasons and planned cesareans on maternal request. Mixed data provides unreliable information.
*As long as a cesarean birth takes place after the start of the 39th gestational week and the mother is planning a small family, then she should not be bombarded with risks that are associated with surgery following a prolonged trial of labor or surgery carried out prematurely for medical reasons unrelated to the surgery itself. It is neither helpful nor ethical to confuse the very different degrees of risk that are applicable to each.
Australia reports maternal request cesarean rate of 3.2%
This latest survey (published in January) from Australia, 'Estimating the Rate of Cesarean Section by Maternal Request: Anonymous Survey of Obstetricians in Australia' by Stephen J Robson et al, provides us with some interesting new information - both about maternal request cesarean rates and Australian obstetricians' views on them - so I have copied the abstract text below (with my bold text)."The findings of a recent population-based study in Australia suggested that elective cesarean delivery of a singleton pregnancy at term without medical or obstetric indications (cesarean delivery by maternal request) may represent a significant proportion of cesarean births in that country. Maternal request cesarean section has been the subject of much debate in both the lay and the medical press, but there is little useful data on this issue in the medical literature. Worldwide estimates on its frequency are unreliable because of differences between studies in the definition used, diagnostic coding, and documentation by obstetricians. Maternal request cesareans in the era predating the current high rates of cesarean section were estimated to account for 4% to 18% of all cesarean deliveries.
To address this issue, the investigators estimated the rate of cesarean section by maternal request in Australia using 2 anonymous 1-page postal surveys, one for all 1239 specialist obstetricians and the other for all 317 registered obstetric trainees (residents) in Australia. The specialists were asked whether they perform cesarean delivery by maternal request and if so, how many maternal request cesareans they performed in the previous year. Trainees were asked if they would perform such deliveries in their future practice. A reminder letter with the questionnaire enclosed was sent 6 weeks after first mailing. Measures were taken to avoid having any practitioners answer the survey more than once.
The response rate for specialists was 99% and for trainees was 81%. From the specialist responses, it was estimated that between 8553 and 12,434 maternal request cesarean sections were performed in 2006. Using the lowest estimate (8553) in calculations, maternal request accounted for 17.3% of all elective cesarean sections and 3.2% of all births in that year. The likelihood of agreeing to perform maternal request cesarean deliveries was higher among specialists who were 10 or less years from qualification. Two-third of trainees expressed the intention of doing such cesareans in their future practice.
These findings support the hypothesis that maternal request cesareans make a significant contribution to the overall rate of cesarean deliveries in Australia."
Thursday, April 22, 2010
€4.5m settlement - delayed cesarean cited in case
RTE has reported on the €4.5 settlement for a 14-year-old boy who sustained injuries that left him severely disabled during his birth in Sligo General Hospital, Ireland.
It was made "without admission of liability by the Health Service Executive", but the report outlines issues during the birth that included "too high a dose of a labour-inducing drug being given to his mother, the detachment of a monitor during the labour process, too long a delay before the decision was taken to carry out a Caesarian section and the delay in a consultant arriving to carry out the delivery."
Evan Doyle has cerebral palsy and is quadriplegic.
14 years
What I notice most about this all-too-frequent story is the number of years that this poor family have had to wait to receive compensation (or rather, announcement of a settlement amount).
14 years of fighting, waiting, suffering...
It was made "without admission of liability by the Health Service Executive", but the report outlines issues during the birth that included "too high a dose of a labour-inducing drug being given to his mother, the detachment of a monitor during the labour process, too long a delay before the decision was taken to carry out a Caesarian section and the delay in a consultant arriving to carry out the delivery."
Evan Doyle has cerebral palsy and is quadriplegic.
14 years
What I notice most about this all-too-frequent story is the number of years that this poor family have had to wait to receive compensation (or rather, announcement of a settlement amount).
14 years of fighting, waiting, suffering...
Saturday, April 17, 2010
Multiple childbirth is linked to risk of stroke
A study published in March, Parity and risk of hemorrhagic strokes (Jung et al), has reported that: "Increased number of childbirths may be related to an increased risk of both intracerebral hemorrhage and subarachnoid hemorrhage."
An article on the study, Multiple childbirth linked to stroke risk, in the March issue of Neurology, explains this finding in more detail:
"Pregnancy and delivery are known to raise stroke risk. To further look into the association between multiple births and stroke risk, researchers compared 459 women who had stroke and 918 who did not. The women were about 56 years old on average at the time of the study.
Among women who had a stroke, 38 had zero or one childbirth, 143 had given birth twice, 107 had given birth three times, and 171 had four or more deliveries. After allowing for many other factors associated with stroke risk such as age, family history of stroke, high blood pressure, diabetes, cigarette and alcohol use, as well as oral contraceptive and hormone replacement use, each additional birth was associated with 27 percent greater risk for stroke. Women reporting four or more childbirths had nearly a threefold higher risk of stroke as women with no childbirths or childbirth.
The findings could be attributed to the speculation that multiple births might further strain and stress blood vessels and other body systems, and the stress of raising children may also raise stroke risk."
An article on the study, Multiple childbirth linked to stroke risk, in the March issue of Neurology, explains this finding in more detail:
"Pregnancy and delivery are known to raise stroke risk. To further look into the association between multiple births and stroke risk, researchers compared 459 women who had stroke and 918 who did not. The women were about 56 years old on average at the time of the study.
Among women who had a stroke, 38 had zero or one childbirth, 143 had given birth twice, 107 had given birth three times, and 171 had four or more deliveries. After allowing for many other factors associated with stroke risk such as age, family history of stroke, high blood pressure, diabetes, cigarette and alcohol use, as well as oral contraceptive and hormone replacement use, each additional birth was associated with 27 percent greater risk for stroke. Women reporting four or more childbirths had nearly a threefold higher risk of stroke as women with no childbirths or childbirth.
The findings could be attributed to the speculation that multiple births might further strain and stress blood vessels and other body systems, and the stress of raising children may also raise stroke risk."
Malta: Safe birth outcomes, not fewer cesareans should be goal
Juan Ameen's article in The Times of Malta, Fewer caesarean section births but top obstetrician has reservations, reports on a reduction in cesarean births in Malta, but includes a warning from the head of the Obstetrics Department at Mater Dei Hospital, Mark Brincat, who believes that cutting the numbers should not be the ultimate goal.
He is described as still welcoming the decline, but with an insistence that the drop "is not a goal in itself as the primary aim should be the safe outcome for the mother and the baby".
The article states that the number of cesareans "increased steadily between 1999 and 2006 but started dropping from 2006 when 35% of deliveries were by [cesarean], further declining to 31%, or 1,321 births, in 2008."
He is described as still welcoming the decline, but with an insistence that the drop "is not a goal in itself as the primary aim should be the safe outcome for the mother and the baby".
The article states that the number of cesareans "increased steadily between 1999 and 2006 but started dropping from 2006 when 35% of deliveries were by [cesarean], further declining to 31%, or 1,321 births, in 2008."
Misleading facts about cesarean rates
Writing in the Times Union a few weeks ago, A. Garry Finkell, President of Perinatal Data Solutions Inc. in New York, made a very interesting contribution to the debate over rising cesarean rates, and one that I hope might help women in the U.S. in particular - but also elsewhere - when making their decision about where to give birth.
While I don't necessarily agree with his choice of words in the last paragraph, "undesirable increase in C-sections" (after all, some of the cesareans contributing to the increase - mine included - was very much desired - by me, at least...), I thought his points were worthy of posting here.
Here's an extract of what he says:
"One common feature of almost all articles on this topic is the inclusion of C-section rates for individual hospitals, implying that hospitals can be compared on this basis. There is some validity to this, but it can also be misleading.
As Dr. Camille Kanaan of Albany Medical Center pointed out, for example, AMC's rate is highly influenced by its role as the Northeastern New York Regional Perinatal Center. As such, AMC has women with high risk pregnancies transported into its birthing center from other hospitals in the region. These women have a much higher than average likelihood of needing C-sections, and this raises AMC's rate.
Further, it is the individual provider who makes the decision to perform a C-section. In any hospital with more than one obstetrical provider, the hospital's average is really the average of all the providers. In my experience, providers in a single hospital can vary widely in their C-section rates.
At the same time, an individual provider may deliver babies at more than one hospital, presumably bringing their same likelihood to do a C-section to each hospital.
An expectant mother should look to her obstetrical provider rather than to the birthing hospital in order to determine her chances of ending up with a C-section. The same is true for analysts who want to understand the dynamics involved in the undesirable increase in C-sections."
While I don't necessarily agree with his choice of words in the last paragraph, "undesirable increase in C-sections" (after all, some of the cesareans contributing to the increase - mine included - was very much desired - by me, at least...), I thought his points were worthy of posting here.
Here's an extract of what he says:
"One common feature of almost all articles on this topic is the inclusion of C-section rates for individual hospitals, implying that hospitals can be compared on this basis. There is some validity to this, but it can also be misleading.
As Dr. Camille Kanaan of Albany Medical Center pointed out, for example, AMC's rate is highly influenced by its role as the Northeastern New York Regional Perinatal Center. As such, AMC has women with high risk pregnancies transported into its birthing center from other hospitals in the region. These women have a much higher than average likelihood of needing C-sections, and this raises AMC's rate.
Further, it is the individual provider who makes the decision to perform a C-section. In any hospital with more than one obstetrical provider, the hospital's average is really the average of all the providers. In my experience, providers in a single hospital can vary widely in their C-section rates.
At the same time, an individual provider may deliver babies at more than one hospital, presumably bringing their same likelihood to do a C-section to each hospital.
An expectant mother should look to her obstetrical provider rather than to the birthing hospital in order to determine her chances of ending up with a C-section. The same is true for analysts who want to understand the dynamics involved in the undesirable increase in C-sections."
Saturday, March 27, 2010
U.S. cesarean rates increase to 32.3% in 2008
The latest CDC figures (preliminary data for 2007 and 2008) show another U.S. rise in cesarean rates to 32.3%, although as usual, there is unfortunately no breakdown in the figures between how many of those were emergency and how many were elective.
Numerous media outlets reported on the rate rise, such as Business Week's Cesarean rates Reach Record High, in which the five states with the highest cesarean rates were named as "New Jersey (38%), Florida (37%), Mississippi (36%), and Louisiana and West Virginia (35%).
On a personal note, the birth of our daughter was in New Jersey in 2007, so we're included in these numbers!
Numerous media outlets reported on the rate rise, such as Business Week's Cesarean rates Reach Record High, in which the five states with the highest cesarean rates were named as "New Jersey (38%), Florida (37%), Mississippi (36%), and Louisiana and West Virginia (35%).
On a personal note, the birth of our daughter was in New Jersey in 2007, so we're included in these numbers!
62% cesarean rate in private Hong Kong hospitals
An article in the Gulf Times on the 22nd March reported that while 40% of women in Hong Kong give birth by cesarean, in private hospitals, the rate is 62%.
It reports that Hong Kong women opt for cesarean births "because of convenience, fear of pain and the desire to give birth on an “auspicious” date".
You might want to listen to a recent radio programme from Beijing that I was invited to speak on, which discusses China's high cesarean rate.
It reports that Hong Kong women opt for cesarean births "because of convenience, fear of pain and the desire to give birth on an “auspicious” date".
You might want to listen to a recent radio programme from Beijing that I was invited to speak on, which discusses China's high cesarean rate.
Tuesday, March 16, 2010
Recent data sheds light on elective c-section debate
I've just read and posted comments on this article by Cassie Piercey, on the San Diego News Network website. This is what I've said:
There is so much that I could write in response to this article but unfortunately, time does not allow this evening. What I would like to simply point out though, is this: you provide case studies of two women's birth experiences – one, a planned cesarean birth and the other, a planned vaginal birth - and their outcomes reflect a common phenomenon.
Mo Davis-White says, "I never once wavered on my decision to have a C-section", and by all accounts was very satisfied with her birth experience. In contrast, Rose says, "My delivery experience was traumatic… It was upsetting to know my baby was suffering."
Greater levels of satisfaction following a maternal request cesarean birth have been confirmed in medical studies too. For example, this one from Sweden: After PCD "women reported a better birth experience compared to PVD women." (Wiklund et al, 2007) I am not suggesting that all women would be wise to choose a cesarean, but rather, I am defending the perfectly legitimate decision by some women to plan a cesarean in preference to a trial of labor.
There is so much that I could write in response to this article but unfortunately, time does not allow this evening. What I would like to simply point out though, is this: you provide case studies of two women's birth experiences – one, a planned cesarean birth and the other, a planned vaginal birth - and their outcomes reflect a common phenomenon.
Mo Davis-White says, "I never once wavered on my decision to have a C-section", and by all accounts was very satisfied with her birth experience. In contrast, Rose says, "My delivery experience was traumatic… It was upsetting to know my baby was suffering."
Greater levels of satisfaction following a maternal request cesarean birth have been confirmed in medical studies too. For example, this one from Sweden: After PCD "women reported a better birth experience compared to PVD women." (Wiklund et al, 2007) I am not suggesting that all women would be wise to choose a cesarean, but rather, I am defending the perfectly legitimate decision by some women to plan a cesarean in preference to a trial of labor.
Science should guide decisions on your health
I've just read and posted comments on this online article by Roger W. Harms, M.D. of the Mayo Clinic. This is what I've said:
I am a firm advocate of women 'looking to scientific information to inform their decisions', but I think it's also important to be aware of flaws that exist in the presentation of some cesarean data, and I would offer the following reports as evidence of a recent example where this has occurred:
*30 Jan 10 Nigel Hawkes: A bad case of bias against Caesareans, Independent
*26 Jan 10 Funny Figures from WHO on Caesareans, Straight Statistics
*12 Jan 10 Study advises against non-medial cesareans but how accurate is the advice?
When bias against surgery is removed, and studies containing mixed cesarean data are excluded, there is evidence that maternal request cesareans can result in better outcomes than planned vaginal deliveries. Read the stories posted on any birth trauma website (physical and psychological trauma) and you will struggle to find a single complaint from a woman who’s had a maternal request cesarean, yet there are thousands from women who planned vaginal deliveries (this is also backed up by research such as a 2007 Swedish study involving 357 women; those with maternal request cesareans ‘reported a better birth experience compared to those with planned vaginal deliveries.’). Women are simply not being informed about the whole truth. Just two examples: 1. The latest CEMACH report in the UK showed that women were less likely to die following a planned cesarean than any other birth type. 2. A 2009 Canadian study of 40,000 deliveries concluded that ‘elective pre-labour caesarean section…at full term decreased the risk of life-threatening neonatal morbidity compared with spontaneous labour with anticipated vaginal delivery’.
I would also like to pick up on the issue of cost and resources. Firstly, current cost comparisons are flawed in terms of maternal request, as they contain medical and/or emergency surgical costs, but more crucially, vaginal delivery costs repeatedly fail to include the financial impact of: 1. all planned vaginal delivery outcomes, including spontaneous, instrumental and emergency cesareans. 2. short and long-term perineal and pelvic floor repair (e.g. prolapse) and counseling when trauma occurs. 3. huge litigation bills when vaginal delivery goes wrong and a baby/mother is injured or dies. In fact, the UK’s 2004 NICE guideline discusses one cost model in which ‘maternal request would lead to savings’ (not that I’m suggesting this as a motivation), but promptly dismisses the finding as ‘not a realistic conclusion’. The bottom line is: there are risks and benefits with both birth plans - vaginal and cesarean - and women should be allowed to make their own informed decision.
I am a firm advocate of women 'looking to scientific information to inform their decisions', but I think it's also important to be aware of flaws that exist in the presentation of some cesarean data, and I would offer the following reports as evidence of a recent example where this has occurred:
*30 Jan 10 Nigel Hawkes: A bad case of bias against Caesareans, Independent
*26 Jan 10 Funny Figures from WHO on Caesareans, Straight Statistics
*12 Jan 10 Study advises against non-medial cesareans but how accurate is the advice?
When bias against surgery is removed, and studies containing mixed cesarean data are excluded, there is evidence that maternal request cesareans can result in better outcomes than planned vaginal deliveries. Read the stories posted on any birth trauma website (physical and psychological trauma) and you will struggle to find a single complaint from a woman who’s had a maternal request cesarean, yet there are thousands from women who planned vaginal deliveries (this is also backed up by research such as a 2007 Swedish study involving 357 women; those with maternal request cesareans ‘reported a better birth experience compared to those with planned vaginal deliveries.’). Women are simply not being informed about the whole truth. Just two examples: 1. The latest CEMACH report in the UK showed that women were less likely to die following a planned cesarean than any other birth type. 2. A 2009 Canadian study of 40,000 deliveries concluded that ‘elective pre-labour caesarean section…at full term decreased the risk of life-threatening neonatal morbidity compared with spontaneous labour with anticipated vaginal delivery’.
I would also like to pick up on the issue of cost and resources. Firstly, current cost comparisons are flawed in terms of maternal request, as they contain medical and/or emergency surgical costs, but more crucially, vaginal delivery costs repeatedly fail to include the financial impact of: 1. all planned vaginal delivery outcomes, including spontaneous, instrumental and emergency cesareans. 2. short and long-term perineal and pelvic floor repair (e.g. prolapse) and counseling when trauma occurs. 3. huge litigation bills when vaginal delivery goes wrong and a baby/mother is injured or dies. In fact, the UK’s 2004 NICE guideline discusses one cost model in which ‘maternal request would lead to savings’ (not that I’m suggesting this as a motivation), but promptly dismisses the finding as ‘not a realistic conclusion’. The bottom line is: there are risks and benefits with both birth plans - vaginal and cesarean - and women should be allowed to make their own informed decision.
Let's be honest about childbirth
This article in The Guardian on Saturday is a must-read for any pregnant women, and I don't say that because I want to scare women into choosing a cesarean birth (before I'm accused of doing just that). I say it because I truly believe that women are not being properly informed about the potential risks involved with a trial of labor; rather, their heads are filled with the evils that await them if they end up with a cesarean.
Certainly, there are planned vaginal births that result in positive outcomes - a healthy baby and a happy, healthy mother - but there are also those that end like this one. That's Mother Nature for you. In case you missed reading it at the weekend, Emily Woof's description of her traumatic birth - 'Let's be honest about childbirth' - dares to reveal what every pregnant woman deserves to know.
Certainly, there are planned vaginal births that result in positive outcomes - a healthy baby and a happy, healthy mother - but there are also those that end like this one. That's Mother Nature for you. In case you missed reading it at the weekend, Emily Woof's description of her traumatic birth - 'Let's be honest about childbirth' - dares to reveal what every pregnant woman deserves to know.
I had a c-section - does that make me less of a mother?
Of course not, but I came across this article yesterday, and while I don't agree with everything the writer says, I just felt that I wanted to draw attention to one particular paragraph. The poetry of it really touched a nerve for me - the nice, tingly kind:
"I had surgery. I had an epidural. I had stitches and pain medication for weeks afterward. Does that make my birth experience unnatural? Does it make me less of a woman or a mother? What do people get out of vaginal birth that I didn't experience? I had a baby, I saw her face and nearly broke from the love of it."
Amy's description of how she felt about her baby completely encapsulates how I felt when presented with my children for the first time. The happiest births are the healthiest ones, and I have never regretted for one minute that mine were surgical.
"I had surgery. I had an epidural. I had stitches and pain medication for weeks afterward. Does that make my birth experience unnatural? Does it make me less of a woman or a mother? What do people get out of vaginal birth that I didn't experience? I had a baby, I saw her face and nearly broke from the love of it."
Amy's description of how she felt about her baby completely encapsulates how I felt when presented with my children for the first time. The happiest births are the healthiest ones, and I have never regretted for one minute that mine were surgical.
VBAC versus cesarean statement from the NIH
There have been a number of media reports following the latest statement on cesarean delivery from the National Institutes of Health, and I have been concerned by the number of headlines that imply that the NIH has said "VBAC is safe". Now, while I am completely in support of low risk women making an informed decision to have a VBAC birth, and sympathize with those who have been refused their birth choice in some hospitals, it is dangerous to start describing a VBAC as 'safe'. There are indisputable risks involved, as there are with a repeat cesarean, and it's a case of choosing which set of risks and benefits (as they apply to your particular medical history) you are most comfortable with.
Therefore, I think it's useful to present the NIH's actual summary here (known as an 'Abstract') for women to read for themselves, and if you are considering a VBAC, I would suggest you read the whole statement in full as part of your birth research. Through my work, I am rarely contacted by women who are trying to plan a VBAC; on the contrary, I hear mainly from women who are trying to plan a cesarean for their first birth. And of course personally, I didn't choose a vaginal birth first time round, much less consider having one after a cesarean. But that was my personal decision, and I think it's important that every woman's personal decision is respected. Respected and informed.
Vaginal Birth After Cesarean: New Insights
Objective: To provide health care providers, patients, and the general public with a responsible assessment of currently available data on vaginal birth after cesarean (VBAC).
Participants: A non-DHHS, nonadvocate 15-member panel representing the fields of TEXT, and a public representative. In addition, 21 experts from pertinent fields presented data to the panel and conference audience.
Evidence: Presentations by experts and a systematic review of the literature prepared by the Oregon Evidence-based Practice Center, through the Agency for Healthcare Research and Quality. Scientific evidence was given precedence over anecdotal experience.
Conference Process: The panel drafted its statement based on scientific evidence presented in open forum and on published scientific literature. The draft statement was presented on the final day of the conference and circulated to the audience for comment. The panel released a revised statement later that day at http://consensus.nih.gov. This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government.
Conclusions: Given the available evidence, TOL is a reasonable option for many pregnant women with a prior low transverse uterine incision. The data reviewed in this report show that both TOL and ERCD for a pregnant woman with a prior transverse uterine incision have important risks and benefits and that these risks and benefits differ for the woman and her fetus. This poses a profound ethical dilemma for the woman as well as her caregivers, because benefit for the woman may come at the price of increased risk for the fetus and vice versa. This conundrum is worsened by the general paucity of high-level evidence about both medical and nonmedical factors, which prevents the precise quantification of risks and benefits that might help to make an informed decision about TOL versus ERCD. We are mindful of these clinical and ethical uncertainties in making the following conclusions and recommendations.
One of our major goals is to support pregnant women with a prior transverse uterine incision to make informed decisions about TOL versus ERCD. We urge clinicians and other maternity care providers to use the responses to the six questions, especially questions 3 and 4, to incorporate an evidence-based approach into the decisionmaking process. Information, including risk assessment, should be shared with the woman at a level and pace that she can understand. When both TOL and ERCD are medically equivalent options, a shared decisionmaking process should be adopted and, whenever possible, the woman’s preference should be honored.
We are concerned about the barriers that women face in accessing clinicians and facilities that are able and willing to offer TOL. Given the level of evidence for the requirement for “immediately available” surgical and anesthesia personnel in current guidelines, we recommend that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement relative to other obstetrical complications of comparable risk, risk stratification, and in light of limited physician and nursing resources. Healthcare organizations, physicians, and other clinicians should consider making public their TOL policy and VBAC rates, as well as their plans for responding to obstetric emergencies. We recommend that hospitals, maternity care providers, healthcare and professional liability insurers, consumers, and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to TOL.
We are concerned that medico-legal considerations add to, as well as exacerbate, these barriers. Policymakers, providers, and other stakeholders must collaborate in the development and implementation of appropriate strategies to mitigate the chilling effect of the medico-legal environment on access to care.
High-quality research is needed in many areas. We have identified areas that need attention in response to question 6. Research in these areas should be prioritized and appropriately funded, especially to characterize more precisely the short-term and long-term maternal, fetal, and neonatal outcomes of TOL and ERCD.
Therefore, I think it's useful to present the NIH's actual summary here (known as an 'Abstract') for women to read for themselves, and if you are considering a VBAC, I would suggest you read the whole statement in full as part of your birth research. Through my work, I am rarely contacted by women who are trying to plan a VBAC; on the contrary, I hear mainly from women who are trying to plan a cesarean for their first birth. And of course personally, I didn't choose a vaginal birth first time round, much less consider having one after a cesarean. But that was my personal decision, and I think it's important that every woman's personal decision is respected. Respected and informed.
Vaginal Birth After Cesarean: New Insights
Objective: To provide health care providers, patients, and the general public with a responsible assessment of currently available data on vaginal birth after cesarean (VBAC).
Participants: A non-DHHS, nonadvocate 15-member panel representing the fields of TEXT, and a public representative. In addition, 21 experts from pertinent fields presented data to the panel and conference audience.
Evidence: Presentations by experts and a systematic review of the literature prepared by the Oregon Evidence-based Practice Center, through the Agency for Healthcare Research and Quality. Scientific evidence was given precedence over anecdotal experience.
Conference Process: The panel drafted its statement based on scientific evidence presented in open forum and on published scientific literature. The draft statement was presented on the final day of the conference and circulated to the audience for comment. The panel released a revised statement later that day at http://consensus.nih.gov. This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government.
Conclusions: Given the available evidence, TOL is a reasonable option for many pregnant women with a prior low transverse uterine incision. The data reviewed in this report show that both TOL and ERCD for a pregnant woman with a prior transverse uterine incision have important risks and benefits and that these risks and benefits differ for the woman and her fetus. This poses a profound ethical dilemma for the woman as well as her caregivers, because benefit for the woman may come at the price of increased risk for the fetus and vice versa. This conundrum is worsened by the general paucity of high-level evidence about both medical and nonmedical factors, which prevents the precise quantification of risks and benefits that might help to make an informed decision about TOL versus ERCD. We are mindful of these clinical and ethical uncertainties in making the following conclusions and recommendations.
One of our major goals is to support pregnant women with a prior transverse uterine incision to make informed decisions about TOL versus ERCD. We urge clinicians and other maternity care providers to use the responses to the six questions, especially questions 3 and 4, to incorporate an evidence-based approach into the decisionmaking process. Information, including risk assessment, should be shared with the woman at a level and pace that she can understand. When both TOL and ERCD are medically equivalent options, a shared decisionmaking process should be adopted and, whenever possible, the woman’s preference should be honored.
We are concerned about the barriers that women face in accessing clinicians and facilities that are able and willing to offer TOL. Given the level of evidence for the requirement for “immediately available” surgical and anesthesia personnel in current guidelines, we recommend that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement relative to other obstetrical complications of comparable risk, risk stratification, and in light of limited physician and nursing resources. Healthcare organizations, physicians, and other clinicians should consider making public their TOL policy and VBAC rates, as well as their plans for responding to obstetric emergencies. We recommend that hospitals, maternity care providers, healthcare and professional liability insurers, consumers, and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to TOL.
We are concerned that medico-legal considerations add to, as well as exacerbate, these barriers. Policymakers, providers, and other stakeholders must collaborate in the development and implementation of appropriate strategies to mitigate the chilling effect of the medico-legal environment on access to care.
High-quality research is needed in many areas. We have identified areas that need attention in response to question 6. Research in these areas should be prioritized and appropriately funded, especially to characterize more precisely the short-term and long-term maternal, fetal, and neonatal outcomes of TOL and ERCD.
Sunday, February 28, 2010
How did we let these barbaric doctors get away with it?
I wrote this to a friend today: "I thought I'd heard it all, but no, there's more...". I'd just read a story in the Irish Herald highlighting new horrors that women have been subjected to during 'normal' vaginal deliveries in hospital.
I knew what an episiotomy was, of course. I also knew I wanted to avoid one. But a symphysiotomy? That was a new one on me, and here's what I learned today:
Note: More information in this SOS (survivors of symphysiotomy) press release
What is a symphysiotomy?
*A drastic operation to widen the pelvis in obstructed labour...
*It was performed on nearly 1,500 women around the time of birth, leaving many of them incontinent, in pain and suffering from depression for the rest of their lives
*The procedure, which dates back to the 18th century, was reintroduced into Ireland in the mid-1940s at a time when it was dying out in medicine in the developed world.
Scandal
*...young and vulnerable women were put through a barbaric surgical procedure around the time of childbirth for dubious reasons."
*So far, around 110 victims of symphysiotomy have come forward, and there may be many more suffering in silence."
*Symphysiotomy was reportedly used to ensure women could continue to have several children, whereas a cesarean section might have limited the number of children they could bear.
*It was feared by some... that facing the alternative of repeated caesareans, women would turn to birth control.
*Those carrying out the procedure appeared to ignore its serious after-effects.
Remind you of anything?
I don't mean to suggest that the use of forceps, ventouse, episiotomy and other vaginal delivery interventions are as dangerous as symphysiotomy, but I do believe that comparisons can be drawn in relation to the final point above (regarding serious after-effects).
Women are simply not being warned about the true risks involved in planned vaginal delivery. Yes, if their outcome is spontaneous without morbidity for mother or baby, then I agree that (with hindsight) it has fewer risks than surgery. However, given that a spontaneous vaginal delivery outcome is neither predictable nor guaranteed, I simply cannot understand the justification for refusing a woman's request to deliver by planned cesarean surgery instead.
Improvements must come
The reporter for the Herald writes this about Ireland: "Some day, someone will properly psychoanalyse us as a nation and society to find out exactly why we put up with so much for so long."
I would make the same observation about some aspects of maternity policy and the disastrous outcomes that too many parents suffer: "Some day, someone will properly psychoanalyse expectant parents to find out exactly why we put up with so much for so long."
I knew what an episiotomy was, of course. I also knew I wanted to avoid one. But a symphysiotomy? That was a new one on me, and here's what I learned today:
Note: More information in this SOS (survivors of symphysiotomy) press release
What is a symphysiotomy?
*A drastic operation to widen the pelvis in obstructed labour...
*It was performed on nearly 1,500 women around the time of birth, leaving many of them incontinent, in pain and suffering from depression for the rest of their lives
*The procedure, which dates back to the 18th century, was reintroduced into Ireland in the mid-1940s at a time when it was dying out in medicine in the developed world.
Scandal
*...young and vulnerable women were put through a barbaric surgical procedure around the time of childbirth for dubious reasons."
*So far, around 110 victims of symphysiotomy have come forward, and there may be many more suffering in silence."
*Symphysiotomy was reportedly used to ensure women could continue to have several children, whereas a cesarean section might have limited the number of children they could bear.
*It was feared by some... that facing the alternative of repeated caesareans, women would turn to birth control.
*Those carrying out the procedure appeared to ignore its serious after-effects.
Remind you of anything?
I don't mean to suggest that the use of forceps, ventouse, episiotomy and other vaginal delivery interventions are as dangerous as symphysiotomy, but I do believe that comparisons can be drawn in relation to the final point above (regarding serious after-effects).
Women are simply not being warned about the true risks involved in planned vaginal delivery. Yes, if their outcome is spontaneous without morbidity for mother or baby, then I agree that (with hindsight) it has fewer risks than surgery. However, given that a spontaneous vaginal delivery outcome is neither predictable nor guaranteed, I simply cannot understand the justification for refusing a woman's request to deliver by planned cesarean surgery instead.
Improvements must come
The reporter for the Herald writes this about Ireland: "Some day, someone will properly psychoanalyse us as a nation and society to find out exactly why we put up with so much for so long."
I would make the same observation about some aspects of maternity policy and the disastrous outcomes that too many parents suffer: "Some day, someone will properly psychoanalyse expectant parents to find out exactly why we put up with so much for so long."
Unethical focus on reducing cesarean rates - another baby dies
This story, published in The Daily Mail on Monday this week, is a harrowing read and absolutely devastating (Why do doctors still use forceps when they killed our baby? by Jane Feinmann). It sickens me when I hear about women whose legitimate cesarean request is being ignored or refused at antenatal meetings, and the stress and trauma that they have to suffer during their pregnancy, but when I read stories like this - where there was a clear and present danger to the baby, the parents are begging for a cesarean, and medical professionals choose a riskier course of action that results in a precious baby's death - I may have tears in my eyes, but my stomach churns in anger and resolve that something must be done to stop this unethical practice.
Maggie Blott, spokeswoman for the Royal College of Obstetricians and Gynaecologists, is quoted as saying: "If we are going to have normal deliveries, we have to keep on training obstetricians to use forceps."
My view: "I planned a cesarean delivery precisely because I did not want a 'normal' or 'natural' vaginal birth. I didn't trust Mother Nature, I wanted to avoid the unpredictability of a trial of labor, and I took comfort in the growing body of research that demonstrates far safer outcomes for babies with planned cesarean delivery at 39 weeks. I wanted a safe birth - not a normal one - and hospital policy should support this choice."
I would encourage you to read this article in full, but here are some of the main details reported as the investigation continues:
The outcome
- Baby Alexandra, born weighing 9lb 4oz, died when she was just three days old
- Baby Alexandra, born weighing 9lb 4oz, died when she was just three days old
- She died as a result of severe injury to her spinal cord inflicted during a forceps delivery that went wrong - 10 hours after her parents had repeatedly begged the obstetric team to deliver the baby by cesarean
- Parents Beatrix and Craig Campbell lost the daughter they had conceived through IVF after 5 years of trying (which had involved both parents undergoing surgery)
The birth
- June 2009, at the Royal Infirmary Edinburgh’s Simpson Centre for Reproductive Health
- Beatrix, a slight 5ft 2in, was past her due date with a large baby lying sideways
- 30 hours after induction started, exhausted and barely dilated, Beatrix told the midwife she wanted a cesarean. The hospital later admitted that this would have saved Alexandra, but the request was refused.
- It took 4 doctors 75 minutes to stitch Beatrix and she had to return a month later for surgery on the wound
What the parents say
- ...they believe she was the victim of medical arrogance and a determination to reduce the rising cesarean rate
- ...they are hoping there will be an independent investigation into Alexandra’s death
- They have begun their own investigation into forceps, discovering that deaths or serious injury are far from rare. ‘We were horrified to discover this is a frequent occurrence that no one seems to be monitoring,’ says Beatrix. ‘Craig has found local newspaper reports of ten examples of babies dying or being damaged during forceps delivery, with the coroners’ reports in many cases saying that a Caesarean should have been performed earlier.’
Informing women...?
Feinmann writes: ‘NHS websites talk about “the slight risks associated with forceps delivery”, citing temporary problems such as bruising or scratches,’ says Beatrix, 32, a researcher. In fact, studies since the Eighties have reported high rates of damage to mothers and babies through forceps use. Recent research confirmed this poses a higher risk of birth injury than other interventions, including Caesareans.
Feinmann writes: ‘NHS websites talk about “the slight risks associated with forceps delivery”, citing temporary problems such as bruising or scratches,’ says Beatrix, 32, a researcher. In fact, studies since the Eighties have reported high rates of damage to mothers and babies through forceps use. Recent research confirmed this poses a higher risk of birth injury than other interventions, including Caesareans.
Over the past decade, there has been a decline in the use of forceps worldwide - the instrument is consigned to medical history in most U.S. maternity hospitals.
Using forceps safely requires a high level of skill and expertise, which ‘means that the outcome is always uncertain, even for experienced surgeons,’ says leading U.S. surgeon Atul Gawande, head of the World Health Organisation’s Safer Surgery initiative.
‘If you’re seeking the safest possible delivery of every baby, you have to take notice of the steady reports of terrible forceps injuries to babies and mothers, despite the training that clinicians have received,’ he says.
Experts are particularly concerned about a type known as Kielland’s forceps, which were used to deliver Alexandra... Unlike most forceps, which are used to speed up the delivery of a baby that has become distressed or obstructed in the final stages of delivery, Kielland’s forceps are used to rotate an infant stuck in a sideways position, usually higher in the birth passage.
The procedure is so tricky, says Professor Nick Fisk, former consultant obstetrician at Queen Charlotte’s Hospital, London, ‘that even experienced senior consultants would not attempt a Kielland’s forceps delivery’.
Should forecps be used?
Feinmann writes: Phil Steer, Professor of Obstetrics and Gynaecology at Imperial College, London, is among the many who have abandoned forceps - they are a rarity in Chelsea & Westminster, where he is a consultant obstetrician, with Kielland’s forceps all but unknown.
Yet at least 31,500 babies a year are delivered by forceps - that’s one in 20. Some hospitals continue to use Keilland’s forceps; at the Royal Infirmary, where Alexandra was born, there are 170 such deliveries a year.
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