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?

Has AIMS misunderstood what women in labor want? You decide...

While listening to a recent episode of Woman’s Hour last week, it struck me how even the most basic research can be misunderstood by its interpreters - and in this case, Beverley Beech, the Chair of AIMS.

Beverley was talking about the subject of 'Birthing Buddies' (which is where a supportive, trained carer stays with a woman throughout her labor), and wanted to emphasize that in this role, the 'buddy' does not necessarily need to take an active support role in the birth - it is merely their presence in the room that is of importance.

However, the research example that Beverley provided as proof of this assertion communicated something completely different to me.

Safe is a Dangerous Word

I've been reading a blog post by Ricki Lake this morning, and while a great deal of what she writes is to be applauded - providing birth plan choices that reflect each individual woman's preference and caring about a woman's postnatal mental health for example - as with many voices on the subject of natural birth, her repeated use of the word "safe" concerns me.

Don't get me wrong - I have used the word safe to describe a planned cesarean too, but in the context of surgery in 2011 being 'comparatively safe' or 'statistically safer' in some respects, than other birth plans.

I would never categorically state that any birth plan is categorically safe.

NICE Stakeholder Caesarean Comments Submitted - Back to Blog

As always, I seem to have a backlog of stories and medical studies to report on here. On this occasion, my time has been largely consumed with reading around 600 pages of the NICE Caesarean Guideline Update Draft, and preparing detailed feedback for the Guideline Development Group before they agree the final text.

C-section Caps Cost Lives and Money

I was appalled to read this story in the Express this morning, "Op Cutbacks Put Mothers At Risk". 

In it, Lucy Johnston writes:  "The Sunday Express has learned a growing number of health authorities have said they will not cover the cost of caesareans if they exceed the national average of 23 per cent. They will instead pay only the rate for a normal delivery, which means hospitals could lose up to £1,300 each time."

And I couldn't agree more with some of the comments quoted in the report:

Breech Birth Choice or Pressure?

Many women have complained that when they wanted to try to deliver their breech babies vaginally (e.g. using ECV), they have been pressured into having a planned cesarean by their doctors.

Obviously, a percentage of these women would have been successful in their trial of labor, and therefore it's good that the SOGC has published guidelines that may help women like this in the future.

In an article that was originally published in 2009, but updated this year (C-section not best option for breech birth), André Lalonde, executive vice-president of the SOGC, said: “Our primary purpose is to offer choice to women”.

But let's hope that the pendulum hasn't swung too far the other way now, and that women who would be more confident having a planned cesarean for breech presentation (as I was) are not being denied this entirely legitimate choice.

Devastating story in BMJ today: 'Living with obstetric fistula'

This is why I often say that there are TOO FEW cesareans in many parts of the world. Published in the BMJ on 9th June, 2011, 'Living with obstetric fistula' is a must-read for anyone who doubts the need for more obstetric care in the developing world.

Maternal Request Children LEAST Likely to Develop Psychopathological Problems

"The likelihood of childhood psychopathological problems may be the lowest in children born by CDMR (cesarean delivery on maternal request), followed by those born by SVD (spontaneous vaginal delivery), whereas the highest probability was observed in those born by AVD (assisted vaginal delivery)."

School asks parents how child was born - cesarean or vaginal?

Yes - as part of its elementary school application process, Dry Creek School District in California is reported to have asked parents how their child was born.

You can read the story in full at CBS' School Application Criticized For Birth Questions, but as the reporter says, unfortunately there is no word yet from the school district.

Frederick Leboyer on Natural Birth - A Must Listen

BBC Radio 4's Woman's Hour: "The French obstretician, now aged 92, discusses the influence of his landmark 1975 book Birth Without Violence."

This is just a short interview that played on Woman's Hour on 31 May, 2011, and well worth a listen - just prepare for your mouth to drop open wide very early on and probably stay like that way right the way through to the end.

Why I Chose To Have An Elective C-Section

I just had to comment on this article by canadian author Rebecca Eckler. Here's what I wrote:

This is a great post, thank you.

May I just add that there are also women who choose to plan a cesarean birth because they've made an informed decision - and not just out of fear.

Forgotten Cost of NHS Birth Litigation

This is the comment I've just posted on an article in The Sun today: NHS pays out for 750 £1m blunders.

"Litigation is a cost of childbirth that is rarely included in cost comparisons between different birth plans.

Study: Exclusive Cesarean Birth Reduces Incontinence Risk

This latest study has been reported on Reuters under a rather different headline: "Choosing C-section may not prevent incontinence"... Hence my comment below:

It's incredible that even this research, which clearly adds to the body of evidence demonstrating prophylactic benefits with planned cesarean birth, should be presented in as negative a way as possible.

Knee-Jerk Comments Criticize Cesarean Cost

I praised the Baltimore Sun's article on cesarean satisfaction rates (May 7, 2011), but others have been roundly criticizing it. The latest comment, titled "Before praising C-sections, consider the cost" (Rosalind Ellis, Baltimore) concludes that if women choose a cesarean, then they should jolly well pay for it themselves.

This was my response:

Tougher Nuts to Crack than Cesarean Rates

The irony in this article (Obesity, elective cesarean contribute to U.S. maternal mortality rate, by Robyn Carlisle, MSN, CNM, WHNP, May 9, 2011) is astonishing, and its headline does little else but feed the anti-cesarean frenzy that it is taking place amongst many birth advocates around the world. Tweet

Irony no.1:

In the developing world,

Moms who planned C-sections report high satisfaction, study says

I have just posted the following comment on this article, "Moms who planned C-sections report high satisfaction, study says" in the The Baltimore Sun (dated May 8, 2011), which begins: "Research adds a new perspective to complex view of Cesareans...".

Firstly, thank you to Meredith Cohn for being one of the first journalists to cover this

Cutting Planned C-Sections Cuts Choices, not Costs

It's the same story on cesareans in Canada as we have here in the UK - full of misunderstanding about the very different risks of planned and emergency surgery, and a determination to reduce the numbers of the safest (and often WANTED) kind while doing little or nothing to address the riskiest (and naturally unwanted) kind.

On top of which, these experts think they're going to save money like this - of course they completely ignore costs like litigation and birth injuries in their calculations...

You Are What You Eat or How You Were Born?

 Could the way you were born REALLY influence your BMI?

A Convenient Cesarean?

Scheduling your cesarean

Today I came across a question that had been posted on a website for birth doulas to answer 'yes or no' to, and it struck me (as it always does when I see maternal request cesareans being discussed in this context) how irrelevant and uninformed it is:

"Should women be able to choose elective cesarean for convenience?"

Of course they shouldn't.

BMJ letter printed: Midwife led care may not be appropriate or cost-effective

Following on from the publication of The King's Fund report in March, my letter to the British Medical Journal: "Positive birth experience: Midwife led care may not be appropriate or cost-effective" has been published in this week's print edition (April 18, 2011) and also online.

This was my original (longer version) letter,

Concern Over "The Big Push" in Liverpool

The Liverpool Echo has reported on "a £10m vision to transform maternity care on Merseyside", with Liverpool Women’s Hospital in Toxteth calling it “The Big Push”.

According to the report, "Trish Dunmore, general manager for maternity at the Women’s, said: “The Big Push is about reviewing our model of maternity care to make the best use of our resources and to give a better quality of service to mum’s”."

My Concern

Cesarean Rates Up, Stillbirth and Neonatality Mortality Rates Down

And that's a headline you're unlikely to read anywhere else today...

CMACE (Centre for Maternal and Child Enquiries) has published its latest report: Perinatal Mortality 2009, and reported that since 2000, stillbirth and neonatal mortality rates in the United Kingdom have shown a downward trend.

I have more confidence in doctors and machines than in midwives

My son's birth in 2009

The statement above is undoubtedly controversial, but speaking personally, it is nevertheless true.
Many midwives do a great job, and if I had no access to hospitals or medical intervention, then absolutely, I would not have wanted to give birth alone, and would have been eternally grateful for the knowledge and expertise of a midwife by my side.

But in the 21st Century, with all its medical advances,