Written Evidence Submitted to UK Parliament Science Communication Inquiry

In August 2016, my response to the Science and Technology Committee's invitation for written submissions was published here.

 

Unfortunately, many advances in science are viewed as negative and unnecessary 'medical interventions' in maternity care, and women are simply not informed about them.

 

 

Planned Birth Research that Does Not Compare Planned Birth Outcomes CANNOT INFORM BIRTH PLANS

Researchers this week warn women and doctors against planning births prior to 39 weeks because of an increased risk of poor child development at school.

Predictably, the media has reproduced their conclusions almost unequivocally:

- American Council on Science and Health: Planned Birth for Non-Medical Reasons not such a Good Idea

- The Sydney Morning Herald: Planning an early caesarean raises the risk of developmental delays, Sydney researchers
- Medscape: Early Planned Birth Tied to Greater Risk for Poor Development

 

What no one seems to have noticed is that the researchers don't factor in two very important risks of waiting until 39 or 40 weeks and/or spontaneous vaginal birth:
stillbirth and intrapartum death or injury.

The babies who died couldn't be assessed for their early child development, but by excluding their demise from the data, this research is unhelpful for the purpose claimed:

Remember - the aim of Planned Birth Before 39 Weeks and Child Development: A Population-Based Study (Bentley JP et al, Pediatrics Dec. 2016) is "'to inform more judicious clinical decision-making" as women approach the end of their pregnancy, by communicating the "benefits of waiting".

In this context, listed below are 8 points that summarize important flaws in this research:

Planned Birth Research that Does Not Compare Planned Birth Outcomes CANNOT INFORM BIRTH PLANS

Researchers this week warn women and doctors against planning births prior to 39 weeks because of an increased risk of poor child development at school.

Predictably, the media has reproduced their conclusions almost unequivocally:

- American Council on Science and Health: Planned Birth for Non-Medical Reasons not such a Good Idea

- The Sydney Morning Herald: Planning an early caesarean raises the risk of developmental delays, Sydney researchers
- Medscape: Early Planned Birth Tied to Greater Risk for Poor Development

 

What no one seems to have noticed is that the researchers don't factor in two very important risks of waiting until 39 or 40 weeks and/or spontaneous vaginal birth:
stillbirth and intrapartum death or injury.

The babies who died couldn't be assessed for their early child development, but by excluding their demise from the data, this research is unhelpful for the purpose claimed:

Remember - the aim of Planned Birth Before 39 Weeks and Child Development: A Population-Based Study (Bentley JP et al, Pediatrics Dec. 2016) is "'to inform more judicious clinical decision-making" as women approach the end of their pregnancy, by communicating the "benefits of waiting".

In this context, listed below are 8 points that summarize important flaws in this research:

Doctor's 2007 Interview Balanced and Measured

I hadn't heard this interview with Jeffrey Ecker MD before, though I had read the accompanying paper in the New England Journal of Medicine (NEJM).

What stands out for me in particular is his support of maternal request, and also his response to being asked whether he's concerned about rising caesarean rates; he says:

"I guess I'm more interested than concerned.

"I think a lot of this is decisions that patients and doctors make together, and when you make decisions about risks there's no one right answer, and really I think what's changed is that we've reset our threshold for what acceptable risk is."

You can listen to the full (7 minute) interview here, in which Jeffrey Ecker (an associate professor at Harvard Medical School and an obstetrician at Massachusetts General Hospital) talks to Rachel Gotbaum (an independent producer based in Boston) about the contributors to the increase in cesarean deliveries.

Warning that Cost Cutting will Risk Babies' Lives

'Babies ‘at risk’ as NHS runs short of paediatricians', warns the president of the Royal College of Paediatrics and Child Health in The Sunday Times today.

In Martyn Halle and Robin Henry's report, cuts to public services are criticized by interviewees, as are the NHS' efforts to save tens of millions of pounds.

My thoughts on this:

The juxtaposition of the NHS trying to save millions of pounds alongside accusations of risking babies' lives couldn't be more ironic to those of us who have watched as the NHSLA racked up billions of pounds in litigation paid (and still owed) to families whose babies (and/or mothers) were injured (or died) during their maternity care.

The push for normal birth at any cost, and the desire to reduce caesarean rates to entirely arbitrary percentage rate targets, have endangered the lives of countless babies. Perhaps if warnings by charities and maternity care organisations had been heeded years ago, the NHS could have made savings by reducing its litigation bill, instead of reducing neonatal care provision...?

Inching Closer to Informed Choice...



I don't want to speak to soon, but momentum seems to be building once again, which might see a move towards greater balance in the way women are informed about different birth plan risks.

Five years after NICE CG132 guidance said maternal request cesareans should be supported, you'd be forgiven for thinking it had never been published in many areas of the country.

And though that in itself is bad enough (informed women who choose a caesarean still being denied this legitimate choice), it also impacts on women who have no particular birth preference and simply want to fully understand their (and their baby's) individual likelihood of risks and benefits with different birth plans.

So it was very welcome news this week when the New Scientist published Doctors should warn women about the real risks of childbirth, and one of its reporters, Clare Wilson, wrote the accompanying article, UK doctors may officially warn women of vaginal birth risks.

You see, Clare Wilson is one of a growing number of journalists who 'gets it'.

When I first contacted her in July last year, she'd just published Stop glossing over the risks of natural birth to cut caesareans, and within months, I'd sent her a copy of our book, Choosing Cesarean, A Natural Birth Plan.

Then just this week, another two journalists told me they're reading it too, and I can't emphasise enough what a shift this is even from as little as 4 years ago (when our book was published, not a single journalist reported on or reviewed the copy we sent to them).

Somehow the world didn't seem quite as ready back then for what our book says; the 2011 NICE guidance on maternal request was being misrepresented and misinterpreted, and 'caesarean choice' (with its perceived elevated cost) didn't juxtapose at all well with austerity cuts in the NHS.

But the Kirkup Report on Morecambe Bay, the Supreme Court Judgment (Montgomery v Lanarkshire Health Board) on birth autonomy, and a plethora of other important developments (more new research and evidence on pelvic floor impact, more focus on late term stillbirths, more MPs noticing the associated ballooning costs of litigation cases with planned vaginal deliveries, and more parents - and even coroners - realising that cesarean rate targets and the 'push for normal birth at any cost' can lead to avoidable deaths and injuries - to name but a few) has changed all that.

Cesarean Choice 'Abandoned By Feminists'

My co-author, Dr. Magnus Murphy, gave an excellent interview on CBC Radio this week (listen here), explaining how "when it comes to caesarean sections, women don't have as much choice as they should."

"There are a lot of women who do feel that the feminist movement has dropped the ball on this... pelvic floor outcomes are completely ignored and that is a huge impact on a woman's quality of life over time."

How right he is.

Beneath the CBC's accompanying article, Elective C-sections are the women's health issue abandoned by feminists, says Alberta doctor, I posted the following comment:

"I am the co-author of one of the heavily referenced books cited in this article, and I am a woman and a journalist who chose a cesarean birth twice. I began working on a campaign to ensure greater balance in the information women receive in their antenatal care back in 2004, and my organisation, which is a Stakeholder for numerous NICE guidelines in the UK, was instrumental in bringing about an update to national guidance on maternal request cesareans in 2011.

I have worked closely with many other incredible women, including Maureen Treadwell (Birth Trauma Association), Penny Christensen (Birth Trauma Canada), Leigh East (c-sections.org), Janice Williams (Cesarean by Choice Awareness Network), and this is to name but a few. I've also worked or collaborated with organisations including the British Pregnancy Advisory Service, Advocacy for All (AFA), Erb’s Palsy Group, Perinatal Illness-UK, Pyramid Of Antenatal Change and AIM New Zealand, with all but one of my personal contacts at these organisations being women. Also worthy of note here is the incredible research and passion of Professor Hans P Dietz and midwife Elizabeth Skinner, at the University of Sydney, Australia, and their continued support for the (voluntary) work that I do, such as communicating with journalists and trying to help women whose cesarean requests are being refused.

National Maternity Review Silent on Life-Saving, Prophylactic Cesareans

Opening the pdf of 'BETTER BIRTHS - Improving outcomes of maternity services in England' today, I was reminded of the faulty Shopkin packet my daughter opened recently - EMPTY, with No Surprises At All.

Not a single mention of how a timely, planned cesarean birth can save lives (especially full-term babies at risk of stillbirth), protect against pelvic floor damage, and result in high maternal satisfaction for women who choose it.

'Safety' on pg.23 reads: "There was evidence from the data of opportunities for improvement in the safety of maternity services. For example: stillbirth ... instrumental deliveries resulting in third and fourth degree perineal tears...[and] almost half of CQC inspections of maternity services result in safety assessments that are either ‘inadequate’ (7%) or ‘requires improvement' (41%)"

And despite the fact that a cursory glance at NHSLA obstetrics cases demonstrates significant (and costly) mortality and morbidity of mothers and babies when cesareans are carried out too late or not at all, England's new National Maternity Review contains just three mentions of cesareans:

Pg.3 refers to an anecdote about watching a twin caesarean delivery.

Pg.27 refers to RCOG Clinical Indicators project data on emergency caesarean sections rates.

Pg.77 cites 'rates of caesarean section' as a marker of quality in South West Trusts.

Compare this to pg.99:

Feedback For Baroness Julia Cumberlege

On February 12, 2016, just ahead of the National Maternity Review being published, I commented on this post by Baroness Julia Cumberlege: "We are shaping services for years to come."

"The focus on natural or normal birth at any cost, and targets to reduce caesarean rates (as though a low percentage rate alone is a measure of good health outcomes - it is not) have endangered - and lost - the lives of countless mothers and babies giving birth in our maternity care system.

Women and their partners are not always listened to - be that a request for a caesarean birth during pregnancy or a request for intervention of any kind after the onset of labour - and all too often there are adverse consequences as a result.

A fleeting glance at the cost and causes of obstetric litigation in the NHS will confirm this, and even this doesn't reflect all the families who decide not to pursue a legal route.

Women who are at full-term in their pregnancy are rarely advised of the risk of stillbirth,

2015 Consultation Comments Submitted to National Maternity Review

On October 31, 2015 my organization electivecesarean.com (also a Stakeholder for various NICE guidance), submitted the following comments during the National Maternity Review consultation:

4.1 Which users/groups/organisation do you represent?
The organisation electivecesarean.com represents women who choose to plan a caesarean birth and also the wider group of pregnant women who don't have a specific birth plan in mind, but deserve access to balanced information on the risks and benefits of different birth plans as they relate to their individual circumstances.

4.2 What do you think are the barriers to providing high quality maternity services?
- The push to reduce caesarean rates to arbitrary levels at any cost (in 2009 the WHO admitted that there is no known optimum rate yet in 2012 the RCOG, NCT and RCM published recommendations to CCGs of a 20% rate).
- There is an emphasis on process (i.e. achieving 'normal' birth) over outcome, positive experience and patient satisfaction.
- Lack of balanced information during antenatal care - risks of planned caesarean are over exaggerated and risks of planned vaginal delivery are underestimated and/or not communicated at all (e.g. stillbirth and pelvic floor damage). 
- Research that does not gather and report on maternity data in a way that best informs both national research and evidence, and women (e.g. the Birthplace Study only compared place of birth and not mode of birth, which is unhelpful; it also excluded stillbirths that occurred prior to the onset of labour).

4.3 What do we need to do to make maternity services better?

Unforeseen Complications of a Summer Cesarean Birth

My silence on this blog over the past year is no accident, and while my cesarean campaign work has continued (via NICE, public speaking, researching, writing and supporting women who are refused their maternal request), my main focus has been on a new campaign - with eerily familiar issues to those surrounding birth choice - related to our child's education.

In short, when we decided that we wanted our son to begin school in England at compulsory school age and not before, our 'request' for this to happen opened a huge can of worms.... that ultimately led to summerbornchildren.org

It's about knowledge and empowerment

I plan to write about Piper Newton again - she's written a courageous book called, 'And Then My Uterus Fell Out', which is due out on October 1st - but for now I'd like to share the blog post she published a few days ago:

"It's about knowledge and empowerment"

She describes how her vaginal delivery has left her "with permanent disabilities, an inability to return to the workforce (at 30 years old) and... facing many high risk surgeries as [she tries to] cope with my disabilities."

Obstetrician changes his mind about Maternal Request

Admiration and respect. These are the words I would use to describe my feelings towards Dr. Silvio Aladje, an OBGYN and maternal fetal medicine specialist at Michigan State University in the U.S.  In his blog posted yesterday, 'Caesareans Section On Demand', he describes how, after reading our book, he has changed his position in the debate over maternal request caesareans. I don't admire and respect him because he has changed his mind, but rather because he is willing to say so publicly (which not everyone would be brave enough or gracious enough to do) and because his actions are one step closer towards wider recognition that maternal request caesarean is a legitimate birth plan.

Birthrights organisation highlights maternal request refusal

Birthrights website reads: "We believe that all women are entitled to respectful maternity care that protects their fundamental rights to dignity, autonomy, privacy and equality."  And on August 9, 2013, in its response to the Care Quality Commission consultation on changes to the ways the CQC regulates, inspects and monitors care services, Birthrights included the issue of maternal request caesareans being misunderstood and refused, alongside the issues being faced by women with various other birth choices (e.g. epidural and home birth).

The document is certainly well worth reading; and I can only hope that the CQC takes serious note of Birthrights' comments, and that its response leads us one step closer towards true autonomy and respect for the woefully misunderstood prophylactic caesarean.

Why women often don't get the birth they want

The answer to why women often don't get the caesarean birth they want is this: Their requests are blatantly refused.

The answer to why women often don't get the vaginal birth is more complicated, but there was an interesting debate today on BBC Radio 4's Woman's Hour, hosted by Kirstie Allsopp.

I have much to write about it, but due to other more immediate commitments tonight, I will leave any comments for another day, and simply post the programme link here and encourage you to have a listen.

Feedback welcome!

NICE says a planned caesarean section SHOULD be offered to women who request it

My letter (title above) was published in the British Medical Journal today; I wrote it in response to another letter, NICE says caesarean section is not available on demand unless clinically indicated, sent in by Mandie Scamell, a lecturer in midwifery, Alison Macfarlane, a professor in women’s and child health, Christine McCourt, a professor in women’s and child health, Juliet Rayment, a research fellow, Judith Sunderland, a lecturer and programme lead in midwifery, and Mary Stewart, a research midwife.

It reads:

Refusal to follow NICE caesarean guidance is unjustified

My letter (with the title above) was published in the British Medical Journal today; I wrote it in response to another letter, NICE promises on infertility and caesarean section are unmet, sent in by Lawrence Mascarenhas, a consultant obstetrician and gynaecologist, Zachary Nash, a medical student, and Bassem Nathan, a consultant surgeon.

It reads:

Midwives worth their weight in gold

Every now and then, I meet or read comments by a midwife who is completely and utterly supportive of women who request cesareans, who understands and respects their motivations, and who is willing to speak up about the very real risks associated with a vaginal birth. This is what one midwife wrote on one Australian blog: 

The wrong debate about cesarean sections

Following a comment I left on his article this week, What Is A Normal Pregnancy?, Dr. Silvio Aladjem invited me to comment on an article he'd written in May 2012, titled, The wrong debate about cesarean sections.

 

Here is what I wrote:

Royal Congratulations to William and Kate!

It's great news today that the Duke and Duchess of Cambridge have become new parents to a baby boy.

No news on the name yet - only that he was born at 4.24pm at St Mary's Hospital in London, weighing 8lb 6oz.

Now, I haven't been particularly enamoured by many of the political and ideological debates about what Kate may or may not have wanted in her (private) birth plan, but I thought I'd share a very short anecdote from my experience of talking with other mums this morning.

Australian Royal Birth debate this month



I'm not keen on the title of this debate (it's not for anyone to say how a woman "should" give birth), but in the context of talking about the risks and benefits of different birth plans, the debate below (more information here) may be of interest.

New NICE Quality Standard Reinforces Support for Maternal Request

electivecesarean.com  2013 NICE Quality Standard Reinforces Support for Maternal Request Caesareans and Mothers’ Satisfaction with Maternity Care PRESS RELEASE

Embargoed until 00:01 Tuesday 11^th June 2013 (GMT)

Published by electivecesarean.com

Following the National Institute for Health and Care Excellence (NICE)’s publication of its Caesarean Section Guideline (update) in November 2011, which recommended ultimate support for women who choose to plan a caesarean birth without any clinical indication, and highlighted a cost difference of just £84 with planned vaginal birth when the adverse outcome of urinary incontinence was considered,[¹] electivecesarean.com welcomes NICE’s Quality Standard for Caesarean Section, and hopes that it results in greater adherence by hospitals and health professionals to its 2011 caesarean recommendations.

Guess which makes headlines - Birth Orgasm 0.3% or Perineal Tears 39.9%?

The fact that some women experience an orgasm during birth is not a new concept, as one midwife commented at the bottom of yesterday's Daily Mail article: "Can I please state in 1984 when I became a midwife this was well known so its not a new study, but in 30 years I have never seen it NOT ONCE." (lizzy2511 Swansea, United Kingdom, 2/6/2013 23:41)

But a new study by Thierry Postel has highlighted the possibility once again.

Prolapse surgery unsuccessful for almost one third of women

A new study from the University of Utah School of Medicine (lead author Ingrid Nygaard, M.D), which followed the experiences of 215 women following reconstructive surgery for pelvic organ prolase, has concluded:

"Results after seven years of follow-up suggest that women considering abdominal sacrocolpopexy (surgery for pelvic organ prolapse [POP]) should be counseled that this procedure effectively provides relief from POP symptoms; however, the anatomic support deteriorates over time; and that adding an anti-incontinence procedure decreases, but does not eliminate the risk of stress urinary incontinence, and mesh erosion can be a problem..."

Hooray for the c-section vacation!

Above is the title of a recently posted blog on the U.S. babycenter website by mum of two Kristina Sauerwein.

Kristina's post begins by asking, "Dare I admit that I enjoyed my c-section birth experiences?" and she goes on to describe with relish what she enjoyed about her hospital stay.

Some of what she writes will certainly be controversial for some tastes, but I really felt it was a blog post worth highlighting here as it's a perspective I haven't really seen anywhere else.

Of course, see what you think.