Monday, October 27, 2008

Is it so shocking that fear of labor pains may be behind some cesarean deliveries?

In this Sunday's Observer newspaper, Louise Silverton, deputy general-secretary of the Royal College of Midwives (RCM) talks about the issue of rising cesarean rates, and is quoted as saying that "women under 40 are less prepared to undergo the physical trauma of childbirth than their predecessors, a trend that is pushing up the rate of surgical deliveries."

She describes England's current cesarean rate of 24.3% as an "unacceptably high and needlessly high" figure that should be brought closer to the 15% recommended by WHO. The fact that Ms Silverton criticizes cesarean rates is of no surprise to me, but what concerns me far more is some of the views she holds about pregnant women. As someone in a position of great power and influence in the world of maternity services, her attitude towards women whose birth preference she does not share is worrying, and her lack of understanding (or willingness to understand) their differing perspective on pain is equally so.

Silverton's solution to pain: 'suck it up like previous generations of women'
Let's examine what Ms Silverton says in the Observer:
"Society's tolerance of pain and illness has reduced significantly."
"Women are less tolerant of labour pains because they haven't developed tolerance of pain. For example, if they get period pain they will either take Nurofen or go to their GP."
"...women under 40 [are] more likely to have an 'epidural in a way that their predecessors wouldn't'."

Ms Silverton describes labor pain as "unbelievably painful" and yet fails to understand or accept that women may have a genuine fear of such pain or choose to avoid it altogether (whether via an epidural or a planned cesarean delivery). What right does she have to suggest that women be encouraged - or forced - to have a natural birth?

The RCM also proposed fees for unnecessary edipurals
This is not the first time that the RCM has been out of step with what contemporary pregnant women want. Back in February 2006, its education and research committee came up with the highly controversial proposal that epidurals should be "free to women who have a definite need of it [but a fee] levied for all other women who desire" one. At the time, Ms Silverton was quoted as saying: "Epidurals provide effective pain relief but, where there is no clinical indication that they are necessary, they can significantly raise the likelihood of other interventions such as caesarean section occurring. "The UK already has an extremely high Caesarean rate and, as the acknowledged experts in normal pregnancy, labour and birth we midwives need to debate ways in which we might help to bring this rate down. "This is a very serious issue and one that is likely to raise significant debate but also something that needs to be debated if we are to improve the normal birth rate."

An argument that is often used against women who choose a cesarean due to a fear of labor pain or labor itself is that they can simply have an epidural. But it is not that simple. First of all, it is clear from the opinion of the very influential midwife above that epidurals are frowned upon too, and secondly, whether it is coincidence or not, I have been contacted by women whose experience of vaginal delivery was that they were refused an epidural or an epidural was 'not available in time' for the start of their pushing. They suffered a traumatic experience and decided to seek support in trying to schedule a cesarean delivery for their next pregnancy.

Clearly, the RCM wants to reduce cesarean rates, but it must ask itself - at what cost physical and psychological cost to the women it claims to serve?

More of Ms Silverton's comments - and my responses to them
"...caesareans have become too easy to obtain"
Not according to the women I receive emails from; they cite experiences with midwives, doctors and hospitals where their cesarean requests are refused. This leads to enormous stress during their pregnancy.

"Women are trying to remove the symptoms of pregnancy as much as they can. They are seeking to control everything. Choosing to have a caesarean gives you an element of control."
Yes, a planned cesarean does provide an element of control, and this benefit is often cited by women whose birth preference is surgery. Is that such a bad thing? The unpredictability of vaginal delivery is not embraced by all women and we shouldn't expect it to be.

"A caesarean is major abdominal surgery. I don't think women realise that. They see it as just another way of giving birth. They see it as easy. And they think that if they can have an elective caesarean they will have no pain because they haven't been in labour."
Of course they realize that it is major surgery, but they have decided to accept the risks associated with that surgery in preference to the risks associated with a planned vaginal delivery. Speaking for myself, I don't view any birth type as 'easy', and I was fully aware that I would experience some abdominal pain following abdominal surgery. However, I also knew that my postpartum pain would be managed (and it was), and that I would be able to tolerate any abdominal pain far better than any perineal pain.

"Some women, tired after a long labour, were wrongly given a caesarean at 10pm to save doctors operating at 2am, when they should be left longer in case natural labour developed..."
I find this comment so reprehensible that I struggle to find the appropriate words. Is it not feasible that the doctor making this decision is making the right one? How many more hours does Ms Silverton suggest that women already "tired after a long labor" continue to labor before undergoing - in her own words - major surgery? And besides the woman, there may also be a danger to the baby in delaying cesarean delivery.

"She also accused junior doctors of approving or undertaking emergency caesareans too quickly if there were any suggestion of risk to the child's health, because they feared they might be sued if something went wrong."
Litigation fear is a reality whether we like it or not, and we might all ask ourselves what would we do in that doctor's position. But the litigation or ethical debate aside, wouldn't most women 'if there were any suggestion of risk to the child's health' also agree with the doctor's (junior or otherwise) decision to perform a cesarean delivery?

" has to question whether the women of this country are physiologically incapable of having normal births, and I don't think they are..."
Then why try to force vaginal delivery on those who don't even want one in the first place?

"She listed a caesarean's main dangers for mothers as 'the risk of infection, the effect on subsequent fertility and the effect on their ability to look after a newborn baby when they are post-operative'. There can also be respiratory complications for the baby, she added."
Yes, there is a risk of infection, and you can read more about that here. There is no association with subsequent fertility following a planned cesarean delivery; a number of studies have found that any reduction in fertility is voluntary. Women's ability to look after a newborn baby following a planned vaginal delivery can also be adversely affected; it is not necessarily any worse following planned surgery ( I personally experienced no such difficulty). Respiratory complications are largely associated with pre-term deliveries and can be mitigated by delivery at 39 weeks confirmed gestation - as advised for healthy women who choose to give birth surgically.


Christine Fiscer, Birthkeeper said...

Pre-term delivery is not just defined by prior to 36/37 weeks.

Pre-term can also be defined as the period before the baby is ready to be born.

Some babies, had they been left alone to grow as they should have, would go to 42 weeks. An elective cesarean at 39 weeks will NOT solve the prematurity issues, or the respiratory issues. Essentially, some babies will be taken WEEKS earlier than they would have been born. Whether or not the cesarean is done at 39 weeks.

You also seem to be forgetting the main benefit to baby during a vaginal birth - the lungs being efficiently squeezed ( mother nature was smart, eh? ) during a vaginal delivery, along with the hormones FROM LABOR that aid in the expansion of the lungs.

The answer is not holding off on elective cesareans until 39 weeks. The answer is holding off on elective cesareans all together.

If for nothing else but the baby's sake.

cesarean debate said...

birthkeeper - A large number of medical studies precisely contradict what you are saying about delivery at 39 weeks confirmed gestation.

Your suggestion of leaving everything (including the bay's readiness to be born) to Mother Nature is again, contrary to medical evidence and opinion. Please read the 2008 study 'Increased neonatal mortality among normal-weight births beyond 41 weeks of gestation in California, Bruckner et al' for just one example of this evidence.

You comment about 'holding off on elective cesareans altogether' demonstrates one of two things. A lack of medical professional experience and understanding, or alternatively, a different tolerance of risk when it comes to the safety of your baby than that of other women.

Christine Fiscer, Birthkeeper said...

Cesarean Debate -

Maybe you'd like to come and hang out on the ICAN list for a while, and see just how many women and babies have been harmed by cesareans.

Maybe you'd like to see the reviews of the higher incidense of late-term prematurity, with a higher prevalence being amongst induction and cesarean babies.

I'm sure you're not really of the belief that medical studies are not skewed.

The interesting part is that you are pointing out a study that shows, in most instances, a risk of less than 1% of infant mortality in babies going beyond 41 weeks.

You can't really be comparing this to the risks associated with elective cesareans? You'd be stringing yourself up by doing so.

Studies actually show a higher rate of stillbirth at 38 weeks, versus 41 weeks. Should we induce, or surgically remove babies before the 38 week mark?

Your over all beliefs about cesarean sections demonstrates one of two things. A lack of education about natural childbirth - and I do not merely mean vaginal birth, or a completely skewed view of birth in general.

cesarean debate said...

birthkeeper - From everything I have read, women are most dissatisfied with 'unwanted' cesarean deliveries, and they are highly satisfied when the cesarean is 'wanted.'

If these women (myself included) are happy with our birth experiences, why does this make you so angry?

Christine Fiscer, Birthkeeper said...

Because no one is allowing the baby to be born in his/her own time.

Women who choose elective cesareans rob their babies of the birth that they deserve. Babies are being hurt by this. And so are women. Even if it comes up years later. I feel badly for babies who are cut out of their mothers' womb before they are ready. I feel badly for babies who are cut out of their mothers' womb at all. Even when it's necessary, and I'm very grateful for necessary and life saving cesareans, I still mourn the baby's entrance into this world. It's important, and it matters.

And don't you ever ask what leads a woman to CHOOSE major abdominal surgery versus a natural childbirth? Could it be the widespread ignorance surrounding childbirth? Could it be the constant abuse that occurs in the hospital? Could it be the coercion, the fear, and the unnecessary battery?

I feel very sorry that you have such a skewed view of childbirth.

cesarean debate said...

birthkeeper - I have never felt that I 'robbed' my baby daughter of anything. I am happy with my birth decision, my birth experience and my beautiful baby daughter.

I think that some of your anger and intolerance of cesarean surgery as a legitimate choice comes from your own obviously upsetting and traumatic experiences.

I am sorry that this has been your experience, and I respect your subsequent personal birth preference, but please, don't assume that women like me are categorically being 'abused' in hospitals. That is simply not the case.