Wednesday, December 30, 2009

Planned Cesarean Delivery Offers Protection Against Pelvic Floor Disorders

Press Release by

Dec 28, 2009 – A new study published this month warns that pelvic floor disorders are set to increase substantially in America over the next 40 years due to changing demographics.(1) Pauline McDonagh Hull, editor of highlights medical studies that demonstrate an increased risk of these disorders following vaginal delivery (VD) and a protective benefit with planned cesarean delivery (CD), plus evidence that women are not being informed of these facts.

You can read the full press release here.

Wednesday, December 23, 2009

Criticism of promoting cesarean delivery on request

A number of bloggers and birth educators have been discussing (and applauding) a recent commentary by Nicette Jukelevics, MA, ICCE, called 'Putting Mothers and Babies at Risk: Promoting the Elusive ‘Cesarean Delivery on Maternal Request’'.

In it, Nicette Jukelevics asks questions including 'Maternal Choice or Physician Choice Cesareans?', and I completely understand that this is a genuine concern for women whose first choice is a vaginal delivery.

However, for me, the most important aspect of her commentary is its 'suggested Patient Information Form', which Jukelevics would like every pregnant women to read, answer the questions and then sign, in order to 'accurately demonstrate that she is choosing a cesarean section that is based on informed consent.'

Patient Information Form
(Surely this is needed for cesarean AND vaginal delivery?)
I actually like the idea of such a form, and while I would like to see some modifications in the set of questions proposed here for maternal request cesarean delivery, what I am even more interested in seeing is the proposed Patient Information Form for pregnant women to read prior to choosing a planned vaginal delivery (primary and VBAC) - in order to ensure that this too is based on informed consent.

I appreciate that my request for equality in aiding informed decisions of both cesarean and vaginal deliveries will strike many birth educators as unnecessary - they may believe that the decision to plan a vaginal delivery is the norm or given, and it is only cesarean delivery 'pushed on women by obstetricians' that requires informed consent.

I disagree.

I believe that the risks associated with planned vaginal delivery - whether spontaneous, instrumental or eventual emergency cesarean delivery in its outcome - are often underestimated or ignored by birth educators, and that women are not consistently informed of the potential negative health implications (physical and psychological) for their babies or themselves.


Monday, December 14, 2009

My interview with BBC Radio Wales aired this evening

Retired urologist Christine Evans interviewed me for this special programme in which she sets out to explore whether cesarean deliveries on maternal request are justified.

The programme is called 'The Irritated Consultant' and it's Episode 4, '...caesarian births under the spotlight.'

Christine concludes that a woman's autonomy in making an informed decision is legitimate, particularly when she is older (35 years or more) or has had medical help to conceive.

You can read details of previous radio and media interviews here.

Friday, December 11, 2009

Barbaric - and untold - aspect of vaginal delivery

This is an horrific story from China about an 18-year-old mother who was given more than 100 stitches - some without anaesthetic - at the birth of her first baby.

According to a China Press report, 'the woman was stitched up by a lady doctor and a trainee doctor after giving birth. However, a medical officer later removed the stitches, saying the wrong threads had been used. He then re-stitched her without anaesthetic.'

Even worse, another senior doctor then 'announced that the thread used by the medical officer was also the wrong one, requiring the woman to go through another process of having the stitches opened and closed again with the right thread.'

It happens in the UK too!
I heard about this happening in the UK some years ago, and in fact continue to be surprised how little attention it is given in the media. According to the Birth Trauma Association, vaginal stitching without anesthetic occurs 'quite often'.

That's true: Many women in the NHS are stitched up following a vaginal tear or episiotomy WITHOUT ANESTHETIC.

Indeed the Birth Trauma Association describes this wholly unnecessary and barbaric birth experience as 'a frequent complaint' by women.

Pregnancy and birth phobia
Unsurprisingly, the young Chinese woman (who 'also claimed that during the process, one of the doctors had accidentally injured her thigh causing her to suffer a three-inch cut') now says that she has a 'phobia about getting pregnant again'.

Birth phobia is often be described as irrational, as though a woman's fear of some of the terrible things that can happen during a vaginal delivery are just 'all in her head.' Well they're not - they're real - and if she wants to avoid even the chance of such terrible things happening to her, then in my opinion, her decision to do so is entirely rational.

Another two babies die because cesareans are not carried out

I read these two stories online today, in which precious babies' lives could have been saved with a cesarean delivery.

The first, by Colin Fernandez writing for the Daily Mail, is titled: ''Chaotic' care led to baby's death', and reports on an inquest into the death of Ebony McCall at Milton Keynes General Hospital's maternity unit.

Cesarean request denied and maternity unit understaffed
According to the report, doctors 'missed two chances to save Ebony's life', and indeed the mother and her family's own request for 'emergency surgical delivery' was 'ruled against'.

Furthermore, staff were 'overstretched as 12 mothers gave birth at the unit that night [and] only four midwives were on duty...'. Eventually, an emergency cesarean was carried out on the baby's mother, who is described as 'rolling in pain' and suffering from other health problems 'including a faulty heart valve, only one working kidney and curvature of the spine.'

The second, 'Jury finds doctors liable in death of newborn', appears in The Buffalo News, and Matt Gryta reports on a $2.2 million award for the family of baby Leah Kreinheder, 'who died of a seizure linked to her mishandled birth'.

Continue with labor and don't do a cesarean!
Despite concerns about 'problems with the baby’s heart rate', the decision was made 'to continue with the labor and not perform a caesarean section'

What happened next is a sadly familiar story - 'the baby became stuck during the delivery and for almost five minutes was deprived of oxygen; as a result, she suffered brain damage and head trauma, multiple bruises on her head and arms and was blue at birth... [She] suffered seizures and was transferred to Women & Children’s Hospital in Buffalo, where she remained for a month.'

I ask once again: How many more babies have to die before hospitals understand that efforts to reduce cesarean rates or avoid 'unnecessary cesareans' can have dangerous and devastating effects?

Wednesday, December 9, 2009

New sealant helps protect from cesarean infections

A new type of surgical sealant is being used to reduce the risk of infection during cesarean deliveries.

This article on the subject focuses on the practice being employed by Dr Jacques Moritz, director of gynecology at St. Luke’s-Roosevelt Hospital in Manhattan, following positive results in clinical trials:

The 'sealant has been shown to seal and immobilize harmful pathogens including MRSA, S. epidermis and E. coli. The sealant is applied to the skin after surgery prep and before the incision is made. The sealant is non-irritating and does not need to be removed in order to close the incision. After surgery, the sealant wears off naturally within a few days. Doctors say the sealant should not be used in surgical procedures involving mucous membranes or the eyes, on patients with hypersensitivity or on skin with active signs of infections.'

Dr Moritz says that, while 'there is no such thing as true sterilization of the skin', this sealant 'gives new moms an added layer of protection.'

It's certainly something worth asking your doctor about ahead of your planned surgery...?

Two Australian babies might have lived if delivered by cesarean

Writing for Adelaide Now, Ken McGregor reports on an ongoing inquest into the deaths of two babies - both delivered by ventouse - in 2006 and 2007.

He describes how 'the babies died of multi-organ failure following a "massive" subgaleal haemorrhage, which may have been caused by the Ventouse machine'. But even more shocking (at least to me) is the reason given by Melissa Sandercock (the senior obstetrician involved) for attempting an instrumental delivery:

She 'told the court that she considered delivering him by a cesarean, but because it was a public holiday and there were no anaesthetists nearby, she decided on using the Ventouse.'

Lessons learned?

Ms Sandercock, says she has 'since changed her delivery methods and now "prefers to use forceps" when a baby shows signs of distress.'

I am not a doctor, but as a concerned mother of two precious children and as someone who values the protection of my pelvic floor during childbirth, the experience described above is just another example of the type of unpredictable vaginal delivery that I chose to avoid when planning my cesarean delivery.

I felt that it was safer for my babies, and I personally didn't want to be delivered via ventouse, forceps or an emergency cesarean. And looking at the increasing rate of elective cesareans in Australia, I think it's fair to say that I am not alone in my thinking.

Tuesday, December 8, 2009

Albany independent midwives' contract terminated by King's College Hospital

The Guardian has reported that London's King's College Hospital has terminated its contract with the Albany group of independent midwives, 'alleging that a disproportionate number of the babies it delivered suffered damage during the birth.'

It says that 'King's decided to terminate the contract after commissioning a report from the Centre for Maternal and Child Enquiries (CMACE) [and it] is believed the investigation was triggered by the death of Natan Kmiecik, one week after he was delivered at Kings by one of the Albany midwives. His mother, who did not speak English, had a caesarean for the birth of her first baby but wanted a natural birth for her second. Her lawyers claimed proper procedures were not followed, because the baby's heartbeat was monitored only by a small hand-held device so she could have a water birth.'

Low levels of medical intervention
While a very positive aspect of the Albany group is its aim for all women to be delivered by a midwife they have built up a relationship with during their pregnancy, it is now in question whether some of its other policies (namely, enbcouraging - almost 50% rate - home births and reduced medical intervention) provide best practice care.

'King's says babies delivered by Albany midwives had higher rates of hypoxic ischaemic encephalopathy brain damage caused by lack of oxygen and lack of blood flow to the brain - than those delivered by midwives it employs directly over the last two and a half years.'

This story reminds me of a UK medical study from 2004, which assessed 540,834 live births and stillbirths in 65 maternity units. It found that a ‘higher intervention score and higher number of consultant obstetricians per 1000 births were both independently and significantly associated with lower stillbirth rates' (Joyce et al, UK, 2004), so it is unsurprising to me that a practice of minimal intervention by the Albany group is reported to have led to negative health outcomes.

Clearly, those women who have enjoyed positive experiences at this midwifery practice are angry and sad to hear this news, and I do have some sympathy for them. But I think it is safe to assume that it was not their precious baby who fell between the cracks and suffered injury (or death) during a planned vaginal delivery.

Otherwise, they might well be interested in reading the Canadian study I blogged about yesterday, which found that 'life-threatening infant morbidity is lower with planned cesareans'.

Monday, December 7, 2009

Life-threatening infant morbidity is lower with planned cesareans

This is a very important study of almost 40,000 term deliveries in Canada. So far, it has received no media attention here, but I think it deserves your attention - especially women who might be worried about a planned cesarean delivery for medical reasons but also women who chose to plan a cesarean and now face a constant stream of criticism by others.

What the researchers did
LS Dahlgren et al studied 1,046 pre-labor, planned cesarean deliveries for breech presentation and 38,021 planned vaginal deliveries with a cephalic-presenting singleton (i.e. a baby in the normal, head-down birth position).

What the researchers found
Life-threatening neonatal morbidity was decreased in the planned cesarean group: ‘elective pre-labour caesarean section... at full term decreased the risk of life-threatening neonatal morbidity compared with spontaneous labour with anticipated vaginal delivery.'

Why is this study so important?
Two reasons.

1) It found that 'life-threatening maternal morbidity was similar in each group'. In other words, that planned cesarean surgery - despite being complicated by a breech presentation - was no more dangerous for mothers than a planned vaginal delivery.

2) Because the vaginal delivery group consisted of straightforward pregnancies and was then compared with a cesarean delivery group of babies in the breech position, the fact that surgery STILL turned out to be the safest delivery method, raises the question how much wider the margin of benefit might have been if the cesarean group consisted of straightforward pregnancies too...

The researchers' conclusions
You can read more about this study, 'Caesarean section on maternal request: risks and benefits in healthy nulliparous women and their infants', here, but in brief, the researchers note that 'the increased neonatal risk was associated with operative vaginal delivery and intrapartum caesarean but not spontaneous vaginal delivery'.

So, if you have a spontaneous vaginal delivery, your baby will enjoy a safer arrival. Of course the problem always remains that spontaneous vaginal delivery can never be guaranteed. Therefore women need to be advised of ALL the potential health outcomes of a trial of labor (which in fairness, many will legitimately accept in preference to surgery), and not just the 'best case' scenario if everything goes according to plan.

Further research needed
Evidently, as the researchers conclude, the 63% of women who planned spontaneous labour and subsequently achieved a spontaneous vaginal delivery may/'would not have benefited from delivery by caesarean section' (I added the word 'may' since maternal morbidity factors such as pelvic floor damage must be considered too), and therefore it is suggested:

'Further research is needed to better identify women with an increased likelihood of an operative vaginal or intrapartum caesarean section, as this may assist maternity caregivers in decision-making about childbirth. Further research is also needed to determine if these findings can be confirmed in a prospective study.'

Thursday, December 3, 2009

Nurse says: 'Outlaw elective cesareans'

Talk about wanting to have your cake an eat it.

Today I came across this comment on the website, posted by 'LadyJaye' on December 1st:

Re: Elective C-sections- moms idea or the providers?
'I hope my response does not offend anyone, and this opinion is specifically for elective C-sections- they should be outlawed. Doctors who push them for easy scheduling or insurance/ money purposes should have their licenses taken away, and women who do not want to give birth to a baby should not have a baby. It is in my opinion that our bodies were made to have children, and unless there is a medical emergency there is no reason to interfere...'

First of all, the comment 'women shouldn't have a baby unless they're willing to have a vaginal delivery' is offensive.

Secondly, if women's bodies are so capable, and Mother Nature is so reliable - 'our bodies were made to have children' - why do so many medical emergencies occur?

Medical intervention verus Natural evolution
Contemporary women are simply not willing to risk death and/or injury to their babies or themselves, and unlike previous generations (we always hear the argument that 'women have been giving birth for thousands of years, so why change things now?'), we are in a vastly improved position.

We have access to a level of surgical care that is keeping pace with our maternal landscape (think: larger babies, heavier and older mothers) better than natural evolution has managed to do (think: increasingly big baby's head, same narrow pelvis to get through).

Personally, I had more faith in my doctor, and the scalpel in her hand, than the unpredictability of Mother Nature. My decision to choose surgery may mean I hold different views to other women, but it does not mean I'm unfit to be a mother.

For goodness sake...!

Tuesday, December 1, 2009

Iranian women shun natural birth and choose cesareans

This article in The National (dated Nov 29, by Maryam Sinaiee) discusses the situation in Iran, where it is reported that in some private clinics, the cesarean rate is 'as high as 100%'.

The article begins with two interesting statements: 'Some obstetricians in Iran are advising women to give birth by caesarean section' and also: 'Many pregnant Iranian women are choosing caesarean section over natural childbirth, according to health officials.'

Doctors' observations
Says Dr Nahid Khodakarami, a member of the Iranian Medical Council: 'More than 75% of all C-section operations are elective and not required medically.'

Says Dr Mina Afkham, an obstetrician based in Tehran: 'They hear a lot about the pain of natural delivery from their mother and other women and can’t be persuaded to have natural birth, but fear of the pain of giving natural birth is not always their only reason to choose C-section... Giving natural birth has somehow become synonymous with lower social stature for some women. Some others even ask to have their babies on a certain date they choose themselves. I agree that some of my colleagues are reluctant to assist natural deliveries but pointing the finger at them only is far from being fair.'

Women's personal views
Sara Namazi, a 23-year-old pregnant woman in Tehran explains her reasons for choosing surgery: 'I have seen horrible scenes of natural childbirth in movies where women writhe in pain and moan and scream and sometimes even die. Only women who can’t afford the high cost of a C-section now have to go through that pain... Having a C-section will mean that if there are no complications I will walk into the hospital on my own feet to give birth which is much better than being carried there crying in pain.'

Samaneh Fadaie, a 39-year-old mother, describes her natural childbirth experience: 'All my friends thought I was mad and the obstetrician was visibly unhappy with my decision, but I wanted to experience what nature has ordained for women. I endured the pain for nearly two days before I could hold my child in my arms. Not even a single friend of mine has since chosen to do the same.'

I don't necessarily foresee rates of this level in the UK and North America, but I do understand why many doctors have said that national cesarean rates are more likely to increase rather than decrease as we move forward into the future.

Well, apart from increases in the emergency and planned cesarean rates for medical reasons (due in part to a continued increase in older, larger mothers and larger babies), I believe that word of mouth will become an increasingly powerful force.

Almost everyone's seen or heard a traumatic vaginal delivery 'horror story', and it is only a matter of time before women realise that they see and hear far fewer horror stories that relate to a woman who chose and planned a cesarean delivery.

Wednesday, November 25, 2009

'New mums 'abandoned' during labour'

Sky News is just one media outlet to report on a survey of 3,500 mums by The Royal College of Midwives and parenting website

The survey found that 35% of mums said they had been 'abandoned' during or after labour, and Sally Russell, co-founder of, says, 'It shows that our members want, need and deserve one-to-one care from midwives but they are not getting this and are left alone and feeling abandoned during labour, and especially in the vital post-natal period.'

Pros and cons of different birth types
I am not about to advocate that women choose surgery in order to avoid some of the harrowing labors and inadequate maternity care experienced by some of these mums (and many more have posted comments on various websites today), but I do believe that avoiding this type of unpredictability and trauma is viewed as a benefit by many women who do choose surgery.

Speaking personally, and obviously my experience was somewhat different since I had my children in America rather than here in England, but one of the things I valued most was the relationship I built up with my OBGYN throughout my pregnancy. I also met with her surgical partner, who would have delivered my babies in the event that I went into labor early and she was not available, so I always knew I wouldn't end up with a stranger who may or may not understand or support my chosen birth plan.

Continuity of care
I enjoyed a fantastic continuity of care; all antenatal appointments with the same doctor, delivered by the same doctor and then postnatal appointments with the same doctor. In fact, I still keep in touch with her now, as do many of her patients.

But unfortunately, today's story is not a new one, and complaints of midwife shortages and inadequate care have been reported for more than 20 years at least (read more here). So aside from the fact that I felt that a planned cesarean was the safest option for my babies and for me, I would have hated to rely on this kind of NHS service in the event that vaginal delivery was my preferred birth plan.

Monday, November 23, 2009

Calculating 39 weeks for a full-term cesarean is a shared responsibility

Numerous studies have stressed the importance of planning a cesarean delivery after 39 weeks, and despite accusations to the contrary, I don't believe that obstetricians are arbritarily scheduling surgery ahead of this date unless there is an indicated medical need (either for the mother or the baby). That is - despite the risks of respiratory distress with preterm births, there is a greater risk of (for example) the baby or mother dying if it remains in utero any longer.

I also don't believe that the vast majority of women choosing a cesarean - despite accusations to the contrary - would urge their doctor to deliver their baby early for convenience, vanity reasons or to bring an end to their pregnancy.

Blame game
But now a study, reported in the media on Friday, suggests that one possible reason behind the U.S.' climbing pre-term delivery rate is that 'Many Women Miscalculate Time to Full-Term Birth'.

The report continues: 'When asked, "What is the earliest point in pregnancy that it is safe to deliver the baby, should there not be other medical complications requiring early delivery?", more than half chose 34 to 36 weeks, 41 percent chose 37 to 38 weeks and less than 8 percent chose 39 to 40 weeks.

However, experts warn that any delivery short of 39 weeks puts a baby at higher risk of respiratory distress, sepsis (blood infection) and needing to be placed in the neonatal intensive care unit, according to background information in the study. Only one-quarter of new moms realized 39 to 40 weeks was safest.'

Education, Access to Early Ultrasound and Less Confusion please
For what it's worth, here are my suggestions for improving this situation:

1) Educate women that when it comes to planning a cesarean delivery, the ideal gestational age is 39 weeks. Ideally, that means taking responsibility for recalling your last menstrual cycle date before you became pregnant - not always possible or indeed accurate, but the more information a doctor has at hand for calculating your gestational age, the better.

2) Arrange an early ultrasound. This is easier said than done sometimes - and you, your doctor, your hospital, and if applicable, your insurance company, must all take responsibility for this. With my second pregnancy, one of the hospitals I was going to go to said they didn't do the first ultrasound until 12 weeks, but my OBGYN insisted that I had it done earlier because research has shown that the most accurate calculation of gestational age can be made during an early ultrasound (read more here).

3) Stop confusing women by quoting data from medical studies with 'full-term' gestational ages described as 34 or 37 weeks one minute, and then 39-40 or 41-42 weeks the next. Women could be forgiven for not knowing the definition of 'full-term', especially in the context of planned cesarean delivery, because there is so much confusion in the presentation of planned cesarean risks and benefits in any case.

For example, when natural birth advocates want to highlight respiratory distress problems in babies born via elective cesarean, they will frequently include studies that invlude 'full-term' getational ages much earlier than 39 weeks. Equally, they are less inclined to present data from medical studies that have found greater fetal demise post-39 weeks.

Delivery at 39 weeks is optimal - for the baby's sake, we should all be working together to make sure that wherever possible, this date is reached.

Sunday, November 22, 2009

And another baby dies.

Just one day after my blog on Friday of the same subject, I read again - this time in The Irish Times - how a baby boy suffered severe head injuries and died after a failed attempt at an instrumental vaginal delivery.

Georgina O'Halloranan writes that 'Parker Meredith Doyle died just one day and 10 hours after his birth by emergency Caesarean section on April 18th, 2008' at the National Maternity Hospital, Holles Street in Dublin. He was 'left severely brain damaged due to brain haemorrhage as a result of 'an attempted instrumental vaginal delivery' using a vacuum cup and forceps.'

What makes it worse
It is reported that the baby's mother, Caroline Meredith, had endured a 'failed forceps delivery 13 years earlier which had resulted in injuries to her baby'.

With the benefit of hindsight, it is evident that this baby's life would have been saved with a planned cesarean delivery, but surely in this case at least (i.e. with the mother's previous birth experience) the medical team might have made a safer delivery decision even without this benefit?

Media headline irony
It is also worthy of note that on the same day that the above article was published in The Irish Times, The Irish Independent published an article titled, 'C-section birth rate still too high', criticizing Irish hospitals for failing to reduce their cesarean rates.

Does Ireland really want to see its cesarean rates fall to dangerously low levels? Or are its obstetricians going to ignore media pressure (and other pressure from natural birth advocates), and concentrate solely on the best outcomes for mothers and their babies - regardless of where that leaves percentage rates?

I hope for the sake of babies like Parker Doyle that it is the latter...

Friday, November 20, 2009

Another delayed cesarean. Another baby dies.

In the NHS in England, as many as 14.9% of planned vaginal deliveries result in an emergency cesarean. Time and time again, we hear that this number is too high, that national cesarean rates should be lowered, and that some of the 9.7% planned cesareans are unnecessary too.

Well, reading this story in The Telegraph today, it becomes all too clear what can happen when a cesarean is delayed (or not carried out):

Tragically, 'Lewis Connolly lived for just four hours and died in the arms of his mother Eleni, 33. Mrs Connolly and her husband Steven, 29, were told at an inquest that their baby's death was avoidable.'

Prevent this happening to another child
The report explains how 'Lewis ended up lodged so firmly in the womb that a doctor at North Middlesex Hospital in Edmonton, north London, fractured his skull in a desperate bid to free him with a pair of forceps.'

'Guidelines state a baby should be delivered within three hours of the mother reaching second stage. But an emergency Caesarean section was not carried out until 2.36pm, more than five hours later.

The parents have said they 'hope that these events will prevent it from happening to anybody else', and I would completely agree with them.

Unfortunately, I'm not convinced that they will, and I remain concerned that women in antenatal classes are simply not being fully informed of the true and real risks of planning a vaginal delivery. Not that all women should or would want to choose surgery instead; only that both types of delivery have their own set of risks, and to over-exaggerate one set and under-state another is wrong.

Monday, November 16, 2009

Surrender to our birth experience? Rely on medical intervention? Or both?

I simply don’t understand the article I read in The Telegraph on Saturday. In it, Laura Donnelly writes that 'maternity guru Sheila Kitzinger says 'fairytale' expectations of childbirth end with dashed hopes for women, and warns that new mothers are often consumed by guilt when they do not experience said fairytale.

Ok, nothing new there…

But who is Mrs Kitzinger blaming for raising women’s expectations of birth in this way? Could it be herself, who has in the past described childbirth as a ‘potentially orgasmic experience’. Or natural birth advocates, who often employ language that encourages women to trust in their innate ‘empowerment’ and a body that’s ‘designed to know exactly what to do’ during the birth process?

No. It’s our ‘consumerist agenda’, our tendency to ‘test everything’ and ‘see birth as a performance’. In addition to the over-medicalization in hospitals, she says that ‘many modern women, accustomed to taking control of their careers, made a mistake in applying the same thinking to childbirth.’ Rather, they should ‘surrender to the experience’.

Yet in every other aspect of a woman’s reproductive life, control is precisely what it’s all about. Is it really feasible that on the day of our baby’s birth, we should all want to simply surrender to Mother Nature? Maybe for some women this is a desirable approach, but I doubt it’s the case for the majority. After all, Mother Nature has a nasty habit of engineering the most undesirable and traumatic experience just as easily as the orgasmic one Mrs Kitzinger suggests.

I never expected nor did I desire an orgasm during the birth of my baby, but in terms of fairytale expectations, is it really fair to blame everyone and everything else (for women’s negative feelings when their birth doesn’t go according to plan), and shoulder no responsibility yourself Mrs Kitzinger? I’m not so sure…

Friday, November 13, 2009

Why are more women pushing for Caesareans?

This is the title of an article written by Dr Mark Porter in The Times last week (2nd November). In it, I'm interviewed by journalist Peta Bee about my own two cesarean deliveries, but what I'd like to draw attention to is the comments written by readers at the bottom of the article.

I submitted two comments in response to Dr Porter's article on the 3rd November, and was very pleased to read his personal response a day later, which read:

"Pauline - I wholeheartedly agree."

Why is this important? Because I was writing about maternal request cesareans in the context of the NHS, where currently, it can be extremely difficult to find support for a cesarean birth. If more doctors in the UK could not only move towards accepting planned cesarean delivery as a legitimate birth choice, but also be willing to open up a public dialogue about it in the way that Dr Porter does here, I hope that we might see positive change in the UK sooner rather than later.

For ease of access, I have copied and pasted my comments here:

I am so glad that Dr Porter recognizes the importance of separating maternal request health outcomes to those of emergency or planned cesareans for medical reasons. When bias against surgical birth 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 has had a maternal request cesarean, yet there are thousands from women who planned vaginal deliveries. This is also backed up by research such as the 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 NHS resources, and to state that studies demonstrate that ‘convenience’ is very low down the list of reasons for maternal request - when it appears as a reason at all. Reasons are more likely to be tokophobia, concerns for their baby's safety and avoidance of pelvic floor injuries.
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 2004 NICE guideline discusses one cost model in which ‘maternal request would lead to savings’ (not that I’m suggesting this is 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.

Counseling against a cesarean delivery

For some reason, I was thinking about this today as I drove home from my daughter's toddler group, and I came up with an analogy for why counseling against a (chosen) cesarean doesn't always work - and why it would certainly never have worked for me.

To take a step back, let me explain when counseling might be used: if a woman has tokophobia - fear of childbirth - and says to her doctor that she would prefer to have a planned cesarean delivery instead of a vaginal delivery, it is often suggested that she should be given counseling (therapy) in order to help allay her fears.

Fear or simply a different choice?
I am not against this idea; if resources are available and the woman is keen to give counseling a try, then I would agree that it should do no harm. In fact, there is some evidence that women can change their minds about their cesarean birth decision and go on to plan a vaginal delivery (unfortunately, these studies don't follow up after the birth to find out if the women were happy with their decision, which might be an idea for future studies).

However, the women I'm concerned about are these: women for whom no amount of counseling will dispel their intense fear of natural birth, and women for whom counseling is viewed as a completely unnecessary - i.e. their decision to choose a cesarean is grounded in a personal health risk-benefit analysis that favors planned surgery.

It's like trying to piece together a broken marriage when one of you is in love with someone else
You see, to me, counseling can only work when the person being counseled is one hundred percent on board, and they WANT to move towards the same goal as the counselor. For example, if a couple is having problems and both of them want to make another go of things, counseling can have very positive results.

If on the other hand, one of the partners has met someone else, fallen in love, and is just itching to move out and start a whole new life elsewhere, the likelihood is that no amount of counseling is going to help.

Therapy during pregnancy
When I became pregnant with my first child, Charlotte, I already knew I wanted a planned cesarean. My decision was not based on a now suddenly impending birth day, and nor was it influenced by the hormonal changes taking place in my body. I firmly believed that a cesarean was the safest route of delivery for my baby and for me, and I would have hated to be marched off to see a counselor for weeks of therapy before a decision was finally made for me.

I was one of the lucky ones. My pregnancy was never impeded by the 'unknown' (would I be allowed to have a cesarean or would I be forced to deliver vaginally?). But this is what happens to many women around the world, in countries where 'maternal request' is a dirty word(s). In fact, one woman in England contacted me through my website, after she was made to jump through every counseling and cognitive therapy hoop available on the NHS in an attempt to cure her of a severe case of tokophobia.

And the result?

She was told at the end of it all that she would still have to endure a trial of labor - either she hadn't sufficiently convinced her therapists of her fear of childbirth or they couldn't accept that the therapy hadn't worked (I don't know) - and she made the deeply traumatic decision to terminate her pregnancy. It's time we started caring as much about women like this as we do about women who want to give birth vaginally and avoid a cesarean delivery. Their desires may be different but they are surely equal.

Wednesday, November 4, 2009

My response to WHO Press Release criticism

Henci Goer, representing Lamaze International, has criticized the CCA's latest press release, 'WHO admits: There is no evidence for recommending a 10-15% caesarean limit'. Her criticism can be read here, and this is my response.

Firstly, inside the red circle in the WHO table that Henci has highlighted, you will see a small letter 'c', and the note beneath the table reads: 'See Section 2.5 for a discussion of this range.'

Since Henci has not reproduced this discussion, I will do so here. It reads:

"Earlier editions of this handbook set a minimum (5%) and a maximum (15%) acceptable level for caesarean section. Although WHO has recommended since 1985 that the rate not exceed 10-15% (125), there is no empirical evidence for an optimum percentage or range of percentages, despite a growing body of research that shows a negative effect of high rates (126-128). It should be noted that the proposed upper limit of 15% is not a target to be achieved but rather a threshold not to be exceeded. Nevertheless, the rates in most developed countries and in many urban areas of lesser-developed countries are above that threshold. Ultimately, what matters most is that all women who need caesarean sections actually receive them."

With regard to minimum and maximum acceptable levels, it says:"Both very low and very high rates of caesarean section can be dangerous, but the optimum rate is unknown. Pending further research, users of this handbook might want to continue to use a range of 5–15% or set their own standards."

My response to Henci
1. The WHO handbook states (above) that users 'might' want to continue to use a range of 5-15% or set their own standards. Given that the WHO itself states (also above) that 'there is no empirical evidence for an optimum percentage or range of percentages', it is entirely your prerogative to choose to continue advocating a percentage threshold that has no basis in evidence.
I do not. I prefer to advocate countries setting their own standards, and in doing so, to explore a far wider body of research than the three studies that you (and the WHO) refer to in your post (more on these below).

2. This is an indisputable fact: On the subject of cesarean rates, the WHO has said in 2009 that 'the optimum rate is unknown'. This is what our press release states and while this fact may not fit in with your birth ideology, that does not make it any less factual.

3. You infer that our press release did not go far enough in terms of quoting the WHO handbook accurately, and in this context, you refer specifically to the extract 'despite a growing body of research that shows a negative effect of high rates'. Please look again - our release does include this line of text and we made no attempt to avoid or hide it.

4. I am open to debating the subject of cesarean deliveries, and in particular, my focus is on demonstrating that a planned prophylactic cesarean at 39 weeks for women planning a small family is a perfectly legitimate birth choice in preference to a trial of labor (since these women are adversely affected by strategies to reduce cesarean rates to 15%).
But what I object to strongly is your effort to censor a press release that does not agree with your point of view. Medical News Today and have both been contacted with the specific request to remove our press release from the internet, and to use your own words, 'shame on you' for resorting to such tactics.

5. Furthermore, in your chat with visitors to your site at the bottom of the page, you are praised for contacting Medical News Today, and you write: 'Your welcome! This is my idea of fun.' Again, I don't think there's anything funny about attempts to censor an opposing viewpoint to your own.

6. In March this year, I spoke at a seminar on the subject of cesarean rates, and my presentation included many studies to support the point of view that a 15% rate is unrealistic and unwarranted (as you know, the CCA is not the first to criticize the WHO's 1985 recommendation). I can provide you with a copy of this, and would like to note here that I received very positive feedback from many midwives and natural birth advocates in the room that day - and that the doctor with the 'opposing viewpoint' to mine in our seminar even admitted that a 15% rate is unachievable. Here is an extract on the subject of infant mortality for example:

"Since extraneous socioeconomic factors affect the U.S. infant mortality rate (deaths <1>Singh and Kogan, 2007), it is less relevant to the delivery method than the fetal mortality rate (deaths at 20-27 gestational weeks or ≥28 gestational weeks), neonatal mortality rate (deaths <28>MacDorman and Kirmeyer, 2009), (Kung et al, 2008)
Northern America, together with Australia (which has a cesarean rate of 30.8%), has the lowest regional stillbirth rate and one of the lowest regional neonatal mortality rates worldwide. The WHO says it has 'shown that one third of stillbirths take place during delivery - deaths that are largely avoidable and closely linked to the place of and care provided at delivery.' (Neonatal and perinatal mortality: country, regional and global estimates, WHO, 2006)
A UK study of 65 maternity units incl. 540,834 live births and stillbirths found that a 'higher intervention score and higher number of consultant obstetricians per 1000 births were both independently and significantly associated with lower stillbirth rates.' (Joyce et al, UK, 2004)

My criticism of WHO's 2009 handbook
1. Its recommendation on cesarean rates is now open to ambiguity. While I am glad that (after much lobbying) the WHO has finally put in print that it has no evidence for recommending an optimum cesarean rate, it is a pity that its statement remains open to this type of debate.

2. It refers to 'a growing body of research that shows a negative effect of high rates' and references three studies, '(126-128)', but there are numerous other large and contemporary studies that demonstrate very positive outcomes with cesarean deliveries, and these are not mentioned in this area of the WHO's discussion at all.

How can the WHO ignore (for example) that women in the UK (where national data on elective and emergency outcomes is separated, unlike the U.S., which only separates primary and subsequent cesareans) are less likely to die following a planned cesarean than any other birth type? Or studies from Sweden that demonstrate greater levels of satisfaction following planned cesarean births than planned vaginal deliveries? Or the latest study from Canada - of 40,000 births - that concludes: ‘elective pre-labour caesarean section… at full term decreased the risk of life-threatening neonatal morbidity compared with spontaneous labour with anticipated vaginal delivery’. And the cesarean group in this latter study were breech deliveries (understandably more complicated than cesareans with cephalic presentations) while the vaginal delivery group were cephalic presentations...

3. When I interviewed Dr Monir Islam, Director of the WHO’s ‘Making Pregnancy Safer’ program last year, he told me that he agrees with the ACOG’s 2007 and NIH’s 2006 statements on maternal request cesareans: that they are ethically justified following individualized consultation.

His exact words were: 'A woman should have the right to decide. Why should she not have the right to decide? 'It should be an informed decision; the doctor needs to give the woman all the information she needs, and then the woman should decide whether she wants a cesarean section or she doesn’t want a cesarean section.'

Clearly, maternal request cesareans add to national percentage rates of cesareans, and this is another reason why a 15% threshold is unrealistic in North America and the UK.

4. The three studies referred to as 'a growing body of evidence' are seriously flawed in the context of this debate when quoted in isolation, and particularly in any debate about maternal request cesareans with no medical indication (the notes below refer to maternal request because this is the context I first wrote about them in, but they are still relevant here because any attempt to reduce national cesarean rates to 15% would have to involve the refusal of maternal request).

*Issues with the Deneux-Tharaux et al study
If you read the research in full, it is evident that in the two causes of death where the majority of maternal mortality occurs, CD does not result in more cases of death than VD. For example, the risk of postpartum hemorrhage (the most common cause of death here, at 38.5%; n.25) is as high with VD as it is with CD. In fact, the maternal mortality risk is higher for CD in the three causes of death that occur least: Venus thromboembolism (n.7 of 10 total); Puerperal infection (n.4 of 5 total) and Complication of anesthesia (n.4 of 5 total), which equates to 15 out of 20 deaths in these areas (the total number of deaths was 65). This is the source of the 'triple the risk' headlines.

Furthermore, Deneux-Tharaux writes: 'It must be noted that 3 of the 4 deaths due to complications of anesthesia in this study occurred after general anesthesia, whereas the 4th death occurred after spinal anesthesia. This suggests that general anesthesia at cesarean delivery is associated with a much greater mortality risk than regional anesthesia.'

PMHull: General anesthesia is usually administered in an emergency CD, not an elective CD. Therefore, any deaths following the use of general anesthesia in an emergency CD should not be used to analyze the safety of an elective CD where spinal anesthesia is used.

Deneux-Tharaux: 'Cause specific mortality could not be analyzed separately for prepartum and intrapartum CD because the numbers of deaths were too small.'

PMHull: The separate analysis of prepartum and intrapartum CD is vital in any research that draws conclusions on the comparative safety of elective CD versus VD. The mix and match of analysis, results and conclusions of 'all CD' and 'elective or maternal request CD' is not an effective measure. Furthermore, maternal mortality following intrapartum CD is a measure of risk that needs to be applied to the category of 'planned vaginal delivery' and not a planned CD. This is important because risk can only be assessed at a birth 'planning' stage, and whether desired or not, the fact is that a planned spontaneous VD can have the outcome of instrumental and/or emergency cesarean delivery.

PMHull: It is also worth pointing out that the three mortality areas, where greater risk with cesarean is demonstrated, are largely preventable in quality hospitals with competent surgical personnel, using medical knowledge that has existed for many years. The data used in this study was from a period spanning 1996 to 2001. It is inadequate to make any conclusive statements using data that is over a decade old, especially when data exists in other studies from births that have occurred more recently.

*Issues with the MacDorman et al studyAlthough the researchers applied the NIH's 'intention-to-treat' recommendation, they have not accounted for one of the most important recommendations by the NIH, which is to wait until 39 weeks EGA for planned cesarean delivery with no medical indication. Instead, the study defines low-risk births as "singleton, term (37-41 weeks' gestation), vertex births, with no reported medical risk factors or placenta previa and with no prior cesarean section." This is important, because while a baby delivered at 39 weeks EGA is certainly not risk free, the neonatal mortality rate is most likely lower than the 1.73 reported here; and this is especially relevant since it is cases of 'no medical indication' that MacDorman et al are questioning.

Planned vaginal deliveries (even those for low risk women) can last beyond 41 weeks, and there is documented evidence of a 'small but significant' risk in fetal mortality beyond this point (Divon et al, 1998), and also after 40 weeks. (Caughey et al) Measuring mortality up to 41 weeks alone may have provided PVD with improved statistical outcomes in this study.

Self-reported limitations of the study include concerns about the accuracy of reporting specific data items on the birth certificate.
MacDorman et al: 'Reporting for the major variables in this study (neonatal mortality and method of delivery) is generally considered to be excellent; however, underreporting of individual medical risk factors and complications of labor and delivery on birth certificates has been documented. is possible, based on either poor reporting or because the risks involved items not recorded on the birth certificate, that the group including cesarean delivery with no labor complications or procedures was still an inherently higher risk group, and those risks accounted for both the decision to perform a cesarean section and the subsequent neonatal death. It is also important to note that birth certificate data cannot be used to infer the intentions of either mothers or their practitioners, so these data do not address 'maternal request' cesareans.'

Dr Marian MacDorman said at the time of the study: ‘Even though we don't know exactly that it's elective cesarean delivery, it is probably the best approximation we can make.'...

PMHull: Critics noted in media reports that because birth records often don't accurately reflect whether a CD was medically necessary, this study could be comparing apples to oranges.

Also, again, death that occurs following an emergency CD follows an 'attempted' or 'planned' vaginal delivery (VD). Therefore, while clinicians and women are being advised to use study data to inform their birth planning, then the mortality results should be compiled in such a way that reflects original birth plans. Grouping all CD outcomes together (i.e. emergency and elective) cannot help inform the birth planning stage, and in fact grouping emergency CD outcomes with VD outcomes would be more accurate than grouping them with planned CD.

Issues with the Villar et al study
This study focused on countries in Latin America, where there are differences in standards of health care as a whole compared with North America and the UK. That is not to say the research should be dismissed; only that there are other studies in North America and the UK (that demonstrate more positive outcomes with cesarean delivery), and these should surely be included in any WHO referenced 'body of evidence'.

As a final note, readers may be interested to know that another study by Villar et al (Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study), published one year later in 2007, met with a great deal of criticism in the form of Rapid Responses on the BMJ wesbite. Headlines included:

A prospective study is still needed Maureen Treadwell (1 November 2007)
Definition of "elective" is misleading Amy B. Tuteur, Sharon, MA USA (2 November 2007)
Avoid interfering with physiology when possible David JR Hutchon (2 November 2007)
Term and preterm deliveries Gordon C S Smith (3 November 2007)
Not much help, really Robert G Buist (17 November 2007)
Somewhat misleading Zhong-Cheng Luo (19 November 2007)
Caesarean section risks and maternal choice Jonathan H West (20 November 2007)
Elective Caesarean section safest form of childbirth Michael P Wyldes (23 November 2007)
Contrary to Epidemiological Logic Dr Mudassir Azeez Khan (19 December 2007)
Anesthesia Effects Martin Dauber (27 December 2007)
New research finds lowest maternal mortality rate with elective cesarean delivery Pauline M Hull (30 July 2008)

5. To reiterate, it is not that I am suggesting that these three studies should not be used in an evidence-based assessment of cesarean outcomes; only that they should not appear as a group in isolation and defined as a 'body of research' that proves negative outcomes with high rates. They belong as part of a much larger body of evidence, which includes studies with very positive birth outcomes following cesarean delivery (including mortality and severe morbidity for both mothers and babies).

Henci, we may just have to agree to disagree on the issue of 'optimum' cesarean rates, and unfortunately, it would appear that the WHO's handbook lends itself to encouraging such an arrangement.

If you wish to engage in respectful dialogue about this issue please contact Penny Christensen at She has volunteered to respond to any concerns or questions regarding the CCA's release. You may wish to read BTCanada’s website at for background information first.

Thursday, October 29, 2009

New Canadian research: planned cesareans are safer for babies than natural birth

How much media attention has this study received? As far as I can see online, none.

Yet the conclusions of researchers Leanne S. Dahlgren et al, just published in 'Caesarean Section on Maternal Request: Risks and Benefits in Healthy Nulliparous Women and Their Infants', are of huge importance in the debate over whether women should be offered the option of planned cesarean delivery in favor of a trial of labor.

They found that, after looking at 1,046 pre-labour cesareans deliveries (with breech presentation)and 38,021 spontaneous labour with anticipated vaginal deliveries:

"An elective pre-labour Caesarean section in a nulliparous woman at term has a lower risk of life-threatening neonatal morbidity than spontaneous labour with an anticipated vaginal delivery."

Unpredictability of planned vaginal delivery is evident
The researchers point out that "the increased risk of life-threatening neonatal morbidity in the spontaneous labour group was associated with an operative vaginal delivery or emergency intrapartum Caesarean section and not a spontaneous vaginal
delivery', and this doesn't surprise me in the least.

But the fact remains that is is extremely difficult, if not indeed impossible, to predict precisely which women will have a spontaneous vaginal delivery outcome with no complications.

More than a third of PVDs did not result in spontaneous VDs
In this particular study, 63% of women with achieved a spontaneous vaginal delivery, and the researchers conclude therefore that these women "would not have benefited from delivery by Caesarean section."

But they too admit the difficulty in isolating these cases at the birth planning stage: "Further research is needed to better identify women with an increased likelihood of an operative vaginal or intrapartum Caesarean section, as this may assist maternity caregivers in decision-making about childbirth."

Wednesday, October 28, 2009

WHO admits: There is no evidence for recommending a 10-15% caesarean limit

This is the latest press release from the Coalition for Childbirth Autonomy (CCA), one year after it officially called on the World Health Organization to provide evidence for its recommended 15% limit:

WHO admits: There is no evidence for recommending a 10-15% caesarean limit

NCT choice focuses on WHERE, not HOW women give birth

This article in The Guardian reports on the latest report from the NCT about women's birth choices. The NCT is upset that women are not being given the choice about where they give birth, although its figures are disputed by the Department of Health in the article.

What concerns me though, is the NCT's focus on the word 'where' rather than 'how.' Surely 'how' a woman gives birth is just as important in terms of her access to choice??

NCT ignores many women
When will women who request cesarean deliveries (and percentage-wise, there are many more of them than there are women who request a homebirth) get the same attention (or even any attention) from the NCT?

Soon I hope, because if it truly believes in choice and access to choice, it cannot continue to ignore the women who make the valid decision to give birth via cesarean delivery.

Cesarean rate in England remains the same at 24.6%

The interesting thing about this newly published data is that it shows a breakdown of all emergency and elective cesareans in various hospitals around the country.

In its coverage, the Guardian has published the byline: 'Section delivery accounts for third of Chelsea and Westminster trust babies, indicating 'too posh to push' outlook persists'.

Private patients

It continues: 'The figures, from the NHS Information Centre, show that a third of babies born at London's Chelsea and Westminster NHS trust are delivered by caesarean section, a figure more than double that in Nottingham, suggesting the rates for the procedure in England could still be influenced by well-off women dubbed "too posh to push".

The Chelsea and Westminster trust, which tops the league at 33.3% of births by caesarean, said that its numbers were swollen by women giving birth in its private delivery wing.'

Reasons behind the rates

I think that there are a number of reasons for the differences in percentages of surgery in different hospitals - particularly with elective cesareans. I already know from the women I receive emails from that it is much, much harder to arrange an elective cesarean with no medical indication outside of the London area. It has also been shown in research that it tends to be more affluent and educated women who request cesareans, so it is indeed possible that these women are affecting rates in certain hospitals.

The other reason, in my opinion, is the attitude of the doctors working in the hospitals. I don't believe that all doctors in the UK are on board with the drive to reduce cesarean rates, and I also know from conversations 'off-the-record' that some of them support cesarean delivery on maternal request, but do so quietly in order to avoid criticism from their NHS Trust.

Postcode lottery

Finally, medical reasons for cesareans aside, and again, particularly in the case of elective cesareans, the differences in rates published today highlights the fact that arranging a cesarean in the NHS is very much a postcode lottery for the women who request it.

There are those lucky enough to find the support they're looking for, and there are those who are being caught up in efforts to reduce cesarean rates - whatever the psychological or physical health costs may be.

Monday, October 19, 2009

Dr Michel Odent blames fathers for cesareans now

I've never been a great fan of the opinions of Dr Michel Odent, and his particular preoccupation with the role of (the hormone) oxytocin during birth, and his latest suggestion, that men should 'stay away from childbirth' in order to help women, simply confirms my belief that he is out of touch with what pregnant women actually want.

You can read the full story in The Telegraph today, in which he is quoted as saying:

The 'tensions caused by the presence of men at birth could lead to more adrenalin, slowing the production of the hormone oxytocin, which assists effective contractions, making labour longer and more painful and increasing the chance of a caesarean section.'

Friday, October 16, 2009

'Mum dies of swine flu after her planned cesarean

The Mirror reported yesterday on the news of a 'Mum killed by swine flu after planned caesarean birth'.

It reports: 'The woman, 21, from Monmouthshire was admitted to hospital in Abergavenny for a planned caesarean but her condition deteriorated after she safely gave birth. She was transferred to intensive care and later to a specialist unit in Leicester where she died last week.

'Another women, 43, from Carmarthenshire, also succumbed to the disease but was said to have underlying health problems. The latest cases bring the number of swine flu-related deaths in Wales to three, although another death is being investigated.'

Infection risk
Infection following surgery is an undisputed risk with a planned cesarean. Other cases of infections have been reported too, such as the risk of contracting MRSA after giving birth in hospital. But the risk exists with both planned surgery and emergency surgery, and since emergency mostly occurs after a trial of labor, it means that post-surgery infection is a risk associated with a planned vaginal delivery too.

Wednesday, October 14, 2009

£7.1m payout for 10-year-old boy whose cesarean delivery was delayed

A BBC article today, 'Brain damage boy gets £7m payout', reports on a '10-year-old Oxfordshire boy who suffered severe brain damage at birth... [His] lawyers said he was delivered by Caesarean section, in February 1999, four hours later than he should have been after his heart rate had slowed.'

It continues, 'Harry Snowdon, from Witney, will always need 24-hour care after being starved of oxygen at Oxford's John Radcliffe Hospital...'

Tuesday, October 13, 2009

How many more babies will die in the UK like this?

I find stories like this one, 'Couple compensated for baby death', published today on the BBC News website, so distressing, and they make me so angry that mistakes like this can happen in a UK hospital in 2009.

According to the report, Ms Rees, 44-years-old at the time of the birth, was '32 weeks into a "high risk" pregnancy [and] told by a doctor she was not in labour but needed a toilet.'

Previously told that her breech baby would need a cesarean delivery
'She said: "I just couldn't understand why they weren't doing anything to help me and my baby. At my last antenatal visit I was told my baby was breech and I would need a caesarean section.'

The BBC reports: 'An emergency caesarean was performed an hour-and-a-half later on a second doctor's recommendation and baby Arun was taken to the special baby care unit. The baby had been starved of oxygen during the birth and had suffered irreversible brain damage.'

Monday, October 12, 2009

RCM says: 'the most important thing is for women to be able to choose'

As it happens, Cathy Warwick, General Secretary of the Royal College of Midwives was talking more about homebirths in this BBC News article back on July 29th, but the language she uses could so easily have been taken from the Coalition for Childbirth Autonomy website.

Warwick concludes that, 'The bottom line here is that what women want is to be able to make a real choice, for the health service to offer them that choice, and for that choice to be based on having all the information needed to make an informed decision.'

Equality of choice
What I'd like to see now is more midwives from the Royal College of Midwives listening to and respecting the informed decision of some women to choose elective cesarean delivery as their preferred birth plan - in the same way that they listen to and respect women's decisions to homebirth.

Czech doctor: 'Vaginal delivery will disappear in evolution'

In this 18th May news article in the Prague Daily Monitor (Respekt: Cesarean section rate rising unnecessarily), Ales Roztocil, head doctor of the obstetrical ward in the Jihlava Hospital, south Moravia is reported to have told the political weekly Respekt, that: 'In my opinion, a vaginal delivery will disappear in evolution.'

For the record, this is not an opinion I share, but I thought it was interesting to record some of the views and opinions on cesarean delivery coming out of the Czech Republic, where cesarean rates are '20% on average'.

Irrational thinking is needed for natural birth

Another doctor, Helena Maslova, expressed her concerns about the increased involvement of medical technology during the birth process, coupled with issues related to women's own behaviour. She believes, ''Women have lost the ability of instinctive behaviour since they have been raised to suppress it and behave rationally for the whole life. Yet during a child delivery the irrational side must be used, which is almost impossible for many women' ...adding it was the result of the obstetrics' technical development since the 1960s.'

Wealthy women
Dr Roztocil also reveals that 'among those who demand a caesarean section unnecessarily are often well-off women, businesswomen and wives of businessmen living in cities.'

Maternal request is against the law

Interestingly, the report notes: 'Under the Czech law, a Caesarean must not be performed without medical reasons. Yet it can apparently be arranged with an obstetrician. According to Internet discussions, such women pay a couple of thousands of crowns unofficially for such 'service''.

Clearly concerned about this law, Dr Roztocil says that the 'introduction of the possibility of Caesarean at request or rather on the basis of psychological indications would prevent medical hypocrisy and frauds'.

I would add that it might also prevent a situation in which only women for whom a maternal request cesarean is financially viable are able to enjoy the birth outcome of their choice.

Sunday, October 11, 2009

Financial cost of vaginal delivery is high - and unaccounted for

I've just come across this letter, published in the BMJ back in 2006, titled: 'Consider the value of a functionally intact perineum', and written in response to the study, ''Caesarean delivery in the second stage of labour'.

It's written by Michelle J Thornton, a consultant colorectal surgeon at the Wishaw General Hospital in the UK, and in it, she talks about so many of the issues I've raised with respect to the unaccounted cost of a planned spontaneous vaginal delivery - specifically, when things don't go accoring to plan and an instrumental delivery is necessary.

This is what she has to say (with references listed below):

'Spencer et al say that instrumental delivery may reduce the caesarean section rate in the second stage of labour.1 Although this may be important for the 2006 NHS budget—saving anaesthetic, operating theatre, and hospital costs in the short term—the longer term health outcomes and costs of a high forceps delivery are concerning and go unmentioned.

Recognised third and fourth degree perineal tears occur in 0.5-6% of vaginal deliveries in the western world.2 3 A further 30-44% are estimated to be unrecognised.1 One of the most significant factors, clinically and statistically, to be associated with perineal injury is an instrumental delivery.2 3

Up to a quarter of women with a tear will experience faecal incontinence.3 Although perineal injury during childbirth may not be the sole factor for faecal incontinence, perineal damage increases its likelihood.3 The economic costs of faecal incontinence are large, lifetime cost estimates ranging from £7000 to £43000, depending on treatment.4 The social implications are immeasurable. In a questionnaire of their personal birthing choices even female obstetricians chose caesarean section over an instrumentally assisted delivery.5

To advocate obstetric management that has been declined by educated colleagues is worrying, particularly when the social and economic costs are so great and the idea of gaining valid informed consent is increasing.'

1. Spencer C, Murphy D, Bewley S. Caesarean delivery in the second stage of labour. BMJ 2006;333: 613-4. (23 September.)[Free Full Text]
2. Sultan AH, Kamm MA, Hudson NH, Thomas JM, Bartram CI. Anal-sphincter disruption during vaginal delivery. N Engl J Med 1993;329: 1905-11.[Abstract/Free Full Text]
3. Abramowitz L, Sobhani I, Ganasia R, Vuagnat A, Benifla JL, Darai E, et al. Are sphincter defects the cause of anal incontinence after vaginal delivery? Results of a prospective study. Dis Colon Rectum 2000;43: 590-6.[CrossRef][ISI][Medline]
4. Adang EM, Engel GL, Rutten FF, Geerdes BP, Baeten CG. Cost-effectiveness of dynamic graciloplasty in patients with faecal incontinence. Dis Colon Rectum 1998;41: 725-34.[CrossRef][ISI][Medline]
5. Al-Mufti R, McCarthy A, Fisk NM. Obstetrician's personal choice and mode of delivery. Lancet 1996;347: 544.[Medline]

Saturday, October 10, 2009

Delay of an 'emergent' rather than 'emergency' cesarean led to baby's death

This report in the Bristol Evening Post today describes how an inquest heard that a 'baby girl who died within days of being born in Bristol could have lived if her birth by Caesarean section was carried out sooner...

Natasha Knowles was just four days old when she died at Southmead Hospital on February 11, 2005. When she was born on February 7 she had no heartbeat and was not breathing.'

Friday, October 9, 2009

Reducing cesarean rates at what cost to women?

Yesterday, I was browsing the website '' to see what they had to say about elective cesareans. On my first search, the video clip that came up was this one: elective caesarean

The woman being interviewed had had two vaginal deliveries and she had torn during both of them (the second birth making the first tear even worse). Fearful that her third pregnancy could result in even further damage, she requests an elective cesarean.

The Royal Sussex County Hospital however, is taking measures to reduce its cesarean section rate, and although in the end, the video shows that this woman does have a cesarean, just listen to what the hospital has to say to her during her maternal request consultation.

Vaginal reconstructive surgery versus planned cesarean surgery
It is suggested that she may want to consider operative perineal repair after the birth in order to avoid a cesarean, and the midwife says, '...if they had a terrible time last time, they haven't thought about the things they could do differently next time and still have a vaginal birth.'

What many obstetricians and midwives don't always appreciate is that the number one goal for every pregnant woman is not necessarily 'natural birth.' On the contrary, a healthy outcome for baby and mother is most likely top of the list. Efforts to reduce cesarean rates for the sake of reducing rates is of great concern to me because I genuinely believe that that in some cases, women and babies are bearing the physical and psychological cost of such arbitrary policies.

I don't believe in underestimating the risks of cesarean surgery - that would be irresponsible. But to underestimate the risks of vaginal delivery is, in my opinion, just as bad.

Jennifer Hudson did not find cesarean recovery difficult

Just a few days after writing my blog on the fact that African American women are more likely to have a cesarean with their first baby, I've read that Jennifer Hudson has given birth to her beautiful baby David by emergency cesarean.

Fortunately, she appears to have had a very positive experience, which is great, and while I'm not suggesting for one minute that her description of recovering from surgery is every woman's experience, I feel that it remains worthy of note.

Jennifer was asked: Your son was delivered via C-section, what was your recovery like?

"Everybody told me how much it was going to hurt afterwards but I think I have a different tolerance for pain than others. By that night after I had the baby, I'm like, 'Look, I can’t sit in this bed anymore. I’ve got to get up!’ I’ve been up and about since he was born. To me, the pain is no different than when you work out a muscle you’ve never worked out before and it’s sore."

Finally: WHO admits there is no evidence for a 10-15% cesarean threshold

Here is an extract from my article, "WHO Finally Admits - the 'Optimum Rate [of Caesarean Section] Is Unknown' and 'There Is No Empirical Evidence' for Its 1985 Recommendation of 10-15%", published on today:-

In its latest 2009 publication, 'Monitoring Emergency Obstetric Care: a handbook', the WHO states that, 'Both very low and very high rates of caesarean section can be dangerous, but the optimum rate is unknown. Pending further research, users of this handbook might want to continue to use a range of 5-15% or set their own standards.'
The statement continues, 'Earlier editions of this handbook set a minimum (5%) and a maximum (15%) acceptable level for caesarean section. Although WHO has recommended since 1985 that the rate not exceed 10-15%, there is no empirical evidence for an optimum percentage or range of percentages, despite a growing body of research that shows a negative effect of high rates.'

Evidently, there is now a degree of ambiguity in what the WHO recommends. It recommends that regions 'use a range of 10-15%' (even though there is no empirical evidence for such a range) or implement their own standards. Consequently, it is perhaps inevitable that different birth advocate groups will take a different view on what the new handbook statement actually means, and arguments over the credibility of an optimum caesarean rate (emergency and/or elective) will continue.

Wednesday, October 7, 2009

Emergency cesareans more likely for older mothers

I've just been searching the internet to no avail, trying to find the actual Irish study being referred to in this Irish Times article published yesterday by Lorna Siggins. It appears in the European Journal of Obstetrics and Gynaecology and Reproductive Biology, but may not yet be available online.

I wanted to find out what age range 'older women' refers to, but in any case, the conclusion drawn in this new study (led by Professor John Morrison in Galway) should be of interest to many first-time pregnant women because they may 'run a much higher risk of emergency Caesarean section, even if pregnancies are not complicated (my italics)'.

The birth outcomes of 45,000 mothers at University College Hospital between 1989 and 2005 were analysed and advanced maternal age was found to have a 'strong bearing' on the likelihood of emergency surgery.

What does this tell us?
Prof Morrison told The Irish Times: "The findings indicate that the uterus does not work so well in older women, when one takes out the standard factors for epidurals, inductions, etc.” He continues: "There has been a lot of controversy over Caesarean sections, here and abroad, and their increasing frequency."
“The confirmation that age is a key factor in surgery is not because obstetricians are taking an ageist approach. The clear message from this is that age has an impact on ability to deliver normally."

Just as I commented in a recent post about pregnant African American women, what readers decide to do with research like this is a personal choice - and one to be discussed with your own midwife or OBGYN - but certainly for some women, in the light of research like this, the decision to avoid the risk of emergency surgery, and schedule a planned surgical birth instead, is a perfectly legitimate one.

Tuesday, October 6, 2009

Likelihood of a primary cesarean delivery is greatest for African Americans

Reuters reports, October 2nd, on a new Kaiser Permanente study examining the racial and ethnic disparities that occur with cesarean delivery, and notes that the study found 'disproportionately higher rate of primary c-sections among African-American women'.

The Californian study, Racial and Ethnic Disparities in the Trends in Primary Cesarean Delivery based on Indications, found that 'compared to Caucasian women, African-American women had significantly higher rates of primary CS while the increase in rates among
Hispanic women was smaller'.

What the study found
Further, it is reported that the disparity 'cannot be explained by education, smoking
during pregnancy, when prenatal care began or maternal age at delivery', and the lead author, Darios Getahun, MD, MPH, continues: 'This study underscores the importance of educating expectant women about the potential impact of CS on the outcome of future pregnancies.'

The figures published in the study's Abstract look at percentage increases in the primary cesarean rate, rather than percentage actual occurence, and it is unclear at first glance what women should do with this information. Perhaps the Full Text would prove a more useful read for African Americans - for example, it would be useful to know how many of these primary cesareans were emergency and how many were planned.

What the study tells African American women
This is the big question, and the answer is quite complex. Does the research call for better preparation for and best practice support during labor, in order to increase the likelihood of vaginal delivery? Or does it suggest that, if a women is likely to 'very likely to end up having surgery anyway', perhaps she'd be better having planned rather than emergency surgery?

Obviously, part of the answer can be found in the woman's personal birth preference, if she has one, and also, very importantly, how many children she is planning to have over the course of her life. Because however her primary cesarean occurs, through medical necessity or through choice, it is highly likely that she will go on to have further surgery in future pregnancies, and of course the health risks increase with multiple cesareans.

As a final note, the study results also note that 'Indication subtypes-specific rates of primary cesarean section varied markedly across race/ethnicity', and again, access to the study's Full Text would be useful for these women.

Monday, October 5, 2009

20% of Israeli babies born by cesarean

This is a very short report, with no details on the breakdown of emergency versus elective or planned cesareans, and no context in terms of whether there is a difference in rate in the private sector compared with public hospitals, but informs us that:

"Every fifth child in Israel is delivered by a Caesarean Section operation, according to a report published in the Hebrew-language daily Haaretz."

Tuesday, September 29, 2009

25.9% of births in Scotland are now cesarean deliveries

Scotland's Daily Record reports today that 15.2% of the 56,821 babies born last year were delivered by emergency surgery, while 10.7% were scheduled for surgery.

Friday, September 25, 2009

Mother's death blamed on failures - £410,000 damages awarded

This story is so distressing to read, and evidently, the hospital have admitted that human error was at fault:

"Joanne Lockham, 45, died at Stoke Mandeville Hospital at Aylesbury in October 2007 during the birth of her first child. She was given a general anaesthetic when the baby's heart rate dropped. The oxygen supply to Mrs Lockham, of Wendover, was not put into her windpipe and she suffered cardiac arrest."

The headline of the updated story today reads: 'Payout over nurse Caesarean death', and is an example of when a caesarean delivery can be publicly associated with high risk.

However, it's important to point out that this was not a planned caesarean, and it was not spinal anaesthesia being used (both of which carry fewer risks than an emergency caesarean with general anaesthetic). This birth was a planned vaginal delivery (PVD) that ended in one of the worst birth outcomes of all.

Tuesday, September 22, 2009

42% of Canadian obstetricians support maternal request cesarean

A report on a nationwide survey of maternity care providers in Canada has found that 42% of obstetricians support cesarean delivery on maternal request, "even in the absence of a medical indication", "despite a push by their own professional body to "normalize" childbirth and reduce Canada's rising C-section rate."

549 obstetricians, 897 family physicians, 545 nurses, 400 midwives and 192 doulas from across Canada were surveyed in 2008-2009, and here are some of the findings reported:

*42% of obstetricians were in favour of a woman's right to choose a C-section without medical indication
*21% agreed with the statement that a C-section is as safe as a vaginal birth for women
*8% would choose C-section over vaginal delivery for themselves or their partners
*25% of obstetricians and family doctors believed sexual problems and urinary incontinence could be prevented by C-sections
*43% of obstetricians disagreed with the statement, "For a woman, having a vaginal birth is a more empowering experience than delivery by cesarean section."

The study is published in the Journal of Obstetrics and Gynaecology Canada.

Friday, September 11, 2009

Do women choose or consent to caesarean delivery?

You may read the full article here - published 11th September 2009.

Problems pasting text

I have read online that other people have been having this problem with Blogger (and if anyone has any information on how to fix it, please let me know), but currently, I am unable to copy and paste text into my Blog posts.

This makes commenting on articles and studies extremely difficult as I simply don't have time to write the text out manually. Therefore, for the time being, I am just going to post links to news articles and medical studies that I think may be of interest to you in the context of the ongoing debate over caesarean deliveries.

My apologies for this.

Australia: 1 in 4 caesareans by maternal request

You may read the article here - published 11th September 2009 - and the medical study here.

Update on activities

In the time that has passed since my previous post, our family has moved back to the UK from the U.S., which, with a newborn baby and a toddler, has left me too busy even to Twitter!

I have managed to make some progress in my caesarean (it's a different spelling here in England!) work however. For example, as editor of my website, I've been accepted as a Stakeholder for the upcoming review of the 2004 NICE Clinical Guideline on Caesarean Delivery.

I've also contacted the All Party Parliamentary Group on Maternity to request membership to the Maternity Care Working Party, as I feel that women who choose caesarean delivery need a voice in an environment where discussions on maternity care are taking place, and more importantly, where decisions are being made.

So watch this space and I'll let you know how I get on with both of these.

The website
I've also updated my website homepage (although there is still more to do!), and have been keeping busy with email correspondence from ec members with questions, comments and concerns.

Thursday, May 28, 2009

Our new baby boy!

It's been over a month since my last blog (I know - sounds more like something you'd hear in a Catholic confessional box...!), but things have been extremely hectic in our lives recently, to say the least, and my blog has had to take a back-seat for a little while.

One of the reasons though is a wonderful one. Our little boy Jack - a gorgeous baby brother for our daughter Charlotte - was born this morning at 9.04am, weighing 8lbs 15oz.

This is 'night one' in the hospital, so I'm looking forward to getting a few hours zzz's starting right about now!

Goodnight all... I'll be back soon...

Thursday, April 23, 2009

Cesareans in Cyprus: doctors defend high rates

In her Cyprus Mail report, 'Doctors defend C-sections figures', Alexia Saoulli writes: "Private doctors said last week they had been unfairly lambasted in the press for favouring c-sections over natural births. Recent reports of doctors “blackmailing” women into booking their delivery at convenient times prompted outpourings of outrage from women, government health authorities and lawmakers."

Dr George Leontiades, head of the Gynaecological Association: “If there is one doctor who encourages his patients to have c-sections you can’t make a generalisation that all doctors do it.” ...He said comparing Cyprus’ private c-section rate of 55% to England’s 25% was wrong... In England, in the private sector, the figures are almost as high as Cyprus,” he said.

...Leontiades said there were very many reasons why Cypriot women chose to have caesareans, starting from how affluent the country had become. “Affluence in societies affects c-section demand. Also women have a mistaken understanding of the hardship of labour. They don’t want to be put out. The way they have three cars, a big house and can buy everything in the supermarket, they think they shouldn’t suffer any hardship in bringing a child to life.”

...The doctor said there was also an increasing trend in repeat c-sections. He said most women who had a c-section for their first child wanted to follow the “tried and tested” method and “don’t want to embark on an adventure that will not guarantee they will have spontaneous vaginal delivery”.

...He said some doctors were also afraid of increased cerebral palsy risks during labour despite the fact that only one in 400 developed cerebral palsy, only 10 per cent of which accounted for events taken place during delivery. Nevertheless in a society where women only had one or two children, some doctors preferred not to chance it, he said."

Dr Gabriel Kalakoutis, a Nicosia’s Aretaeio hospital gynaecologist-obstetrician: "said although women were not encouraged to have a c-section, there was greater sensitivity to a woman’s wants. “A lot of women prefer to have a c-section because they are afraid of childbirth and the pain. I’m more prone to take the woman’s feelings into consideration and what makes her feel more psychologically comfortable. C-sections are much safer now, with very small risks and only slightly more dangerous than natural births.”

...Kalakoutis said the attitude that a c-section was a “failed” delivery no longer held true and that if there were medical indications for why one should be performed he no longer insisted on going the natural route.

...“Some women want to have a natural birth and I encourage that. If some are afraid and from the beginning think they want to have a c-section then I am more open to that. I don’t tell them from the beginning that they should have a c-section,” he said.

Numbers of women asking for cesareans in Cyprus
...The gynaecologist said in his experience four out of 10 pregnant women asked for c-sections. He also said culturally women had changed and were having fewer children. “Women have two or three children, not five or six. If they had that many caesareans it would be dangerous but up to two or three is safe,” he said."