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.

No comments: