My interview for Toronto Star article

Journalist Andrea Gordon told me when she interviewed me a couple of weeks ago that she found our chapter, "The Day of Surgery: What Happens, Step by Step", particularly helpful when researching for her article, Caesarean section: The Star goes inside the operating room for this look at why C-section rates matter, which was published today. Here's what she says about our book:
"Pauline McDonagh Hull says while it’s a small number, women should have the right to request a planned C-section covered by health insurance. The British journalist, who opted for caesarean birth for her two children, makes the case in a new book she co-authored with Alberta obstetrician Dr. Magnus Murphy.

No financial incentive behind Michigan's CS rate

Researchers in the U.S. asking the question, Does medical insurance type (private vs public) influence the physician's decision to perform Caesarean delivery? concluded that "No significant disparity was found in the odds of Caesarean delivery between privately insured and Medicaid patients in Michigan after adjusting for other Caesarean risk factors. A positive disparity would have provided de facto evidence that financial incentives play a role in physician decision-making regarding Caesarean delivery."

Cost-effectiveness of saving lives with c-sections

It's a shame that it's so very often 'money talks' above all else, but if this new research on the cost-effectiveness of MORE CESAREANS in the developing world means that fewer women and babies die or are injured, then I'll certainly accept it.

Obstructed Labor and Caesarean Delivery: The Cost and Benefit of Surgical Intervention is summarized well in this article, in which lead author Blake Alkire says,

FIPO condemns Bupa over its caesarean policy

A day after my blog post about Bupa's decision to only pay for cesareans in private hospitals if the mother's life is at risk (not the baby's), the Federation of Independent Practitioner Organisations (FIPO) strongly condemned Bupa’s policy changes in this press release: "In a letter sent to obstetricians and hospitals Bupa has advised that it will no longer pay for caesarean sections unless “there is a risk to maternal life”. This contradicts the NICE guidelines, which clearly state that emergency Caesareans should be carried out not only if the life of the mother, but also if the life of the baby is in danger, or

If birth is a marathon, not everyone wants to run

Last week, I came across this article: Midwife uses marathon running principles to coach women through childbirth, and the birth-marathon comparison is something I've discussed in the past to demonstrate that while marathons can be an amazing experience for people who want to take on that challenge, it's perfectly understandable to us as a society that others would rather opt out of the challenge - and not spend a single day of their lives feeling as though they've missed out on anything.

Similarly, most women who choose to have a cesarean simply never have any desire to experience natural birth and shouldn't be criticized for this.

Bupa refusing to pay for life-saving emergency c-sections?

In a letter titled "Caesarian conflict", published in The Scotsman yesterday, Dr John Cameron claims that Bupa will only pay for an emergency cesarean that saves the mother's life, but not the baby's.

I'm genuinely shocked. Can this really be true? I hope not.

Here's the letter in full:

Letter published in BMJ - Birthplace study flaws

My letter to the BMJ outlining concerns about flaws in the Birthplace study was published today.

Titled, "Concerned that flawed analysis may be used to restrict birth choices", it reads:

This analysis of the 2011 Birthplace study(1) suffers from some of the same inherent flaws in the study’s collection and analysis of comparative data. But while all research has its limitations and weaknesses, the current economic climate and imminent restructuring of the NHS mean that the promise of “cost-effectiveness” here may well be used for political and ideological influence. As such, these are my concerns:

Eliabeth Ross, creater of the wonderful website that is The Mommy Pledge Blog is sharing a series of interviews with women about their birth experiences over a period of two weeks. She says she hopes to "explore birth options and choices in an objective, balanced way".It's a really great series, and has so far included a number of very different birth experiences, which makes it a great read for first-time mums to be, or even mums who are looking to read about shared birth experiences. Elizabeth has interviewed me for the series too, with my story appearing on Thursday - do take a look if you get a minute, and at the end of the series, readers can add their own birth stories too!

Fears women could be forced to give birth without doctors

This article, published in today's Telegraph newspaper, is worth reading as it raises some very important issues, some of which I touched on in my letter to the BMJ on April 18, 2011.

It is very concerning that UK policy or guidelines may 'instruct' ALL women with "low risk" pregnancies to be cared for in midwife-led birth centres.

Aside from the fact that no one knows which birth will be low risk until it's over, the fact is that many, many women DO NOT WANT to give birth in a place where doctors and an emergency operating room are not immediately available.

Providing choice for women that want a homebirth or exclusive midwife-led care is dangerously turning into an ideological push for all women to give birth in the place (not necessarily the way) thought to be most appropriate for them.

Why cesarean? Because celebrities have them!

I've often read the accusation that the reason some women are choosing a c-section birth is down to our increasingly celebrity copy-cat culture, and even though I still believe that for the majority of women, this is not the case, I do think that there may be a risk of this becoming a more frequent occurence - especially now that greater media attention is being given to the issues surrounding cesarean choice.

Just recently, I watched the January 11, 2012 episode of One Born Every Minute (Series 3, ep.13), and listened to a very happy stewardess talking about her birth plan. She said,

"I want to have a c-section because I think it'll be less painful.**

Probably because all the celebrities have them, and they seem to be stick thin after they've had them,.. and that's just why. I didn't fancy the natural birth to be honest. I'm a bit squeamish; I don't like blood or anything like that. Um, so that's why I chose a cesarean."

As someone who is a strong advocate for cesarean choice, I support informed cesarean choice, with a woman fully versed in the risks associated with surgery (and subsequent surgeries), and not someone who is solely 'following the latest trend', so when I first heard this, I was a little concerned to say the least.

However, watching it back again, I noticed that there was a programme editing point at ** above (just after "less painful"), and realised that a portion of that particular interview had been cut. Therefore this woman may well have talked about other reasons for wanting a cesarean (after all, she was a 38-year-old woman, pregnant for the first-time with twins, and likely to have been advised by doctors). We simply don't know.

But I do know that if (for example) some of my perceived benefits of planning a cesarean were taken out of context, they would sound like very weak justifactions for making this choice too, which is what an individualized consultation betwen a woman and a health professional is for.

Properly discussing the risks and benefits of surgery versus a trial of labor, whether that woman's perceived benefits have come straight from the pages of a celeb magazine or via an online medical journal. After all, some women are just as likely to be swayed by the natural birth choices of celebrities too...!

(...ironically, this episode involved a celebrity visit, causing great excitement amongst hospital staff.)

Driving after a c-section - how long did you wait?

Did you wait 6 weeks? 3 weeks? What were you advised to do? It seems that there is some confusion about when you should start driving again following a cesarean, and new research from Australia shows that confusion reigns there too.

"Women receive conflicting advice, and current recommendations are not reflected in women's behaviour. Women are driving earlier than advised with minimal reported complications." 65% had been advised to wait for 6 weeks or longer, yet 72% said they'd driven before 6 weeks, and 35% before 3 weeks; "women reported minimal discomfort and rarely discontinued driving".

When staff were asked what advice they give women, this was inconsistent, "ranging from no advice to 8 weeks of driving abstinence. Other recommendations included following insurance company guidelines (of which there were none specific to postcaesarean) (34%), 'listen to your body and be able to perform an emergency stop' (27%)."

Back in 2005, I wrote about this subject,

Nigerian CS choice more likely in tertiary care

New research from Nigeria suggests that tertiary educated women are more aware of c-section on "demand", and that maternal request is more common in tertiary health care centre'; these women are also more likely to "favor a woman's right of autonomy to choose her mode of delivery."

Against a background of reported increased rates of maternal request cesarean, researchers NS Okonkwo et al set out to "determine the perception and attitudes of Nigerian antenatal clients towards MDCS, their willingness to request MDCS, and the relationship between willingness to request MDCS and sociodemographic characteristics."

They found that:

The proportion of women aware of MDCS was 39.6%.

Doctors were major sources of information on MDCS (30.8%) as well as friends (24.3%).
Common reasons reported for MDCS were fear of labor pains (68.9%), and fear of poor labor outcome (60.1%), and fear of fecal (20.2%) and urinary incontinence (16.8%).
However, willingness to request MDCS was low (6.6%).
More than 50% of those willing to request MDCS would likely be criticized, mainly by their husbands.

And they concluded that:
"Provision of epidural anesthesia and improved safety of vaginal delivery is recommended." This may prevent Nigerian women from making a difficult choice for MDCS based on fear of pain and poor labor outcome. The role of the male partner should be taken into consideration in order to make sustainable policies or guidelines for MDCS in developing countries."

Philosophy vs. Facts - 'Birth' journal declines our book

Like many other publications, Birth was offered a review copy of our new book, Choosing Cesarean: A Natural Birth Plan, but the Lamaze International journal declined, stating:

"The content of this book does not match the philosophy of our journal."

I thought readers ought to be aware of this because Dr. Murphy and I disagree with the premise that birth plan information and education should be based solely on any particular philosophy or ideology. All birth choices should be better understood and supported.

We do not advocate cesarean births for all women, but we do believe that many women - and indeed medical professionals - are simply not being made aware of the risks associated with planned vaginal birth, and it is disconcerting that a major publication such as Birth should decide that what we've written is irrelevant to their readers - before actually reading it.

Cesarean Choice in China - one woman's story

We've written about c-section rates in China in chapter 8 of our book, Choosing Cesarean, and in the Shanghai Daily this week, new mother Michelle Qiao writes about her birth plan decision.

It's a very interesting look at some of the reasons why women choose a cesarean there, and also why ultimately, Michelle decides to have a vaginal delivery with an epidural.

And while I'm not convinced that this birth "experience increases her love for her baby" (or at least, I don't believe that not experiencing vaginal birth by default decreases a woman's love for her baby), her story (and the opinions of friends, family and medical professionals in China) is one that we don't often get to hear.

Inquest into brain injury and death of child whose mother requested a c-section

This story appeared in The Australian this week, and while the inquest is clearly ongoing, and therefore the report is based on alleged claims, Pia Akerman writes how (my bold):

"Dishita Madamshetty died at the age of one month after being delivered in an emergency caesarean at Sunshine Hospital in Melbourne's western suburbs in 2007."

"An inquest investigating the circumstances of Dishita's birth yesterday heard that a midwife had left her mother, Shashi, alone for 25 minutes before returning to find the fetal heart rate monitor showing "non-reassuring" levels. Mrs Madamshetty was rushed into surgery and gave birth by caesarean about an hour later, but the baby was not breathing and had suffered multiple organ failures.

"Mrs Madamshetty told the inquest she had repeatedly asked for a caesarean delivery throughout her pregnancy. She had been worried about her baby's health as Dishita was conceived through IVF in India with the help of an egg donor.

"This baby was very precious to me and I believe that if she had been born by caesarean when requested by me that she would still be with us today," Mrs Madamshetty told the inquest. "Every month I had a checkup and I requested for the caesarean."

Read more here.

MedicalScienceBooks.com reviews our book

Read what they say below (or click here for more info):

"Choosing Cesarean: A Natural Birth Plan gives an honest assessment of the risks and benefits of both vaginal and cesarean births.  The book is one of the first to support elective cesarean as an important option for women, citing circumstances when planned cesarean is a healthier and even more economical option than vaginal delivery.  The authors present evidence disproving much of the accepted thought on vaginal and cesarean delivery, giving us all something to think about.

"Most of the information available until now has been in support of a vaginal delivery, with cesarean as a last option.  Therefore, when the mother is unable to deliver vaginally, she can become disappointed, feeling less adequate than a woman who delivers vaginally.  In Choosing Cesarean, the authors give evidence proving that elective cesareans can have much more desirable outcomes, and should not be considered a last resort, but rather a suitable option to prevent complications of all kinds.

"It is worth mentioning that the authors are not against vaginal births, but rather present factual evidence to support the medically acceptable option of a scheduled cesarean delivery.  When weighing all of the options for delivery, this is an important, often overlooked method.  Any woman making a birth plan should add this book to her reading list, while healthcare professionals and policy makers would also benefit from the information presented in this book."

On Saturday 17th March, Radio 4's Today Health Correspondent Jane Dreaper presented a report on the history of the National Childbirth Trust (NCT) programme, and interviewed me as part of this report.

[Extract of JD] "The NCT is pledging to keep campaiging to improve services for all new parents, but Pauline Hull, who runs a website called electivecesarean, questions whether the NCT has stayed too close to its roots, in promoting all things natural.

[My response] "Because of its size and power, it's presented these choices to MPs as being something that all women want, when in fact for example, more women are choosing a cesarean than a homebirth, and there are women who choose not to breastfeed and there are women who choose to breastfeed. So I hope that going forward, the NCT is more willing perhaps to listen to the views of other smaller organizations that represent women, and that they can be fully supportive of all choices."

20 years after birth: Incontinence 3 X more common with vaginal delivery

This is the conclusion of new research from the Sahlgrenska Academy at the University of Gothenburg in Sweden. You can read the full release at ScienceDaily, but in brief, there were 6,000 women involved in the research, all of whom had babies between 1985 and 1988.

"Overall, the prevalence of UI was considerably higher after a vaginal delivery (40.3%) compared to women who delivered by caesarean section (28.8%). The study also found that the prevalence of UI for more than 10 years almost tripled after VD (10.1%) compared to women who had a CS (3.9%)."

The authors also note that the risk of UI in obese women more than doubled in comparison to women with a normal BMI after VD and more than tripled after CS.

Interesting article on C-Sections in the U.S.

I've just commented on Kirstin Hendrickson's article in Scientific American (worth a look), Cesarean Sections in the U.S.: The Trouble with Assembling Evidence from Data, to say:

This article perhaps might have been subtitled, "The Trouble with Assembling Evidence from Mixed Cesarean Data".

One of the biggest problems in the ongoing cesarean debate is the number of research studies that rely on mixed cesarean data (i.e. they do not separate planned and emergency surgeries, or planned surgery 'for a medical/obstetrical reason' and planned surgery 'on maternal request' alone).

Similarly, there are too many research studies that do not properly compare intent to treat (i.e. a comparison of each planned mode of delivery and ALL the actual outcomes of each).

Going forward, we need better data collation, more standardized methods for comparison of different birth plans, and a willingness to include the longer term health and cost outcomes (e.g. incontinence and prolapse) of each birth plan.

There is a great deal of truth in the last paragraph of this article, and while the U.S. does might not yet have achieved the correct balance in terms of wanted and unwanted cesareans, it's worth remembering that in many other countries, the ideological focus on normalizing birth at all cost has resulted in tragic outcomes for some mothers who pleaded for a cesarean birth but were ignored.

Curbing C-sections could save countries billions - REALLY?

I blogged about this research a few weeks ago, and since then, various news outlets have reported on it, including Reuters.

Aside from the obvious issue with the authors' continued use of the WHO's 1985 recommended cesarean threshold of 15% (which is not evidence-based), the idea that a ""better distribution" of resources could allow more women in poorer countries to get medically needed C-sections" is somewhat unconvincing.

If redistribution of wealth and resources was this simple, many more problems in the developing world would have been solved a long time ago - health, education, clean water for example.

I agree absolutely that more women in the developing world should have access to c-sections, and more needs to be done to save lives and reduce severe morbidity (e.g. maternal fistula and infant birth birth injuries), but to suggest that reducing the cesarean rate in the developed world would have any real impact is hypothetical at best and distinctly unhelpful at worst.

It's all very well to decree hospital birth policies of "necessary c-sections only", but if a woman WANTS a cesarean, or if she CHOOSES surgery after a doctor has explained the risks and benefits of both birth plans, she should not be FORCED to have a trial of labor, simply because there is a CHANCE she'll avoid adding another decimal point to an all-important cesarean rate.

Hindsight is a wonderful thing, and if medical professionals were capable of identifying every "necessary" cesarean correctly, perhaps the litigation bill for obstetrics wouldn't be so large.

But they can't, and no one knows when low risk will become high risk - therefore women should (if they choose to) be allowed to decide on their birth plan independently of any cesarean rate cost-cutting plans, and doctors should be allowed to consider planned cesarean birth as an option without fear of criticism from hospital accountants.

CTV Interview with Choosing Cesarean co-author Dr. Magnus Murphy

Dr. Magnus Murphy has appeared on CTV's Morning Live today with interviewer Sage Pullen, to discuss our new book, Choosing Cesarean: A Natural Birth Plan. If you'd like to watch the interview, visit ctv.ca and then click on the fourth story down in the right-hand-side list, titled 'Choosing Cesarean'.

Parents of brain damaged baby wanted a normal life, not a normal birth

Another heartbreaking birth story, another injured baby, and another mother whose repeated request for a cesarean was refused and ignored.

The South Wales Argus reports how ten weeks after his birth on November 9, 2011, baby Casey's parents were told that he had suffered brain damage as a result.

His mother, Nahella Hard, had had a previous emergency cesarean with her daughter due to preeclampsia and a placental abruption, and suffers with a bowel disorder, yet despite her repeated requests for a repeat c-section, she was made to have a "traumatic" vaginal delivery.

His father, Anthony Hard, describes how he was looking forward to doing normal things with his son, like "taking him to football", but just hopes now that he'll be able to "walk and talk".

They have just submitted a formal complaint to the Aneurin Bevan Health Board about their experience at the Royal Gwent Hospital in Wales, as reported here, and following a full invesigation, I hope they get the answers they deserve.

Criticizing Cesareans - What will they blame high rates for next?

New research this month has concluded that cesareans "that are potentially medically unjustified appear to command a disproportionate share of global economic resources."

Authors from the World Health Organization (WHO) and the Institute of Clinical Effectiveness and Health Policy (IECS) set out to "describe the unequal distribution in the performance of" surgery by measuring how much it would cost to attain a c-section rate of 10% in countries below that rate (US$ 432 million) and reducing rates to 15% in countries currently above that (US$ 2.32 billion).

I have only been able to read the Abstract unfortunately, but here is the email request I have just sent to the lead author of the research to ask her a few questions about the choice of 15% as an appropriate rate, and any cost analysis of economic resources associated with vaginal birth rates of 85% and 90%. You can read my email here:

Pelvic Organ Prolapse and Surgery for young mum on Channel 4 show

This week's episode of C4's Embarrassing Bodies illustrates the reality of pelvic organ prolapse following vaginal birth with the following case study: "Cat, who at just 24 is struggling daily to keep her waterworks under control." The programme follows her story through from initial examination and diagnosis, to prolapse surgery lasting two-hours.

This (series 5, episode 1) is really worth watching - not because it scares viewers about childbirth, but because it is making a genuine effort to confront issues head-on that are affecting more women than we might realise.

One thing I thought while watching was how terrible it is that this poor woman was suffering with this condition for more than a year before finding help, and how many more might be suffering in silence, long after their six-week postpartum check-up is over.

Please note that the programme contains 'full frontal nudity, intimate examinations and graphic scenes of surgery', but it also contains some useful stats and clear explanations about what prolapse is (for blog readers outside the UK, I have transcribed the contents of the programme below).

Was ‘Frankenstein’ really about childbirth?

Last November, for a local newspaper interview, I was asked, "Who would you most like to be stuck in a lift with and why?" I answered, "[It] would be different if this question was in the context of a dinner party or desert island, but to spend a few hours stuck in a lift, my first choice would be a posthumous one - author Mary Shelley, whose own mother and first child died in childbirth, and whose novel 'Frankenstein' explores areas of medical debate and ethical controversy such as organ transplants and genetic engineering. I'd love to discuss her views on contemporary cesarean birth." So today when I came across this New Republic article by Ruth Franklin, I found it a very interesting read. For example, when Mary Shelley began writing her novel, she had already given birth in 1815 to a premature daughter who subsequently died, and also her own mother, Mary Wollenscroft, died just days after giving birth to Shelley in 1797.

New DVD promises to accept ALL birth choices

From: "It's a joke!" and "I think major abdominal surgery should be a last resort." To: "all the power to her!" ...In seven months, Ricki Lake's opinion on women who choose to have a cesarean has thankfully changed, at least according to an interview posted this week on celebritybabyscoop. 

Back in July 2011, on the same website, Ricki answered the question, "What do you say to women who choose to have scheduled C-sections to protect their “vaginal integrity”?" like this (and I blogged about it here):

"It’s a joke!

CHOOSING CESAREAN Book Review by Library Journal

VERDICT: This book is unique in its willingness to openly address the risks of vaginal delivery, making it a valuable addition to any pregnancy- and childbirth-related shelf.

Expectant mothers should keep the authors' obvious preference toward elective C-sections in mind as they process its information.
While this title may not change readers' views of childbirth, it presents an idea worth exploring.—Mindy Rhiger, Mackin Educational Resources, Minneapolis

FULL REVIEW of Choosing Cesarean: A Natural Birth Plan
In this title, physician Murphy (obstetrics & gynecology, Univ. of Calgary; coauthor, Pelvic Health and Childbirth: What Every Woman Needs To Know) and former BBC journalist Hull (editor, electivecesarean.com) argue for one particular method of childbirth they think should be available to all women: elective Cesarean sections (C-sections).

They are quick to point out that they are not advocating for all women to have C-sections; rather, they want women to be aware of the risks and benefits of vaginal vs. C-section births and make evidence-based choices.

Despite the authors' apparent sincerity in their argument and the extensive references they offer to support their case, many readers are unlikely to be swayed.

The challenge of new mothers being older and older

ONS figures reported in the Daily Mail yesterday show that not only is there something of a baby boom going on, but the average age of new mothers is now almost 30, and there are more and more women giving birth at older ages.

This is creating unprecdented obstetric challenges for doctors and midwives, and these are compounded by the fact that pregnant women in general are heavier weights than ever before, and giving birth to bigger term babies too.

I'm not for one minute suggesting that all of these women might want to consider a planned cesarean birth, but I do think it's important that they are fully informed of the specific risks associated with giving birth at an older age so that (if they want to) they can make their own decision between choosing surgery or a trial of labor.

Repeat c-section risks are real and relevant

Photo: Press Association

Amanda Holden has been talking to The Sun newspaper about her recent birth experience during which she almost died.

Thankfully, both Amanda and her new baby Hollie are safe and healthy, but their experience demonstrates the very real risks associated with repeat c-sections - and in particular, placental problems.

Amanda told The Sun, "I had something called placenta previa - a low-lying placenta that prevents you from giving birth naturally. I also had placenta accreta - which meant my placenta was stuck to the C-section scar from the two previous births."

We write about placental complications in our book, and of course individual women will balance these risks with the risks associated with planned vaginal birth too, but I decided to blog about them here to highlight that no birth plan - no matter how 'safe' it seems - is inherently risk-free.

Call the Midwife but Celebrate the C-section too

The dedicated midwives depicted in this BBC drama undoubtedly deserve our praise.

But so far at least, there seems to have been a dearth of recognition (in reviews) for another praiseworthy life saver: the c-section.

The often untold stories of babies and mothers who died or were seriously injured during natural births in the 1950s are touched on in this series, and it's evident that the technology available to us today, including ultrasound and emergency or planned cesareans, would have prevented so much grief and heartache.

We marvel at how far we've come (e.g. contraception, IVF, pain relief and hygiene), and yet advances in the comparative safety of cesarean surgery can sometimes be overlooked, taken for granted or even maligned.

Let's celebrate the call to midwifery, yes, but we should celebrate the cesarean too; it's just as deserving.

Australian Hospital says NO to C-section (Same Story in UK and Canada)

According to this Northern Star article, "under the Towards Normal Birth policy, the [NSW] state is aiming to reduce the cesarean rate to 20% before 2015."

Remember - there is NO EVIDENCE for ANY ideal cesarean rate - yet (as is happening in the UK and Canada too), an ideological focus on achieving normality is deemed more important than best physical and psychological outcomes for babies and mothers.

Lismore pediatrician Dr. Chris Ingall is quoted here as saying that 'the rights of the both babies and mothers have to be balanced out'... "It's not just the mum's choice. It's also the baby's choice as to how the delivery transpires."

You may disagree, but having read this mother's very genuine and legitimate reason for wanting to schedule a c-section, I don't believe for one minute that - if such a consultation was even possible - her macrosomic baby would make a different choice. Do you?

Why are cesarean rates rising in India?

Photo: iloveindia.com

In response to a recent article in The Economist, journalist Sriram Vadlamani has written a very interesting rebuttal titled, "Auspicious C-Sections in India? Not really".
I've just commented on his blog, but for brevity here, I would have to agree with Vadlamani that when it comes to discussing c-sections, "context is paramount".

I also think it's likely that, as is the similar case in China, when it comes to birth choices, "Astrology is a probable side-effect of this new found awareness and risk averseness".

Latest news from Portland hospital makes interesting reading

The statistic most likely to hit the headlines soon is this London private hospital's c-section rate - 53%.

I don't know the elective/emergency breakdown yet, and will endeavor to find out, but given that the rate of emergency cesareans in public hospitals is around 15%, it's very likely that the elective number is very high.

The other interesting statistic is The Portland's 89% normal delivery (standard vaginal delivery) rate.

This is only for second time or subsequent mothers, and I'm not sure why this Private Maternity News report doesn't mention the first-time mothers rate too, but on the face of it, it looks as though this hospital, with its 2,230+ deliveries in 2011, deserves credit for striving to provide mothers with their preferred birth outcomes.

How to restore your sex life after having a baby

Not every woman who has a vaginal birth has sexual health issues months or even years later.

But some do.

Articles like this one, 'How to restore your sex life after having a baby' are helpful for at least getting the subject out in the open and informing women that there are risks with vaginal birth and they shouldn't be kept in the dark about the truth.

The French Government Wants To Tone My Vagina

This Slate article by Claire Lunberg is worth reading alone, but just as importantly, read the comments posted below, and in the Huffington Post version of the article, posted a few days later.

It's all about French postnatal care for the damage to a woman's pelvic floor that can happen during vaginal birth, something Pamela Druckerman also wrote about in the New York Times back in 2007.

We don't have anything like this in the UK or the U.S., at least not for the average woman (private medical care may differ), and what resonates most with me are the comments from women who, like so many others, echo the words, "No one told me this could happen."

Latest £3.35m NHS settlement for 1985 birth - Millions more still to be paid

No one knows how any birth will turn out, and no one knows how much more money the NHS (tax-payers) will have to pay when mistakes are made. But what we do know is that NHS litigation bills are already at unaffordable levels (and millions of pounds are yet to paid for claims already made), and that when it comes to birth (in the eyes of the law), the delay or absence of cesarean surgery is the most costly mistake of all. Perhaps if maternity budgets were directly affected by these litigation costs, then more hospitals might remove their target driven pressure to 'reduce cesarean rates'. The NHS can't afford it, and more importantly, mothers and babies deserve better care (you can read the BBC story about 24-year-old Adam Spinks here).

NHS bailed out of litigation black hole - Obstetrics Claims Cost the Most

And things can only get worse...

As the British Medical Journal reports that the NHS compensation fund gets £185m bailout as claims rise by 30% in a year, it's important to remind readers that the largest litigation costs for the NHS arise from OBGYN claims.

When planned vaginal birth goes wrong, and especially when a baby is injured, the financial costs are substantial - and the backlog of these claims is huge.

When will maternity care policy makers understand that it's not a focus on "normal" birth that's most important (or cost-effective), but rather a focus on best health outcomes?!

Perhaps it'll take cash-strapped MPs to understand this first.

Why do I keep writing this blog? Because of emails like this...

Photo: allaboutincontinence.co.uk

I receive many emails from women, and especially from those who are facing difficulty in having their cesarean birth choice understood, respected or supported.

But there are other emails too, telling of the devastating consequences of a cesarean birth request that was ultimately denied.

Here are just two of the most recent I've received - from courageous women who are willing to speak out about the often downplayed risks of vaginal birth, and who don't want other women to suffer in the way they have.

Transfer risk from midwifery-led birth centers is real

A wait of just under two hours for an emergency cesarean transfer, and now brain damage is suspected.

The Braintree & Witham Times reports that a full internal investigation has been launched by the East of England Ambulance Service NHS Trust, and that parents Sarah Jenkins and Jamie Murray say "they have been “failed” by the NHS after what should have been a straight-forward birth in Braintree ended with baby Riley Murray being starved of oxygen and eventually being taken to intensive care at Addenbrookes Hospital, Cambridge."

Last April, my criticism of current thinking to encourage all 'low risk' woman to give birth in midwife-led birth centers' was published in the BMJ, as it's a policy I am wholeheartedly against.

Mother and baby would have died if VBAC was attempted elsewhere

Photo by Simon Finlay

This birth story was quite rightly reported as a good news story in last week's Norwich Evening News: 'Our little boy is just cool after 72 hour fight for life'

But there's also something very troubling about the story if you consider the fact that had this VBAC been attempted in a different hospital - one without the specialist life-saving equipment that was needed - both mother and baby would have died (according to the report).

Baby Adam's mother, Marie Jermy, is quoted as saying, “I wanted a natural delivery with Adam, as my other two kids were born by C section, and the hospital were very supportive.".

Yet despite being considered 'low risk' enough to attempt labor, Marie's experience emphasizes just how quickly problems can escalate during labor, leading to possible death or disability.

Cesarean delayed and denied. Baby dies.

The photographs in this South Wales Argus report by Alison Sanders. are just heartbreaking, and while the investigation into the death of this baby, at just 2 days-old, remains ongoing, anyone
involved with maternity care in the UK needs to read.

In Sanders' report, the baby's mother alleges that she requested a cesarean during labor.

As readers of this blog will know, this is not the first time a mother has requested a cesarean in order to save her baby's life, only to have her request ignored or refused, with the same tragic outcome.

The circumstances surrounding this birth were reported in Gwent News just two days before the birth of Blue Ivy Carter - and of course it was the latter that captured the world's attention, as is so often the way.

Why are people so quick to judge and vilify obstetricians?

It's an issue I could write more about if time allowed, but in Viv Groskop's article, Welcome to modern motherhood, Beyoncé..., I've just posted the following comment:

Why are so many commentators so quick to judge and vilify obstetricians, the absolute majority of whom should be applauded for the amazing work they do, while simultaneously placing midwives on a pedestal when it comes the antenatal advice they give to women? Do we really, as a society, distrust our doctors SO much?

It’s also worth remembering that celebrities are all individual women with their own perception of birth risks and benefits - so regardless of what advice their money can buy, they may also have their own personal preference for one birth plan over another, and this would be exactly the same even if they weren’t famous.

Call the Midwife: 'There isn’t much comedy delivering a baby'

I just had to post this comment on Morwenna Ferrier's article in The Telegraph today, especially given the way NHS maternity policy seems to be heading:

Let me start by saying that I think that the majority of midwives do a great job and I agree that there is evidence to show that midwife-led care can enhance the experience of women who would like to have a natural birth.

However, I would not describe midwifery-led care as  categorically "uncontroversial", as it appears to be represented in this article's conclusion.

Listening to and reading the stories of women who have experienced birth trauma, it is very clear that the "care" provided by some midwives is extremely poor. They do not always respect women's feelings or birth choices, and their treatment of  women, both physically and psychologically is sometimes described as dismissive and even cruel.

IMPORTANT INFORMATION: The NICE c-section handout for pregnant women

Are you thinking about choosing a c-section? Are you worried that you will not be taken seriously when you attend your antenatal meetings? Have you already tried to discuss a cesarean birth plan and been refused point blank? Are you unsure of your rights as a patient in the NHS?

If so, please read the NICE (National Institute for Clinical Excellence) NHS patient leaflet: Understanding NICE guidance

Also see: NEW GUIDELINES YOU SHOULD BE AWARE OF

First-time moms' unrealistic views about having uncomplicated births

An Australian report by Evelyn Yamine in the Daily Telegraph discusses a new study showing an increased risk of post-natal depression in first-time mothers with "unrealistic views about having uncomplicated births".

This does not surprise me in the least, and I think that women are often not being helped in forming realistic expectations during their antenatal care.

Beyonce Gives Birth to Blue Ivy and Colorful Debate

Jim Spellman/ Wire image (TIME Healthland)

I've posted this comment on TIME article, Beyoncé's Baby: C-Section? Natural Childbirth? Why We Care So Much:

Bonnie Rochman picks up on some interesting points in this article - namely the hierarchy of c-sections, and indeed the perceived hierarchy of all birth types.

Unfortunately, birth plans and birth outcomes are often discussed within a context of mixed data and anecdotal evidence, and when a celebrity has a baby - however she has it - this provides a fresh opportunity to discuss and debate issues surrounding the birth choices women make (or want to make).

What has proved particularly interesting in the case of Beyonce's birth experience is the way different people have reacted to different information about whether it was natural or surgical.

Personally, I believe that choosing a cesarean is as natural a birth plan in the 21st century as planning a vaginal birth - as long as the woman is fully informed of both sets of risks, is planning a small family, and schedules surgery at 39+ gestational weeks (assuming no medical indication for earlier delivery). Of course, not everyone agrees with this, which is why there is so much debate on the subject.

What I would say is this: It's not celebrities that have been leading the way with cesarean birth choices. Rather, it is doctors, as demonstrated in a number of research studies on their birth choices, and the choices of their wives and partners.

Finally, however Beyonce gave birth, it is her business (unless she chooses to discuss it) and she should be neither condemned nor put on a pedestal because of it. What matters most is that this mother and daughter are healthy, and that as a society we do everything we can to give other mothers and babies the same chance of healthy outcomes too.

November and December 2011

A very busy few months, filled with completing the final stages of our new book and ongoing cesarean campaign work.

I've highlighted some of the main activities below, but plan to post more details about many of these as soon as possible.

December 09, 2011
Contacted BBC Complaints and Woman's Hour programme makers in response to Jenni Murray's November 23 report on the NICE Caesarean section guideline (update), in light of her Daily Mail article, published just weeks earlier.

November 30, 2011
Attended the NHS Alliance Conference in Manchester, speaking with many representatives from many healthcare organizations on the subject of cesarean rate targets and maternal request. Request made for information (incl. DoH letter, below) to be handed to Health Secretary Andrew Lansley; response was affirmative by NHSA staff but no confirmation yet that it was received.

November 24, 2011
Interviewed on BBC Scotland's Call Kaye programme on the subject of the NICE Caesarean (update) guideline

November 23, 2011
Interviewed on ITV Daybreak, Sky News, BBC London 94.9, BBC Radio Leeds and BBC Radio Humberside on the subject of the NICE Caesarean (update) guideline recommendation on Maternal Request, published today

November 22, 2011
Interviewee for BBC 1 The One Show's cesarean request film, presented by Angellica Bell.

November 18, 2011
Submitted an open letter to the Department of Health outlining my concerns with target cesarean rates that are in place in many hospitals throughout the UK. Both Jeremy Hunt MP and Daniel Poulter MP have agreed to forward my concerns to the DoH. On November 22, Jeremy Hunt MP contacted me to confirm that my letter has been forwarded to Anne Milton, Minister for Public Health. As at December 11th, no confirmation yet from Daniel Poulter. MP.

November 04, 2011
Together with co-author Dr. M Murphy, submitted a formal request to FIGO for a review of its 1998 statement regarding Ethical Aspects Regarding Caesarian Delivery For Non Medical Reasons: “At present, because hard evidence of net benefit does not exist, performing Caesarean section for non-medical reasons is ethically not justified.”

November 04, 2011
Interview (and pictures) by Associated Press journalist Maria Cheng, "Too posh to push? More C-sections on demand in UK", published online.

November 03, 2011
Research published in the British Journal of Midwifery: Why do some women prefer birth by caesarean? An internet survey. By Pauline Hull, Carol Bedwell, Tina Lavender (BJM, Vol. 19, Iss. 11, 02 Nov 2011, pp 708-716)

November 01, 2011
The NHS Litigation Authority formally confirmed that in response to my request for claims data to be separated into births relating to an emergency or a planned cesarean, it will "introduce a system for recording this information on new claims in future."

U.S. cesarean rate is down from 32.9% to 32.8%

According to this report by USA Today, the latest figures from the United States show that the country's overall cesarean rate fell from 32.9% in 2009 to 32.8% in 2010.

Why do some women prefer birth by caesarean? New research published

It's taken a few years to publish but it's finally here - my website survey results formally published in the British Journal of Midwifery:

Why do some women prefer birth by caesarean? An internet survey by Pauline Hull, Carol Bedwell, Tina Lavender

BJM, Vol. 19, Iss. 11, 02 Nov 2011, pp 708 - 716

Abstract: Caesarean section at maternal request remains a contentious issue, fuelled by reports of associated morbidity. To explore the motivations behind women's expression of preference for a planned caesarean birth, an internet survey was conducted using semi-structured questionnaires available via a UK-based international website, www.electivecesarean.com, over a 9-month period. A convenience sample of 359 pregnant women who stated that their preferred delivery method was 'elective caesarean section through my own choice' was included.

More NICE cesarean media coverage

Media coverage of the NICE draft guideline on caesarean section continues, and in the last few days, I have commented on the following:

Telegraph: Cruel cuts to midwives have made Caeasarean sections a cheaper option for NHS (3rd Nov)

Practical Ethics: The moral case for elective caesarean section (2nd Nov)

Marie Claire: All women will have the right to a caesarean, Hannah Thomas (31 Oct) 

Huffington Post: Midwives are Able to Help Women Make the Right Choice About Their Childbirth, Cathy Warwick, Chief Executive of the Royal College of Midwives (31 Oct)

Huffington Post: Why didn't I have the right to a Caesarean, Sue Hedges (31 Oct)

Interview on BBC Breakfast Television

I was interviewed this morning on BBC Breakfast television, and for a short while at least, a shortened version of the discussion can be viewed here.

Sian Williams and Bill Turnball interviewed me and made the whole experience a very enjoyable one.

I must also thank

RCOG's response to the NICE guideline media reports

This is what the Royal College of Obstetricians and Gynaecologists (RCOG) has to say about the past few day's media headlines and stories:

"The RCOG does not comment on draft consultation documents since the content and recommendations are subject to change. 

However,

Comment posted on media NICE guideline stories today

So many stories, so many views.

The news that the draft NICE caesarean guideline supports maternal request for all informed women who want one has undoubtedly caused a media storm.

Here are a selection of links where I have registered (variations of) my comment below:

Express: Folly of caesarean births for everyone, Vanessa Feltz
Guardian: Caesarean sections should be life-saving, not a lifestyle choice, Louise Foxcroft
Telegraph: Childbirth finally leaves the Stone Age, Cristina Odone
Daily Mail: Now all women have the right to NHS caesareans in hugely expensive move, Tamara Cohen
AOL: All women to get the right to a caesarean birth on the NHS, Ceri Roberts

My Comment

The most important things here are