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).