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Birth in the balance
Sunday, September 21, 2008 By Jennifer O’Leary
It has never been safer to have a natural birth, so why is it that female doctors are opting for caesarean as their delivery method of choice?

Ask a first-time mother the kind of birth she is hoping for, and you are likely to have the following response: a natural one. Nowhere in the birth plan, tucked in beside the words ‘gas and air’ and ‘birthing ball’ will you see the phrase ‘elective caesarean’. Because, apart from the instinctive wish to deliver their baby as nature intended, and far apart from the thought of being cut open while you’re awake and aware of it happening, few if any relish the idea of having to recover from an invasive surgical procedure while grappling with the responsibilities of new motherhood.

But when the British Journal of Obstetrics and Gynaecology (BJOG) recently asked the females who experience the other end of childbirth - the health professionals assisting deliveries - they got a different answer.

In assessing the maximum level of risk first-time mothers would be prepared to accept before requesting an elective caesarean over vaginal delivery, the journal found that first-time mothers-to-be will accept greater risks than clinicians for a natural birth.

A total of 102 women, 84 midwives,166 obstetricians, 12 urogynaecologists and 79 colorectal surgeons were interviewed by the BJOG to find out whether different complications would prompt the women to choose to deliver their child by caesarean. In all categories, the first-time mothers were far more likely to be prepared to put up with complications in order to have a natural birth.

The results showed critical variation between the groups, with only 2 per cent of pregnant women preferring elective caesarean compared to 11 per cent of midwives, 21 per cent of obstetricians, 44 per cent of colorectal surgeons and 50 per cent of urogynaecologists.

The news should go down well in Ireland, which has a high track record of caesarean delivery. Despite a World Health Organisation recommendation of a caesarean section rate of 10 to 15 per cent of all births, the latest Irish figures show a rate of 26 per cent recorded in 2005.This is up from20 per cent in 2001 - meaning that the percentage of women giving birth by caesarean is continuing to grow. So are the preferences of the medical professionals themselves an implicit endorsement of our increasing caesarean culture?

Professor Cecily Begley, director of the School of Nursing and Midwifery at Trinity College Dublin, attributes the differing reactions to caesarean of each group of health professionals, to the various aspects of the birth process to which they are most exposed.

‘‘Midwives carry out most normal deliveries; 60 per cent of the women they care for have a normal vaginal birth,” she says. ‘‘Obstetricians, on the other hand, are called to assist when something goes wrong and they do forceps, vacuum deliveries or caesarean sections, so they have a totally different, more medicalised view of birth. And all colorectal surgeons ever see is women with perineums that need repair, so [of the medical professionals surveyed] they have the most biased impression of the risk of normal childbirth.”

The perception of risk also contributes to differing priorities, says Dr Louise Kenny, consultant in obstetrics and gynaecology at Cork University Maternity Hospital. ‘‘Risk aversion is a subjective area and doctors are guilty of letting their personal experience bias their objectivity. But because of our role we tend to see complications, and that does affect our personal perception of what risk is [in childbirth].”

Begley attributes the contrasting perceptions of risk to the philosophy and ethos of each professional group involved in the birth process. ‘‘I think the good obstetricians are the ones that realise that they have an inbuilt bias but are willing to stand back and listen to the mothers and midwives and see what should be done in a situation by listening to everyone.”

According to Professor Philip Steer, an obstetrician and BJOG editor-in-chief, the evidence suggests that more than 90 per cent of women would prefer a normal birth ‘‘provided everything goes well, but there is a significant minority who would like a caesarean section’’.

He says obstetricians are reluctant to coerce that cohort of women into changing their minds. ‘‘Although I encourage women to have a normal birth, if they are determined to have a caesarean section, I do tend to think that I don’t want to put too much pressure on them to have a normal birth because if something goes wrong they are going to throw the book at me and I’ll end up in court.”

The number of babies being delivered by caesarean section in Ireland is now one in four, or 26 per cent of all live births, according to the latest ESRI report on Perinatal Statistics for 2005, published earlier this month.

However, Begley says the figures should be interpreted carefully, as they do not differentiate between women who are put forward for caesarean section and those who choose them for non-medical reasons. ‘‘The number of women actually requesting a CS for no good medical reason here is actually very low, at less than 2 per cent.”

The ESRI report does not outline the reasons behind the rise in caesarean births in this country, a form of delivery that stood at 20 per cent in 1999.

Nevertheless, the fact remains that the incidence of caesarean section in Ireland is rising - a fact that is of some concern to Mary Brosnan, director of midwifery and nursing at the National Maternity Hospital, Holles Street, in Dublin. Brosnan says the figures are of concern to ‘‘all senior people in midwifery and obstetrics ... because a women who has a caesarean section in her first pregnancy has a much higher chance of caesarean sections in future pregnancies’’.

While the rate continues to rise in Ireland, some countries are actively attempting to reduce their rate of caesarean birth. In Britain, the National Institute for Clinical Excellence advises against caesarean section on demand.

‘‘The maternal mortality rate has shot up significantly in Britain over the last six years, due to long-term complications of recurrent caesarean sections,” says Dr Suzanne O’Sullivan, consultant obstetrician and gynaecologist at Cork University Maternity Hospital.

‘‘And because women are dying more commonly of peripartum haemorrhages, there has been a big push by the British government to reduce the rate of caesarean sections.”

According to a spokesperson for the Department of Health and Children, a review of maternity services being undertaken by the HSE hopes to provide a comprehensive evaluation of the Irish data, as recommended by the Institute of Obstetrics and Gynaecology, in order to determine the cause or causes of our high caesarean rates.

Dr Michael Robson, master of Dublin’s National Maternity Hospital, warns against any professional bias for or against caesarean sections.’ ‘We are now in a situation where the caesarean section rate is going up, but we should not jump to the conclusion that a high rate is bad and a low rate is good. Instead we should invest more to record the results so we can actually review outcomes and the balances for and against.”

To this end, Robson has developed a caesarean classification system that is used internationally as away of categorising the population of pregnant women requiring caesarean delivery. It makes possible any comparisons of caesarean section rates over time in one hospital and between different hospitals.

A 2007 report by the CSO may, however, hold a clue as to the root of Ireland’s rising incidence of caesarean births.

The report, which charted Ireland’s total fertility rate for the year, showed an increase in the fertility rate across all child-bearing age groups, with the most dramatic increases among women in their 30s. It recorded an 8 per cent annual increase in fertility among women aged 30 to 34, and an 11 per cent annual increase in fertility among women aged 35 to 39.

Is the fact that more women are becoming first-time mothers in their 30s and 40s a factor in caesarean birth?

The National Maternity Hospital’s Dr Michael Robson offers a qualified yes. ‘‘Undoubtedly weight, age and other factors do affect the likelihood of having a caesarean section,” says Robson.’ ‘The uterus is a muscle, and it may not contract well as you get older, but too much is made of the age factor.”

And what of the perception garnered from the BJOG report which found that a third of female obstetricians opt for a caesarean when they have their own children. Do female obstetricians know something other women don’t?

‘‘The first thing to point out about that study is that the majority did not choose a caesarean,” says Dr Louise Kenny. “That data should be interpreted with caution. My perception is that it’s not a true assessment; most of my colleagues that I know are as pro-vaginal delivery as anyone else.”

Dr Suzanne O’Sullivan says that her experience of female obstetricians working in Ireland is that they would all agree that a vaginal delivery is best and safest form other and baby.’ ‘All the evidence supports that,” she says.

She attributes the study’s findings back to each health professional’s role within birth. ‘‘Obstetricians in Britain only get involved in the complicated vaginal deliveries, and those cases undoubtedly colour people’s views. It does not necessarily mean the obstetricians know something else - it’s just that they are getting a skewed view of things when their experience is only in the abnormal [births].”

With such a high amount of support among Irish health professionals for natural birth, why is the rate still on the increase here, as it is internationally?

‘‘The more safe we make it [caesarean delivery], the less the argument is for not having one,” says the BJOG’s professor Philip Steer. Yet, despite the risks being much lower than what they were, Steer says new evidence suggests caesarean delivery is not such a good thing for the baby.

‘‘They have more trouble with breathing because they don’t get their lung fluid squeezed out, the way they deal with sugar in terms of the risk of diabetes and blood pressure control is affected, and we are evolved to cope with stress at childbirth, so risk-taking factors are programmed around the time of birth.

‘‘In short, a certain amount of stress at childbirth is good for us. If you are delivered by caesarean section with no stress at all, it can have long-term negative effects.” Women’s own perceptions of caesarean delivery may also feed into the rise.

‘‘People think a caesarean section is an easy and simple way out; it’s not,” says O’Sullivan.’ ‘You need to be straight about the risks in comparison to a labour and vaginal delivery.”

‘‘Some people who are not informed think it’s quite a straightforward procedure, that you just come in and have an operation to have your baby,” says the National Maternity Hospital’s Mary Brosnan.’ ‘But the fact is there are morbidities attached to caesarean section; you are more likely to need the procedure in future pregnancies.”

Brosnan warns of the dangers if childbirth becomes too medicalised, stating also that ‘‘inducing normal pregnancies because someone wants to have their baby at a particular time, or for social reasons, is contributing to the rise of caesarean section’’.

‘‘Childbirth in the developed world has never been safer for mothers and babies,” says Dr Louise Kenny, ‘‘and vaginal birth in the absence of any medical indications for caesarean section is in the mother’s best interest.”

In some cases, fear of childbirth, whether it stems from something that may happen or something that has happened in a previous pregnancy, is a factor for women who request a caesarean section for non-medical reasons.

‘‘About 2 to 3 per cent of women have serious fear of childbirth which may or may not be justified,” says Steer.’ ‘Being in labour is for a lot of women the most pain that they will ever undergo, so it’s not unreasonable for people to have a degree of fear and need to be reassured and supported.”

Professor Cecily Begley confirms that childbirth here is safe, with high standards of obstetric and midwifery care, yet is aware that the system is failing women’s emotional needs. With the highest birthrate in the EU, Ireland’s maternity services are under stress, and Begley says it ‘‘does not have sufficient numbers of staff to care for women properly’’.

‘‘The low proportion of women who request a caesarean section for non medical reasons most often do so because of fear - they are absolutely terrified of birth, which is so sad because childbirth can be a fantastic, wonderful and enriching experience to go through at best. Fear paralyses women when they are in labour, and the only way to get around that is to be able to talk with someone.”

Steer advises that an elective caesarean section does not provide the control many women hope.’ ‘Some women don’t want the uncertainty of trying for a natural birth, because they see a caesarean as being more controllable, which is not actually correct.”

It is pregnancy, not birth, says O’Sullivan, that causes most of the changes in the body that women fear.’ ‘Caesarean sections don’t protect against incontinence or the development of a prolapsed uterus; they can make the treatment of those conditions more difficult. There is no absolute safe way of doing anything.”

‘‘My basic philosophy is that women should have choice,” says Begley, ‘‘I personally would not choose a caesarean section, because I know the risks and think a vaginal birth is much better. But if a woman seriously wants a caesarean section, then it’s her choice – I would council her and give all the information that shows medically a vaginal birth is safer, but at the end of the day, it’s a woman’s choice.”

Cuidiú – the Irish Childbirth Trust

Niamh Healy is an antenatal educator with Cuidiú:

‘‘Cuidiú would like to see more normal births. By that I mean labours that start spontaneously, proceed without any intervention and where the baby is pushed out under the mother’s own powers. While there are women for whom that is not always possible, it is for the vast majority. Nevertheless, over 50 per cent of first-time mothers in this country don’t push their own baby out and have assistance; essentially there is something wrong with the system and not the mothers.

‘‘It comes down to resources and too much of a focus on getting women through the system as fast as possible, when decisions should be made on the basis of the wellbeing of the mother and baby, and not the clock.

‘‘Women are conditioned to be afraid of childbirth, largely as a result of its portrayal in the media, especially films and soap-operas. Hence women are conditioned to hand themselves over to medics and yield to the patient mentality that allows them to be managed. If women were being supported adequately, many more could progress through labour without an epidural. It’s not about being a martyr, childbirth without intervention is possible.

‘‘How many babies are most women going to have; one, two, three – so why should women not be treated specially, respectfully and warmly?

‘‘I don’t agree that older mothers will more likely need a caesarean section. Women nowadays look after themselves much better in terms of exercise and diet, so even if you have your first baby at 40 there should not be any need for intervention.

‘‘I have a problem with such scenarios: ‘your labour is going slow, oh, let’s speed it up’ which makes the contractions more difficult to cope with, so the woman then asks for an epidural and subsequently the labour slows down.

‘‘But then the drip is increased to speed up the labour, which is okay for the woman, she can’t feel it, but the baby does and finds it difficult because the contractions are stronger. Eventually the women gets tired or the baby gets distressed so then it’s ‘oh look, now you need forceps or you need to undergo a caesarean section.

‘‘Of course, I would never claim that a woman who has undergone a caesarean section did not need to but, in many cases, it’s what goes on beforehand that has led to the baby’s distress and that could that have been prevented.”

Caesarean births: the statistics
* The latest available figures, for 2005, show that 26 per cent of babies born in Ireland in that year were delivered by caesarean section. In 1999 this figure stood at 20 per cent.

* The World Health Organisation recommends a caesarean section rate of 10 to 15 per cent.

* The average length of hospital stay for mothers post-childbirth is continuing to decline – from 4.4 days in 2001 to 3.8 days in 2005.

* The breast-feeding rate has increased to 44 per cent in 2005, compared to 39 per cent in 2001.

* In 2005, there were 183 home births attended by independent domiciliary midwives, compared with 245 such births in 2001.

* The perinatal mortality rate (deaths around the time of childbirth) in 2005 was 7.2 per 1,000 live births and stillbirths, the lowest since the Economic and Social Research Institute (ESRI) began collating such data in 1999.

* Ireland’s birth rate tops the table for 27 EU countries. France has the next highest birth rate, followed by Britain.

* The average age of mothers giving birth has risen from 30.3 years in 2001 to 31 years.

Data from the ESRI report, Perinatal Statistics 2005, published earlier this month

Too posh to push?
In the celebrity sphere, those who have had a C-section reads like a who’s who of Hollywood: actress Kate Hudson, models Elizabeth Hurley and Claudia Schiffer and singers Christina Aguilera, Madonna, Britney Spears and Victoria Beckham – who was pilloried for being ‘too posh to push’ after opting for Caesarean births for each of her three sons.

Indeed, they’re so popular among the upper class in Brazil, a rate of 80 per cent in many hospitals, the joke is that the only way you won’t get one in Rio de Janeiro is if your doctor gets stuck in traffic. Increasingly, mothers that have a C-section are portrayed as a bad example for society.

‘‘I don’t like the ‘too posh to push’ phrase,” says Professor Cecily Begley at the School of Nursing and Midwifery at Trinity College Dublin. ‘‘Because, first of all, it denigrates women, but secondly I don’t think it’s true. The number of women actually requesting a C-section for no good medical reason is actually low at less than 2 per cent.”

Dr Michael Robson, master of the National Maternity Hospital, says the media should be more discerning in its portrayal of the subject: ‘‘Sensitivity is necessary because there are women who have not had a caesarean section when they should have, or vice versa.”

He warns against making assumptions without any review of the facts: ‘‘The rate [of C-sections] is going up, and that is a concern if we do not know why or indeed what the consequences may be . . . so let’s encourage different ways of looking at it. If the media could present that philosophy rather than ‘it’s right’ or ‘it’s wrong’, that would be a huge step forward.”

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