Is the genie out of the bag?


The Caesarean rate has been on my mind a lot recently. Firstly there was the news that the Irish Childbirth Trust has audited all Irish hospitals, and found an enormous discrepancy in the amount of caesareans performed, from Sligo with a rate of 18.9%, to Kilkenny general at 35.6%.

The UK figures are even more striking, ranging from Chelsea and Westminster, where 34.5% of births are by caesarean, to four units with a rate of less than 18%, including Pontefract, Staffordshire and Sutton-in-Ashfield.

Then there was this news from Sussex that local Primary Care Trusts will not pay for more than 23% of local births to be by caesarean – and also this week I came across a proper piece of academic work published in Cochrane, also about reducing the caesarean rate.

It seemed, then, it’s on the professionals’ minds, too – and indeed I was talking to a pregnant woman just yesterday, who quoted her obstetrician’s concern over the rising caesarean rate, and his reluctance to give her a caesarean unless there was no other course of action. He mentioned the cost of such an operation.

I applauded internally, then, at the Sussex PCTs, the Cochrane researchers and the anonymous obstetrician. But sometimes it seems to me that I’m a lone voice in the wilderness.

Further probing in conversation with the pregnant woman suggested she did not feel reassured at his reluctance to pick up his scalpel – quite the opposite. She worried that the management of her labour would now be dictated by cost, or some obscure target culture where she would be denied the necessary surgery to save her or her baby. Comments on the web page of the Sussex newspaper reflect this view.

Something weird has happened to our culture of birth, then, in the last 40 years or so. Because in 1970 the caesarean rate was around 5%. By 1990 it was up to 12%, and by 2003 it was at 22%. The most recent UK figures, for 2008-9, put it at 24.6% nationally.

You might think that Jo Public would have something to say about this. They might wonder what on earth has happened to women, to birth, to babies, which means that in only 20 years, it has become twice as hard? You might think that the rate of very poorly or dying mums and babies must have gone right down – especially given the frequency of the refrain ‘without my caesarean, we both would have died’.

So what if I tell you that there has been no reduction in maternal or infant mortality or morbidity to match the rise and rise of surgical birth? (That’s a posh way of saying all these extra caesareans don’t seem to be saving any more lives.) The world health organisation states that beyond a caesarean rate of 15%, there’s no improvement in illness or death rates, in fact. Even that’s contentious – some commentators would put the figure closer to about 8%. What if I also tell you that the good ole US of A, which has the highest caesarean rate in the G8, also actually has the highest rate of mother and baby death in that group of countries?

My conclusion, then, is that we’re in a right muddle. An astonishing mental shift has taken place over only 20 years or so, from ‘birth might hurt a bit, but we’re healthy and well looked after, and we’ll probably get away unscathed. Hell, we might even find it’s OK…’ to ‘birth is inherently dangerous, and we might well need rescuing from it.’

Because very few wants to look back at a serious, and scary surgical intervention and wonder whether things could have been done differently – whether it was avoidable. That means losing faith in the people and the system that have been looking after you, or will be looking after you. It means become bitter and cynical and untrusting. Hey, it means questioning, and even taking responsibility for your own care – and that’s one hell of an unsettling place to be.

But don’t tell me that women in Sligo are all that different from women in Kilkenny – or that women birthing at Chelsea and Westminster have different pregnancies from those in Ilford. Not that different, anyway.

And that means that the uncomfortable truth is that there are a whole lot of caesareans being performed out there unnecessarily. We know very well what increases the chance of caesarean – induction of labour, epidurals, augmentation with sytocinon (pitocin for my American friends), continuous montioring, fear (of a breech vaginal birth, a multiple birth, a scar rupture)… but we enter into it anyway. And that means that either explictly or implictly, a whole generation of women and their families are being lied to, because without that caesarean they wouldn’t have died, actually. Most of them would have given birth naturally, and everyone would have been fine.

There’s one last piece I came across this week on the caesarean rate, which made a big impression on me. Over to Gloria Lemay, Canadian midwife

‘everyone knows how to lose weight (eat less, exercise more) but only a few get into action. We DO know how to lower the cesarean rate, but committed action is needed.’

In the last 20 years the caesarean genie has well and truly been taken out of the bag. And the only chance we have of getting him back in, is to keep asking the difficult questions, and carry on unsettling those too complacent to question. Only that way do we stand any chance of getting back to a healthy rate of vaginal birth.

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~ by Kedi Simpson on June 19, 2011.

7 Responses to “Is the genie out of the bag?”

  1. Hooray! Common sense! Thanks Kedi :)

  2. Kedi, sadly rate at King George’s Ilford is because any woman with any risk factors in pregancy or for labour will be cared for at Queen’s. Then 8% begins to sound high.

  3. We have an organisation in Australia called GETUP which created a discussion on this subject here in Australia where we have reports of Caesarian Rates up to 50% in one private hsopital and the rates are not reducing.

    The conversations were lively and I found my self fending off brick bats and insults from people who incessantly speak from their one experience which transfers to the entire world population – evidence based NUP. The title was unnecessarians and it reached the high ranking of 5th in line to be taken up by GET UP as an issue. A very powerful lobbying group – which is doing good things and can produce great outcomes

    This site dropped way off because not enough are educated enough to present an argument. and I and others just plain wore out. Although I did start getting sensible questions from a Medical Student in Tasmania who was highly insulting at first until he realised I was not going to insult back and may be I knew a lot more than him.

    I am an experienced midwife and nurse of over 50 years but in the latter part of my career I obtained higher degrees in Law Education Ethics and Health Sciences and became a Senior Lecturer. I taught Midwifery and General Nurse Graduates for over 15 years and prior to that passed on my knowledge in many clinical settings. I am now a lobbyist and continue to educate and consult about Lactation helping babies to breastfeed some continuing for up to 2 years and more.

  4. A few examples of GETUP chats The administration came in and stopped the insults being hurled and some were removed. I still occasionally get a new email on this subject.

    Chat_24 New comment on ‘Reduce Caesarean Rates’
    0

    Lyn Cliff commented on Reduce Caesarean Rates

    The current caesarean rate is absolutely disgusting. Women absolutely need Continuity of care with a known midwife to bring these numbers down! Women need to educate themselves and they need the support of a known midwife to help them through the challenge of child birth. Natural childbirth feels like a glorious victory. Caesarians take this right of passage away from women.

    Carolyn Charles commented on Reduce Caesarean Rates

    While I am grateful that I live in a country where we have access to life saving technology should the need arise, I am appalled that our caesarean rates are so high. This speaks of so many other interests being served before the health and wellbeing of babies and mothers.

    The research is there, the WHO recommendations are there. There is no cogent argument to explain why so many women ‘require’ major surgery. No explanation of why having private health insurance is such a big predictor of a woman’s likelihood of having a caesarean. No questioning why obstetricians have gone from attending births only when required to become the star performer in a technological opera.

    Unnecessary surgery is dangerous and traumatic for mothers, babies and their families, it is expensive and wasteful of health budget dollars, it affects feeding, bonding, future birth outcomes. Huge ramifications that are brushed over by hospital staff who have contributed to making it seem almost equal to normal vaginal birth.

    Put birth back into the hands of women, mothers, midwives, and call the doctor only if and when s/he is needed. Stop ‘managing’ and commercialising pregnancy, labour and birth.

    0

    Lee Keegan commented on Reduce Caesarean Rates

    I agree that the current caesarean rate in Australia is way too high, if there was more education about how important the birthing environment is to the birthing Mother, such as soft lighting, quiet, relaxing music and homely atmosphere etc., as well as pre-natal class information being focussed more on the miracle and ease of natural birth, rather than ‘pain relief choices’ and fear, I doubt the rates would be as high. Women need to feel as though they are totally empowered and able to bring new life into the world, rather than being in need of medical assistance, as if they are experiencing some terrible illness, requiring rescue.

    Kate (admin) commented on Reduce Caesarean Rates

    Hi All,

    It’s great to see inspired and passionate conversations around birthing options, please keep the comments coming.

    A few points:
    This is a public forum and respectful debate is encouraged. That is, questions are able to be asked, and differences of opinion are welcomed, so long as commenters have respect for fellow GetUp community members and their opinions, and refrain from personal attacks.

    Personal attacks and threats of any kind will not be tolerated. It is disappointing that this has occurred. Please consider this a polite warning, and be aware that any comments made on this topic from now on that are abusive, derogatory, or in any way threatening to another individual/group will be removed, and the instigator blocked from this site.

    That said, please continue the conversation, the GetUp team has been enjoying reading your thoughts on this and the other campaign ideas on the forum. Just make sure you keep things nice.

  5. Well-said Kedi. What is the ref to Cochrane please?

  6. The other risk factor for caesarean – the ultimate and first intervention. Leaving home and walking into a hospital. Then birth becomes normal only in retrospect.

    Jane A-C

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