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.