Is Cesarean Birth a Better Option for Mothers?

I don’t know how to quite describe my disdain for the article I recently saw published in Saturday’s (13th August, 2011) “West Australian” newspaper. It was a summary of an article which was published in the Victorian paper “The Age”. The article can still be viewed online.

My first reaction when I read this article was an eye roll (my husband should have known better than to show it to me, but I believe that he takes great delight in seeing me get angry over such childbirth issues). I have just received a Masters in Midwifery, where my main focus has been breech birth so I have repeatedly picked the ‘Term Breech Trial’ (Hannah, Hannah, Hewson, Hodnett, & Willan, 2000) paper to pieces and contradict ever single recommendation that the authors made via more current and better controlled research. Then as the days went on I couldn’t let it go. I had planned many ‘letters to the editor’ and I figured that I would have a limited audience and the newspaper editors would not publish the mad woman on her soap box anyway!

So many questions have emerged in my midwife/mother brain.

1. Why are they using a study which has been poorly controlled, repeatedly debunked, criticized, picked to pieces and recommended to have the findings withdrawn (by obstetricians as well as midwives) as an example to demonstrating outcomes (Banks, 2000, 2001; Barker, 2010; Daviss, Johnson, & Lalonde, 2010; Glezerman, 2006).

I could talk all day about this but the main reasons the data from the TBT are irrelevant to use as an example here are:

Many of the vaginal breech births were attended by birth attendants that were not considered appropriately skilled to attend such births (despite that being a requirement of the study), however, there were 100% skilled obstetricians at 100% of the cesarean sections.

The “planned vaginal birth group” remained grouped despite how the births occurred (for example, spontaneous natural labors and births were grouped with women that had inductions, epidurals, instrumental assistance and non-elective cesarean sections).

The researches themselves acknowledged they could only measure short term maternal morbidity, that the true impact on a woman’s health, her future pregnancies and future children after undergoing a cesarean section were possibly greater.

Childbirth is complex phenomenon and you cannot accurately compare two groups of women and say “that is the outcome”. There are too many factors at play and randomized control trials have been described as inappropriate for application to complex phenomena. (If you were comparing two different cesarean section methods, that would be more appropriate as there is much more control, there is too many factors at play during a vaginal birth – ie, the labor, the attendant, the birth position, medications, analgesia, mode of birth etc.) (Kotaska, 2004).‘Vaginal birth’ is not simply ‘the birth of a baby via the vagina’ – you may have induction, augmentation, instrumental assistance, etc.

2. Authors of the TBT attempted to perform a study randomizing elective cesarean and planned vaginal birth for cephalic presenting babies in normal, healthy women after their conclusions of the TBT were published and were denied by ethics committees (Hannah, 2004).

3. In New Zealand, women are not able to access publicly funded cesarean sections for no obstetric cause. One Auckland district health board sought legal opinion – which supports the refusal of non-medically indicated cesarean sections.

4. In the USA, women are being forced into court ordered cesarean sections. A woman who refused a cesarean and home birthed her twins – one which subsequently one died was arrested and charged with murder!!!

5. Cesarean section does not “save” a mother from experiencing pelvic floor problems later in life. The weight of the enlarged uterus and contents during pregnancy (including amniotic fluid, placenta and baby!) in conjunction with relaxing hormones do more ‘damage’ to the pelvic floor than the actual act of birth. A recent study showed that women who had never had a labor still had some urinary incontinence in 40% of cases when compared to women who had not had only had vaginal births experiencing urinary incontinence in 55% of cases. There was no difference in levels of fecal incontinence. Cesareans not as “posh” as commonly believed:

6. The sample size of 1000 women (500 elective cesarean and 500 planned vaginal birth) is too small to have significant results which can definitively prove either delivery method to be more superior over the other. It lacks the ability to truly measure the rare, yet major risk factors associated with either birth method.

7. I have concerns that this will measure short term outcomes only – not look at the long term impact on women who undergo unnecessary major surgery nor the impact that may result in future pregnancies.

As a midwife, I am all about choice. Well informed and ethical decision making. I also believe that caesareans are a fantastic tool to have… as a life saving operation for mother and/or baby. The current childbirth culture in Australia (and much of the developed world) seems to have taking this life saving procedure and turned it into a ‘birth choice’. Women state reasons for electing to have a non-medically indicated caesarean for many reasons:

Fear of birth – without seeking any assistance to address these issues during pregnancy. Who do we blame for the rate of fear instilled in women today? More to the point, why is it not addressed appropriately in the antenatal period?

Fear of complications – to “prevent” a potential birth complication. We must remember that major surgery has a phenomenally high range and severity of potential complications.

To plan around the arrival of the baby, because we know what day the baby will be born (unless of course you go into labor before your very convenient schedule!) Don’t want to face the “indignity” of childbirth – because laying on a theater table like a star fish, surrounded by at least 10 strangers, having a urinary catheter inserted and then most of your body exposed and you have several hands on and in your belly manually manipulating a baby through a surgical incision is sooooooo dignified! Maybe next time I should count how many times the theater door actually opens during the procedure – it is many!

What I find the most disturbing is that those who require cesarean section surgery (for whatever reason) are often left being treated as “depressed” or “needing referral” if they feel sad or disappointed by experiencing a cesarean section instead of a vaginal birth. Has the world really come to this, that when a woman is disappointed at her birth outcome that the hospital midwife/doctor will spit at her that she should “just be happy that you (she) have a healthy baby and not to worry – you (she) will be able to wear a bikini again” (this is what was said to a friend of mine earlier this year who was teary after an emergency cesarean section!).

If a woman wants to “choose” a cesarean section with no medical reason to have one I say “OK”. I am sure you are thinking I am completely mad and how can I call myself a midwife? Truth is, I think that woman is completely mad, but she is the one that has to live with the consequences of her choices and who am I to tell her what is best for her? If she can articulate to me that if she has a cesarean she is:

  • Four times more likely to die
  • Will lose, on average, double the blood loss of a vaginal birth
  • Will not be protected from pelvic floor damage
  • Is at an increased risk of thromoembolism which could lead to pulmonary embolism, myocardial infarction or stroke (all which could be fatal)
  • Could experience a wound infection which could be mild or severe enough to be fatal
  • Painful adhesions leading to future, ongoing, gynaecological problems
  • May experience difficulties lactating
  • Is more likely to experience post natal depression and bonding issues with baby
  • Will be unable to lift heavy objects or drive a motor vehicle for approximately 6 weeks
  • Could have complications from an epidural anaesthesia including infection, meningitis, severe headache, seizure, temporary or permanent paralysis, death
  • If the epidural is unsuccessful – she will need a general anesthetic and she will be unconscious when her baby is delivered (who will also be unconscious)

Future pregnancies could be impacted including:

  1. Fertility problems and difficulty falling pregnant
  2. Increased risk of miscarriage
  3. Increased risk of unexplained still birth
  4. Abonormal placentation including placenta praevia (placenta over the cervix, which not only means repeat cesarean section but also a risk of life threatening heamorrhage, preterm birth and hysterectomy at delivery); placenta accreta/percreata (the placenta implants through the scar which results in a hysterectomy being required at delivery – and therefore increasing the risk of death from blood loss exponentially)
  5. Increased risk of preterm birth with the presence of adhesions
  6. The baby has a greater chance of requiring admission into the neonatal nursery for respiratory assistance at delivery and for at least 24 hours after birth, feeding difficulties, unexpected prematurity (accidentally delivering the baby prematurely), anesthetic complications (more common with general anesthetics)
  7. The baby has an increased chance of experiencing asthma, allergic disorders (including anaphylaxis) and eczema in childhood.

It really doesn’t paint a pretty picture. I thought that maybe I should be giving Dr Stephen Robson the benefit of the doubt. Maybe is on the “natural birth” team and is constantly frustrated by these very able bodied women requesting unnecessary cesareans while those that might be better suited to a cesarean delivery beg for natural birth. Then I read his quote: ”It dawned on people, what if it turns out to be safer to have a cesarean birth if you’re a healthy mother? … What would that mean? How would that affect society? The topic led to great discussion at a meeting I was at recently where one cheeky guy said, ‘Maybe we could do away with labor wards forever and save hundreds of millions of dollars,’ ”

My very small, slight glimmer of hope quickly turned into disappointment. While I want to hope that he does have staggering results and multiple complications in his elective cesarean section group, I don’t want to wish such heartache on those families. Let’s just hope that common sense prevails and maybe the government can take a leaf out of New Zealand’s book and stop giving away my tax dollars for very expensive major surgical procedures which are completely unnecessary. I wouldn’t want to pay for someone’s facelift, so why should I pay for an non-medically indicated, unnecessary cesarean section when my mother, grandmothers and all their mothers before them just sucked it up and got on with it. Let us just hope that the women recruited to this study already had their non-medically indicated cesarean sections on their wish list and are not coerced into the procedure for research purposes and those in the vaginal birth group are on the path to an uncomplicated, happy delivery! It doesn’t cost anything to dream…

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