Mothers-to-be must believe in miracles — a natural childbirth

Women and doctors tend to get defensive when it comes to caesarean sections. Sarah Carey argues the costs of rising rates demand a solution

ONE broaches the subject of caesarean sections gingerly, knowing this thorny subject will raise hackles among women who can extract a sense of inadequacy from any of their life’s accomplishments. Doctors get a tad shrill, too, when challenged on the subject. But as our national section rate breaches 30pc, it behoves any commentator on matters of public health to cease hiding behind the “no judgment!” defence.

No one is judging any single individual who, either by choice or circumstance, has delivered by caesarean section. But we must examine those circumstances and deconstruct the concept of choice. For all circumstances have causes, and all choices are framed within particular contexts.

Last Tuesday, I listened a doctor from St Luke’s Hospital in Kilkenny, being interviewed by Pat Kenny on Newstalk about c-sections. The doctor deflected Kenny’s query about medical practice in small hospitals, failing to volunteer the fact that last November, 61.9pc of first-time mothers in his own hospital had caesarean sections. There is no possible way each of those mothers was incapable of delivering naturally, and the end of the matter can’t be a cheerful explainer on the radio.

While we can acknowledge the life-saving benefits of the procedure, neither can we ignore the longer post-natal recovery times; the long-term medical effects of repeated sections; the increased vulnerability of the babies to allergies; and the significant cost to the health system. At the very least, this is costing too much money.

For my part, I regret that so many women have been denied their greatest moment — pushing their babies out into the world.

Why is our rate so high? There are several factors at work. Some are related to the condition of modern mothers and some to medical practice. Each of them, in their incremental way, adds up to what I consider to be a crisis.

On the maternal side, there’s no doubt that the health of mothers is a problem. Some issues stand out, such as age and obesity.

The closer you get to 40, the more likely you are to develop risks, although I can’t help wondering if simply being in that age group encourages doctors to practise defensively, rather than take each case on its merits.

The same goes for obesity. While overweight mothers are more likely to develop conditions such as gestational diabetes, which can result in larger babies and high blood pressure, it’s also true that doctors have less confidence in the ability of an overweight mother to deliver naturally and will place her in the at-risk category, even if she has a good chance of delivering normally.

When you consider that obesity is also a risk factor for breast cancer (fat cells produce extra oestrogen, which can increase the risk of several types of cancer) women are going to have to accept that those muffin tops don’t just look bad — they’re lethal.

But it’s not all about the mothers. We know medical practice is a huge factor just by looking at the variation in c-section rates between different hospitals. The difference can often (though not always) be accounted for by the size of the unit. As with cancer, volume counts.

Holles Street, with its mass throughput of nearly 10,000 births in a busy year, has the lowest c-section rate in the country, while St Luke’s, that much smaller unit in Kilkenny, repeatedly shows up as one of the highest.

They aren’t alone and one presumes the high rates are symptomatic of defensive medicine in hospitals located far from expertise and facilities. It’s unfair to condemn mothers in those catchment areas to a c-section just to be on the safe side. Lowering the bar to ‘we’ve live babies and live mothers’, while comforting, cannot be an excuse for poor practice.

Other medical practices, such as inducing labour, are also an issue as babies are put into distress by the artifical oxytocin used, thus creating an emergency. When it was suggested that my first baby should be induced for no other reason than being overdue, I refused. The calendar is a tenuous and insufficient reason for induction, yet a common one. If we want to reduce c-sections, we have to start by reducing inductions.

So is the relatively recent practice of presuming that a vaginal birth after a caesarean (VBAC) is too risky to try. One expert told me that VBACs were relatively common until a single paper published in one journal claimed the risk of uterine rupture was marginally increased if a woman tried to push a baby out after she’d had a c-section.

Almost overnight, medical practice in Ireland changed, and now a woman who has a c-section with her first baby is pretty much guaranteed to have subsequent c-sections, irrespective of her health. It’s just not good enough.

The other one that really bugs me is when, halfway through a pregnancy, consultants start muttering about the “big baby”. Babies grow in spurts, and it’s nonsensical to suggest that a baby big at 32 weeks will be big at 40 weeks.

Anyway, as any midwife will tell you, presentation matters far more than size. A small baby facing the wrong way will give plenty of trouble; a big one nicely presented will be fine. But this “big baby” doubt is put into a mother’s mind, already full of anxiety, thus priming her to accept that a c-section is on the cards. I wish someone would keep a log of the supposedly big babies delivered by c-section that turned out to be seven or eight pounds.

And finally we have the private patient factor. The phenomenon is real. Research by Richard Layte and others found that between 2005 and 2010, the rate of increase for caesarean sections for private patients was double that of public patients. I don’t interpret that as the usual pejorative “too posh to push”, but rather too scared to push.

Middle-class women are accustomed to order and planning over chaos. Doctors prefer neatly scheduled operations over the uncertainty of labour. With a mentality of suiting the client’s wishes (re-framed as maternal choice) it’s natural that their combined fears will result in a mutual agreement that on the slightest pretext a c-section is preferable.

It’s all neat and clean, and so normal everyone assures themselves it doesn’t matter.

But if it takes you six weeks to drive a car; if private health insurance is picking up the tab to finance easy options which we all pay for; if hospitals jam-packed with mothers have to keep them in longer to recover from surgery.; and yes, if rarely the tragic happens and complications arise and we lose a mother, then it does matter.

And if the bill is ultimately footed by everyone else, then we should at least pay more attention.

So what helps? One hospital in California lowered its rate just by publishing the records of its individual doctors. Those with a higher rate were embarrassed into changing their practice.

Another in Florida achieved similar results by disallowing any decision-making on elective sections until 38 weeks. These simple behavioural changes proved just how much practice is driven by non-medical motives.

But for me, the real solution is more midwifery-led care. I had the extraordinary experience of having my babies with the community midwifery system in Holles Street in Dublin, the first of its kind in Ireland and now spreading throughout the country. Midwives believe women can give birth. Doctors are terrified women can’t. Their outlook drives almost everything else.

As long as the defensiveness goes on, we face relentlessly rising rates and future generations of women who’ll forget what miracles they can do.

‘It’s not the pejorative “too posh to push”, but rather too scared to push’