Michel Odent Speaks Out About Caesareans

Michel Odent, the man who, in the words of the Guardian, “encouraged women to experience pain-free labour in warm pools of water and was the first to write about the importance of placing newborn babies to the breast” has now warned about the dangers to the human race of the rise in caesarean sections.

In a new book called The Birth of Homo, The Marine Chimpanzee, Odent argues that modern medicalised births are working against evolution. Caesarean-born babies are more likely, for example, to be autistic. From the Guardian article:

“One effect of modern obstetrics is to neutralise the laws of natural selection – the laws that foiled us all [in the past]. We have neutralised those laws. It means that at the beginning of the 20th century, a woman who could not give birth naturally would die, whereas the one in the village who could give birth easily would have 12 children. Today, the number of children one has depends on other factors than the physical capacity to give birth.

“I mainly talk about obstetrics, but we can also talk about conception. If you cannot have a child, you can have medicalised conception. So we have neutralised the laws of natural selection. It is one of the biggest problems for humanity today and people don’t realise that. Any mathematician, any statistician interested in this topic will find ways to calculate what will happen – in my book I give several examples.”

“One of the biggest problems for humanity today”? That’s a pretty big claim – particularly if you think about global warming, pollution and the decline in the bee population. And those are just the environmental problems – don’t let’s forget the rise in antibiotic resistance and the imminent threat of nuclear war.

Evolution is brutal

So is Odent right to identify modern methods of childbirth and conception as a problem? Well, in a sense, yes. A hundred or so years ago, as he points out, a woman who could not give birth naturally would die. These days, a woman who can’t give birth naturally survives, thanks to surgical intervention.

Any normal person would surely see this as a cause for rejoicing. You could argue, as Odent does, that as a result of caesareans and other interventions, we’re breeding a race of humans who are ill-equipped for survival: women who have pelvises too narrow for a baby to pass through will give birth to daughters with similarly narrow pelvises. And so on. But it’s difficult to see why this is a problem. Modern medicine is saving lots of people who would otherwise have died: premature babies, babies with disabilities, children with diseases such as measles and meningitis. Vaccines for diseases such as polio and diphtheria mean that children who would previously have been too weak to survive those diseases are now never exposed to them in the first place. Unless we abandon using modern medicine altogether, then we simply have to accept that the laws of natural selection are well and truly “neutralised”.

When he argues that caesarean sections result in more autistic children, then he is, as the Guardian points out, confusing correlation and causation. The paper quotes autism specialist Paul Wang:

“A foetus with developmental issues may have low muscle tone that can interfere with moving into proper position for natural delivery. In this and other ways, the foetus plays a crucial role in initiating and advancing natural labour.”

Don’t worry your pretty little heads about science

But suppose he’s right? Suppose caesarean sections were causing more children to be born with autism? What could we possibly do? Stop performing caesareans and allow babies and their mothers to die?

Obviously not. It’s difficult to see how the argument achieves anything other than to make pregnant women, bombarded with advice from all sides, even more worried than they already are. Odent is quoted as saying: “I put a caveat in my books – they are not for pregnant women. I tell them not to read them. They are books for people who are interested in the future of human beings – preferably ones with a scientific background, people interested in thinking in terms of the future and the future of the species. That’s the public I want to reach.”

In Odent’s mental Venn diagram, there is clearly no overlap between women who are scientists and women who are pregnant.

Pregnancy sickness is good, apparently

But Odent has form for this. While acknowledging that women used to die in childbirth before modern medicine, he accuses modern doctors of terrifying women through the use of medical terminology. In a 2013 interview with the Telegraph, he apparently “uses the example of dramatizing healthy morning sickness that indicates a thriving foetus into the much more serious condition of ‘Hyperemesis Gravidarum.’”

This sounds plausible until you meet a woman who has suffered hyperemesis to the extent where she is vomiting 24 hours a day, and cannot keep down anything, even a sip of water. Women die from untreated hyperemesis.

In the same article, Odent attacks the use of synthetic oxytocin which also, he argues (but with very little evidence), correlates with a rise in autism. (Autism has clearly become Odent’s thing.)

Odent wants us to believe he is motivated by genuine scientific curiosity. But in identifying intervention in childbirth, rather than, say, antibiotics or vaccines, as a threat to natural selection, we can see a more sinister agenda at work – a desire to turn the clock back to a time before modern medicine. Though only, of course, for women.

 

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Why birth is traumatic – and how we can make it better

During birth trauma awareness week in August, dozens of women took the opportunity to tell their birth stories.

Psychologist Emma Svanberg collected 75 stories and published them on her site, Make Birth Better. They make for a harrowing read as women recount experiences of being left for hours in pain, being torn apart in childbirth, coping with infections, being ignored by doctors and midwives, suffering from incontinence problems, fearing their baby was about to die, and much more.

As well as publishing the stories, Emma analysed them and picked out five themes. Anyone who has heard women talk about their traumatic birth will find them familiar: A force bigger than me; Heroes and villains; Delivery into parenthood; I had no idea; Make birth better. Together, the five themes give both a powerful account of what is wrong with the way women are treated in birth and a guide to how we can do it better.

Violence and brutality

“A force bigger than me” talks about the overwhelming physicality of birth. This includes things like the unbearable pain, physical damage such as pelvic fracture or bowel problems, but it also includes the sense of violation: “Being stitched up was a violence”, “Everything in my labour felt like a war”, “It was comparable to rape”. Many spoke of actions being taken without consent.

The “Heroes and villains” theme makes for particularly dispiriting reading. Women write of having staff talk over them, of arguing with colleagues, of shouting at them and of ignoring them. It hardly needs saying how distressing this is for women who are giving birth, and already fearful about whether they or their baby will survive. But when a midwife is kind or supportive, that makes an impact too. “I got the most amazing midwife who I remember as my superhero,” one writes.

“Delivery into parenthood” provides a vivid account of the psychological impact of a traumatic birth both on themselves and their partners. They have flashbacks and nightmares; they feel ashamed or like failures. They may feel permanently changed and scarred by what has happened to them. They feel they’ve missed out on the opportunity to form a bond with their baby. For partners, it was the “most brutal thing he has witnessed” or ‘he thought that was going to be the last time he saw us”.

Pull yourself together

The fourth theme, “I had no idea”, recounts women’s feelings of shock at the experience of birth, which they were often ill-prepared for, compounded by a lack of communication from health professionals who didn’t tell them what was happening. Another topic that comes up is what is often these days referred to as “gaslighting”: a deliberate minimising by health professionals of the trauma the woman has gone through: “Dr telling me there was no need to cry”, “she told me to stop wasting time”, “stop making a fuss”, “pull myself together”. In many cases women felt they had nowhere to turn for help.

Finally, in “Make Birth Better”, women talk about what they think women should know before giving birth, and what health professionals and providers should know. They talked about the need to be better informed, without scaremongering, about what birth could be like. They talked about the need for health professionals to keep them informed about what was happening, and to think about the language they used. And they talked about the need for better support after a traumatic birth rather than leaving them to fend for themselves.

I felt a weary sense of familiarity in reading women’s accounts of what happened to them. In the UK, 700,000 women give birth every year. Birth is an unpredictable business, and emergencies can happen very suddenly. It’s understandable that sometimes health professionals have to act quickly without much time to talk. And yet is it really necessary to treat women as if they’re idiots? To argue with colleagues in front of a labouring woman? To perform invasive procedures without asking their consent? To abandon a woman who has been distressed by a traumatic birth and tell her she simply has to get on with things? Calm, informative communication doesn’t require an investment in resources, simply a willingness to treat women in labour as autonomous adults, deserving of normal amounts of respect and kindness.

Until we put women and their needs at the forefront of maternity care, however, then stories like this will keep on coming.

If we really want to help women with birth trauma, we need to learn to listen

One of the things that practically everyone involved with mental health seems to agree on is that we need to talk more. People bottle their problems up, which makes everything worse, and sometimes leads to depression and suicide. If only we talked more about our feelings, everything would be much better.

This truism is trotted out time and time again. It’s rare, however, for someone to make the simple point that talking is only of any value if someone is listening. Yet that, in my experience, is where the real problem lies.

“Listening” doesn’t, of course, just mean listening. Real listening is hard work: it means paying attention to what the other person is saying, trying to understand their point of view, not telling them about your similar experience or suggesting they cheer up or offering advice about what they should do.

Women who have experienced postnatal PTSD come up against this problem all the time. A characteristic of PTSD is the urge to talk about the traumatic experience continually, to try to make sense of it. This isn’t surprising, as PTSD sufferers often find themselves reliving the trauma: it doesn’t feel like something that happened in the past, but that is always present.

Yet when they talk to their partners, their family or even to health professionals, they come up against the same response over and over again:

“You’ve got a healthy baby – focus on that instead.”

“The health professionals were only doing their best for you.”

“Other women have had babies and don’t make this amount of fuss.”

“It’s time to move on and put it all behind you.”

None of this is helpful, because it minimises the experience and also makes the woman feel as if she’s being unreasonable. It’s also useless, because PTSD is not something anyone has control over – no-one chooses to experience flashbacks, or to be constantly anxious, or to feel terror every time they walk past the place they experienced the trauma (usually a hospital, for women with postnatal PTSD). PTSD causes real, physical changes in the brain – they don’t disappear by force of will.

The reason why the blogpost “I had a shit birth. Here’s six reasons why I really want others to know” went viral is that the writer accurately captured this need to have people actually stop and listen, without judgement. As the blog’s author says: “Silencing anyone who has lived through trauma is not okay.”

Her follow-up post, How to avoid birth trauma, by expert commenters of the interweb, after her story was featured in national news sites, nicely captures that failure to listen, from people on the internet who have never experienced trauma and have no clinical or academic expertise in the subject, but nonetheless have a view on how other people should deal with it.

One last thing. During Awareness Week, the Birth Trauma Association was inundated by emails from women desperate to tell their story. Reading those stories shows that the listening problem starts well before the trauma: story after story relates how women told medical professionals there was something wrong, or that they were in severe pain or distress, only to be told that everything was normal. There are even stories of women who knew they were ready to push being told that they weren’t ready to push. In one extraordinary account, a woman describes how, post-birth, her extreme pain was dismissed by doctors and midwives alike, until a healthcare assistant spotted her racing heart – the first sign of septic shock – and called for help, thus saving her life. Even allowing for understaffing, this seems negligent.

Yes, it’s good to talk. But it’s even better to listen.

Breaking the silence – why we need birth trauma awareness week

Next week – August 14 to 18 – is birth trauma awareness week. It has two main aims. One is to make more people aware of what birth trauma is and how it affects women (and their families) who experience it.

The other aim is to raise money so that the Birth Trauma Association can start extending its services to women by offering peer support by phone and face-to-face.

If you’re interested in helping, there are a few things you can do:

  • Tweet links to women’s birth stories using the hashtag #BreakTheSilence
  • Hold a fundraising event – you can download a fundraising pack for ideas
  • Follow the Birth Trauma Association on Twitter
  • Change your social media profile pic to include the Birth Trauma Association logo
  • Register with Thunderclap to post a message about birth trauma awareness on your timeline at 5pm on Monday 14th – the more people who register, the more impact the message will have

It’s long been clear that there’s a huge unmet need for support services for women suffering from birth trauma. Although it’s hard to know the exact number, the current best guess is that 20,000 women every year suffer from postnatal PTSD in the UK (3% of the total number of women giving birth).

One of the reasons the condition is little known about is because women don’t speak about it. And the reason they don’t speak about it is that people don’t listen. Women are used to hearing the dismissive phrase: “All that matters is that you have a healthy baby.”

Two weeks ago, a blogger who writes under the name of Mummy Truths wrote a post called: I had a shit birth. Here’s six reasons why I really want others to know.

It’s a wonderful, eloquent, powerful piece about what it’s like to experience birth trauma. Within a matter of days, it had received 90,000 hits, having been shared on Facebook parenting groups, midwife groups and birth groups. Sarah brilliantly describes how women with birth trauma are silenced, about how dignity and respect are neglected in birth and how it feels to experience the constant hypervigiliance of PTSD: “The triggers are many and they are everywhere. A letter for a smear test, a shadow flickering past the window when you’re alone in the house at night. Shouting. The baby crying. It can all trigger symptoms – feelings of fear and threat – reducing a mother’s ability to parent well.”

The reason the post was shared so often was because it resonated with so many women. They read it, thinking, Yes, that’s how I felt. That’s what it was like for me.

If you want to know why birth trauma is important, then read Mummy Truths’s post. It’s time women’s stories were heard. It’s time to #BreakTheSilence.

Why forceps can be dangerous

 

Forceps deliveries and Ventouse deliveries are significantly more dangerous for both mother and baby than a caesarean section, according to new research published in the Canadian Medical Association Journal. The risk of severe complications to the baby is 80% higher.

The study looked at 187,234 births. The main finding was that “among women with dystocia and prolonged second stage of labour, midpelvic operative vaginal delivery was associated with higher rates of severe perinatal morbidity and mortality compared with cesarean delivery.” To put it more simply, more babies died or were injured during an instrumental delivery than during a caesarean section. Although the study found that maternal mortality was no higher during an instrumental delivery, “rates of obstetric trauma” (this refers mainly to tearing) were higher.

This matters because in the UK, as in many other countries, there are moves to reduce the caesarean section rate, partly because caesareans are expensive, and partly because of the risks attached to abdominal surgery. The caesarean rate in this country is one in four, which many experts think is too high – and as a result, many hospitals now have “normal birth” targets.

The findings of the new research suggest that this drive is misguided. There have been a number of well-publicised cases over the past five years of babies dying after the mother was refused a caesarean section.

But there is a risk to the mother too. The Australian obstetrician Hans Peter Dietz has been outspoken about the target to reduce caesarean section rates in New South Wales, which has resulted in a huge increase in forceps deliveries, but also far more cases of women with severe pelvic floor and anal sphincter damage – something that can be absolutely devastating for women. Dr Dietz found that 81% of women who had forceps deliveries suffered internal damage.

Obviously there are caveats. A response to the research article by obstetrician Nicholas Pairaudeau argues that the decision to use or not use forceps should depend on factors such as the size of the woman’s pelvis and the positioning of the baby. He writes: “Even though I have used forceps for nearly 50 years I have, in my own practice, reduced many of the complications quoted, by careful selection of the patient, forceps, and type of pelvis. C-section is not a simple option in many cases, and is associated with major complications too.”

The question of risk in childbirth is never a simple one: often it’s a case of having to decide which is the lesser of two risky options. The worry is, however, that by setting a target to reduce caesareans, hospitals then become focused on the process rather than outcomes. A caesarean in itself is not a bad outcome: a dead or injured mother or baby is. Doctors’ decisions should be based entirely on whether they will lead to a healthy mother and baby – not on they meet an arbitrary external target.

We need better postnatal care – and Mumsnet is on the case

I’ve been delighted to see the mighty Mumsnet launch a campaign to improve postnatal care in hospitals. Women with postnatal PTSD often mention poor postnatal care as a contributing factor.

After a traumatic birth in which you have nearly died, or your baby has nearly died, or you have lost several pints of blood, or been in pain for hours but denied drugs, or experienced a violent forceps delivery, or had multiple painful stitches, or had a retained placenta, or an emergency c-section after the baby’s heartrate has dipped – or, as is often the case, a combination of several of those things – then it’s not unreasonable to imagine that you will be treated gently, with some kindness and consideration.

In practice, this is far from the case. When Mumsnet asked women to recount their experiences of postnatal care, they offered depressingly similar stories of being left for hours and hours unattended, often on a noisy postnatal ward, or refused help with breastfeeding, or not being given food and drink despite being too ill to get out of bed.

Some of this can be put down to staff being overworked, but the dismissive, unkind attitude that accompanies it cannot. In an article for the Independent last year, I wrote about Rachael, who after a deeply traumatic emergency c-section resulting from placental abruption, was told by a midwife: “Don’t go thinking you’re anything special – we see bigger abruptions than you had.”

A new blogpost describes an experience that is all too typical. The writer, who blogs under the name IslandLiving, recounts an immensely difficult labour ending in c-section. Left alone with her baby afterwards, she felt petrified. She goes on:

“I stayed in a side room for two days. In those two days I struggled. I felt overwhelmed and scared. I was petrified. I was told to ring the bell, that I was not to pick up my baby myself. Yet every time I rang the bell no one came. Every time I cried for help no one came. I struggled out of bed because that was my job. I struggled to feed her because that was my job. I struggled to change her because that was my job. Yet, I didn’t know if I was doing my job properly. I didn’t know if she was getting any milk. I needed help and it didn’t come. The nights were the worse as I would feel alone, like I was ringing a bell into the great abyss. No one ever came.”

IslandLiving says, generously, that she doesn’t blame the nurses or the midwives because the unit was understaffed. But it depends whether you see caring for a woman after she’s given birth as a fundamental part of the job or not. If it’s not – if adequate postnatal care is simply a “nice to have” rather than an absolutely essential part of the midwife role – why expect women to stay in hospital at all? Why not send them straight home?

Apart from being inhumane, skimping on postnatal care makes no sense economically, because it so often leads to physical or mental health problems that need treatment. One of the women quoted by Mumsnet wrote that she asked for help cleaning round her episiotomy scar, but was told not to worry because “it’s a dirty part of the body anyway”. She ended up with a major infection.

Poor care isn’t inevitable: a few Mumsnetters gave examples of excellent care. It’s high time that other maternity units followed suit.

Should we think of birth as normal, or as dangerous?

 

A few weeks ago I gave a talk to a group of health professionals about the impact of a traumatic birth on relationships. At the end of the talk, an obstetrician in the audience took me gently to task for using the phrase “when birth goes wrong”: problems such as retained placenta or postpartum haemorrhage were so commonplace, she said, that they were a routine part of the experience, rather than a sign of something going wrong. She added: “The day she gives birth is – apart from the day she’s born – the most dangerous day of a woman’s life.”

It was a striking comment, and one I’ve been thinking about ever since. There is an alternative view of childbirth, which is that it’s a “normal, physiological process”. It’s a view that’s endorsed by the Royal College of Midwives (RCM), and some NHS trusts have appointed midwives to act as “normal birth leads”, helping women to “achieve” a normal birth. Many midwives believes that an important part of their job is to support women to give birth “normally” – that is, without a caesarean section or intervention such as forceps or Ventouse. Proponents of normal childbirth would argue that an over-cautious approach to risk is in itself damaging, leading to unnecessary interventions that result in a more traumatic experience for mother and baby.

Childbirth is possibly unique amongst medical specialisms in that it is dominated by two professional groups who to some extent have competing views of what the job is about. Obstetricians see risk and danger; their job is to make sure that mother and baby come out of the process alive and, ideally, unharmed. Midwives see their job as supporting women to do what their bodies are designed to do: women have, after all, given birth for the entirety of human existence, and are therefore quite capable of doing so today.

You can see, of course, that both arguments have merit. Lots of women do have straightforward births, with minimal intervention. In the past, certainly, unnecessary medical intervention (the eagerness to induce labour, or speed it up artificially, or to give women episiotomies as a matter of routine, or to force them to give birth lying down) worked against the female body’s ability to do what it is designed to do, which is to push a baby out.

On the other hand, you can’t deny that, left to labour without intervention, things don’t always go according to plan: the baby is in an awkward position, or the birth canal is too narrow, or the baby’s shoulder gets stuck on the way out, or the placenta is retained and the woman haemorrhages.

Are women’s expectations too high? Or too low?

I hesitate to suggest there should be a happy medium, because I don’t know what a happy medium would look like. But what bothers me about all this is that women are caught in the middle of two competing narratives. Obstetricians at the talk I gave expressed the view that the reason some women find birth traumatic is that their expectations are too high: they think that they can give birth “normally”, with minimum intervention, and are then disappointed to find that that isn’t the case.

But where does that expectation come from? Not, surely, from an innate sense of hubris or over-confidence, but from imbibing the message that it’s possible to achieve a normal, problem-free childbirth by taking a positive mental attitude: if you believe in your own body’s capacity to give birth, the argument goes, then you’re much more likely to have the birth you want than if you approach it fearfully.

Thus are women caught in a Catch-22: going into birth in the hope and expectation that your experience will be “normal” means that you are more likely to be traumatised when things don’t work out as planned; going into birth with an awareness of all the potential problems and risks mean potentially that your own feelings of fear and anxiety will make the experience more difficult and painful.

And women get the blame. Women’s choices are mocked: they are “too posh to push”, for example, or they are “selfish” for wanting a home birth, free of intervention. They are naïve or silly for imagining they can give birth naturally; or they are wasting the NHS’s money by demanding a planned caesarean. A woman’s place is in the wrong, James Thurber once wrote: and if we’re talking about giving birth, then Thurber hit the nail squarely on the head.