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.

 

 

 

 

When childbirth goes badly wrong: one woman’s account

Nilufer Atik has written a striking account of her experience of PTSD after childbirth. Atik was in labour for 53 hours, after which she was given an emergency caesarean.

But it shouldn’t have happened like that. Atik’s labour started with contractions that were “sharp and hard, beginning four minutes apart and lasting between 50 to 90 seconds each time.” The hospital – St George’s in Tooting – told her not to come in because she wasn’t in active labour. She stayed at home in increasing pain for 19 hours until eventually she could stand it no longer. At hospital:

“I was taken to a pre-delivery bay and more torturous hours passed with the contractions increasing in intensity and frequency. I cried out for pain relief and was given the powerful painkiller pethidine four times (most women are only allowed two injections) but it did little to help. With no sleep, food or water, and feeling so exhausted I could barely speak, I became fearful that, if the baby did come, I wouldn’t have the energy to push him out.”

She was eventually given an epidural, followed by a caesarean section when the baby appeared in distress. But the most remarkable part of her story is this:

“Poor Milo was in a bad birthing position with his back against mine and his head hyperextended. It meant not only that my labour was much more painful than it should have been, but I would never have been able to deliver him vaginally. His head was blocking my cervix from dilating, which was why I was having contractions for so long with no progress.”

The time that Atik spent in labour was wasted – physiologically, she wasn’t able to give birth. Why staff at St George’s didn’t realise this is an interesting question, but it may have been to do with the fact that when Atik arrived at the hospital in labour, the maternity ward was extremely busy.

Two weeks ago an NCT survey found that, in the Guardian’s words, “A chronic shortage of midwives across the UK means women in labour are left feeling unsafe and frightened or as if they are being treated ‘like cattle’ or ‘on a conveyor belt’.” It’s not just lack of midwives, it’s a lack of space: one woman even described giving birth on the antenatal ward, because there was no room on the delivery ward.

It’s been said so often that NHS services are at breaking point that perhaps nobody takes it seriously any more. But cases like Atik’s show that the seriousness and the urgency of the problem. When midwives are overworked, the quality of care for women is never going to be good enough. Women will suffer unnecessarily, as Atik did, and may as a result experience physical trauma or psychological trauma that will need treatment later on. Sometimes, babies will die.

 

 

What should the RCOG advise women about risk?

The Royal College of Obstetricians & Gynaecologists (RCOG) is to consider giving pregnant women advice about the relative risks of vaginal births and caesarean sections, according to the New Scientist.

The magazine reports that the RCOG has been prompted to look at the issue by a 2015 UK Supreme court ruling awarding damages for a baby who sustained brain damage during a vaginal delivery. The report continues:

“The plaintiff had a higher than usual risk of having a difficult birth, due to having a small pelvis and diabetes. But doctors didn’t inform her of these increased risks – an act of ‘medical paternalism’, said the presiding judge, who decided in the mother’s favour.”

A decision by the RCOG to warn women of the risks of vaginal birth will be controversial, because vaginal birth is the default option – this is how babies are supposed to be born. When it goes well, a vaginal birth is much easier for a woman to recover from than a caesarean. It seems to be better for the baby too (though the evidence isn’t completely clear-cut).

But of course, not all vaginal births go well and, as the article states, the risks of injury to a woman’s pelvic floor muscles increase as she gets older. Many women are now having first babies in their 30s and 40s, making them more susceptible to injury than younger women. The article points out that older women are also more likely to need emergency caesareans, which carry higher risks than planned caesareans.

The big problem is that decisions to do with birth are not black-and-white: they’re all about assessing relative risk. Some older women have straightforward, uncomplicated vaginal births. Some younger women require emergency caesareans or have difficult forceps deliveries.

In an ideal world, health professionals would be able to assess factors such as a woman’s age, general health, pelvic size and position of baby and advise her of the most sensible course of action accordingly. Until someone collects and analyses the data, however, we can’t confidently predict what combination of risk factors mean that a woman will find it difficult to give birth vaginally.

When women talk about their experience of birth trauma, some report being coerced into having a caesarean (usually an emergency caesarean) when they wanted to continue trying for a vaginal birth, while others who wanted a caesarean have been forced against their will to attempt – or continue attempting – a vaginal delivery. Both are traumatic, and both can result in physical and mental health problems. The worry is that sometimes the advice given to women is driven not necessarily by what’s best for them and their baby but by targets, ideology or a desire to save money.

So where does this leave the RCOG? My view is that they should make women aware of the likely risks both of planned caesarean and of vaginal birth (and also that the risks of attempted vaginal birth include an emergency caesarean). Women should be allowed the opportunity to make decisions based on the best available evidence.

Caesarean sections – a feminist issue?

A Canadian doctor has provocatively argued that women should be able to choose to deliver their babies by planned caesarean section. (Normally women are only offered a planned section if they have particular obstetric problems that would make it dangerous to deliver vaginally.)

Dr Magnus Murphy treats pelvic floor dysfunction – bladder and bowel problems often caused by a vaginal delivery. He is quoted as saying: “There are a lot of women who do feel that the feminist movement has dropped the ball on this.” Murphy adds that the feminist movement has allied itself to the movement for natural childbirth, abandoning women who might want a caesarean section.

Is he right? Well, last month the outspoken Australian obstetrician Hans Peter Dietz presented research at the International Continence Society in Montreal showing that “between 20 and 30 per cent of first-time mothers having a vaginal birth will suffer severe and often permanent damage to their pelvic floor and anal sphincter muscles”.

Dietz notes that in New South Wales, the rate of forceps birth has doubled in 10 years as the result of attempts to reduce the caesarean rate – with the result that women experience much more physical damage.

His colleague Elizabeth Skinner interviewed women who had suffered traumatic vaginal deliveries and found that two-thirds suffered PTSD symptoms. She, like Murphy, believes that feminists need a change of heart: “Previously feminists fought to return control to women giving birth. This is still true but the new 21st Century feminist issue is ensuring that women are correctly assessed for their risk of complications and given full and frank information to prevent such injuries.”

For a very long time, women in the 20th century fought to regain control of childbirth from the medical profession. Childbirth was as a medical process in which doctors were in complete charge: instead of being allowed to give birth naturally, to walk about, to squat, to give birth in their own time, women were strapped to delivery tables with legs in stirrups forced to have episiotomies and epidurals, hooked up to monitors, passively waiting for their baby to be delivered by an obstetrician. Feminists did an important job in rescuing childbirth, in making sure that women could give birth unfettered, undrugged and free to move about as they wish. It has, for many women, been an empowering experience.

And yet, could Murphy and Dietz be right? Babies are getting bigger, and for some women childbirth is a long, arduous and painful experience. Having to deliver a baby in a way that permanently damages your pelvic floor and may even leave you incontinent doesn’t seem like such a great victory for feminism. Neither does it seem particularly “natural” or “normal”, epithets that are often applied to the process of vaginal birth.

When you’ve fought to take control of birth back from the medical profession, caesarean sections, which put the process entirely in the hands of surgeons, can feel like a retrograde step. And yet if it is a choice freely made by a woman who doesn’t want to risk long-term injury and incontinence, isn’t that a choice that feminists should be fighting for?

Too posh to push? I think you’ll find it’s a bit more complicated than that

A story last week claimed that caesarean sections were on the rise because women are demanding them.

The Times story, headed “Hampstead mothers are behind rise in caesareans” began like this:

“Caesarean sections are twice as common in some NHS hospitals than others, according to a report that suggests some doctors are more willing to give in to women’s demands for the procedures.”

Middle-class women – and middle-class mothers in particular – seem to be a particular focus of hate for a lot of the press, which is odd, given that middle-class mothers make up much of their readership. “Hampstead mothers” is a real dog-whistle phrase, conjuring up as it does posh, entitled women who have the nerve to think they should be able to deliver their babies whichever way they want, rather than meekly doing what the doctor tells them. (Let’s assume the Times doesn’t want us to believe that women living in Hampstead are literally behind the rise in caesareans throughout the country.)

There’s even a faintly disapproving quote from Louise Silverton of the Royal College of Midwives: “Some women do opt for a caesarean section because they can’t cope with the uncertainty. They control the rest of their lives, but they can’t control labour.”

What a bunch of feeble losers, eh?

Or could there be another reason why women have caesareans? Both Susanna Rustin and Hadley Freeman in the Guardian do a good job of showing how ridiculous this story is. Freeman points out that the rising age of women giving birth and the growing size of newborns are both factors in the growth in caesarean sections.

But we should also remember that most caesareans aren’t carried out as a result of the woman demanding them. The national c-section rate now stands at 26.2%. Half of those are emergency caesareans, carried out when something has gone wrong and the procedure needs to be performed urgently to save the life of the mother or the baby.

The other half are “elective” or “planned” sections – a misleading name, because they imply that the woman has elected to have them. In practice, “elective” simply means that the caesarean has been scheduled in advance, almost always for medical reasons: placenta praevia, which means the birth canal is blocked, and the baby cannot be born vaginally; a breech presentation, which makes a vaginal delivery more difficult; or the woman has had a previous caesarean, and a vaginal delivery might be dangerous.

Sometimes women do choose a planned caesarean (and sometimes doctors refuse – it’s not a given that obstetricians will agree to perform the procedure). Why? Well, not because they’re entitled or pushy or hate uncertainty. Very often it’s because they’ve had such a traumatic experience the previous time that having a caesarean feels like the safer, less frightening option. Or perhaps they’ve had a caesarean before and don’t want to risk rupturing the scar (a small risk, but nonetheless a real one with potentially fatal consequences). Perhaps they suffer from tokophobia – an extreme fear of childbirth.

For what it’s worth, I’ve never met a woman who has opted for a caesarean because she “can’t cope with the uncertainty” or is “too posh to push”. Giving birth is almost always going to be an intense and painful experience, however the baby comes out. It’s time to stop making women feel worse by berating them for supposedly giving birth the wrong way.

Do we need a drive to bring down the caesarean section rate?

The president of the Royal College of Obstetricians and Gynaecologists (RCOG), David Richmond, has called for an NHS-wide drive to reduce the number of first-time mothers having caesarean sections, according to a report in the Observer.

About one in four babies are delivered by caesarean section in England and Wales. You can see why Richmond is concerned: it’s a high rate of surgical intervention for something that is supposed to be a natural physiological process. It also carries risks for the mother and baby, involves a longer recovery rate for the mother and is more expensive for the hospital.

Richmond points out that the proportion of caesarean sections varies from hospital to hospital, suggesting that the high rate in some hospitals isn’t entirely related to medical necessity. He is quoted as saying that the increased rate of c-sections is being fuelled by “the rise in maternal obesity, obstetricians’ fear of being hit with a lawsuit if something goes wrong during labour, and a small number of women asking to have the procedure.”

So, is he right? Well, perhaps. The difficulty is that we don’t know why so many first- time mothers with apparently normal pregnancies have caesarean sections. The “small number” of women who ask for c-sections is unlikely to have a major impact on total numbers. As for the rise in maternal obesity, and obstetricians’ fear of lawsuits, we don’t know how much these factors influence the c-section rate. It’s possible, too, that the variation between hospitals is not about a difference in attitude but a difference in the profile of patients: a hospital with a greater number of older first-time mothers is probably more likely to have a higher c-section rate.

The trouble with having a drive to reduce the number of c-sections is that it encourages clinicians to focus on the target rather than on the individual women. In my work with the Birth Trauma Association, I’ve seen numerous horror stories of women with difficult, prolonged or dangerous labours whose requests for caesareans were initially denied, but who ended up having one anyway. In one case, the woman eventually delivered her baby by caesarean under general anaesthetic, a much riskier procedure than a caesarean under local anaesthetic. The consequences for the mental health of the mother in circumstances such as these can be devastating.

It is, of course, a good thing to look at a high caesarean section rate and ask what’s causing it. If it turns out that women are being given caesareans unnecessarily, then it makes sense for doctors to look at what they could do differently. In the Observer article, Cathy Warwick, chief executive of the Royal College of Midwives, says that women’s fear of giving birth makes them tense, and therefore less able to have a “normal” birth: in which case, why not make hospitals more relaxing and welcoming places to give birth? Noisy, bustling labour wards where women are left unattended for hours on end are bound to make anyone tense.

But simply trying to drive down the caesarean rate without looking at the root cause is asking for trouble – and could result in poorer outcomes for both mothers and their babies.

More mothers are dying in America. Why?

Throughout the developed world, the number of women dying in pregnancy or childbirth is going down.

The big drop happened in the 20th century, but even in the last 20 years, it’s continued to fall. Except, that is, in America.

A striking graphic in the Economist shows how, on average in developed countries, the rate has halved between 1990 and 2013 from 25 maternal deaths per 100,000 live births to 12. (In some countries, the rate is even lower: in Britain, there are six maternal deaths for every 100,000 live births.)

But in the US the reverse has happened. In the same 23 years the rate increased from 12 to 18.5.

Why? The Economist article posits various explanations: one is that the country has got better at counting the data, though it says that this can account for only a small part of the increase.

Another is that women are having their first child at an older age, which increases risk. But this also applies in other developed countries, where rates are falling.

It also considers that possibility that a rise in caesarean sections is to blame. Although caesareans are risky, again it seems unlikely that this accounts for such a dramatic rise.

The explanation favoured by the Economist is that American women are in poorer health when they become pregnant:

“Chronic health conditions, such as obesity, hypertension, diabetes and heart disease, are increasingly common among pregnant women, and they make delivery more dangerous.”

Shockingly, the maternal mortality rate among black women is roughly three times that of white women, because black women on average are more likely to suffer from these health conditions.

Chronic health conditions on their own don’t account for the difference between the US and other countries – British women also have problems of obesity, diabetes and so on but Britain has a much lower maternal mortality rate.

Perhaps the biggest problem still is the historic lack of universal healthcare.

“Medicaid already pays for almost half of all births in America, but millions of new mothers lost coverage 60 days after delivery, with the result that many entered their next pregnancy in bad shape,” the article says.

Obama’s Affordable Care Act may help to change things. But it’s scandalous that, in one of the richest countries in the world, pregnant and labouring women are still dying unnecessarily.