Ask questions…

It can be challenging to separate a truth from a half-truth or indeed an out and out lie in some media stories. I’m not talking about fake news here, but simple carelessness or personal bias. But when you think about this challenge in relation to women trying to make decisions regarding their birth, it is more than disconcerting, it is alarming.

Rightly or wrongly, news reports, blogs, TV dramas, each others’ birth stories are all absorbed and digested, feeding our perceptions of what is ‘normal’, what is best for the baby, what is safe and what is not etc.

As I researched my book it became disappointingly apparent that media reports frequently look only as far as the Abstract of a research paper, and then make broadbrush statements that fit their intended message. On reading the papers themselves it is in fact sometimes the case that the reporter has misrepresented or over emphasised the significance of the findings. Yet it is often these media stories, not the research papers, which form the basis of what many women believe to be true and on which we understandably base our own decisions.

Added to this, uptake of antenatal education is only around 60% and significantly lower for women that have already had one baby, (according to a UK Maternity Survey Report by the National Perinatal Epidemiology Unit, 2010). Important information doesn’t always get through, so questioning the truth of what we read elsewhere is important.

Personal bias, political or economic bias can all impact the truth of a report or blog and indeed the advice being given by health practitioners. Really it is only in reading around a subject – going to the original research papers, indeed more than one, that we can start to uncover the detail behind headlines. For example, often a research paper contains caveats – some of which can render a result interesting but very far from conclusive. Yet the media may report the results of that same research paper as beyond a shadow of a doubt – caveats rarely make it into an Abstract.

But a single research paper is a single viewpoint, a single investigation, a single set of conditions and single point in time. It is often possible to find papers that expand upon an idea or indeed completely contradict it – see below – and it is only in reading around, asking questions and questioning the agenda of the author, the researcher or the doctor that we can start to formulate our own position.

This all sounds very scary. How can we know that what we are hearing or reading is reliable. In reality we don’t, but by reading around an issue we stand a greater chance of knowing what questions to ask, it makes us more able to determine what is fact and what is a current best guess, what is a trend and what is plain persona, political or economic bias.

With a background in research I am used to reading research papers and statistics and I will never forget reading a published paper which claimed caesarean section caused obesity in children. It’s good headline fodder and no surprise has been covered time and again in the media. However, in this particular instance, on reading the full paper, I discovered the researchers failed to accommodate several important variables, in particular familial obesity. The presence of such a relevant, confounding variable renders the finding highly questionable. Being unable to rule out the impact of family patterns of behaviour with regards attitudes to food and eating habits makes it impossible to say with any degree of certainty that caesareans cause obesity.

An illustration of how media bandwagons often create more problems…

For quite some time, studies have been talking about the benefits of breastfeeding for babies born by caesarean. Research, suggesting composition of gut bacteria is subtly different according to whether the baby is born vaginally or by caesarean section, this study for example, typically finds caesarean babies breastfed for at least the first 4 weeks will demonstrate broadly similar gut bacteria to babies born vaginally by the time they are 8 weeks old (with implications for immunity systems). In other words, breastfeeding may mitigate the potential impact of a caesarean birth – with regards immunity. Naturally this has fed into the ‘breast is best’ campaign – no bad thing (assuming it is not used to guilt trip mothers about breastfeeding).

But media spin on such studies have on occasion also gone on to suggest – with regards immunity that caesarean born babies are at a significantly disadvantaged adding risks of obesity and asthma to the mix. All of which can understandbaly scare the pants off those women facing an unplanned or unwanted caesarean.

However, in 2017 yet another study, published in Nature Medicine, investigated levels of microbiota found in several locations around baby’s body and found that regardless of age at delivery ALL babies developed very similar levels of microbiota by the time they were 8 weeks old. Indeed by 6 weeks old the microbiota had expanded (and diversified) across ALL infants regardless of their mode of delivery.

The researchers said “We conclude that within the first 6 weeks of life, the infant microbiota undergoes substantial reorganization, which is primarily driven by body site and not by mode of delivery.”

In other words – the link between caesarean delivery and an increase in immune disorders is far from confirmed. Despite this, the media continue to generate emotive headlines, particularly when attempting to regurgitate old myths about the selfishness of women too posh to push, blaming caesareans for all sorts of childhood issues. As you might expect, in line with such scare mongering there has been an increase in the number of women asking about vaginal seeding when told they will need a caesarean delivery as a means of combating their worries about immunity complications. Ironically these women are asking for a procedure far less researched and far less understood than the caesarean itself.

As an aside – please note – the current stance of the UK’s NHS  is “vaginal seeding has unknown risks and is not recommended.”

While in the US ACOG state “At this time, vaginal seeding should not be performed outside the context of an institutional review board-approved research protocol until adequate data regarding the safety and benefit of the process become available.”

Such incomplete articles lead some women to actually consider adding procedures to their birth experience which are in fact far from proven and may actually prove to be harmful to their baby.

It is my intention with this post to draw attention to the challenges women face when trying to make informed decisions. Newspapers print the story that increase readership or reflect the bias of their readership and the onus really has to be on us to conduct our own investigations, asking lots of questions. Most articles name the study or author and with the Internet it is quite easy to get to the source to see what the researchers have actually said.

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Caesarean Birth: A Positive Approach to Preparation and Recovery – A table of contents

For those interested in seeing more detail about the content and structure of my book – the following is the table of contents from the 2nd Edition – available on Amazon and from various other on-line bookstores.

Foreword……………………………………………………………………………… 5

Introduction………………………………………………………………………….. 7

  • 1 Caesareans explained………………………………………….. 11
  • 2 Why prepare for a caesarean birth?………………………….. 19
  • 3 I would prefer a caesarean…………………………………….. 27
  • 4 I do not want a caesarean……………………………………… 37
  • 5 How can I make the most of my caesarean?……………….. 55
  • 6 How can I improve my recovery?…………………………….. 75
  • 7 I am the birth partner, what can I do?……………………… 113
  • A The caesarean procedure……………………………………. 139
  • B Why do caesareans happen?………………………………… 151
  • C The benefits and risks of caesarean and vaginal birth….. 165
  • D Clinical definitions of difficult reactions………………….. 191
  • E Birth guide template………………………………………….. 195
  • F Questions to ask your practitioners………………………… 199

Glossary…………………………………………………………………………….. 203

Other resources…………………………………………………………………… 209

Acknowledgements………………………………………………………………. 217

References…………………………………………………………………………. 221

Index………………………………………………………………………………… 247

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Where can I get advice?

Hospitals remain under pressure to reduce their caesarean rate – despite recommendations to Inspectors to refrain from judging hospitals in this way. And where there are no targets in place, women can still face opposition from individual care givers.

This is why BirthRights – a UK information and advice centre – offer the option for 1:1 advice via their website.

They firmly believe in a woman’s right to an informed choice.

“Women have a right to make choices about the circumstances in which they give birth. This simple but powerful principle was established by the European Court of Human Rights in Ternovszky v Hungary (2010) under the right to private life in Article 8 of the European Convention which encompasses rights to physical autonomy and integrity. Article 8 is a ‘qualified right’ and so limitations on the right are permitted. The Ternovszky case concerned the right to give birth at home, but the principle applies equally to all choices that women make about childbirth. The decision represents a profound challenge to medical authority: if women have a legal right to make a choice, any limitation on that right must be justified. The decision-maker, whether a hospital or a doctor or midwife, must give proportionate reasons for their decision based on the individual circumstances of the woman and their reasons can be tested in court before a judge.”

To ask them a question click here.

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Why Do We Fear a Caesarean Birth?

Australian Birth site, Natural Parent Magazine, recently posted one of my articles. It is great to see more and more birth sites willing to talk about the possibility of a caesarean delivery. Knowledge is power!

“In reality a caesarean is an extraordinary addition to the tools available to those who help us with our births and it should be respected for the advantages if can bring to those who need it.”

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What if I have to have a caearean?

Australian Birth site, BubHub, recently posted one of my articles. It is great to see more and more birth sites willing to talk about the possibility of a caesarean delivery. Knowledge is power.

“With knowledge, a caesarean can be a really powerful experience. One we can remember positively even if it was not the way we thought our birth would pan out…”

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Caesarean targets for hospitals

For years hospitals have been asked to record data about caesarean births. The results of a Freedom of Information request revealed that the way in which this information was recorded varied significantly from one hospital to another.

For example:

  • Inconsistency in criteria used for recording whether a caesarean delivery was emergency or planned
  • Inconsistency in criteria for recording a delivery as a maternal request or performed as a result of an obstetricians recommendation

It is easy to see that in reality reports about current rates face an impossible task – the truth is hard to discern. Despite this many hospitals faithfully report their figures and face judgement for their caesarean rates – some praised for low rates, some criticised for rates that are considered ‘too high’.

In fact the WHO retracted their recommendation for an ideal caesarean rate back in 2009 because there was insufficient evidence to define one.

Despite this, UK hospitals have continued to be scrutinised and judged according to their rates. Loaded statements by official bodies and the press have pushed many hospitals into defining, formally or otherwise, ideal targets for themselves. Stories of women requesting caesareans and being refused are all too common and maternity litigation claims in the UK are now thought to run to billions every year. The personal cost to families of these arbitrary targets can be shown to result in: loss of life, life altering injuries as well as obvious psychological distress.”

Now, finally as the Sunday Times reports “Inspectors have been ordered to stop judging maternity units on their caesarean rates after the care watchdog accepted that it had sent the wrong message on normal birth.”

Heidi Smoult, deputy chief inspector of hospitals – commenting on the report by P Hull which led to this directive – stated that “medical intervention, while important “should never be at the expense of a woman’s or baby’s health.”

The Sundays Times speaking to Alison Wright, of the Royal College of Obstetricians and Gynaecologists, recorded the view that: “The need for a medical intervention can vary dramatically across services and regions, depending on the local demographics and the health needs of women. Therefore, we believe the approach should be more nuanced than promoting a particular maternity indicator, such as a caesarean birth rate.”

A step in the right direction. However, if you are trying to investigate your own birthing options, whether that is to have or avoid a caesarean be aware that internal politics within your hospital may be an additional factor to consider. Despite this new recommendation, it is worth finding out whether your hospital still refers to target levels for caesarean births.

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Clinical Director NHS England says – stop focusing on CS rates!

For too long, healthcare providers have been concentrating on optimum caesarean rates, this despite the fact that nearly 10 years ago the World Health Organisation retracted their recommendations as there was “no empirical evidence for an optimum percentage”.

Now the Clinical Director for NHS England – Matthew Jolly – joined the fight by stating that caesarean rates should not have targets set as these can lead to “all sorts of unfortunate consequences.”

Attempting to artificially driving down the caesarean rate is dangerous. Over half the litigation costs in the NHS are still in obstetrics many of which relate to birth outcomes which could have been avoided if a woman’s concerns or wishes had been respected.

  • 47% of maternity units set target rates
  • 50%+ are graded on whether they encourage natural births

Cost is the major factor driving these targets and where cost is considered above a mother and/or baby’s safety, bad decision are going to be made and bad advice is going to be given to mothers.

NICE guidelines clearly state women should be able to make an informed choice about how they give birth. But targets like these are reducing options and we are regularly contacted by women at their wits end, wanting to know how they can challenge the advice given by their carers which they believe to be compromised.

But, is the tide turning? We are working with the Care Quality Commission to understand more about women’s caesarean experience, feeding into the development of this year’s Care survey. Watch this space to see whether such statements are actually reflecting a change in the behaviour of our Trusts.

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Caesarean Birth: A positive approach – goes to 2nd Edition

The 2nd edition of Caesarean Birth: A positive approach to preparation and recovery is now published and available globally via Amazon.

The update came about because conversations with many women in the 7 years since this book was first published reveals little has changed in terms of a woman’s experience of a caesarean or the extent to which it is included in antenatal education and the need for up-to-date information is as vital as ever.

That said, once a caesarean is agreed, ideas about how to improve the experience are being more readily accepted by some practitioners and the ‘natural caesarean’ approach is now more commonly discussed. However, the barriers faced by women wanting to discuss their options in the first instance are still many. Hospitals and individual practitioners, driven by economics and/or professional bias, continue to make things difficult for some women wanting more say their birth options.

Despite the World Health Organisation’s retraction of their recommended target levels (retracted in 2009), which clarified that the “optimum rate is unknown”, hospitals continue to be threatened with unachievable targets and women labelled ‘too posh to push, are blamed for driving the caesarean rate up.

This update:

  • Adds new research
  • Updates facts and figures pertinent to both caesarean and vaginal birth
  • Adds learning from women and birth partners who have shared their experiences with the author
  • Highlights the needs and issues of same sex birth partners – in this last case the needs of this group are frequently over looked and while much of their experience of birth is the same as for male birth partners, research suggests that these co-parents actually have a significant number of additional emotional factors to deal with and the impact of this is only just beginning to be researched and understood
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Vaginal seeding – a safe fad?

Some women seem to be taking matters into their own hands when attempting to address the issue of whether or not a caesarean birth places babies at a disadvantage in the development of their microbiome (the colonisation of their gut with health bacteria).

In recent years there has been a lot of talk in the press linking caesarean born children with a higher incidence of obesity or asthma. Such media scaremongering is not helpful for those mothers whose medical situation has meant a caesarean has been a necessity and whose recovery has already been hampered by emotional trauma.

A recent study looking specifically at birth mode and a baby’s microbiome found there to be no lasting difference even as early as 4-8 weeks after birth, particularly if they are also breastfed. Chu 2017

Similarly, while some studies suggest there is a moderate risk of obesity in children born by caesarean, most fail to acknowldge that maternal BMI during pregnancy as well as maternal and paternal BMI post birth are also found to have an noticeable effect. A study attempting to evaluate a collection of studies on this issue still only found moderate risk and could not rule out the above confounding variables. Li 2013

And on the issue of asthma, studies are also contradictory and inconclusive, at best finding either no link, Maitra 2004, or include significant additional factors such as prematurity, maternal asthma, allergic parents, being born with respiratory difficulties etc. rendering the results unreliable. Debley 2005, Roduit 2008, Smith 2004

Despite this, the media continue to propogate such stories, despite the fact that even the research papers themselves rarely say anything more concrete than for example: It could be that C-section physically prevents newborns from acquiring microbes they would during vaginal births”.

Instead women are putting their babies at risk through inadvertent exposure to dangerous STIs including HIV, chlamydia, herpes and gonorrhoea.

Dr Patrick O’Brien, from the Royal College of Obstetricians and Gynaecologists states: there is “no robust evidence” that vaginal seeding actually has any health benefits to a baby. And a colleague leading the review of studies looking at vaginal seeding, Dr Tine Dalsgaard Clausen, Consultant obstetrician at Nordsjaellands Hospital, Denmark adds “Currently, there is no evidence to show that the potential long-term benefits of vaginal seeding outweigh the risks or costs associated,…it’s important that healthcare professionals promote other factors that are known to improve a baby’s colony of bacteria, such as early skin-to-skin contact, breastfeeding and a healthy diet.”

Until there is robust evidence that this technique is both safe and effective, parents could be well advised to evaluate the megre information presented in media stories and review current research for themselves.

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Women’s requests are being turned down

In 2011 the UK National Institution for Clinical Excellence (NICE) recommended that women be allowed to make a request for a caesarean delivery, even in the absence of any recognised medical need. Despite this, a recent Freedom on Information request submitted by the Daily Mail found that:

  • 21/91 hospitals do not offer maternal request caesareans
  • In four hospitals where Maternal request was supported, bosses rejected requests on cost grounds
  • Several hospitals insist on mental health counselling prior to giving agreement for a caesarean (this is unfortunately a recommendation in the 2011 NICE guideline – completely failing to recognise a whole group of women who have made an informed choice to request a caesarean)
  • Only four hospitals offer Maternal Request caesareans even though their Clinical Commissioning Group do not fund it

Kim Thomas, of the Birth Trauma Association, says in response to the findings: “Women usually have very good reasons for requesting a planned caesarean. Often they’ve already had one traumatic birth and want a less frightening experience next time round. Denying these women their request is cruel, and goes against Nice guidelines.”

Similarly, campaigner Pauline Hull, said: “Women are increasingly choosing a caesarean birth because they’ve decided it’s safer for their baby and safer for them. The maternal landscape has changed. Women are older, heavier, and having fewer babies; babies are heavier.”

Incredibly, Trusts are still using cost as justification for these rejections and define policies to drive down their overall caesarean rate. Trust managers are failing to join the dots…

The costs associated with a straightforward, uncomplicated planned caesarean are actually less than many medicalised vaginal births. This is because unless a vaginal birth is totally straightforward and natural (i.e. not involving any form of medical intervention or pain relief and Mum and baby leave hospital the same day), the costs immediately begin to creep up. Over 50% of UK births involve some form of intervention (NHS Information Centre statistics). In the USA, 67% of births involve anaesthetic, 30% of women are induced and 13% have an episiotomy (Listening to Mothers – USA). You can see how the cost arguement immediately starts to fall apart.

As far back as 2003, studies revealed that just adding induction using pitocin “nullified any cost differences; if epidural anaesthesia was also used, total costs exceed the cost of elective caesarean delivery by almost 10%. The cost of a failed attempt at vaginal delivery was much higher than elective caesarean delivery.” Bost 2003

“A culture of choice has been promoted in recent years, but contrary to the anticipated demand for less obstetric intervention by those promoting choice, there has been an increase in demand for delivery by caesarean section. With the balance in favour of benefit for the baby from delivery by caesarean section, it is now difficult to sustain the argument favouring vaginal delivery…A critical evaluation of costs indicates that there are probably few grounds for denying women their request for caesarean section for economic reasons”. Morrison 2003

And this is before you start looking at the cost to Trusts of longer term issues arising from vaginal birth. Studies reveal the long-term risk of stress urinary incontinence and pelvic organ prolapse surgery is significantly higher for women giving birth vaginally and of course there are significant costs associated with each repair work.

Come on hosptial pencil pushers – JOIN THE DOTS!

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