'Too posh to push?' Really?

So my daughter was at a Pilates class the other day and overheard a conversation between several young  pregnant women. It covered a lot of ground involving designer baby clothes and baby carriages du jour, there was some talk about epidurals and lots of shuddering about childbirth and various negatives about breastfeeding. 

My daughter reported to me that she felt like going up to them and saying 'Get over yourselves! Just push it out and put it on the boob!' 

And I was proud. 

Welcome to the third compartment of my brain! Work/women's stuff. (Home/ family, and World events/Jewish stuff being the other two.)

My question is this: What has gone wrong when we have Caesarian rates of 33% overall in Victoria? By overall, I mean that private hospitals are nudging 50% rates. That's one in two to three births being surgical deliveries. That's not counting other interventions such as epidurals and episiotomies and suction and forceps. 

Now, I am a doctor and I trained in the 70s and we were told then that '80% of women could deliver in a paddock', in the charming words of Sir Lance Townsend, famous OBGYN and Dean of O&G Melbourne Uni. That left 20% who needed some sort of intervention. That included episiotomies and forceps. So about 10-15% would need a C-section. This figure tallies pretty closely with the current WHO predictions of 15%. So what has changed?

Well, older mums. Ok. So the 'elderly primigravida' ie 37 years plus, having a first child, could be expected to have more difficulty. Although 37 is a bit of a spring chicken in some circles! And IVF and other sorts of reproductive technologies mean that women in their 40s+ can give birth, pretty much out of the old range. And we can see the shift in general to older first timers. 

(If I wasn't writing this on my iPhone but on a real computer I would do some quick research and give you exact figures, but I don't think it's really necessary for this blog post. Another time maybe.)

Another shift since the innocent 70s has been the growing litigiousness of the community. Anything wrong with the baby is the OB's fault. Even though it has been shown that most cases of , gor example, Cerebral Palsy, are not birth-related but originate in utero, enough high profile cases make everybody scared, so the C-Section is the cure-all. So higher risk births, eg breech, twin, are generally operative deliveries. Short stature, older mum, narrow pelvis, high head at term, unstable lie. Posterior position! I don't know when that happened, but suddenly that too has become dangerous and needs CS. 

(I'm sorry if I'm using terms you may not be familiar with, but if you're reading this far already, I think you know what I am talking about. )

Back in the day, you could go 2-3 weeks overdue also, but there are statistical risks with this. So even though nowadays we can easily assess placental function and fetal well-being, many doctors either get a bit antsy, or, in many cases, mums have had enough, and hello, induction. 

And the trouble with inducing labour is that once you intervene in this process, you often set up a chain of events. Prostin gel, break waters, synocinon (pitocin) drip, slow progress, pump up the volume, maternal distress, epidural, failure to progress, fetal distress, failed suction, failed forceps, emergency Caesarian. 

We saved your baby! We saved your life! Thank you doctor! Thank you so much!

I'm not saying that there should NEVER be an induction or epidural or whatever. But NOTHING should be routinely done. Because when interventions are done routinely, all you are left with is the side-effect risk. 

So when pregnant women are shopping for the perfect pram or the loveliest blanket, well, that's ok. A consumer-driven decision. But it's not ok to let the consumer drive the kind of delivery. 

If you ask an OB with a high CS rate why he does this, he might say that he has a lot of high-risk deliveries. But he will also say, if that's what the mum wants then fine, that's what I will do. 

Because it's a consumer society. A highly litigious consumer society. And he is a bit scared, a bit undermined and he pays enormous medical indemnity. And many OBs have lost the attitude of 'masterly inactivity' or 'watchful waiting' because they need to make a lot of money to pay their huge insurance fees, and time is money. And mama is in a hurry too. So chop-chop! Let's get this over with. 

So have the rates of maternal deaths home down? Not really, they've been pretty steady at 3-4 a year for the last 30 years or so, in Victoria. How about perinatal death and illness? Well, not so straightforward because with better fetal diagnosis, many pregnancies are terminated for chromosomal or genetic conditions, so they don't make the count. Prematurity is still a major cause of perinatal illness and death. 

In general, when the rate of CS went from 20% to 33%, it is not at all clear that mothers or babies did better. In fact, having a CS, which is major surgery, comes with its own passel of problems, not only for that delivery, but for subsequent deliveries. 

In 1970, in Victoria, the rate of initiation of breastfeeding was around 20%. You read that right. One in five babies was even offered the breast. This came about mainly because of the attitude of the day among doctors and nurses that formula was just so much better and more modern and civilized, cleaner and more convenient, than the breast. There was not much research in the field, therefore not much evidence, and shameless marketing from formula companies.  Most young mums, migrants or children of migrants, less educated than the clever doctors and nurses, nodded and bought the bottle. It took a grassroots movement of housewives, the Nursing Mothers Association of Australia (you couldn't say 'breast' in 1964, now it's the Australian Breastfeeding Association) who forced change through activism, education and support of mothers, to turn that ship around. Breastfeeding rates still aren't what they could be, but around 90% of mothers at least give it a shot. That's for another post. 

What I'm saying is, if we wait for OBs to suddenly say, 'Hey! I'm doing too many C-Sections! What's with that? What, have women's bodies become unsuitable for vaginal birth, after millions of years of evolution??', well, don't hold your breath waiting for that to happen. (Although some have suddenly woken up to the fact that they don't even know what natural birth looks like any more, and most have lost the skills needed to apply forceps properly, and there is some minimal change afoot. Because if the only tool you have is a hammer, then everything looks like a nail.)

Change must come from the grassroots. If the mums ask for a chance to give birth naturally; if they know about the positives of natural childbirth rather than scare themselves with negatives; if they put some trust in their own bodies, in Nature or in G-d or whatever; if they seek education through LaMaze or whatever; in short, if they CARE; then there will be change. There has to be.