Surgical birth

So much so, that NSW has already taken steps to limit its further encroachment - and Western Australia seems likely to follow against vocal opposition. But is it women, or the medical profession, or just plain old fear that's driving this new phenomenon? Kirsty Stuart reports.

So much so, that NSW has already takensteps to limit its further encroachment - and WesternAustralia seems likely to follow against vocal opposition.But is it women, or the medical profession, or justplain old fear that's driving this new phenomenon? KirstyStuart reports.

It's been a widely reported - and hotlydebated - topic in the media that Australia's caesareanrate is skyrocketing out of control, with a staggeringstatistic of less than half of all births at some privatehospitals being normal deliveries.

According to a report in the April issue of the WesternAustralian doctors' magazine Medical Forum that state'scaesarean rate is 33 per cent with 53 per cent of babiesbeing born by caesarean at Perth's larger private hospitals.Although the World Health Organisation wants to seethe current rate reduced to about 15 per cent in developedcountries, in Australia the caesarean rate has increasedfrom 10 per cent in the 1970s to 30 per cent in 2005.In fact, some experts are going as far to predict thatit will reach 40 per cent by 2010. Why is it that caesareansincreasing so rapidly?

Interestingly, the prime caesarean candidate is a first-timemum in her mid 30s with private health insurance. What'smore, women aged between 35 and 39 years having theirfirst baby in a hospital face a caesarean rate of 40.4per cent. Some commentators point the finger at highflying corporate women booking in caesareans in betweenboard meetings and spa appointments, suggesting thatit's all due to women wanting the least disruption totheir lives as possible when it comes to childbirth.They say that as a society we have become 'too poshto push' and natural childbirth is no longer in vogue- however, the statistics say otherwise.

First, it must be stated that there are different typesof caesareans. In a nutshell these are: planned - wherethe mother has chosen this type of birth; recommended- where the mother's obstetrician has recommended it;and emergency - when problems occur during the birthor the pregnancy. According to a report given at theRoyal Australian and New Zealand College of Obstetriciansand Gynaecologists' scientific conference in 2005, onlyfive to ten per cent of Australian women who have caesareansactually choose the surgery. Rebecca Lawther, 32, hasfour boys aged seven, five, three and nine months. Thefirst was by caesarean, the second by vaginal birth,the third by caesarean and the fourth by vaginal birth.

Rebecca says she felt pushed (perhaps an ironic choiceof word) into her second caesarean by medical staff."My second caesarean came about because I endedup getting a cervical lip and I don't know why but theobstetrician just wanted to take control of the labourand I ended up being wheeled off for a caesarean. Ijust found out recently that the second one was totallyunnecessary because I developed another cervical lipwith my fourth son during the birth and my midwife dealtwith it calmly and confidently. We stopped pushing andwe waited a while and it just disappeared of its ownaccord and I had a normal birth." Comparing hercaesareans to her natural births, Rebecca says: "Ididn't like the experience of major surgery and therewas also the fact that I knew I could do it myself.I found it very difficult to look after my other childrenafter my second caesarean, so I was very keen not tohave another one so I'd be okay after the birth. Whenyou've had major surgery, you need looking after andnurturing yourself. After vaginal birth I felt likeI could take on the world - I was so ecstatic."

Having experienced both caesareans and vaginal birth,Rebecca prefers the latter. "I don't think caesareansare the wonderful thing a lot of people make them outto be. I think there is this misconception that theyare the easy way out - but there is no easy way to geta baby out of you! In the long run, healthwise for thebaby and for me, it was better to have a natural birth."

Sally Westbury is an independent midwife who's beenin private practice for 16 years. She says she's seenan increasing number of clients coming to her wantinga Vaginal Birth After Caesarean (VBAC). "In thelast five years the growth has been exponential,"she says. "Five years ago, I had one or two homebirths and last year I helped 11 women who were planningto have a home birth after caesarean. This year, I'vegot 12 women booked in over the next six months wantingvaginal births after caesarean.

"The sentiment of most of them with regard totheir caesarean experiences is that most of them feellike there is a high degree of medical impatience andthey are put on a timeline that is not reflective ofindividual variation. They feel deeply traumatised bytheir experience of caesarean section and are lookingfor a journey that is more supportive and healing forthem. These women go on to have vaginal births thenjust feel incredibly healed and complete."

Bronwyn Key, a 52 year old registered midwife of 25years who has delivered hundreds of babies, agrees.She's had one child via natural home birth, a surprisinglyquick labour of three hours - drug-free.

"I think if women can have a natural birth it'sreally to their advantage and the advantage of theirbaby, the women come out feeling empowered and the babieshave gone through the whole process of managing to maketheir way out into a loving environment so they're comingwith a positive attitude as well.

"If you're induced or start interfering with thenatural process, you need to interfere more and moreand they call it cascading intervention. With more womenbeing induced, the need for more caesareans is happening.

"There is such a culture of fear around childbirththat it predisposes it to being more painful than itneeds to be. The fear factor makes labour much morepainful and there is a lot of research that proves thatyou tighten up if you are frightened and then you areworking against the force of nature that is going topush the baby out and it's far more painful."

So with only five per cent of women actually choosingto have caesareans - that's 90 to 95 per cent beingtold they should have them - are doctors pushing thetrend and encouraging what is now being called a "caesareanculture"? In Delivery by Appointment, a book thatinvestigates caesarean birth today, author MichelleHamer questions whether our culture may encourage highintervention births. In other words, asks Michelle,have women lost confidence in their ability to birthnaturally?

She writes: "Given the pressure on doctors withthe fear - and often experience - of litigation hangingover their heads, the scalpel can usually achieve amore predictable outcome. And that's an important wordin this debate - predictable. In this era of globalisation,when we feel comfortable with the familiar brands weeat, wear and furnish our home with, when there is safetyin chain restaurants which serve up the same tastingfood no matter what country we're in, in this homogenisedlandscape there is little room for unpredictability- and that is just what labour can present."

And on the concept, which she refers to as McMothering,she writes: "Our society doesn't seem to toleraterisks or manage uncertainty well, but are we in dangerof becoming McMums? Of turning birth into a productionline, offering much more predictable outcomes - butwith a sense that maybe something was lost along theway? Just as we are prone to over-scheduling our children'slives with stimulating, educational activities and therebysqueezing out any room for the vital playing and ponderingof childhood, are we also scheduling their births andsqueezing out the chance for a 'natural' experiencein the quest for perceived control and safety? And by'we' I mean society as a whole; as well as the doctorsand parents making the final decisions."

As noted previously, why are 90 to 95 per cent of mothershaving caesareans not by choice?
Theories abound. While Australian rates of caesareanare worryingly high, it's the same story in Britainand the US - the three societies with the highest ratesof obesity worldwide. Couple that with the fact thatpregnant women are likely to be older first-time mothersand, with increasing IVF rates, having more multiplebirths. According to the American Journal of Obstetricsand Gynaecology 2002, obese women are six times morelikely to have a caesarean than their thinner counterparts.Other reasons touted are that women want to keep theirpelvic floor intact and retain sexual sensation anddoctors' fear of being sued, not to mention the conveniencefactor where it's easier to schedule surgery than unpredictablebirth times. Then, it seems once women are on the caesareanbandwagon by having their first c-section, a staggering80 per cent go on to have subsequent caesareans.

On the subject of doctors being sued, Michelle pointsout that the rate of obstetricians being sued in Australiahas tripled since 1991, with more than half of Australianobstetricians having received a "letter of inquiry"from a patient's solicitor - the first stage in thelitigation process. On the other hand, she notes, noAustralian doctor has ever been sued for performinga caesarean.

It's interesting to note that in the Netherlands, whereall pregnant women consult with midwives, the caesareanrate is just 14 per cent. Most Australian women arewell versed on the argument that caesareans make itharder for the mother and baby to bond. And that aftercaesarean, women are at greater risk of bleeding, bladderinjury, ongoing pelvic pain, wound infection and thatcaesarean section leaves a scar in the uterus that canhave implications for further pregnancies.

Apart from the fact that natural childbirth is a goddess-likeexperience that every woman is entitled to experience(with safety in mind, of course) there are wider societalimplications at stake. The danger with the situationin Australia, according to some experts, is that itbecomes a Catch 22 situation whereby the more caesareansthat are done, the more caesareans became normal practice,pushing up the rate even higher.

Michelle summarises it most eloquently: "Somehowthe issue of childbirth, surely one of the oldest, mostbasic processes in life, has become highly politicised,emotive and increasingly medicalised. Naturally we don'twant to go back to the days when women laboured in agonyfor hours and died with their babies still inside them- but what does the future offer? Do we want to headdown the path towards completely surgical births?"
Delivery by Appointment: Caesarean birth today by MichelleHamer is published by New Holland.