More medical groups bleating about the caesarean rate

Same old tune, different verse. This one's Canadian.

I wholeheartedly agree that our c-section rates are appalling (Australia's is currently standing at 30%) and measures must be taken to reduce them, but this article is just Wrong.

First of all, as with most articles like this, the blame for the rising c/s rate is not-so-subtly aimed at the women. They're too fat. They're too scared. Their babies are too big. Their pregnancies last too long. Their labours last too long. They're too uninformed. They want convenience. Apart from the first sentence of the article, nothing is said about the surgeons' responsibility for these women's birth outcomes even though it is the surgeons performing the surgeries. Stop and think about that for a moment. It is the surgeons performing the surgeries. THEY are the ones making the ultimate decision to cut a woman open. It really rankles me when doctors throw their hands up in the air and say "I couldn't help it; she forced me to do the surgery." Bah! When was the last time a birthing woman and a doctor got into a disagreement and the woman won? Oh yeah, when that woman was fighting for a natural birth. And while I'm at it, let's not forget: obstetricians are surgeons. They are trained to perform surgery and they are (usually) very good at it. Surgery, not natural birth, is their comfort zone. What's that proverb about a man with a hammer?

Secondly, the article contains several fallacies, inconsistencies and jumps in logic. For example, it emphasises the importance of women being well-informed about natural birth and what their choices are. Yes, that is absolutely true. But then it goes on to state a total fallacy as if it is fact ("Obese women tend to have bigger babies, as well as longer labours, which increases the risk of a C-section"). When such myths as this are perpetuated by doctors, the media and popular opinion, it's unfair for women to be held responsible for their lack of knowledge about natural birth. (However, of course in a hospital setting big babies and long labours do increase the risk of a C-section so perhaps that sentence is not a total fallacy after all. But only because of another dearly-held myth which is that big babies can't come out vaginas and long labours mean babies can't come out vaginas.)

In another example, it mentions that only about 1-2% of c/secs are performed at the mother's request, and yet in the very next sentence convenience and fear are listed as two of the top three reasons for the increase in c/sec rates. What. Ever.

I also love the way the article mentions a statement released by the Society of Obstetricians and Gynaecologists of Canada which apparently calls for the promotion of normal childbirth ("whenever possible", of course) but the statement itself is not actually quoted and the next sentence is a quote from the president of the Canadian Midwives Association. How about we get a statement from the president of SOGC which backs up this alleged statement? The best they can do is later on quote a Dr Andre Lalonde as saying "Health professionals want to provide support for women to make an informed choice regarding childbirth." Oh yeah, Dr Lalonde? And what's preventing them from fulfilling this noble desire? But it doesn't stop there. He also says "For each woman and her health-care provider, this decision must be scientifically sound and ensure maximum safety for the woman and her pregnancy." Make no mistake, that is obstetrician-speak for "We think it's best if women leave all the decisions to us. Of course we'll act in our - I mean, their - best interests."

I also can't stand the double speak and get-out-of-jail-free cards. Apparently, surgeries should be prevented whenever possible. Oh, whenever possible, huh? Right. I thought you were only talking about sometimes. Women who are at low risk for complications should be informed. Oh, so high risk women don't deserve to be informed? Does this information include a thorough analysis of why she's considered low or high risk? Here's a pearler: "Medical interventions such as C-sections, inducing labour prior to the 41st week of pregnancy and using devices like forceps and vacuum assistance to aid delivery should be discouraged if there [is] not a valid medical reason like the labour and birth is not progressing as it should." There are so many problems with this I barely know what to say. But hey, I'm already fired up; let's rip it apart. Inducing labour is always risky regardless of whether it's done at 40+6 or 41+1. Forceps and vacuums aren't needed if a woman has been active, upright, and properly supported during labour. Again there's that ever-so-useful bailout term "valid medical reason" and then ooooooh boy, the "valid" reason they give as an example? Where to start on that one?

Does it occur to any of these medical groups bleating on about reducing the c/sec rate and informing women that THEY ARE THE ONES WITH THE POWER TO REDUCE THE C/SEC RATE AND INFORM WOMEN??????????

So let's get real for a little while.

One of the biggest factors that contributes to the high c/s rate is the surgeons' unwillingness to give VBAC the place it deserves. How is it really possible for women with a previous scar to avoid a second one when so many care-providers are unwilling to support her? It is true that VBAC does happen, in *some* hospitals, but it is rare (about 15% of all VBAC "attempts" are "successful") and one has to wonder why this is the case. In most cases, a woman can't escape her fate; she is told that her risk of uterine rupture increases by 50% (which is true, it goes from something like a 0.5% risk to a 0.75%) which of course sounds deathly scary, and this doctor or this hospital doesn't "do" them. Or she's told that she can have a trial of labour (Great positive language there! Go the power of suggestion, eh?) but she must be prepared if something goes wrong. And then of course you have to look at the utterly woeful way VBAC is managed in hospital settings.

Of course, the other huge contributor to the number of c/secs being performed is how often they are resorted to by the surgeons unnecessarily. Women are so often consigned to the high-risk category for reasons that have nothing to do with their uterus' ability to contract and push out a baby (overweight, underweight, previous caesarean, big baby, small baby, gestational diabetes, breech, twins, polycystic ovaries, endometriosis, 41+ weeks gestation, etc etc), given arbitrary and unrealistic deadlines on their labours, totally mismanaged in labour with unnecessary interventions and/or failure to make changes that would actually help. It's no wonder so many of them end up "needing" emergency caesareans when they are not supported by their caregivers to have a normal, natural birth in the first place.

What about the argument that women should demand better care? I have a serious issue with that. The care-providers should simply provide better care. Labour is not the time to be insisting on the way you want things done when the hospital staff are manipulating, threatening and coercing you to "consent" to xyz interventions -- or worse, simply performing them without even telling you about it or waiting for your consent. Labour is an extremely vulnerable time and a woman should not need to fight for anything -- she needs respect, love and support. And even during pregnancy, it is the care-provider's responsibility to provide care, not the woman's responsibility to "demand" it. She's scared of the pain of labour? This is the time for the care-provider to educate and support her to work through her fears, not say "Well OK then, let's schedule a c/sec". She develops pre-eclampsia? This is the time for the care-provider to educate and support her to make changes to her diet which will manage the condition so that a c/sec does not become necessary. And so on.

I hate articles like this. They scratch the surface of some deep-rooted and complex issues, provide no real solutions, and only perpetuate the status quo in the process. Medical associations have been paying lip service to the need to reduce the c/s rate for years, and yet the c/s rate keeps rising. People already agree that a natural, normal childbirth should be the aim in most circumstances and yet it is not happening. It's time for the medical establishment to stop saying that something needs to be done, and stop pretending that something is being done. It's time for it to start actually doing something, and a good long hard look in the mirror is the first port of call.