PARENTING:WHAT IS IT with Irish women and obstetricians? Most of us feel so much safer putting our pregnancy in their care. That makes absolute sense for the minority of expectant mothers who have complications. But why do the rest of us not see midwives as the experts on normal birth? It is abnormal births that are the business of consultants, writes SHEILA WAYMAN
Obstetric care is certainly a big earner for the Republic’s 100-plus consultants involved, the majority of whom work in both the public and private sectors. A private patient can expect to pay fees in the region of €4,000.
“Sometimes the idea of ‘my obstetrician’ is flaunted like a Prada bag. It is a real Irish thing. I have never seen it in any other country to that degree, except in America,” says Krysia Lynch, press officer for the Association of Improvements in Maternity Services (AIMS) – Ireland.
“They feel if they get an obstetrician, somehow it is going to be safer. What a lot of women don’t realise is that what you’re doing with an obstetrician is you are getting continuity of care, that is the only thing that is different; when you are going for antenatal visits you are seeing the same person.
“But when you have your baby it is the same midwives that will deliver your baby as are delivering the public patient in the next room and I think a lot of woman feel very taken aback by this,” Lynch suggests. (Although I would have thought that at that point in labour, you should be glad that you don’t need the services of your consultant.)
There is plenty of evidence to suggest that the “medicalisation” of straightforward births increases the risk of complications, with one intervention leading to another, until an emergency Caesarean section is the best option. Some pregnant women, terrified of the pain and unpredictable nature of labour, see a planned Caesarean as the best choice from the start.
This ultimate intervention into the natural birth process has risen dramatically in the past 15 years. More than one in four mothers in the Republic now delivers by Caesarean, compared with just over one in 10 in 1993.
According to the World Health Organisation, Caesarean sections should account for no more than 15 per cent of all births. It found there were no additional health benefits associated with a higher rate.
However, some doctors argue there is no evidence to back up this recommendation.
There is no doubt that a Caesarean section increases the risk to both mothers and babies, when compared with spontaneous vaginal birth, and it is also significantly more expensive for the health service.
While the rise in the rate in the Republic is crystal clear, the reasons behind this increase are much more opaque. Ongoing ESRI research is trying to explain the trend, using data from the National Perinatal Reporting System.
The authors of the working paper, Recent Trends in the Caesarean Section Rate in Ireland 1999-2006, found that known risk factors, such as older maternal age at birth and the earlier gestational age of the child, only explained half of the increase in the rate among first-time mothers. "This suggests that changes in physician behaviour over the period may well play a significant role," comment researchers Aoife Brick and Richard Layte.
Much more detailed data needs to be collected about the circumstances of each Caesarean section before the reasons for the rise can be identified, says a spokesman for the Institute of Obstetrics and Gynaecologists, Dr Michael O’Connell.
Nothing came of an approach by the institute to the Department of Health two years ago, he says, about doing a study akin to the national audit of Caesarean sections that was conducted in England and published in 2001.
The Caesarean rate here is “reasonably similar” to the UK, O’Connell points out, and “well behind” the rate of 31 per cent in the US.
“I would not be keen that it would rise much more and it would be nice if it fell back a bit, but we are not standing out as disastrously high or disastrously low.”
He continues: “If we are saying the section rate is too high, we have to come up with logical reasons as to how we can decrease it.”
But, he argues, the data is not there to inform those reasons.
What does he think is an acceptable rate? “To be honest, an acceptable rate is what delivers a healthy mother and a healthy baby, that is the bottom line. I don’t think you can pluck a figure out of the air and say this should be the rate.”
Our maternity services certainly have an excellent safety record, with a joint UN/WHO report in 2007 finding that Ireland had the lowest rate in the world of women dying during or just after pregnancy – one out of 47,600 women, compared with one in 4,800 in the US. But many other social and healthcare issues affect those rates.
From interviewing a cross-section of interested parties, the factors at play in driving up the rate of Caesarean births seem to range from medical and health policy issues to cultural and social influences.
The huge variation in rates from hospital to hospital indicates the complexities of the situation, says Dr Jo Murphy-Lawless, a sociologist in the School of Nursing and Midwifery at Trinity College Dublin.
A consumer guide, compiled by Cuidiú, the Irish Childbirth Trust, based on hospital figures for 2005, shows that Caesarean rates range in Dublin from a low of 18 per cent in the National Maternity Hospital to 37 per cent in Mount Carmel. Outside the capital, it goes from 21 per cent in Sligo General Hospital to almost 33 per cent in St Luke’s in Kilkenny.
Firstly, says Murphy-Lawless, we have no national guidelines on Caesarean section – or indeed on maternity services for women in 21st-century Ireland. “If we did, and they were applied across the board, we would have possibly lower C-section rates.”
Secondly, she points to the “very poor working conditions” in the maternity hospitals. “We have a high birth rate, too few midwives; we have quite inadequate circumstances for dealing in proper one-to-one care for women in labour.”
She sees a third major factor being the “inappropriate” use of routine foetal heartbeat monitoring, known as CTG. Research shows that continuous monitoring of the heartbeat leads to a substantial increase in the risk of a woman having a Caesarean section.
“The reason routine CTG is being used in this way is because we do not have proper one-to-one care in the maternity hospitals.”
The problem, she argues, is the way the information from the CTG is read. “More C-sections will be performed for abnormal foetal heart rates, but they may not really be abnormal foetal heart rates.”
Fourthly, there is a perception that Caesarean section is a safe and trouble-free intervention – that is a view held not only by the public but also by the consultants, she argues. “Women are not informed of complications.”
Niamh Healy, an antenatal educator with Cuidiú, has noticed a definite change in attitude among women towards having a Caesarean section.
“People sometimes come to classes with the notion that maybe they would go for an elective section, they would consider it. It has become sort of accepted that this would be an option. I think some women would be very glad if there was a reason an elective section had to be performed.”
She attributes much of that to fear: “They are not hearing that many good stories from their friends, their sisters and their cousins about birth – particularly birth in the current maternity services. It doesn’t really allow women to build up any degree of confidence.”
What Healy describes as “my precious baby syndrome” among older mothers is also a factor. “They have either waited a long time to have their first baby, or perhaps in some instances unfortunately it took a long time to conceive their first baby.
“People are acutely aware that they don’t have too many shots at this and they need to be taken better care of. In actual fact, Caesarean isn’t safer at all, but the general population thinks that it is.”
When she hears back from clients who have had an emergency Caesarean section, they typically talk about feeling very grateful that their baby was saved and that nothing terrible went wrong.
“That is great, except what I would often question is what went before it? Was there a cascade of intervention that is a well-known phenomenon in the medicalised birth?”
Research shows that continuity of care, typically provided in midwife-led units, and lack of time pressures, increases the chances of a normal birth.
Mothers are not caught in the following cycle: induction causing greater pain, leading to the need for epidurals, which slow down labour, that is speeded up with synthetic hormones, which result in faster and harder contractions, that may distress the baby and require a surgeon to come to the rescue.
Healy sympathises with the maternity hospitals that are coping with record workloads. “I think it is kind of herd control you have to apply, as opposed to individualised care for every woman.”
She believes the way to cut the rate of Caesareans is to look at more low-tech solutions and to get more midwives in there.
“Conceiving your baby for most people is not a high-tech activity; birthing your baby also shouldn’t be,” she adds. “If we supported women, they would have a more enjoyable experience, which is a better start to motherhood.”
O’Connell agrees the extra strains on the maternity hospitals, which are dealing with a record level of births without extra staff or investment in infrastructure, is a factor. “It is not a reason to do Caesarean sections, but it may play a part.”
Consultants exercise “clinical judgment based on experience” in deciding when to do a C-section, he says.
However, it is rarely an “all or nothing” situation. In the case of a slow labour, often it is the “softer factors” which influence the decision, such as the presence of meconium, how the pregnancy has been, the condition of the mother, and so on, he explains.
O’Connell was involved in UK research that found the philosophy of any given maternity unit is also influential. “If you have a high section rate, you have a high instrumental delivery rate, you have a high intervention rate.”
The fear of litigation is there, he agrees, but not a significant factor. “I don’t stand and look at a person and think I’m going to do a Caesarean section because I might be sued.”
On the point of foetal heart monitoring, he says it has been shown that as long as it is accompanied by sampling of the foetal blood, it does not increase the rate of sections. Where the sampling is not done, twice as many sections will be performed for foetal distress.
Other possible reasons for the rise include the influence of immigration, he suggests. “I am not saying it is a massive contribution but it may be. There are a lot of health issues that come with a lot of our immigrants.”
The impact of increasing obesity is also not clear. “There is a feeling that obesity predisposes more C-sections on the basis that obese women are more likely to develop diabetes, more likely to have bigger babies, more likely to have problems delivering the baby.”
In Dublin’s three public maternity hospitals, the principal increase has been among women who have had previous Caesareans, he says, and patients’ wishes will often determine that.
The Master of the Coombe Women and Infants University Hospital in Dublin, Dr Chris Fitzpatrick, says his hospital, which currently has a Caesarean section rate of about 25 per cent, supports the development of midwifery-led units for low-risk mothers within our women and infants hospitals.
“Evidence suggests,” he adds, “that this less interventionalist model of care is associated with a lower Caesarean rate, together with increased rates of client satisfaction.”
Tracy Donegan, author of The Better Birth Book, is hopeful that the overload on hospitals and financial realities currently being experienced will help to shift maternity services towards more coll- aboration between consultants and midwives, and midwife-led care.
“It is going to come down to what makes sense for healthcare budgets. Obstetric care doesn’t make sense, unless a woman has complications.”
She believes changes are imminent as policymakers focus on normal birth and the cost of intervention. Positive findings are coming through in research on the few midwifery-led schemes.
“In 10 years’ time I think we will be looking at a very different maternity system,” Donegan says. “But while consultants are seen to be the experts on maternity care, I think Mary Harney is going to have her work cut out for her.”
- Useful websites: www.cuidiu-ict.ie and www.aimsireland.com
C-sections: risks versus benefits
The increased risks from birth by Caesarean section, rather than vaginal delivery, include:
- Abdominal pain
- Further surgery
- Hysterectomy
- Longer hospital stay
- Rupture of the uterus
- Blood clots
- Maternal death
- Breathing problems for the baby
- Difficulty in establishing breastfeeding
- Not having more children
- It decreases the risk of:
- Urinary incontinence
- The uterus slipping into the vagina in later years
NB: These risks do not apply to all women in all circumstances