`Nobody forgets their experience of childbirth - whether for good or bad reasons." It's a simple comment which for many women holds the key to their physical health and sometimes even emotional well-being long after having a baby. It was the opening comment of Sue Jameson, president of Cuidiu, the Irish Childbirth Trust, at last week's launch of Preparing Together for Birth and Beyond - a consumer guide to the maternity services in Ireland.
The guide presents statistics for the rates of Caesarean sections, epidural anaesthetics, deliveries with forceps (curved metal tongs) or ventouse (a suction cap), episiotomies (which involve cutting the tissues behind the entrance to the vagina to ease the delivery of the baby) and breast-feeding in 24 maternity units in the Republic. It shows there's a huge variation in the figures between the hospitals.
It seems that if your baby is to be born at the Rotunda Hospital, Dublin, at the all-private Mount Carmel Hospital, Dublin, the all-private Bon Secours Hospital in Cork or St Munchin's Maternity Hospital in Limerick, you have an almost one in four chance of having a Caesarean section (22 per cent of deliveries are by Caesarean section at the Rotunda, 23.4 per cent at Mount Carmel, 23.1 per cent at the Bon Secours and 24.58 per cent at St Munchin's), whereas if you attend the Coombe Women's Hospital, Dublin or the National Maternity Hospital, Dublin, your chances of having a Caesarean section are one in seven or one in eight. (Caesarean rates are 14.6 per cent in the Coombe and 12.5 per cent at the National Maternity Hospital.) The World Health Organisation, meanwhile, sets the maximum acceptable levels for Caesarean sections at 15 per cent.
Dr Mary Henry, physician at the Rotunda Hospital, who launched the Cuidiu guide, says that unfortunately she believes the rate of Caesarean sections may be so high in some hospitals due to fears of litigation.
"This is very unfortunate because there is an increased risk to the mother with a Caesarean section, and it really would be better if Caesarean sections only took place for good medical reasons. The increased risks include pulmonary embolism, which are clots to the chest from the legs, infection of the wound, and problems associated with an operation which involves a longer recovery period."
Dr Henry's comments were echoed in a recent report in the British Medical Journal which stated that "the number of babies being delivered surgically has doubled or tripled at many maternity units in Ireland during the past 10 years". Reasons cited in this report were: more older women having babies; an increased tendency among patients to resort to litigation; doctors' wanting to speed up birth; patients' preferences; and a better detection of foetal distress. Orla Hastings, a mother of two whose second child was delivered by Caesarean section, says: "A Caesarean section saved both my baby's life and my own but I believe Caesarean sections chosen for convenience need to be discouraged. It's a major abdominal operation requiring a longer recovery, which makes it more difficult to look after a new baby."
The new Cuidiu guide also shows an increased use of foetal monitoring during labour in many hospitals (the National Maternity Hospital states that 65 per cent of mothers in labour on their first baby are monitored, while 30 per cent of those in labour on second or subsequent babies are monitored). "The use of electronic monitoring during labour has not been shown to improve the outcome, and I think fear of litigation is present here too because if, as a doctor, you can say you monitored the foetal movements all the time during labour, the judge may be more sympathetic," says Dr Henry.
Epidural rates also vary hugely from hospital to hospital. For example, 90 per cent of first-time mothers (74 per cent of mothers on subsequent births) have epidurals in Mount Carmel hospital, and 80 per cent of first-time mothers (60 per cent of mothers on subsequent births) have epidurals at the Portiuncula Hospital in Ballinasloe, Co Galway, while only 4.5 per cent of mothers at Letterkenny General Hospital have epidurals (due to a limited service) and six per cent of first-time mothers (and three per cent of mothers on subsequent births) have epidurals at Longford/Westmeath General Hospital in Mullingar, Co Westmeath. (This figure has subsequently risen to about 20 per cent, according to Dr David Mortell, obstetrician at Longford/Westmeath General Hospital, since the implementation of a full epidural service in January 1999).
The epidural rate in Cork city also varies hugely. St Finbarr's Hospital records that 16.7 per cent of women have epidurals, while the Bon Secours Maternity Hospital states that 69.85 per cent of their mothers have epidurals. As a measure of comparison, one notes that the overall epidural uptake in Australia is 30 per cent.
While there is general acknowledgement that epidurals are "promoted" more in some hospitals and availability is an also an issue in some places, it is also interesting to note that the highest rates are in private hospitals. Does this mean women choosing private maternity services have a lower tolerance to pain or that epidurals are given to them more freely on request?
When questioned on why they think such variations in maternity services exist, the Irish Childbirth Trust says it is not in a position to comment.
"We are here to provide the information," says Sue Jameson. "We didn't set out to select the best or the worst but to give people the chance to know what is available. We have, however, noted an increase in instrumental deliveries and we would ask the Department of Health to look into this and also to look into why rates in different hospitals vary so much."
Expressing her personal view, however, Jameson adds that the increased expectation of a perfect pain-free birth among some women can mean the likelihood of intervention increases. "Intervention must happen to save lives, and lots of babies I know wouldn't be here if it wasn't for intervention but the infant mortality is probably as low as it's going to get and further down the road we go towards that perfect, pain-free birth we go, the likelihood for intervention increases."
Dr Muiris Houston, Irish Times medical correspondent, believes the varying rates of Caesarean sections reflect an overall debate within obstetrics regarding when a Caesarean section is appropriate, as well as overall trends towards more elective Caesarean sections. "Generally speaking, there is a trial of vaginal delivery, and if the baby shows certain signs of distress, some hospitals will opt for a Caesarean section more quickly than others. The theory behind having Caesarean sections earlier is to avoid any likelihood of the baby showing signs of oxygen depletion at birth and possibly cerebral palsy.
Dr Houston adds that the rate of epidurals is linked to the availability of anaesthetists, as well as and the fact that the procedure is "slightly trendy". The consequences of epidurals, he explains, are that there is a definite link to a forceps/ventouse delivery and the woman is much more likely to have a surgical episiotomy, which means stitches.
The medicalisation of childbirth is an old debate which has often divided women into two camps - the home or natural birthers versus those who opt for high-tech, pain-free birth. However, Kaye Marshall, former head physiotherapist at the Rotunda Hospital who now runs a pelvis floor clinic in Dublin, believes regardless of which type of birth women will ultimately choose, they need to be better informed about the long-term effects of some interventions.
"Much recent research has demonstrated that childbirth is a major cause of many bladder and bowel problems in young females. Some of this is related to obstetric injury when the structure of the pelvis floor is damaged due to tears and bruising during a prolonged second stage of labour (i.e. the pushing stage)," says Marshall.
She points out that the significant contributing factors to urinary and, in some cases, faecal incontinence are "a prolonged second stage of labour on your first baby, an instrumental delivery, an episiotomy and an epidural". Seventy per cent of those who suffer incontinence can, however, be completely cured if treated sooner rather than later. The Irish Childbirth Trust guide also shows large variations in deliveries aided by forceps and ventouse in different hospitals.
If women were better informed of the risks of epidurals, forceps/vacuum deliveries and Caesarean sections, one wonders if the high rates of such interventions in some hospitals might be reversed.
Preparing Together for Birth and Beyond - a Consumer Guide to the Maternity Services in Ireland is available at a cost of £3 from Cuidiu - Irish Childbirth Trust at Carmichael House, North Brunswick Street, Dublin 7 (01-8724501)