First published in Good Weekend, November 8, 2003
“What is normal birth? I wonder if we really know anymore. The modern birth has been so managed, arranged, choreographed, augmented, drugged, sliced and diced that many of us have forgotten its very nature.” - US veteran midwife Valerie El Halta
“To my knowledge, there has been no subject connected with medicine which has created more bitterness of feeling and animosity…” - Thomas Radford MD, Observations of the Cesarean Section, Craniotomy and on Other Obstetric Interventions (1880)
THERE ARE THREE BOYS calling for Where’s Wally and drinks of water and goodnight kisses. It is past their bedtime. “There are two ways to become unconscious,” warns their mother, Jo Bainbridge, “voluntarily and involuntarily…” (Sound of scampering feet). A birth activist and feminist, (she describes her wholly male household as the “great irony of her life”), Bainbridge is convenor of the South Australian-based Caesarean Awareness Recovery and Support (CARES) group, one of a number of organisations around the country providing support for women who have had difficult caesarean births.
Bainbridge formed CARES after the birth of her first child, Bailey, in a public hospital labour ward, in 1997. Contractions had been underway for 17 hours (not unusual for a first birth), when Bainbridge’s labour stalled, her cervix halting its slow but steady dilation, at eight centimetres – two short of the requisite 10 that will allow the baby’s head to enter the birth canal. An examination confirmed Bailey was posterior, that is facing forwards, rather than backwards.
“At that point, I was really needing somebody to tell me that everything was okay,” says Bainbridge. “I didn’t want saving from it. What I wanted was somebody to get in my inner circle and tell me I was doing good. But nobody seemed to do that.”
The obstetrician took Bainbridge’s husband outside – “a tactical move to get him on side, which I now realise is quite common”. He diagnosed “failure to progress”, said the baby wasn’t going to come out and was in distress. “I asked if I could have an epidural to try and calm down and get refocused, but they said that it was too late.” Confused by the sudden turn of events but unable to voice her doubts in the face of what was now being declared an emergency, Bainbridge was “whisked off to surgery”.
Despite the anaesthesia, Bainbridge says she could feel the first incisions, although her obstetrician assured her that she couldn’t. (The anaesthetist topped her up after she almost broke his fingers). After a few minutes, Bailey was delivered in perfect condition, with high scores on the Apgar scale that rates newborn health. The hospital notes showed his heart rate never fell below a happy 120 beats per minute – no sign of the foetal distress that instigated the rush from labour ward to operating theatre.
Recovery was hell, however. In hospital, Bainbridge’s abdominal wound became infected and later burst; she developed a painful itchy rash in reaction to the anaesthetic; and was having trouble breastfeeding. Medicated to the eyeballs and unable to pick up her child unassisted because of the surgery, Bainbridge discharged herself after four days.
“I felt really incapacitated, which was against my character,” she said. “Needing to rely on other people was wearing down my self-esteem, and the amount of pethidine, and all the other drugs they were giving me after the surgery, was really throwing my system out. I don’t even take a Panadol for a headache. I felt completely out of control.”
Before the invention of antisepsis and anaesthesia, the caesarean section – in which an infant is delivered through incisions in the mother’s abdomen and her womb – was an emergency procedure designed to save the baby’s life at the inevitable cost of the mother’s. According to popular belief, Julius Caesar was delivered by this method – hence the name – but it was more likely to have been one of his ancestors, as Caesar’s mother survived his birth. The first successful caesareans in which both parties survived were recorded late in the 19th century in Italy, aided by surgical breakthroughs involving the sterilising of instruments and the use of chloroform.
Today, about one in four Australian babies is born by caesarean, in what should be considered a “normal way of bringing a baby into the world”, according to Dr Caroline de Costa, the Australian co-author of Caesarean Section: Understanding and Celebrating Your Baby’s Birth, a book published in the US. De Costa, senior lecturer in obstetrics and gynaecology at Queenland’s Cairns Base Hospital, believes women need to be better informed about caesareans, especially those first-time mothers who arrive at the hospital armed with aromatherapy oils and birth plans and often end up feeling guilty for failing to achieve a natural birth.
“Trusted physicians reassure mothers and mothers-to-be: It’s okay to say yes,” states the blurb on the cover of de Costa’s book, which she wrote with US colleague Dr Michele Moore. And an increasing number of women are saying “yes” to caesareans, with rates across the developed world rising steadily since the 1970s. The Australian rate of 23.3 per cent, up from fewer than 5 per cent in the mid-1960s, is higher than many comparable countries and varies radically from state to state, and hospital to hospital. The 1999 Australian senate inquiry into birth practises and caesarean rates found this trend “particularly disturbing”.
Older and first-time mothers, and women with private health cover are more likely to have a caesarean than younger, second-time mothers and public patients. According to the latest figures from the Australian Institute of Health and Welfare, 35 per cent of privately insured first-time mothers aged 35 to 39 have their babies by caesarean, while some private hospitals have rates of up to 50 per cent.
Public health bodies around the world have expressed concern at rising caesarean rates, which have eclipsed the World Health Organisation (WHO) recommended rate of 10 to 15 per cent in much of the developed world. While there is no argument that in an emergency, the caesarean section is a life-saving operation for both mother and baby, what seems to be in doubt is whether or not a higher rate of caesareans saves more lives. The WHO-recommended caesarean rates were based on evidence that several countries with very low rates of mother and child mortality had caesarean rates close to 10 per cent.
Countries, like Denmark and the Netherlands, that have government-supported midwifery care, with high home birth rates of 20 to 30 per cent, and much lower caesarean rates of about 10 per cent, also boast among the world’s best maternal and perinatal health outcomes.
In his 19th century treatise on caesarean birth, English surgeon Thomas Radford claimed “there has been no subject connected with medicine which has created more bitterness of feeling and animosity”. More than a century on, caesareans are safe and the choice of millions, but the rancour continues, with midwives and obstetricians at loggerheads, as they have been for decades. And for every woman who pays homage to the medical model, there are others devastated by their surgical births.
WOMEN HAVE CAESAREANS for a range of reasons. There are medical factors, such as placenta praevia – in which the placenta partially covers the cervix (the baby’s exit), increasing the risk of a life-threatening haemorrhage; or a cord prolapse – when the umbilical cord slips into the birth canal ahead of the baby, cutting off its oxygen supply; cephalopelvic disproportion – where the baby’s head is too large to fit through the woman’s pelvis; and maternal infections – like active herpes or HIV. There are difficult births, such as the bottom-first breech baby or twins, which were once the domain of the skilled midwife or obstetrician, but which have become routine indications for caesarean in recent years (less than 13 per cent of breech babies are now delivered vaginally).
But there are the murkier waters, where reasons are less clear and where fear dwells.
Women are afraid of giving birth. They are afraid of the pain, afraid their babies will be harmed, that their bodies will fail them. “Fear is huge. It’s grown,” says independent Sydney midwife and childbirth educator Jane Palmer. “When I first started, people came to me for natural birth. These days they come because they’re just so frightened – they need information to cope with their fear.”
Gail Hancock, convenor of Perth-based caesarean support network, Birthrites, agrees. “Not only do we get fear from our mothers and our aunties and our sisters but we get it from mothers’ groups. There’s a kind of macabre fascination among women, with the horror stories – ‘I was in labour for 48 hours and tore from here to there’. And just the fact that we live in a medicalised society – if you’ve got a headache you take a pill. You don’t have to put up with pain. With birth it’s the fear about the pain that makes it more painful.”
Sydney mother Claire Sharman* said her fear about birth became so overwhelming while she was pregnant with her first child that she begged for a caesarean. “I was absolutely terrified of doing it the natural way,” she says. “I was scared of the pain. I was scared of being deformed down there afterwards because of ripping and tearing. I thought, ‘If you’re going to cut me anywhere you can cut my belly.’
“I guess from about the age of 18 when you start listening to other people’s stories, they all mount up until you’ve got one giant horror story,” says Sharman, who plans to have more children by caesarean. “It wasn’t a nice experience by any stretch, but it was the lesser of two evils.”
Obstetricians, too, are afraid of error; that they will fail to deliver on technology’s promise of a perfect baby every time; of being sued. The two most common reasons for an emergency caesarean today are foetal distress (diagnosed through the admittedly imperfect science of foetal heart-rate monitoring) and failure to progress, as edgy obstetricians practise what is known in birthing circles as “defensive obstetrics” – acting to circumvent any possible problems (and litigation) before they eventuate. Specialist obstetrician and gynaecologist at Sydney’s Prince of Wales Private Hospital Dr Jules Black has more than 30 years’ experience and thousands of births under his belt. He says he has no doubt the fear of litigation has had an impact on caesarean rates. “The prevailing attitude is: this is too hard, let’s do a caesarean,” he says.
While payments for birth-damaged babies have reached record levels – Sydney woman Calandre Simpson, who has cerebral palsy, was awarded $14.2 million by the NSW Supreme Court in 2001 (reduced to just under $11 million on appeal) for a failed forceps delivery – obstetricians are rarely criticised for unnecessary interventions. According to evidence before the 1999 senate inquiry, “nobody has been sued for doing a caesarean. Many people have been sued for failing to”.
“There is no doubt that the fear of litigation exerts a powerful influence on obstetrical practice,” according to the inquiry’s report, titled Rocking the Cradle. Caroline de Costa agrees. “Not only do I have to think about what I’ve been taught to do in this situation, I have to think about explaining it to the woman and her partner and I also might have to explain it to a court,” she says. “For an obstetrician in Australia today, that is hanging over us with everything we do.”
TRUST IN THE BIRTH PROCESS is disappearing. Instead we trust in technology – in a medically managed birth in a hospital. While the rate of home births is increasing, they still account for fewer than 1per cent of Australia’s 260,000 annual births. Most Australian women have their babies in hospitals, apart from the small number, living in urban centres, who manage to find a place in a birth centre (midwife-run birthing suites attached to public hospitals, which provide a less medical environment than the standard labour ward).
At the other end of the spectrum are independent midwives (qualified nurses trained in midwifery, working outside the hospital system), who represent the remnants of a woman-centred birthing tradition, providing one-on-one care throughout pregnancy, birth and the post-birth period. However these midwives lost their medical indemnity insurance in 2001, causing many to leave the field. The 70 or so who are still practising in Australia do so uninsured, which prevents them from working in hospitals or birth centres.
In her book The Whole Woman, Germaine Greer rails against caesareans. “The healthiest women who have ever lived on earth now have more aesareans than any others,” Greer states. “Not simply because they are rich enough to pay for them, or because birth by caesarean section is less likely to deliver a damaged child and a subsequent malpractice suit, but because patriarchal authority is relentlessly driven towards controlling the unpredictability of pregnancy and birth.”
Such issues of power and control are close to the heart of women’s growing dissatisfaction with their medically-managed births. Indeed, the Rocking the Cradle inquiry reported that women resented the takeover of birth by the medical profession, while US perinatal epidemiologist and midwifery enthusiast Marsden Wagner compares an obstetrician attending a normal birth to having a paediatric surgeon babysit a healthy two-year-old. So why do women choose to give birth in hospitals?
The primary concern of birthing women is the health of their babies and many believe that access to experts and the latest technology will ensure a safe delivery. But other women choose to birth at home, far from the experts and their machines, for the same reason.
One thing is certain. Studies have consistently shown that birth in a medical environment greatly increases the chance of intervention that frequently interrupts the natural progress of labour, initiating what is known as a “cascade effect”, where intervention begets intervention. It goes a bit like this:
A woman wakes during the night with the first of her contractions and labours at home for several hours before going to hospital, where (some combination of bright lights, hospital gown, smell of antiseptic, vaginal examination later) her labour stalls. If they have not been already, her waters are broken – manually – to help things along. Intermittent contractions follow. But in her waters, there are some signs of greenish meconium (a foetal bowel movement), which can signal distress, so she is attached to a foetal monitor and “augmented” (put on an intravenous drip that contains oxytocin to strengthen and speed up contractions).
Now the contractions are coming hard and fast and she is having trouble coping with the sudden increase in pain. Moving around, which may help her manage the pain and her labour to progress, is restricted because of the drip and the monitor. An epidural is suggested for relief. The woman agrees and a needle is inserted in her back between the vertebrae of her lower spine, followed by a tube through which the drugs are administered. She is now numb from the waist down. Movement is impossible. An internal examination shows her cervix is dilating too slowly, and, more than 24 hours into labour, there are signs that the foetal heart rate is dipping during contractions. The obstetrician arrives and says he is concerned about the wellbeing of the baby. Within 15 minutes, the woman is on the operating table.
Evidence before the Rocking the Cradle committee suggested close to 90 per cent of Australian births include some form of intervention. “Some interventions are life saving… others greatly reduce trauma… However, many appear to be almost routinely undertaken without any scientific evidence of their benefits as against their costs,” it found.
De Costa concedes there is some truth in the cascade theory. However, she describes the birth of her first baby in 1968 after a four-day labour as “an appalling experience” and commends the “efficiency” of drug-assisted, instrumental birthing. “Even independent midwives agree there is a limit to which labour should be allowed to last,” she says.
Jules Black agrees. “The radical midwives have a point. Babies are stuffed up and mismanaged. But when these interventions are done for the right reasons, they save lives. Even I, the doyen of natural birth, advocate the need to interfere at times.”
A recent opinion piece in Good Weekend (“Great Expectations”, July 12) described the epidural as “God’s gift to women” and slammed the “vocal group of childbirth zealots who rail against pain relief and ‘intervention’”. However a review of available research by international healthcare research group the Cochrane Collaboration, has linked epidurals to longer labours and increased risk of instrumental delivery or caesarean.
ANOTHER FACTOR BEHIND THE INCREASE in caesarean rates is that women are demanding them, even when there is no underlying medical reason to do so. Dubbed “too posh to push” by the British media, these women do so for convenience, out of a fear of the unknown, or the promise of a relatively pain-free birth (not taking into account the post-operative pain of major abdominal surgery). Others are concerned about birth-related pelvic-floor injuries, which may lead to faecal or urinary incontinence or to prolapse, when the pelvic organs sag and can protrude out of the vagina, requiring surgical repair.
At a conference of the Perinatal Society of Australia and New Zealand in 2001, a leading obstetrician from one of Britain’s top women’s hospitals, Nicholas Fisk, said the risks of a vaginal birth were “arguably greater than other risks society rejects such as drink driving or riding a motorbike without a helmet”. Fisk predicted that by the end of the decade more than half of all women given the choice will elect to deliver their babies by caesarean.
But a recent Norwegian study suggests that while there may be a small increased incidence of pelvic-floor damage among women who deliver their babies vaginally, the major risk factors are a hurried second stage of labour, forceps delivery and episiotomy (in which the vaginal opening is cut to avoid tearing), not natural vaginal birth per se.
“Women do pay the price, physically and emotionally, for childbirth,” says Jules Black. “But caesarean is not guaranteed to prevent pelvic-floor problems in later life. A lot of women who have their babies by caesarean still become incontinent.” And yet, of a group of British female obstetricians surveyed in 1997, one in three said they would choose a caesarean rather than a vaginal birth.
Both de Costa and Black support a woman’s right to choose a caesarean. According to Black, many of the older first-time mothers he sees in his private practise know exactly what they want. “And who am I to deny them that choice?” he says. “Of course, I ask them why. If they say it was in their tarot cards, then that’s not a good enough reason, but it’s their body, their pregnancy. I’m not going to force anything on them. Nor am I going to watch them writhing around on the floor in pain and deny them pain relief because it’s a woman’s rite of passage.”
The contentious issue seems to be whether or not these women really understand what they’re getting themselves into. Some women complain they were coerced into “choosing” caesareans. In a recent South Australian study, more than one third of women said they felt they were “not involved” in the decision to have a caesarean.
Perth mother Diana Holden, whose diabetes increased her chance of having an abnormally large baby, says her obstetrician pushed her into having a caesarean, rather than supporting her desire for a vaginal birth. “He kept saying it would be safer for me to have a caesar, but I stood by my decision until he told me this horror story about another diabetic whose baby was so big they had to dislocate its shoulder to get it out. I burst into tears and agreed to the caesarean.”
WHILE MANY WOMEN become happily absorbed in the demands of mothering once their physical wounds have healed, others bear psychological scars from their surgery. The senate inquiry drew attention to increasing evidence of “long term psycho social problems” among women who’ve had caesareans, such as difficulties bonding and breastfeeding and increased rates of postnatal depression.
“We often look after women, especially those who’ve had emergency caesars, who are depressed, disappointed and feel that they’ve done something wrong,” says de Costa. “That’s not right. The important thing is having the baby, not the method. It’s like worrying a lot about your wedding and not the person you’re marrying.” She describes these feelings as “a lot of retrospective angst”.
“You’ve got a woman in labour and she’s finding it more painful and more difficult than she thought and then you find there are some changes in the baby’s heart rate and you watch them and they don’t get any better, so you say to the parents – you’re going to be a number more hours in labour, the baby’s showing signs of being distressed. I have to say a caesarean section will deliver the baby now and the baby, I’m sure, will be healthy.
“They agree this is what we should do. Then later, there’s a lot of discussion with other people and then there’s this accusation that ‘I was pressured into it. I could have waited’. And maybe you could have, but if you don’t know, then you’ve got to make a decision at the time.”
Four months after Bailey’s birth, Jo Bainbridge began to spiral downward. “I started feeling really betrayed by the whole experience,” she says. “I talked to other women who had posterior labours who stalled and then went on to birth their babies vaginally. There were a lot of questions, doubts and frustrations. I wrote to the hospital and was basically told to go away – that I was just one of those whingeing mothers who didn’t get her fantasy birth.”
About the same time, Bainbridge began showing symptoms of post-traumatic stress disorder. “I wasn’t depressed. I was having anxiety attacks. It was like being trapped behind a piece of glass and watching this imposter be me. When my husband came home he didn’t know if he was going to find me throwing something at him as he walked in the door or crying in a corner. I was an emotional wreck.”
Around the world, in community halls and hospital rooms, in each other’s homes and in internet chat rooms, women gather to share these deeply personal stories. In Australia, the Maternity Coalition acts as an umbrella body for a number of groups that provide support, host annual conferences, lobby government and promote the national day of action, initiated by CARES and held in September each year.
The shame around their negative feelings is what keeps women silent, says Bainbridge, who realised she wasn’t the only one psychological scarred by her caesarean when she became pregnant with her second child. Scared of being pushed into a repeat surgery she organised a gathering, with the help of an independent midwife, of women who’d had caesareans and gone on to birth subsequent babies vaginally.
“What struck me was the amount of emotion this group of women had around their caesareans,” says Bainbridge. “There was one woman who drove around the block four times before she could pluck up the courage to come in, because she’d had two caesareans herself and she didn’t want to speak to anybody who’d had a vaginal birth. I felt like I’d finally found people that understood where I was coming from.”
*Names have been changed