Tuesday, June 19, 2007

It is nearly a year since we returned to Australia from Russia and here in one of the world's safest places there is more time to think about perhaps more important things. There is time to ponder the wrongs of the world or the potential wrongs of this world of which there are many. Perhaps there is too much time to ponder but, anyway, I shall continue to do so.


The medical profession is not backward when it comes to issuing warnings about what we should or should not do and never more so than in the case of pregnancy.

The list of “thou-shalt-nots” is much longer than when I had babies in the Sseventies. Most of us were sensible about smoking and drinking while pregnant, but we were not paranoid about the occasional cigarette or glass of wine. and T the main emphasis was on maintaining a nourishing diet and getting plenty of sleep. Needless to say, the scores of babies from those years have all grown into healthy adults without too much trouble, even those whose mothers continued to smoke.

But times have changed and fingers now wag censoriously, not only about tobacco and alcohol, but also about soft cheeses, salami and prepared salads -because of the risk of Listeria bacteria; canned tuna - because of mercury - and freshly- squeezed orange juice - because of Salmonella. Fresh oysters and smoked salmon also seem to be no-no’s for pregnant women these days and heaven forbid that you should dip a baby’s dummy in honey, as I confess I did more than once, because of the threat of botulism.

Needless to say, the mothers of France and Italy have spent centuries surviving the risks of runny cheese, made even riskier by the fact that they use un-pasteurized milk, and smelly sausage and no doubt continue to do so today, even while Australian women are obeying doctor’s orders and pushing away the plate. Not only that, they have been quaffing their glass or two of wine a day without, it seems, any discernible damage to the bodies or minds of their children.

While heavy smoking and/or drinking must represent a risk to babies, in the same way as does that poor diet does, the reality is that the other ‘risks’ are slight. One can understand that, given the litigious nature of today’s society and the ‘nanny’ approach of governments, the medical profession feels obliged to point out any and all potential risks, no matter how small they may be.

Which makes it all the more surprising that one serious risk factor – elective caesarean – is not only not the focus of a censorious finger, but is all too often, supported, by omission or commission, by the medical profession. Is this a case of a double standards, in that elective caesareans are financially profitable both in the here and now and in a variety of possible futures, in a way that camembert
and mettwurst mettwurst are not?

There is no doubt that, while the consumption of soft cheeses and sausage amongst pregnant women in Australia has taken a dramatic dive in recent years, the rate of elective caesareans has gone up to such a degree that Australia has one of the highest rates in the western world. Some 40 per cent of all births in this country are caesareans. and s Some medical experts believe they will soon become the norm, despite the fact that the World Health Organisation considers any rate higher than 15 per cent to be an indicator of “‘inappropriate usage.”’

So why are women who live in fear of soft cheeses opting for major surgery which has risks both for the mother and her unborn child? And where are the warnings informing pregnant women that, not only do caesareans increase the risk of unexplained stillbirth following pregnancy, as stated in a 2003 study in the British medical journal, “The Lancet”; but has the following impacts:

— that aA caesarean affects the placenta's ability to provide optimum levels of oxygen and nutrients to a future baby;
— that Aa caesarean carries with it the risk of life-threatening uterine rupture;
— that Ffollowing a caesarean, women are at greater risk of bleeding, bladder injury, ongoing pelvic pain, wound infection and deep vein thrombosis;
— that Yyour body will still undergo ‘contractions’ to varying degrees, because it continues to do what it believes it needs to do …. but with a painful wound in your belly;
— that Bbreastfeeding and caring for a baby with stitches following surgery is both inconvenient and painful;
— that tThis is major surgery which will scar your uterus and have implications for further pregnancies - only 20 per cent of women in Australia who have a caesarean go on to have a vaginal birth later;
— and that the reality of Aa caesarean is that it is major surgery and your body will be in pain and in shock for weeks after the birth, at a time when all you want to do is enjoy your new baby and a return to normal life?

In the September 2006 issue of “Obstetrics and GynecologyGynaecology”, a group of French researchers found that the rate of maternal death from C-section was three times that of vaginal delivery, due mostly to increased risk of blood clots, infections, and complications from anaesthesia. In addition, the first study to examine risks to babies born via elective ceasarean, published recently in “Birth”, reported that, in 6 six million births, the risk of death to newborns delivered vaginally was 0.62 per thousand 1,000 live births, versus compared with 1.77 for those delivered by elective C-section.

Women who have their first child by caesarean are more likely to have placenta-related problems in their second pregnancy, the research suggests indicates. The risk of a placenta attaching low down in the womb or rupturing increases by almost 50 per cent, data from 5 five million pregnancies shows. Both conditions cause bleeding during pregnancy, the report warned. A low placenta on a scar is a dangerous situation and one of the most frightening in obstetrics. In mothers who had their first baby by caesarean, the risk of placental praevia - a condition where the placenta attaches over or near the internal opening of the cervix - was 47 per cent higher in their second pregnancy than of women who gave birth naturally.

The risk of a second condition, placenta abruption - where the placenta separates from the womb prematurely - was 40 per cent higher in women who had a previous caesarean. The researchers said scarring inside the womb caused by caesareans may affect the attachment of the placenta in future pregnancies, which then has an impact on the ability of the foetus to be nourished.

Study leader Dr Qiuying Yang, of from the University of Ottawa in Canada, said the study was the largest to- date and showed an important link between caesareans and subsequent pregnancy complications.

“More than 1 one per cent of pregnancies with a prior caesarean section had one of these events, which had a 50 per cent increase compared to women without previous caesarean section,” he said.

“This has important implications on the management of these pregnancies. It also introduces new and important evidence in the debate on the risks of caesarean sections ‘on demand’.”

Beyond the negatives associated with caesarean delivery, there are the positives of vaginal birth. Not surprisingly, Mother Nature has good reasons for doing what she does. Labour is important to both mother and baby, because of the hormones which are released . in the process. In addition, as the baby passes through the birth canal, the squeezing removes any fluid from the lungs. This is crucial in newborn babies, where the ability to breathe well impacts upon brain function.

Another plus in Nature’s way is that the baby gets the benefits of its mother’s bacteria as it passes through the birth canal. Normally, these quickly take up residence in the newborn’s gut and provide increased immunity. Caesareans can change or delay beneficial bacteria making their home in the baby’s intestinal tract. and Iit is now believed, following intensive studies, that this is the reason why such babies have a dramatically increased risk of food allergy, some 106 per cent, and infant diarrheadiarrhoea, by 46 per cent. It perhaps also offers some insight into as to why allergies have made such an astronomical rise in Western societiesnations. The current medical view is that our homes are ‘too clean,’ and the Americans have even gone so far as to create a ‘dirt pill’ to give to children. The real answer may well be that there is too much medical intervention in childbirth, in general, and too many caesareans, in particular.

There’s a paradox here which that remains unexplained and which is not in the interests of mother or baby. It is hardly surprising perhaps that the women in this country who are most likely to have a caesarean are first-time mothers aged in their mid-30’s, with private health insurance. An Australian Institute of Health and Welfare report shows that caesarean rates are 15.9 per cent for mothers under 20 and that this rate rises to 43.2 per cent for women over 40.

No-one is denying denies that caesareans are life-savers in certain situations, but there is no reason why age isshould be, by necessity, a factor. Like many women of her generation, my mother had her fifth child at 40, in a natural birth. My sister had her first child at 43, and perhaps, unlike many women of her generation, also naturally. Women have been giving birth in their forties for generations. It may be unusual to start having children at 40, as we see today, but there is nothing unusual about giving birth naturally in our forties.

And tThen there is the psychological side of it, where, unsurprisingly, studies show that the self-esteem of first-time mothers is highest for women who have vaginal births.

“Women who had caesarean deliveries were significantly more likely to experience a deteriorationdeterioration in mood and in self-esteem,” said a report in the “AAustralia & New Zealand Journal of Psychiatry”. And a fact sheet published by The International Caesarean Awareness Network states that a caesarean can lead to “psychological outcomes such as negative feelings, fear, guilt, anger, and post-partum depression”.

A midwife to whom I spoke said: “Look at it this way - . Wwhen a woman gives birth herself she feels empowered. When a woman gives away that opportunity, or right, she feels disempowered. There’s a difference between having a caesarean because you have no choice and it is being done to save your baby- and choosing to have one for convenience. Caring for your first baby can be scary and the more empowered you have been by the birth experience, the more you will be able to trust that you can do the job. Women who have been disempowered will lack that trust in themselves and that can lead to post-natal depression.”

A recent study by Perth's Telethon Institute for Child Health Research of more than 430,000 births over 20 years found that the rapid increase in caesarean deliveries was instead caused by ‘societal’ factors - including a fear of natural birth and a misunderstanding of the risks of surgery. It shows that the likelihood of a woman having an elective caesarean more than doubled from 1984 to 2003, even after taking into account various medical and demographic factors, including the risks associated with higher maternal age.

The likelihood of an emergency caesarean rose by nearly 90 per cent over the same period, according to the study. by experts from Perth's Telethon Institute for Child Health Research.

Study co-author Professor Fiona Stanley, director of the Telethon Institute, said the findings “suggest there's some social or lifestyle factors that may be influencing women” to ask their obstetricians for a caesarean.

Rising caesarean rates have already sparked alarm in Australia. Last month, NSW Health issued new guidelines to its obstetric staff, stipulating that “maternal request on its own is not an indication for elective caesarean section” and any more specific reasons had to be discussed and recorded.

“If you are going to have something that's expensive, you have to justify it clinically, other than saying mothers just want it because they are 'too posh to push' or that obstetricians may be worried about being sued,” said Prof.essor Stanley, the director of the Telethon Institute.

It’s all a bit too easy to accuse women of being ‘too posh to push’ when the overwhelming majority of them, once they become pregnant, want only what is best for their baby. The other reality is that most people do not challenge doctors over their advice, and never more so than when a woman is pregnant, particularly with a first child and has not only her life to consider, but that of her baby.

As with many other things, like antibiotic use, the blame - it seems - is put on the patient, not the doctor, when logic suggests that generally, people do what their doctors tell them to do, rather than the other way around. Women may well choose to discuss all of their birth options, including caesarean, but I doubt that many would demand a surgical birth if their doctor advised them that it was not in the best interests of either baby or mother and described, in detail, the many disadvantages.
It is an insult to suggest that our soaring caesarean rates are the result of women being selfish and cowardly, when common sense dictates that the person most likely to be ‘calling the shots’ is the doctor. If as much effort was put into warning women about the risks associated with caesareans as goes into warning them about what they eat and drink, I have no doubt that Australia’s caesarean rate would take a dramatic dive. First and foremost, women want what is best for their babies, no matter how inconvenient or difficult it may be for them personally. They also want the information which will enable them to make the decisions about what is best for their babies and - when it comes to caesareans -they are simply not getting it.


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