Dear Ozmid
Here’s some interesting reading posted to the Maternity Coalition by our man
in Qld, Bruce Teakle. Those of you who read the Courier Mail may have seen
it. There are lots of points that are begging response in the form of well
crafted letters to the editor.
To inspre you I enclose also Bruce's wonderfull thorough response
Denise Hynd
Caesarean sections a legitimate choice
David Molloy
30jun04
Reproductive freedom for women includes choosing how they'll give birth,
argues David Molloy.
Caesarean section rates are always controversial. Interest in pregnancy and
the birthing process is an inherent part of human nature.
Strangers pat pregnant women on the stomach in supermarket queues and stop
to admire their newborn babies in strollers.
Caesarean section rates, therefore, are an emotive issue.
There are groups who fervently believe that natural childbirth by vaginal
delivery is almost the only acceptable method of delivery and represents the
ultimate bonding experience between mother and baby.
However, caesarean section rates are rising. They now represent about 23
per cent of all deliveries in Australia and the rate is going up every year.
There are four main drivers for this – patient request, litigation,
increasing maternal age and second-generation caesarean section for women
who inherited a difficult pelvis from their mother and were delivered by
caesarean section themselves.
The most important is patient choice. Women are requesting caesarean
section as their preferred mode of delivery. There is good data to show
elective caesarean section performed under a spinal block with antibiotic
cover has the same risks for mother and baby as when the delivery is
performed vaginally.
Caesarean section, effectively a vaginal bypass procedure, will reduce (but
not negate) the risk of subsequent vaginal prolapse and the need for pelvic
floor surgery in later years.
Modern, emancipated women are increasingly exercising their right to choose
by deciding that a planned caesarean section is their preferred mode of
delivery. This is not a decision lightly made. Most patients carefully
research the subject using a wide range of references including their
birthing classes.
What seems to have great influence on their decision-making process is
talking to their friends and mothers who have had vaginal deliveries and
face up to a year of pelvic floor exercises with occasional urinary and
flatal incontinence as constant irritants.
It can be argued that women exercising their rights to choose a mode of
delivery is a logical end point in female reproductive emancipation. For
centuries women have been limited in their lifestyle and career choices by
their reproductive systems. All of that began to change with the
introduction of safe contraception, especially the Pill, in the 1960s.
Reproductive emancipation is now enhanced by many contraceptive choices,
the provision of safe termination of pregnancy services, in vitro
fertilisation and other infertility treatment, which includes oocyte (egg)
freezing as a method of insurance against reproductive ageing, and good
childbirth education classes.
When childbirth education classes were introduced it was assumed informed
women would reject technology and medical interference and opt for the most
natural childbirth choices available. It is a great irony that this has
turned out not to be the case.
Informed women increasingly are choosing pain relief and surgical delivery,
which fits the pattern of their otherwise busy, productive and
technology-based lifestyles.
Elective caesarean section provides them with definition and control over
their birthing process, including knowing the exact time their babies are
delivered up to a month or two in advance.
The fact that many women are making these choices is driving the natural
birth lobby bananas.
A majority of women will continue to choose natural childbirth as their
preferred option and so they should. However, lobby groups should not seek
to take away the full spectrum of birthing choices for women. They attempt
to bully women only into their way of doing things.
Women can now choose when they become pregnant, get assistance if they are
have trouble falling pregnant and finally choose when and how they will have
their babies.
There are now lots of safe ways to have a baby and women's choices need to
be respected and protected.
• Dr David Molloy is president of AMA Queensland and vice-president of the
National Association of Obstetricians and Gynaecologists.
© Queensland Newspapers
Published Courier Mail 6/7/2004
Choices Cut From Birthing Options
Bruce Teakle
A woman should have the right to choose a caesarean delivery, but don’t
blame women for Queensland’s extreme caesarean rate.
In the Courier Mail last week "Caesarean Sections a Legitimate Choice"
Queensland Australian Medical Association President David Molloy argued that
women’s lifestyle choices, failing bodies and inclination to sue were
responsible for Queensland’s current caesarean epidemic.
Nearly one third (31%) of Queensland births are by caesarean, increasing by
1% to 2% of births per year, and much higher than other similar countries.
Considering the stress this puts on health resources (costing 2 – 5 times as
much as a normal birth), and the well established additional health risks to
women and babies, it is certainly timely to consider what is, and isn’t,
driving this change.
The claim that rising caesarean rates are being driven by women’s request is
completely unsupported by evidence. A recent Griffith University survey of
expectant Queensland women reported that under 1% of women preferred a
caesarean, in the absence of a medical need or a previously traumatic birth.
The British National Health Service reports that just over 1% of births are
caesareans soley by women’s request. In Britain several times more women
choose a homebirth than choose a caesarean, and both choices are respected.
No figures on this are kept by Queensland Health.
Also, the portrayal of birthing women as a mob of litigants looking for a
quick buck is another myth lacking supporting evidence. Changes to state
laws have made it very difficult to sue for poor birth outcomes, and federal
funds are available for large payouts, but caesarean rates continue to rise.
If, as Molloy seems to imply, major surgery is being done on healthy
pregnant women purely to reduce professional indemnity premiums, then
doctors, mothers and the Health Minister need to act urgently to find the
real facts and develop a solution which meets everyone’s needs.
The increasing age of mothers does have an effect on the ease of birth, but
in the Netherlands, where maternal age is also increasing, the caesarean
rate is 12% and birth outcomes are excellent.
Molloy claims that a high proportion of todays mothers have "difficult
pelvises" because their mothers had caesareans. Why hasn’t evolution had the
same effect on women in other countries? In New Zealand and Britain, 21%
caesarean rates are understood as a public health problem, not a sign of
genetic decline.
If we can’t blame women for the caesarean epidemic, what are they driving
factors?
Private obstetricians are frequently heavily booked and overworked, and don’
t have the time to wait all night for women to give birth normally.
Medicare and private insurance provide financial incentives for caesareans.
Also, Medicare gives a monopoly in birth care to doctors, excluding
midwives.
Taxpayer subsidies to private care are drawing women to private hospitals
with extremely high caesarean rates.
Models of care designed to support normal birth are not generally available
to women in the public or private systems. Also, State and Federal
governments have ignored all these problems, and excluded women from policy
development.
When Molloy states that there is a "full spectrum of birthing choices"
available, he is presumably referring to obstetrician controlled care in a
public hospital, or obstetrician controlled care in a private hospital.
Molloy forgets that Queensland women cannot access the choice made by most
New Zealand, British, and Dutch women: one-to-one care from a
community-based midwife working collaboratively with doctors, obstetricians
and hospitals.
Strong evidence shows that for a healthy woman in normal pregnancy,
one-to-one midwifery care gives excellent outcomes for women and babies, at
lower cost to the health system and with lower caesarean rates. This model
has a consensus of support from Australia’s maternity consumer groups,
midwifery groups, and nursing groups and unions. In other Australian states
implementation has already begun, with support from medical advisory groups.
Last month Victoria announced a major shake-up of its maternity services
that will expand midwife-led births, including a $500,000-a-year emergency
service to whisk mothers and their babies to larger hospitals during
midwife-led births if complications arise, and another $450,000 to train
doctors and midwives.
Some women prefer a caesarean. Their choice must be respected and it appears
they have access to that choice. Other women just want to have a normal
birth, but our current services are failing to support that preference,
causing health funding to be drained by many unwanted and avoidable
caesarean operations.
Given Dr Molloy’s stated strong support for choice, what will the AMA’s
position be on reforming Medicare and Queensland’s maternity care policy,
and supporting community-based midwifery as another choice for Queensland’s
mothers?
Bruce Teakle is President of the Queensland Branch of Maternity Coalition
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