Important Guardian article on Birth Choice and Risk – but see ACOG and RCOG Recommendations

Pelvic floor damageToday’s Guardian article, Women have the right to know about injuries of vaginal birth beforehand, has garnered much praise and support, and rightly so.

However, until maternity recommendations, policies and information leaflets are updated, vaginal birth risks will continue to be hidden or downplayed.

Even more importantly, arbitrary targets to reduce caesarean rates will continue to come before mothers’ and babies’ health outcomes, and women’s autonomy.

IMPORTANT:

In October 2015, ACOG Urges More Frequent Use of Operative Vaginal Delivery with the precise aim of avoiding and reducing caesarean use.
 In August 2012, RCOG guidance urges CCGs to increase births without epidurals and reduce caesarean rates to 20% (“It is important to try to increase [the] rate [of] vaginal birth, which includes delivery by forceps and ventouse.”).

Why are doctors, who understand the pelvic floor damage that women can suffer, encouraging increased forceps use, often without communicating risks or gaining informed consent?

TO PREVENT THE CAESAREAN RATE FROM CLIMBING

This is the number one objective in many maternity care policies – and indeed the underlying or express objective cited in countless research papers.

Yet my organization has (as have the BTA, BTC and ABTA) heard from women who’ve lost their careers, husbands, partners, mobility, personal interests, self esteem, dignity and (almost) sanity, as a direct result of pelvic floor injuries and their aftermath.

Worse still are those whose babies died or were injured too.

They don’t care or worry so much about the caesarean rate.

Informed Choice

Obviously, the worst case scenarios don’t affect every women who has a vaginal birth, and there are undoubtedly traumatic post-caesarean stories too.

But the point cannot be made enough – women should have the right to be informed about the risks and benefits of both birth plans, and quality indicators should be based on HEALTH OUTCOMES that don’t exclude (all) stillbirths, pelvic floor damage and maternal satisfaction.

Ultimately, different women will reach different decisions, as Sascha Callaghan and Amy Corderoy describe in The Guardian:

Two perfectly well informed, intelligent women may have totally differing opinions about the type of intervention they are comfortable with. One might feel that a vaginal birth is an experience they value highly, and that the surgery involved in a caesarean section (with its associated recovery time, potential for complications, and increasing risk with each additional pregnancy) is something they would like to avoid at almost any cost. Another women may feel her personal circumstances make vaginal delivery unappealing, and believe that if such a delivery needed forceps then it is a risk that she would not be willing to take. Many more will fall somewhere between these two views.

Are vaginal mesh injuries vaginal birth injuries?

Callaghan and Corderoy also draw attention to the Australian College of Midwives’ May 2017 submission to the Senate Community Affairs References Committee inquiry into transvaginal mesh implants and related matters, and the College’s concern that media coverage of the issue has increased fear around childbirth in many women...

“…it is important that the issues surrounding the transvaginal mesh implants are separated from the issues surrounding vaginal birth”.

Honestly – can we imagine any situation in which a surgery sought out by women to repair a specific caesarean birth injury would not be cited as a caesarean birth issue?

I’ve read the submission, and this is something else the ACM says:

The transvaginal mesh implants issue is not a reason to call for an increase in the elective caesarean section rate.

AGAIN – NOTE THE FOCUS ON THE CAESAREAN RATE

Firstly, informing women, and allowing them to choose their own birth plan, is not the same as an official ‘call for more elective caesareans‘, and secondly, where was the ‘with woman’ outcry on behalf of caesarean choice women during decades of ‘calls for more vaginal births‘?

Facts and Fear

Certainly, many women fear childbirth, but arguably the greatest fear in all of maternity and obstetrics is a rising caesarean rate.

High rates mean criticism, questions and even funding threats.

It wouldn’t be as bad if public policy was preoccupied with reducing emergency caesarean rates (those most dangerous and costly), but it’s not.

Instead, forceps are encouraged and caesarean requests are denied.

This is not patient-centred care.

This is not informed choice.

This is a litigation bill destined to rise (@Jeremy_Hunt take note).

  • Written by author and journalist Pauline Hull

 

2 comments

  1. I don’t understand why fear of litigation alone isn’t provoking doctors and trusts to make sure women sign every form under the sun when they go for vaginal birth. When I was requesting (and was denied and then later granted) a C-section I had to go through the risks at almost every appointment and I had to sign a form more than once saying I understood. Many of the risks were overplayed by the doctor trying to discourage me, or presented without stats. (NB Both my 2 C sections went ahead without complications) Are they relying on a culture of silence where women typically don’t admit their birth trauma or injuries, let alone sue? That can’t work forever, so surely informed consent covers them against litigation (though you’d like to think patient care was the motivator!)

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  2. The excellent points made in this essay are exactly the points Birth Trauma Canada has been making for decades. The response from the majority of those supposedly working ‘with women’ has been ridicule, denial or completely ignoring the facts. Vaginal mesh IS a vaginal birth problem. So are the overwhelming majority of pelvic floor disorders. The costs to women and the medical system over a woman’s life time are exorbitant and heart breaking yet those responsible for doing better by women consistently do nothing. Medical advances in obstetrics (cesarean and regional anesthesia) are deliberately discouraged. What other medical specialty would behave in such a manner? Despite being a problem for centuries women still aren’t given information to make informed choices or given the right to have their informed choices respected in quality hospitals with competent staff. Little progress has been made in understanding long standing and deadly conditions like preeclampsia, HELLP and amniotic fluid embolism. The entrenched attitude that women must achieve ‘natural’ at all costs has been a huge barrier to all medical advancement in obstetrics. None of this is patient centred. Hiding the real (and very common) risks associated with planning a vaginal birth is not informed choice. Women have never been at the apex of the obstetrics hierarchy. Medical paternalism needs to stop.

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