Wednesday, October 14, 2009

Is the increasing rate of caesarean birth linked to the age of mothers?

An interesting discussion into the rise in caesareans took place on ABC Radio National's Health Report, 12 October. The transcript and the audio are available online.

The research team analysed data collected from all births in Scotland over a period of time, and identified women having an uncomplicated first pregnancy.

Here's a brief excerpt of concluding remarks in the interview:
Gordon Smith: There are a whole number of issues about caesarean section, and I think one of the things I would say it's about like the issues around hysterectomy 20 years ago, for a proportion of women a caesarean section is an extremely helpful and valuable intervention, but I think there is a general concern about it in terms of say health economics, that it's much more expensive to provide a caesarean delivery compared with normal delivery, from a philosophical approach that we should try to encourage normality and for many women we attach quite rightly a real importance to achieving a normal birth, and then there's also concerns about the long-term effects of caesarean section, effects on subsequent pregnancy, where there's certainly increased rates of complications. And particularly one of the things we're seeing now is women who've had high numbers of previous caesarean sections. They are a group of particular concern, because some of the most serious and life-threatening consequences that we see in obstetrics are occurring to women who are coming back with four and five previous caesarean sections where there can be real problems.

Norman Swan: The risk of rupture.

Gordon Smith: Risk of rupture, but also the risk of abnormal insertion of the placenta, particularly what we call placenta praevia where the placenta is in the lower part of the uterus and also what we call morbid adherence of the placenta, where the normal relationship, the way the placenta invades into the muscle is affected by the presence of scar tissue and in fact the placenta over-invades into the wall of the womb which can lead to life-threatening bleeding, which can be difficult to control even under optimal circumstances. So I think caesarean section has many advantages in a certain context, and particularly for those women who aren't planning many, many future births, but I think there's going to be an ultimate long-term consequence of increased rates of caesarean section which will become increasingly apparent over the next few decades.

Smith GCS et al. The effect of delaying childbirth on primary caesarean section rates. PLoS Medicine 2008;5(7):e144
[Gordon Smith is Professor of Obstetrics and Gynaecology at the University of Cambridge.]

How does this sort of discussion inform a midwife, or a mother anticipating birth?

"Think globally"

Epidemiological research seeks to tease out information from large sources of data. The information we glean from this sort of research helps us to understand the big picture, but it does not influence the way we approach the maternity care of an individual woman. The big picture concern that Professor Smith has identified is that the women today who are having caesarean births will, in future births, face an increased risk of life-threatening haemorrhage.

The obvious conclusion that I draw is that regardless of the age of a woman, or the 'risk' of needing caesarean, the maternity service has a duty of care to do all it can to promote and support normal birth, and to use caesarean surgery judiciously.

"Act locally"

The midwife's professional advice to a woman in her care is finely tuned to that individual woman. The midwife takes into account the woman's whole self - physical, social, psychological, spiritual ... wellbeing, as well as outside factors such as the weather conditions that may have an impact on events. The woman who is working in partnership with a trusted midwife also has knowledge about herself that she shares with her midwife as her time to give birth approaches.

Every woman giving birth has elements of her situation that may enhance or detract from her chances of proceeding with physiologically normal birth. The skilled midwife acts to promote normal birth, taking into account the realities and risks, as well as the advantages that apply to an individual mother.

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