11 April 2007

new elective caesar policy

This article is causing some profoundly mixed emotions for me. On one hand, it's truly fantastic that the NSW government (that's New South Wales, the most populous state of Australia for non-Australian readers) has acknowledged that not only is the rate of elective caesareans increasing but that it is also possibly endangering the lives of women who are uneducated about the procedure.

However, I have strong feelings about taking women's responsibility for their own bodies away from them and giving control over to the government to decide what is best for birth. Clearly, major abdominal surgery is a significant leap from vaginal delivery but is it really fair to insist that women must not have a technologised or interventionist birth if that is what they really want? Sure, some of you might say 'Well, how does she know what she wants if she doesn't know the risks?' That goes without saying but adult decision making is kind of like that. We make decisions about lots of things without knowing all of the associated risks. With birth, it seems like everyone seems to know what's best for pregnant women except women themselves.

We dont have to agree with the choices other women make but I think we need to respect them. I might not choose to have an elective caesar but I don't think my choice not to have one should prevent another woman from having one if that is what she feels comfortable doing. I think it would be a completely different story if for instance, the NSW government decided to ban women from having pain-reducing drugs during labour because pain relief is non-surgical. All of the most common pain killing drugs have side effects and there is plenty of research to support that. Hell, epidurals are injected into the spine. That's a major risk; but women who want to have less pain in labour should never be forced to 'suffer' needlessly and many women are willing to take a risk to be comfortable. I think this is the same issue. Maybe it seems a little strange to some of us that a woman would rather have surgery than give birth vaginally but in my own work, I have interviewed a number of women who have had elective caesars for various reasons. Fear of pain is a primary reason and who can really fault them for that? It's not my place to do so and it's not the government's place either. Women need to make up their own minds about how they have their babies. Caesareans should remain an 'option' because women should have every opportunity available to them to have a comfortable birth and if that means being cut open, who am I to judge?

Caesars can either serve or impair women's agency not so much by the inherent character of the procedure (in terms of obvious physical risks), but in how the politics surrounding elective caesareans coalesces with the needs of variously situated women (economically and politically and also varying by race, class, and sexuality). What is 'good' for some women is not necessarily appropriate for all women.

NSW hospitals move to block caesarean option
7 April 2007, The Age

WOMEN will not be allowed to insist on caesarean deliveries in NSW public hospitals without a medical reason, under a new health department policy. Under the new rules, women must be told in detail about "the benefits and risks of caesarean section compared with vaginal birth specific to the woman and her pregnancy". The policy cites a US study of more than 5 million births, which found that babies born by medically unnecessary caesarean were three times as likely to die in the newborn period as those born vaginally.The new policy also obliges health professionals to advise women about the implications for subsequent pregnancies. A 2005 study of 136,000 second pregnancies across NSW found those women who had had a caesarean first delivery were at much greater danger of a ruptured uterus, hysterectomy orinfection, while their babies were more likely to be premature, have serious breathing problems or need intensive care. Elective caesareans have increased by 25 per cent since 2001, and now account for one in six births. Many of these are for medical reasons, but doctors say more women are opting for caesareans from preference. Andrew Child, a member of the NSW Health Maternal and Perinatal Committee,which drafted the directive, said that while first caesareans were generally safe, dangers escalated steeply with subsequent births. Hannah Dahlen, secretary of the NSW Midwives Association, said: "People are... thinking of it as just another option for birth, rather than major abdominal surgery."JULIE ROBOTHAM


Sazz said...

This is one of those issues I think we're might disagree on :) I'm thrilled that NSW government has decided that caesareans should only be preformed for medical reasons (it sounds like common sense to me).

I believe it is medically irresponsible for wimmin to be given the impression that caesarean is just another way to birth because of the risks associated with it. I would also prefer it if the health risks and and problems associated with pain relief drugs were more widely known. Before I was aware of how the body's hormones and the synthetic hormones worked I wouldn't have thought twice about using pain medication in birth, but now I'd rather explore pain relief methods that allow my natural hormones to do their job(see Sarah Buckley MD http://www.sarahjbuckley.com/articles/ecstatic-birth.htm)

I have massive problems with the concept of "choice" (as I've bloged about), given the context wimmin make so-called choices in (i.e. patriarchy generally, but specifically male-dominated medicine, and reproductive health care that is not based on evidence-based reserach).

A really great article I read about "choosing caesareans" was written by Marsden Wagner, M.D.M.S.P.H. "Choosing Caesarean Section" The Lancet, vol 356, pp 1677-80, November 11, 2000.
it's accessible here: http://www.marsdenwagner.com/chooseall.html.

Ultimately, I think that the NSW government has taken responsible action against the suspiciously high rates of caeasearn in Australia. Something I wish every Australian state would do, so that hopefully one day soon we'll be down to the "10-15%" caesarean rate for any one region, as The Fortelesa Declaration (World Health Organization) recommends.

Anonymous said...

I agree with Sazz,
I think its a about time that there was some policy decsions around caesarean birth. Caesarean surgery is a risky procedure for both mothers and babies and there are ethical issues here too. The Federation of International Gyneacologists and Obsetricians (FIGO) states that elective caesarean without medical indication can not be ethically justified due because there are no benefits and many risks to the procedure. I agree with Sazz that it is "medically irresponsible for women to be given the impression that caesarean is just another way to birth" - its not just another way to give birth, its an emergency procedure that has become more and more widely used for non-emergency births. Women can't go into hosptial and ask for an organ to be removed without medical reason, so why should we be able to go and ask for non-necessary surgery?
The choice argument in regard to caesarean birth is a contenious and problematic one. we have media and doctors telling us that women are demanding elective caesarean in increasng numbers (as this newspaper article highlighted here does.) However research internationally and in Australia shows that very few women actually choose caesarean without a doctor's reccomendation or percieved medical necessity. THe context in which women make decsions about caesareans also needs to be acknowledged: if women are making these decisions in the context of medical knowledge that distrusts and pathologises vaginal birth and presents vaginal birth as risky, dangerous and disfiguring, are they really making informed choices?
THe power relationship between women and their doctors also needs to be considered when understanding decsions around elective c-sections. Most women trust thier docotors and take that advice without question.
The choice/elective c-section arguement also conceals the real reasons behind the skyrocketing caesrean rate which is first time so called 'emergency' caesers resulting from the mismangement of labour and birth and then the discourgament of VBAC (vaginal birth after caesrean) resulting in most women having repeat caesrean surgery for 2nd and subsequent babies.
While the NSW intiative is a good start, I can't wait for the day I open the paper and see that there is an national inquiry into the obscene caesarean rate in this country, that does not blame women who are 'too posh to puch' for the rise, but looks at all the converging factors that contribute too it.

A really good feminist perspective on the debate is "Choosing Caesarean Section- Feminism and the politics of childbirth" by Catherine Beckett in 'Feminist Theory'journal- not availble on line unfortunatley...

Sazz said...

Great comment Monica. And thanks for the suggested reading.

I was inspired by Meredith, and couldn't stop writing after posting my comment the other day :) so I wrote about the same issue at length on my blog. And I touched on some of the issues you raised in your comment, Monica.

If anyone is interested you can check it out:

Anonymous said...

I couldn't agree more!

I wonder how this will effect the obstetrics industry & thier (sometime) culpability in the inadvertant promotion of caesarians. All too often I hear "Oh my OB told me the baby was too big, my pelvis was too small, baby was too high up in the birth canal" etc etc & I feel robbed on behalf of these women.

Surely all this convenient mis-information is suggestive in the extreme for women who are experiencing misgivings & fear regarding the birth process.

This can only add to easy options for women choosing caesareans.

Nb. After all the baby/pregnancy/parenting websites I have looked at what a great relief to finally see one simply presenting articles & information WITHOUT bias or inflamitory opinions. Well done!

nixthings said...

Hmm. Great idea in principle. All women should be educated so they can be empowered to make a CHOICE. I do worry very much that doctors can decide what is right for a woman. For eg. the opposite situation when women have to quite literally FIGHT for the right to NOT have a caesarian when they want a VBAC (oh everyone is oh so helpful until the final trimester when suddenly you are told you are putting your baby's life at risk by your choices) and when again when women have to FIGHT to not have an induction if they go over term. Funny thing is - in both of these situations it is because the woman is educated about the risks that she is wanting something different to the doctor. Black and white blanket laws regarding women make me very nervous.

Anonymous said...

I have no problem with c-sections only for medical reasons. Why not make it like abortions where the "mental and physical" health of the mother (and in this case baby too) are considered. C-sections are slightly riskier for the mother but LESS risky for the baby in almost all cases. So in lots of cases the medical reasons will be the BABY's health not the mothers - there will be a trade off and women WILL be getting them at some risk to themselves for the sake of sparing their babies extra risk. Sounds like a natural kind of decision to me.

So the definition of medical reasons is not as simple as Ms Fashion-Celebrity-obsessed blogger thinks.

Second let's dispel this "major surgery" nonsense ok? Yes a c-section is "major surgery". Do you know what the definition of "major surgery" is? It is anything that can't be done with local anesthetic. So getting my wisdom teeth out (under general anesthetic) was major surgery, getting my appendix out was major surgery, getting my very badly ingrown toenail out was also major surgery.

If you're going to argue that c-sections are too dangerous then argue that but leave the tag "major surgery" at the door. Sounds so important and is virtually meaningless. Anything worthwhile is major surgery by the profession's definition.

By all means restrict c-sections to medical reasons, I applaud that. But be aware that your definition of medical reasons (probably the mother has a 75% chance of death or something stupid) and a sensible definition are 2 different things. Also understand that major surgery is NOT necessarily A BIG DEAL. It can be. But the tag "major surgery" is not what makes it a big deal.

Anonymous said...

A question fo sazz - I so agree that I too "have massive problems with the concept of "choice", ..given the context wimmin make so-called choices".

In my case it is women being propagandized by midwives and doulas that epidurals are a sign of weakness, or because the woman feels incapable of birth.

Given that propaganda I don't think any woman rationally chooses to go without pain relief.

So your choice argument cuts both ways since I'm sure you think epidurals are poison.

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