BTCanada


The High Cost of a ‘Normal’ Birth Policy

November 17, 2016

 

A new report by Birth Trauma Canada, a group advocating for honesty in obstetrics and maternal autonomy, says current obstetric policies fail both women and health care systems.  Canada has a long history of seeking to reduce its cesarean rate on the basis it will improve women’s health and reduce health care costs.  Nothing could be further from the truth. 

‘Normal’ birth policies, in Canada, and around the world:

·         Cost health care systems billions

·         Increase rates of substandard care

·         Ignore the basic principles of medicine to full disclosure and informed consent

·         Force women to accept pain when the technological ability to safely and effectively eliminate it exists

·         Undermines quality research, medical advancement and maternal autonomy

·         Makes the most dangerous and expensive birth mode – planned vaginal births – the default standard of care

·         Set barriers between childbearing women and the most skilled obstetrical care providers

 

 

The High Cost of a ‘Normal’ Birth Policy

 

Canada has a long history of seeking to reduce its cesarean rate on the basis it will improve women’s health and reduce health care costs.  In this report, we seek to explore the validity of the data that underpins this assumption. The Canadian Institute of Health Information (CIHI) is, by no means, the only organization perpetuating this ideology but their words emphasize the magnitude of the misleading attitude around all cesarean deliveries.

Since unnecessary C-section delivery increases maternal morbidity and mortality and is associated with higher costs, C-section rates are often used to monitor clinical practices. The implicit assumption is that lower rates indicate more appropriate as well as more efficient care; therefore, variations in rates can serve as a flag to examine appropriateness of care, as well as maternal and neonatal outcomes.

Across many Organisation for Economic Co-operation and Development countries, C-section delivery rates have been rising. The Society of Obstetricians and Gynaecologists of Canada promotes normal childbirth, without technological interventions, when possible.

 

CIHI, Low risk cesarean section rate, 2010-2014

 

A consortium of obstetrical care experts/ providers, including the Society of Obstetricians and Gynecologists of Canada (SOGC) and the Canadian Association of Midwives (CAM), reinforced their vision of what ‘normal’ birth is in 2009. 1    The Joint Policy Statement on Normal Childbirth is clear that spontaneous vaginal birth is normal, even if it involves induction/augmentation, intermittent electronic fetal monitoring, pregnancy complications, managed third stage of labor, perineal trauma and repair, post partum hemorrhage and admission to a neonatal intensive care unit.    Normal labour does not include epidural anesthesia according to the SOGC.  According to them, inhaling nitrous oxide and opioids are the only pain relief considered normal during labour.  Cesareans, spinal anesthesia, general anesthesia, fetal malpresentation, continuous fetal monitoring and induction prior to 41+0 weeks’ gestation are considered abnormal.  Dr. Michael Klein, a Canadian family physician and darling of the normal birth movement, was reprimanded by the SOGC for his opposition to early epidural use in labour despite evidence to the contrary. 2   The SOGC is correct but it is hard to swallow their hypocrisy when they have stated the same themselves.  CAM also makes their bias clear with their Position Statement on Elective Cesarean stating that “cesarean surgery on demand will have disastrous social and financial consequences for health internationally”.  CAM takes it a step further than the SOGC, stating “only non-pharmacologic methods should be used to help women work with normal labour pain”. 3   Pity the poor woman who either wants a planned cesarean to avoid the extreme pain and serious, common physical and psychological damage ‘normal’ childbirth presents or who requires a cesarean for currently accepted medical indications.  They are considered failures by the very people they should count on for obstetrical expertise and compassionate, professional care. 

No other organization has denigrated cesareans more than the World Health Organization (WHO).  In 1985 they stated a safe rate of cesarean was between 10-15%. 4 Those numbers were pulled out of thin air, without any credible supportive evidence.  They quietly admitted they had ‘no empirical evidence to support a safe cesarean rate’ in 2009.  5   After making that admission, and in the same publication, WHO goes on to state ‘users of this handbook might want to continue to use a range of 5-15%’.  Cognitive dissonance in obstetrics isn’t just a local problem; it is global.

WHO’s ideology is oft-quoted by those who control the ‘normal’ birth policy that has existed in many countries for decades.  It is clear that cesarean rates don’t indicate quality of care and targets are dangerous. 6   WHO’s millennial development goals with respect to maternal mortality and health were doomed to fail because of their unsubstantiated anti-cesarean ideology.  They wanted to reduce maternal mortality rates by three quarters between 1990 and 2015.  They didn’t.  In 2013 an estimated 289,000 women died during pregnancy and childbirth.  A woman’s life time risk of dying in developed countries is 1 in 3700.  The risk of maternal death in sub-Saharan Africa is 1 in 38.7   These are shocking (and shameful) numbers in both the developed and developing world and largely preventable if 1) the unmet demand for contraception was met 2) easy access to safe abortion was a reality and 3) cesarean rates in quality facilities with competent surgical personnel were increased.   

A number of changes to clinical practice, meant to lower cesarean rates, have been suggested and implemented in several countries including promoting assisted deliveries, encouraging a permissive approach to longer second stages and vaginal birth after cesarean section.  Each are known to increase maternal and neonatal morbidity and mortality. 8   Assisted vaginal birth rates in Canada for 2010-2011 were 13.5%.  Of that 9.6% were assisted by vacuum extractor, 3.2% with forceps.  Alberta remains the only province with increasing forceps delivery rates from 3.8% in 2006-2007 to 4.2% in 2010-2011.  9   In England forceps rates have doubled since 2004 from 3.3% to 7% and this trend is also evident in Australia. 8 10   In the United States recent statements by the American College of Obstetrics and Gynecology encourage the use of forceps to avoid cesarean section. 11   There is no lack of evidence regarding pelvic floor risks and planned vaginal birth (PVB); this has been known for centuries.  A wise urogynecologist states “Detecting maternal birth trauma in clinical practice is not rocket science.  The diagnosis of avulsion and hiatal overdistensibilty requires nothing more than an index finger, a ruler, one functioning eyeball and the most elusive of commodities, an open mind.”  8   

Why isn’t pelvic floor damage recognized as a key performance indicator of obstetric services in countries with ‘normal’ birth policies?

 

“The authors believe that the risk of pelvic floor dysfunction (PFD) needs to enter the obstetric decision making process and should be a key performance indicator of obstetric services, rather than being ignored because such attention could interfere with the lowering of the caesarean rate.”  8 12 13

 

 

 

Childbirth is the top reason for hospitalization in Canada.  In 2012-2013, 369,454 women gave birth in Canada. 14   It is easy to see why reducing costs associated with childbirth would be low- hanging fruit to those wanting to cut health care spending.  Doing so by reducing cesarean sections is detrimental to women, their babies and the health care system.

Are costs associated with planned cesarean births really more expensive than planned vaginal births?  Neither Birth Trauma Canada or the Birth Trauma Association in the UK have seen any credible evidence to support that position and we have heard from many thousands of mothers.  We don’t hear negative childbirth stories from healthy women who have chosen planned cesareans and had that decision competently respected.  The negative stories are about planned vaginal births, congenital abnormalities, pregnancy complications and pre-existing medical conditions responsible for maternal and neonatal mortality and the permanent damage sustained by women and their babies.  Modern obstetrics has not advanced far enough to alter most congenital abnormalities or pregnancy complications.  Pregnancy and childbirth in women with pre-existing medical conditions continue to pose challenges to medical professionals that, despite best efforts, can’t be altered.  Birth mode will not alter these difficult realities to any great extent.  The same can’t be said for risks posed by planned vaginal births.

Any meaningful and useful cost analysis has to start with the only two birth options available.  There is no sense comparing the costs of all cesareans with all vaginal births (as Canada does).  Those are not the decisions a woman can make.  Costs for planned vaginal births (PVB) must be compared to those for planned cesarean births (PCB).   PVB costs must include vaginal birth by any means and all costs associated with attempting a vaginal birth.  PVBs include spontaneous vaginal birth, assisted vaginal births with forceps and/or vacuum extractors, induced and augmented labour, reconstructive surgery necessary after a vaginal birth and all costs associated with any attempt at a vaginal birth that ends as a cesarean.  Attempts to reduce emergency cesarean numbers are commendable as long as it doesn’t involve increased use of forceps or vacuum extractors, which are also dangerous to both women and their babies.  Given the unpredictability of planned vaginal births, reducing the number of assisted vaginal births and emergency cesareans, at the same time, is impossible without also increasing maternal and neonatal mortality rates.

Analyzing PCB costs is relatively straight forward.  They are costs associated with cesareans that do not involve a trial of labor.   It is essential to categorize PCB between those in healthy mothers at term (healthy mothers at term are the majority of all pregnancies) and those done for pregnancy complications, multiples, breech and congenital disorders where PCB is the safer option over PVB.  Quality research doesn’t ignore these differences.

Starting with costing numbers provided by CIHI the average hospital cost of all planned vaginal births that end as vaginal birth can be ascertained. 15   Based on the top 10 most expensive types of Hospitalization in Canada by Diagnosis that number is $1687 CAD.  [n=435,069 vaginal births.  Total cost is $734,000,000].  Adding the cost of emergency cesareans is a more difficult process.  Canada refuses to separate planned cesareans from emergency cesareans in statistics kept.  CIHI lists ‘Primary Cesarean Section, no induction’ costs at $4,132 CAD [n=37,999}.  Total cost is $157,011,868].  Primary Cesarean is a term used to refer to any cesarean that is a first cesarean for any particular woman.  Given Canada’s barriers to Cesarean Section on Maternal Request (CSMR) for a first child, in compliance with the ‘normal’ birth policy that is current conventional wisdom, it is likely that most of these costs are associated with emergency cesareans.  Determining what portion of that cost is associated with emergency cesareans takes some deduction using cost estimates per procedure using CIHI’s Patient Cost Estimator. 16   The other available break down of cesarean costs provided by CIHI are:

Primary CS, induction $5,440 [n = 18,494].  These are definitely emergency cesareans as induction is only used during labor.  Total cost is $100,607,360.

CS, with scar, no induction $3,281 [n=40,508] These may very well be repeat planned cesareans without labor but there is no way of knowing for sure.  It is the cheapest type of cesarean CIHI lists which would be truthful for planned CS.  It does not separate cesareans in healthy, term women and those who are not.  The latter would be more expensive.  Total cost is $132,906,748.

CS, with uterine scar, induction $4,937 [n=852] These are repeat emergency cesareans and known as VBACs (vaginal birth after cesarean).  Total cost is $4,206,324.

Totalling all costs definitely, or likely, associated with cesareans after a trial of labor the additional cost added to the PVD cost we already have ($1,687) is $4565.80. [n=57,345.  Total cost is $261,825,552].  Costs associated with planned vaginal births are $6,252.80 per PVB.  The corresponding cost for what are likely planned cesarean births is $3,281.  

Looked at logically from the perspective of costs associated with available birth options a planned vaginal birth is more expensive than a planned cesarean birth by at least $2,971.18 CAD.  These are short term hospital costs only and do not include physician fees but Canadian doctors make the same regardless of birth mode.  Relative costs would not change.

A study involving 27,613 low risk nulliparous women giving birth in a tertiary hospital in Nova Scotia between 1985-2002 listed costs associated with different birth modes. 17   Average costs for a spontaneous vaginal birth were $1,340 (n=11,457).  A vaginal induced birth was $1,715 (n=5,233). Assisted vaginal births cost $1594 (n=5846).  The cost of a cesarean after a trial of labour was $2137 (n=4,218).  Notably, the cost of a cesarean without labour was $1,534 (n=859).  Costs for planned vaginal births were higher ($1,595) than those for planned cesareans in this study as well, for a time period going back 3 decades. The cost of a cesarean after a trial of labour was 1.4 times the cost of a planned cesarean, similar to the factor separating costs in my numbers above.   

The United Kingdom’s National Institute of Clinical Evidence (NICE) provided numbers and costs associated with different birth types.  For planned vaginal births (n=573,054, total cost £1,000,649,416) the average cost is £1,746.  Of that, emergency cesareans (n=87,777, total cost £266,999,548) had an average cost of £3,042. For elective cesareans in healthy mothers (n=1,897, total cost £3,456,334) the average cost is £1,822.  Emergency CS costs in the UK were 1.7 times higher than elective cesareans in healthy mothers, higher than the relationship in Canada.  PVB were cheaper than PCB in the UK by a mere £75.83 without considering any downstream costs.  Planned cesareans done for complications during pregnancy (n=57,462, total cost £137,165,435) had an average cost of £2,387.06.  Cesarean delivery was safer for these women than an attempt at a vaginal birth.  Of all the planned cesareans done in the UK through the National Health Service (NHS) 96.8% of them were done for complications during pregnancy. 18 

 

Direct hospital birthing costs and physician fees for service are not the only, or largest, costs associated with planned vaginal births.  Vaginal births, or attempts at them, particularly after second stage, are the primary reason for health problems in mothers and babies throughout their life time.  Planned cesareans carry the same risk of pregnancy complications but they do not involve the extreme force, prolonged pressure, crushing and tearing of the ligaments and musculature of the pelvic floor, genital tract, pudendal nerve and peripheral branches, external genitalia, fascia, skin, rectum, anus and lower urinary system that planned vaginal births do.  That damage can cause serious, permanent and common health problems for mothers immediately after birth or in the years to follow as time adds to the delivery insult.  Levator ani avulsion, pelvic organ prolapse, urinary incontinence, fecal incontinence, perineal trauma, sexual problems, sexual fear and disinterest, chronic nerve pain, psychological damage (post traumatic stress, anxiety, depression) are overwhelmingly caused by planned vaginal births and the cost to women and the health care system to fix (or attempt to fix) these problems is staggering. 19   There were 56,556 gynecological repair surgeries in Canada in 2014-2015 unrelated to malignancies.  Total cost of those surgeries was $258,425,519 (hospital costs only).  Average cost associated with gynecological surgery was $4569.37. 16   Stillbirth and neonatal deaths, litigation and maternal mortality are also part of the downstream costs.

A) Levitor ani avulsion– This damage is caused exclusively by vaginal births and is a common consequence of vaginal birth. The forces involved in giving birth vaginally exceed the strength of the muscle/pelvic bone attachment and the pelvic floor is partially or completely separated from bone.  This can occur on either the left or right side or both.  36% of first vaginal births result in this damage. 20   Levator trauma is associated with pelvic organ prolapse. 21  

B)  Pelvic Organ Prolapse (POP)– Pelvic Organ Prolapse is caused primarily by planned vaginal births.  Pelvic organs can slump into the vagina, lower urinary tract and the rectum.    Other causes, beside levator trauma, include hiatal overdistensibility - permanent damage to the other musculature of the pelvic floor and complete or partial damage to the pelvic nerves caused by PVB.   Vaginal delivery is associated with a 255% increased risk of symptomatic pelvic organ prolapse compared with cesarean section two decades after one birth. 8 22   There are a number of surgical techniques that fix, or attempt to fix, this common problem and none of them come with a long-term guarantee of effectiveness.  Up to one third of all prolapse surgeries are repeat surgeries. 23 Pessaries and pelvic floor physiotherapy are commonly used to attempt improvement or buy time before surgical intervention.  Hysterectomy is one surgery done to correct uterine prolapse.  In 2014-2015, Canadian physicians performed 35,123 hysterectomies unrelated to cancer at an average cost of $4,984 per surgery. 16    250,000 surgical procedures are carried out per year in the United States for prolapse. 21   The direct cost of prolapse surgery in the United States is greater than 1 billion dollars.  Like all maternal childbirth damage, pelvic organ prolapse increases with age.  

C) Urinary incontinence Cesarean at any stage of labor reduces postpartum urinary incontinence. 24 25 26   A planned cesarean without labor is the most protective.  The overwhelming cause of urinary incontinence after childbirth is planned vaginal births.  The increase in bladder neck descent was markedly increased in women who gave birth vaginally (particularly those with levator avulsion) but not in those who gave birth abdominally. 20   Pregnancy (and any relatively quick, extreme weight gain) can permanently damage the urinary system.  Urinary incontinence persists in about ¾ of women 12 years after childbirth and that risk was only reduced with cesarean section if women had no other delivery mode. 27   The risk increase of developing urinary incontinence in women 20 years after either one vaginal birth or one cesarean birth was found to be 71% after vaginal delivery compared with cesarean delivery. 8 28 29   The conservative approach to UI is pelvic floor physiotherapy that includes pelvic floor strengthening, functional electrical stimulation, vaginal cones and bladder training, none of which cure the underlying problem but may improve symptoms if physiotherapy is sustained long term.   Mechanical devices (pessaries), periurethal injections of a bulking agent and urethral plugs are used as ‘conservative’ measures to avoid surgery.  Surgical techniques include retropubic procedures, laproscopic and open Burch, tension-free vaginal tape (TVT) and other sling procedures, anterior colporrhaphy and needle suspensions.  None of these procedures offer long term solutions.  All have enormous costs to the health care system for those women who elect to go these routes.  The majority of women do not.  This is true for any type of damage caused by planned vaginal births.  They suffer in silence.  It is worth noting the multi-million-dollar lawsuit in Canada involving trans-vaginal mesh.30   The manufacture and sale of incontinence products is a multi-million-dollar industry and there is good reason the advertising targets women.  A ‘normal’ birth policy makes those profits sustainable.

D)  Fecal incontinence– Obstetrical Anal Sphincter Injuries (OASIS) are caused exclusively by planned vaginal births.  The incidence of anal sphincter defect in primiparous women, when diagnosed using endoanal ultrasound, is 27 – 35%.  31   Outcomes following primary repair of OASIS are not encouraging, with studies reporting that many women still suffer from various degrees of anal incontinence after surgery, with rates from 31 – 54%. 32   Women with this injury can opt for colostomy surgery as a means to limit fecal incontinence, but they also have negative consequences.  In Canada, the average cost of that surgery is $22,400. 16   This is usually after they have endured several other costly invasive testing, surgical and physiotherapy interventions.

E) Perineal trauma– Always associated with PVB, it is estimated that 85 – 90 % of women having a first vaginal birth will have lacerations and/or an episiotomy.  Even those very few who do not have visible damage to the genital tract and surrounding area after a vaginal birth could sustain occult (unseen) damage to deeper tissues.  Any tearing (visible or occult) indicates that the forces involved in vaginal birth exceeds the physical integrity of the musculature and nerves involved.  Episiotomies, once widely believed to reduce pelvic floor trauma *, actually increase the risk of the most serious perineal trauma. Many of the risks associated with perineal trauma have already been discussed.   Sexual problems or disinterest and chronic nerve pain are other common associated difficulties that have devastating consequences for women.  The costs associated with this damage aren’t considered openly by the health system but they are huge costs to mothers, their partners and society.  Beyond the physical damage to mothers, maternal damage of this nature causes depression, post traumatic stress and other anxiety issues as well as many marriage breakdowns.  The medical profession and society would be justifiably outraged if this damage was sustained by men or children.  In mothers, it is considered acceptable and normal.

*  This fallacy was supported by studies at the time.

F)  Psychological wellnessStress has toxic effects on health and what is done to the mother is also done to her child.   Limited research exists on the effects of negative childbirth experiences despite the fact this has been known for centuries.  Two decades of listening to mother’s negative and positive experiences leave no doubt it is planned vaginal births, and the resulting permanent damage, causing the overwhelming majority of maternal post partum post traumatic stress.  All other cases of full or partial PTSD, not related to emergency cesareans or vaginal births, are associated with substandard care, life threatening complications in pregnancy for mother and/or baby and stillbirth, neonatal, infant death and miscarriage.   A cesarean was only traumatic when it was performed as an emergency procedure.  The majority of women presenting with PTSD symptoms delivered vaginally. 33   Eighty percent of women who developed PTSD had vaginal births without pain relief.  Dr. R. Strous, Associate Professor of Tel Aviv University, states, “The less pain relief there was, the higher the woman’s chance of developing postpartum PTSD”. 34 35   Dr. Strous’ work was also clear that support during labor by a midwife or doula, socioeconomic conditions, marital status and religion had no impact when it came to avoiding PTSD after childbirth.  The American Society of Anesthesiologists are confirming this in their research. 36   An article published in the Canadian Medical Association journal in 1997 made the link between PTSD and traumatic birth.  As well, the article made the link between elective cesarean and the avoidance of traumatic birth in women. 37   Yet the problem persists and ‘normal’ birth policies have not been reversed.  Current estimates of full and partial post partum PTSD caused by planned vaginal births is 1 in 3. 35   PTSD increased for those wanting to deliver by planned cesarean but who were forced to attempt a planned vaginal birth. 38   None of this is normal.  It is a travesty.  Full and partial PTSD after childbirth should be recognized as a separate category for psychological morbidity along with depression and psychosis.  It isn’t in Canada.  Most of the psychological damage caused by planned vaginal births is dismissively referred to as ‘baby blues’ and blamed on ‘female hormones’.  Women are told to ‘get over it and be happy you have a healthy baby’. 

The only ‘cure’ for PTSD is prevention.  Time, psychological therapy and pharmaceuticals are used to blunt symptoms.  Sleep aids, anti-depressants and anti-anxiety medications are costly and prices range depending on the drug and those drugs are top revenue producers for pharmaceutical companies.  Trauma counseling in Canada costs approximately $200 per 50-minute session and trauma counseling requires months of sessions.

Suicide is the overall leading cause of maternal mortality.  Maternal mortality rates are calculated using direct and indirect causes of death during pregnancy, birth and the first 42 days of the post natal period, as per WHO specifications.  If looked at beyond that limited time period, the numbers would be considerably higher.  Current calculations of MMR are an excellent example of pretending not to see what you refuse to acknowledge.   The UK Centre of Maternal and Child Enquiries (CMACE) looked at 13 suicides using the standard classification of MMR.  Looking beyond the 42 days to 6 months’ post partum another 16 suicides were examined.    Of those 29 suicides, 19 had a psychiatric history, many undoubtedly caused by previous negative birth experiences or grim life circumstances.   Ten had no history of previous psychological problems. 39    In Australia, in the five years from 2008-2012 and only up to 42 days, 16 maternal deaths were attributed to psychosocial morbidity.  12 were suicides, 2 were murdered, 1 had an adverse reaction to prescribed medication and 1 overdosed (intent was unknown).40   

Physical and psychological health problems have a significant negative and long term impact on women’s wellbeing and daily functioning. 41    The risk of developing any serious mental illness are markedly elevated after childbirth.  39    Women traumatized by planned vaginal births often delay or avoid needed medical help because they do not trust mainstream medicine.  Many turn to alternative medicine, further reducing the credibility of conventional medicine.  Some women, terrified of how barbaric and inhumane maternity wards are, choose to avoid hospitals, doctors and midwives and give birth alone.  Women with traumatizing childbirth experiences delay and avoid having another child.  Those who have confided in health care professionals about problems, and were then subsequently betrayed when those same care givers call social services to have their children removed, only have their trauma compounded.  More reliance on specialized mother/ baby/ other sibling units for respectful, compassionate, supportive care is called for.  Instead, the stigma around disease with mental implications is often as strong among medical professionals as it is in general society.  It is no small wonder that most traumatized mothers never seek help from the medical profession.

There is evidence that maternal post partum post-traumatic stress has lasting negative impacts on her child involving motor skills, communication and social and emotional development. 42     Other studies link perinatal trauma and less pain relief during planned vaginal births with higher rates of suicide among those infants as adolescents and adults.  43 44   Other researchers feel the link between obstetric care and suicide in offspring is more likely to occur through mental illness.  Evidence exists that obstetric complications causing neurological impairment (like oxygen deprivation) are associated with schizophrenia and major affective disorder in their children.  45 46   No cost analysis exists that considers the cost of suicide and mental illness to society, health care systems and police forces but a reasonable person can assume the costs associated with traumatizing mothers are enormous. 

Parity is linked to increased risk of Alzheimer’s disease (AD) long after child-bearing has ceased.  Women are at the epicenter of the Alzheimer’s crisis; almost 2/3 of American seniors living with AD are women. 47   Women with children have a significantly increased risk than those who remain nulliparous of developing AD. 48 49 50   With each pregnancy, the age of onset of AD was reduced by three years.  The more pregnancies a woman had the greater her risk of developing AD. 49 The link has been made between psychological distress and risk of Alzheimer’s disease. 51   If the risks are associated with trauma associated with PVB (and the hypothesis is reasonable) a change away from ‘normal’ birth policy could save health care systems billions, yet this isn’t on any research radar.  Costs associated with Alzheimer’s disease varies from $5.6 billion to $88.3 billion USD. 52

G)  Stillbirth and Neonatal deaths– In 2011 in Canada 2,275 perinatal deaths were recorded using the same definition of perinatal death as Scotland.  1,115 were listed as late fetal deaths, defined as those occurring at 28+ weeks gestation.  1,160 were listed as early neonatal (0 – 6 days after birth).  53   It is impossible to tell which of these deaths were caused by PVB or PCB, as Canada is secretive about that.   Scotland is not so secretive and there is much to be learned from the openness of Scottish researchers.  Stillbirths and neonatal deaths have a number of causes.  Prematurity, antepartum death and perinatal death due to fetal abnormality often can’t be changed even with medical advancements made to date.  Great strides have been made in management of infants delivered preterm and they are largely responsible for the decrease seen in developed countries among those infants born between 501 and 750 grams.  In the US mortality in this birth weight decreased from 60% in 1991 to less than 50% in 1997-2002. 54   Those survivals come with a price in a high prevalence of disabilities throughout the child’s life span.

Perinatal deaths in infants at term are another story altogether.  At term, using Scottish research and after exclusion of antepartum stillbirth and perinatal death due to fetal abnormality, most intrapartum and neonatal deaths are associated with intrapartum anoxia.    Plainly speaking, these babies were killed by the ordeal of labour and a vaginal birth, or an attempt at a vaginal birth (n=432).  There were no deaths ascribed to intrapartum anoxia among women delivered by planned cesarean.  Of the perinatal deaths (n=287) by other causes, 96.9% were attributed to planned vaginal births; 3.1% were attributed to planned cesarean delivery, likely associated with life threatening complications of pregnancy. 55   In these cases, delivery by cesarean is the safest option available.   Major birth trauma in infants has decreased over the last several decades as cesarean section rates increase. 56    Fetal injuries associated with cesarean delivery are the result of emergency cesareans (planned vaginal births) or medical incompetence.57   

The biggest single way to reduce stillbirth numbers is to ensure women are given accurate information about the comparative risks of planned vaginal versus planned caesarean birth and then allow them to make their own choice.  Increasing the rate of planned cesareans, particularly among post term pregnancies, would decrease stillbirth rates yet there is complete silence from the medical community on this issue.  There are staggering costs associated with the loss of these babies and the associated physical and psychological damage to mothers, yet they aren’t considered by the health system and they are difficult to quantitate.  The Stillbirth Foundation of Australia has put a cost on these losses at 681.4 million dollars (AUS). 58  

Given the high rate of stillbirths caused by PVB it is a given that the number of children who survive the ordeal of PVB with lifelong disabilities would be considerably higher.    The associated costs include living expenses, earning income lost, health care, caregivers, specialized education and litigation.  The emotional cost to parents raising these disabled children, as well as those who have lost their babies, are incalculable.

H)  Litigation-  No analysis comparing PVB and PCB can ignore the enormous cost to health care and taxpayers resulting from litigation.  The Toronto Star summed the current situation for mothers and their children in Canada stating “the true scope of patient complaints and medical complications involving OB/GYNs remains veiled in secrecy.  The College of Physicians and Surgeons does not release information unless it triggers disciplinary action.  Complication rates of individual physicians are also a tightly guarded secret within the profession”. 59   Tens of millions were paid to Canadian families for botched deliveries that left at least 25 babies dead, two mothers dead and untold numbers of children disabled and the vast majority of mothers with legitimate claims are never looked at.  The Canadian Medical Protection Agency (CMPA) is the malpractice insurer for Canadian doctors and they employ a stable of highly competent lawyers to, by their own admission, ‘aggressively’ defend against patient claims.  Yearly average CMPA premiums charged to OB/GYNS were $72,456 in 2016, the highest of any medical specialty.  [The next highest were neurosurgeons at $53,100].   Those charges are subsidized by Canadian taxpayers from 80-100% depending on where the doctor practises.  Patients are not similarly funded by taxpayers for their legal costs.  Physician’s CMPA premiums do not change when actions are taken against them so they have less motivation to change.  A 2007 report from the US suggested 6% of physicians are responsible for 58% of malpractice payments. 60   There are no comparable numbers provided in Canada but it is reasonable to assume Canada struggles with the same situation.  A competent, transparent, regulated system with a meaningful, compassionate disciplinary process would weed out serial problem physicians and midwives.  The College of Physicians and Surgeons does not provide this.   Since most doctors are independent contractors, when a patient sues a doctor they are usually not suing the hospital at the same time.  As a result, there’s less pressure for systemic change.  In 1978 the Supreme Court of Canada set a maximum cap on damages for pain and suffering of $100,000.  Adjusting for inflation that cap, in 2016, is approximately $350,000.  As a result, it is extremely difficult, if not impossible, for mothers in Canada to get any meaningful compensation or recourse for damage to them that results from the ‘normal’ birth policy.  They have the weight of the law, the state and taxpayer’s dollars against them.  Additionally, legal requirements in Canada stipulate that the loser in any court case has to pay a portion of the winner’s legal costs.  To win a lawsuit, patients must prove that the doctor acted below the standard of care and that a reasonable doctor would have acted differently.61   It should be abundantly clear that, if the bar is set low with regards to what constitutes standard care by those responsible for setting maternity policy, the harder it is to prove a breach of quality of care.  The American Medical Association would like to see similar barriers placed before mothers in the US.  So far they have failed. 62   The CMPA wants to further reduce obstetrical litigation claims by focusing on safety and education of obstetrical care providers.  As long as those programs reinforce the current ‘normal’ birth policy by continuing to denigrate planned cesareans in healthy mothers and continuing the obsession with reducing the overall rate of cesareans they will be ineffective.  The SOGC’s Advances in Labour and Risk Management (ALARM) program is proof of this.  In place since 1996, it has failed to influence CMPA premiums charged to OB/GYNs. [In Ontario, the fee was $57,000 in 2014 and $75,000 in 2016]. 61    

The CMPA refuses to disclose details of cases, citing patient confidentiality and the ‘professional integrity’ of the doctors involved.   They will not name doctors or families or give costs of settlements but we do know that, from 2005-2014, the CMPA reviewed 169 lawsuits and college complaints.  They cite ‘situational awareness’ (defined as not knowing what is going on, and what’s likely to happen next) as a factor in many of the tragedies. 63    Details of cases settled out of court remain secret as they are never reported by the media.  36% of cases brought against obstetricians between 1996 and 2003 had to be settled out of court because they were deemed to be indefensible. 64 Cases we do know about include failure to recognize uterine rupture during labor, delay in doing an emergency cesarean, damage done during planned vaginal births using forceps and vacuum extractors and anoxia/hypoxia/ acidosis that result from labor (all planned vaginal births). 

“I might be able to forgive (Dr.) Potts.  But I can’t forgive the system and the CMPA that tortured us for 13 years”

Laura MacGregor, mother of Matthew who was left with quadriplegic cerebral palsy after forceps assisted vaginal birth 59

 

 

 

 

 

The Healthcare Insurance Reciprocal of Canada (HIROC) provides similarly aggressive legal insurance protection to hospitals and hospital employees with the same determination to keep obstetrical cases as secret as the CMPA.   We need to go outside Canada to countries with similar maternity policies and more open reporting to learn anything meaningful.  

Maternity claims represent the highest value of clinical negligence claims reported to the United Kingdom’s National Health Service Litigation Agency (NHSLA). 65   Between April 1, 2000 and March 31, 2010 there were issued (those claims paid out, not those still pending) maternity claims valued at a staggering £3,117,649,888.  The majority of those claims resulted from planned vaginal births, complications of pregnancy and medical error as outlined below.  Any wise obstetrician can tell you that you don’t get sued doing cesareans; you get sued if you don’t”.

Cerebral Palsy resulting from poor intrapartum care and failure to diagnose hypoxia leading to acidosis and long term neurological outcomes for baby – 40.52% (£1,263,581,324)

CTG Interpretation failures– 14.95% (£466,393,771)

Management of Labor – 13.60% (£424,039,651)

Operative vaginal delivery – 3.00%( £93,659,223)

Perineal trauma – 1.00% (£31,202,836)

Shoulder dystocia – 3.32% (£103,520,832)

Retained swabs – 0.1% (£3,021,910) Those left during genital tract reconstructive surgery after vaginal birth (£1,282,398)

Retained swabs left after cesarean surgery (no distinction between PVB and PCB) – (£1,267,464)

Retained swabs (unspecified) – (£472,048)

[Retained swabs are always medical incompetence, regardless of mode of delivery. ‘Unspecified’ or ‘other’ relates to poor quality data collection and this is a serious problem in maternity care]

Bladder – 0.28% (£8,824,269)   None of these claims involved costs incurred during surgery.  [Any damage to the bladder during a planned cesarean birth in a healthy mother is medical incompetence].  £1,065,787of claims were the result of poorpostnatal bladder care following surgery, likely reconstructive surgery after a vaginal birth or emergency cesareans.  £1,432,653 of claims were clearly associated with vaginal delivery.  £6,325,829 were the result of ‘unspecified’.  Operative vaginal births carry the highest level of risk to the bladder. 

Cesarean Section -  6.93% (£216,167,223).  There was no differentiation between PVB and PCB related to complications of the procedure in this category.  Given National Health Service (NHS), Royal College of Obstetricians and Gynecologists (RCOG) and the Royal College of Midwives (RCM) fierce opposition to elective planned cesarean in healthy mothers and adherence to the same ‘normal’ birth policy as Canada, we can assume most of the cesareans in this category were emergency or planned for maternal or neonatal reasons.  Emergency CS and CS for maternal or neonatal co-morbidities are considerably riskier than PCB in healthy mothers.  This is not necessarily due to medical incompetence, although the fact these were successful claims implies they were.  These procedures are done under duress where every minute counts and lives hang in the balance.  No human, even those trained and competent, can operate under these conditions without making mistakes. Complications of the procedure had claims of £45,099,097.  Delay in performing a cesarean cost £154,736,115.  The rest of the claims were categorized as unspecified ‘other’.  They resulted in claims totalling £16,332,011. 

Drug error -  0.28% (£8,759,430) Drug errors are medical incompetence and the drugs involved are those commonly used in midwifery and obstetric practice.   44 of the errors (£2,534,268) occurred in labor, 7 (£498,150) occurred during post natal care.  The remaining 32 claims (£5,727,012) were ‘unspecified’ and had no data indicating when the drug error occurred.  

Anesthetic Issues – 0.61% (£19,249,853) There is no differentiation between PVB and PCB or between general anesthesia and regional anesthesia so little worthwhile information is available for these claims regarding the cost difference between PVB and PCB.  General anesthesia, by far the most dangerous form of anesthesia, is primarily used for emergency cesareans and for long, complicated reconstructive surgery following a vaginal birth.  General anesthesia is rarely used for PCB except in cases where regional anesthesia is impossible or contraindicated.  It is reasonable to assume that the majority of litigation costs associated with anesthesia issues arising from cesarean section would be related to PVB and anesthesiologist incompetency.  Again, it is important to understand that handling anesthesia and monitoring vital signs under duress where minutes are critical leads to errors even with the most competent anesthesiologists.  Claims related to anesthesia issues in labor cost £308,288.  Claims related to CS were £12,041,527 and claims to unspecified ‘other’ were £6,900,038. 

Uterine rupture – 3.31% (£103,264,627) Of the 85 claims associated with uterine rupture 19 were linked to previous cesarean section, all of them were vaginal births after cesarean.  There is no information about previous cesarean surgical techniques, inter-pregnancy intervals, past number of cesareans or hospital/surgical competence for these previous cesareans, all of which influence outcomes with subsequent cesareans.  They accounted for £15,479,634.  The other 66 claims (£87,784,993) were not linked to previous CS.  They had to be linked to PVB other than VBACs, complications of pregnancy and post term pregnancies or medically necessary previous uterine surgery that did not include CS. 

Stillbirth – 0.50% (£15,712,695) We have already established that stillbirths are the result of PVB, birth defects and complications of pregnancy. 

Psychological – 0.02% (£681,791).  We have already established that psychological damage results from PVB and complications of pregnancy. 

Postpartum hemorrhage – 0.1% (£3,021,910) Nothing meaningful regarding cause of PPH by birth mode is included in the NHSLA analysis.  Most cases of litigation involving hemorrhage were related to retained products, likely after PVB.  It is generally accepted that PCB, particularly when they are elective, pose less risk of PPH than PVB. 66 67 68   The most frequent cause of major obstetric hemorrhage (MOH) is uterine atony (the inability of an exhausted uterus to contract) which is usually related to PVB.   Prolonged labor, induced/augmented labor, rapid labor, history of post partum hemorrhage, episiotomy, pre-eclampsia, over distended uterus, inverted uterus (the uterus turns inside out after delivery), ethnicity, multiple pregnancies and chorioamnionitis are associated with uterine atony.  46.9% of all MOH in Scotland were related to uterine atony.   By comparison, the incidence of MOH caused by morbidly adherent placenta is considerably lower at 5.5%. 45 

Nursing care – 0.01% (£511,700) These are undoubtedly medical errors that could happen with both PVB or PCB.

Maternal Death – 0.64% (£20,253,906) There were 38 claims for maternal death. (see below)

Antenatal investigations – 4.81% (£149,986,770) Antenatal care – 4.64% (£144,811,665) Both categories refer to poor antenatal care where pregnancy complications and fetal abnormalities that should have been identified were not.  These are medical errors and not associated with either birth mode. 

Accident – 0.02% (£728,796)

Other – nothing worthwhile can be deduced from this unspecified category but it had 1.29% of all maternity claims and accounted for £40,252,783.

 

 

I) Maternal Mortality-  The NHSLA had 38 claims for maternal death between 2000 and 2010 totalling £20,253,906 (0.64% of total claims). 65   Canada’s maternal mortality rate was 8.8 per 100,000 hospital deliveries between 1996-1997 and 2010-2011 (excluding Quebec).  346 mothers died during that time period. Given the number of deliveries per year in Canada that equates to 23+ per year.  63   Maternal mortality is overwhelmingly associated with PVB or life threatening pre-existing medical problems or those complications caused by pregnancy. 45   The costs to remaining children, other family members, the health care providers involved and society associated with losing a mother are incalculable but enormous.

If elective cesareans in healthy mothers warranted the fierce opposition they get from ‘normal’ birth advocates one would expect to see higher death rates for mothers undergoing this birth mode.  Nothing could be further from the truth.  The UK Centre for Maternal and Child Enquiries (CMACE) looked at direct and indirect maternal deaths according to birth mode from 2006-2008. 45   Direct deaths are caused by pregnancy, labor, birth and the puerperium.  Indirect deaths are those resulting from pre-existing disease or disease developing during pregnancy that the physiological demands of pregnancy made lethal.   Of the direct deaths (n=79) only one was an elective cesarean on maternal request.  Only one uneventful cesarean (medical parlance for without complications) was specifically discussed in the CMACE document.  The cause of that death was a rare auto-immune response to a spinal infection introduced during installation of regional anesthesia.  Aseptic technique is a basic tenant of competent placement of regional anesthesia.  This death was not related to the cesarean; it was caused by anesthetist incompetence.   Seventy eight of seventy-nine direct deaths were caused by PVB or serious prenatal or intrapartum complications.  5 out of the 86 indirect deaths were elective cesareans but, given the definition of indirect death, they did not happen in healthy mothers. 

The same report lists 70% of direct deaths and 55% of indirect deaths as having some degree of substandard care.  The overwhelming majority of that substandard care was because more junior or locum maternity staff, both doctors and midwives, were too unskilled to recognize the severity of a pregnant woman’s condition and who did not refer ‘upwards’ at all or in time to an obstetrician or anesthesiologist - the more skilled obstetrical professional.  This problem remains unchanged from previous CMACE reports.  The Morecambe Bay Enquiry confirms this problem. 69   Some maternal deaths occurred in maternity centres not able or equipped to care for pregnant women with major complications either preceding pregnancy or developing during pregnancy.  One has to question why these facilities are maternity centres in the first place.  Clearly, removing barriers between women and the most skilled obstetrical care providers would result in an immediate decrease in substandard care and high rates of maternal and neonatal mortality and morbidity. It is also clear that providing honest pre-conception information to women living with pre-existing health problems would decrease the mortality related to pregnancy and childbirth in that population.  If they knew how unhealthy pregnancy was for them many would forego motherhood. 

 

 

 

 

CMACE assessors, looking into the quality of the serious incident/ serious untoward incident report forms related to maternal deaths, were frank about what they found. 45

 

“Some were not worth the paper they were written on and a few were actually whitewashes and cover ups for unacceptable situations.  For these poor reports, there was little to no evidence of critical thinking, an acceptance of shortcomings, little or no self-reflective discussions and no evidence that obvious lessons had been identified let alone learned.”

 

 

 

 

The 2015 Report of the Morecambe Bay Investigation (UK) looked at failures on all levels from the maternity unit to those monitoring and regulating the University Hospitals of Morecambe Bay NHS Foundation Trust.  69    Eleven babies and one mother died because midwives were ‘pursuing normal childbirth at any cost’.  The midwives involved considered themselves ‘musketeers’, denying any wrong doing, rejecting criticism as unjustified and turning hostile.  Records went missing.  All parties involved colluded in concealing the truth in behaviour that can only be called inexcusable and unprofessional.   These issues aren’t exclusive to the UK.  These are stories we hear over and over again, year after year. These people do a great disservice to competent midwives, medical regulators and the entire maternity service.

The report on Maternal Deaths in Australia stated the rate of avoidable factors in maternal deaths was 80% of the 135 direct, indirect, unclassified and incidental deaths.  The problems in Australia mirrored those seen in the UK – inability to refer up and in time, inability to recognize the seriousness of situations, refusal to follow established guidelines and poor data reporting.  Of the 105 direct and indirect maternal deaths, only 3 were categorized as ‘cesarean timed to suit mother or staff’-  a euphemism that could mean an elective cesarean.   One death was attributed to amniotic fluid embolism (a life threatening immune mediated response to fetal cells entering the maternal bloodstream), one was related to subarachnoid non-obstetric hemorrhage secondary to a ruptured aneurism 2 weeks postpartum and unrelated to mode of birth and another thought to be related to anesthesia.  There were 43 deaths in mothers who delivered by cesarean but 42 of them had other specific causations unrelated to the cesarean.  In other words, they were not planned, elective cesareans in healthy mothers.  The one that was directly related to cesarean was the anesthetic related death and little information was given about this death except cerebral edema and craniostenosis was observed.  These morbidities are related to general anesthesia and likely related to incompetence. 46 

 

The National Institute of Health in the United States (NIH) used ‘moderate’ quality evidence, after throwing out the preponderance of low and very low quality research they found on the risks of planned cesarean.  Using this moderate quality research, they determined that planned cesareans cause less maternal hemorrhage than planned vaginal births. 66 The American College of Obstetricians and Gynecologists (ACOG) agreed there was a decreased risk of postpartum hemorrhage (PPH) and need for blood transfusion in all planned cesareans. 67   It is important to note that both these organizations did not differentiate between planned cesareans for pregnancy complications and planned cesareans in healthy women and that is an important distinction.  Elective cesarean in healthy mothers would have the least risk of all cesareans.  68   The NIH, using the same moderate research for all planned cesareans, determined an increased risk for longer hospital stays, neonatal respiratory morbidity, subsequent placenta previa or accreta and subsequent uterine rupture.   The known life-threatening risks of medical complications during pregnancy, that we know account for the majority of planned cesareans, is not considered.  The NIH and ACOG admit that neonatal respiratory morbidity is a risk only in planned cesareans that must be done before term (39 weeks).  All premature births, because of underdeveloped fetal lungs, carry this risk.  We have already established that uterine rupture risk is associated with labor attempted after a cesarean (VBAC) or because of situations unrelated to CS.  Equally important to remember, planned CS is the immediate go-to delivery option in all cases of symptomatic uterine rupture and placental implantation issues because carrying on with an attempted vaginal birth is a far more dangerous option.  Late pregnancy scans can identify placental problems and should be used more so those women with identified problems can elect to have a planned cesarean.  There were no deaths associated with placenta previa in elective cesareans in the CMACE Enquiry.  The reason given was that these types of cesareans always involve senior obstetricians and anesthesiologists.  45   

The risk of placenta accreta with no prior history of cesarean is 0.2%.  It rises to 0.3% with a second cesarean and to 0.6% with a third.  The risk of this life-threatening condition rises to 2.1% and only after the third cesarean.  After the fifth cesarean the risk rises to 6.7% 69   The risk of requiring a hysterectomy to curtail MOH is 0.7% with no previous cesarean, 0.4% with a second cesarean and 0.9% after a third.  The risk jumps to 2.4% with a fourth cesarean.  70   These numbers are a decade old and don’t consider advances in MOH treatments other than hysterectomy since then, nor do they consider variables known to affect risks after previous cesarean.  Inter-delivery intervals less than 24 months between cesareans increase the risk of placental implantation and uterine rupture (VBAC) risks by 2-3 times. 71 72 73    Surgical techniques have varying risk profiles with ‘T’, ‘J’ and vertical uterine incisions posing greater risks to both mother and baby than lower transverse uterine incisions. 37   Variations in hospital quality and surgical skill are known factors in cesarean outcomes both short term and long term. 

Women wanting large families need to know these risks.  Multi-parity is the biggest risk factor for any form of MOH – both uterine atony and morbidly adherent placenta.  Women need to know that the risk of morbidly adherent placenta increases with multi-parity if they only have vaginal births or have medically necessary uterine surgery unrelated to cesarean (ie: a myomectomy) as well.  Any scar on the uterus – whether it is caused by previous uterine surgery or a previous placental implantation site – increases the risk of placental implantation problems.  

Canada lists hospital stays for all CS deliveries at 3.2 days.  The stay for vaginal births is 2.3 days.74   No worthwhile information on length of hospital stays for PVB versus PCB exists. It is impossible to determine if hospital stays really are longer for planned cesareans, particularly with elective cesareans in healthy mothers.   In our experience, they are not.  

 One of the risk adjusted birth related indicators the Fraser Institute (Canada) tracks, and the only one related to cesareans, is ‘Obstetric trauma – cesarean section’.  It tracks cases of potentially preventable trauma related to 4th degree lacerations and other obstetric lacerations.   These are planned vaginal births of the worst order.  These unfortunate women attempted a vaginal birth that ended as badly as possible and then endured an emergency cesarean when it was clear that an attempt at a vaginal birth was impossible.  The average for Ontario in this category was 6.0/1000.  The worst hospital had a rate of 91.2/1000.  It is notable that the best hospitals had NO adverse events for these cesareans. 75   A range from 0 to 91.2/1000 is staggering and it highlights the variation in quality of care among hospitals seen in every region in Canada and every country in the world and for every existing surgerical or medical procedure.  Substandard hospital administration and design, substandard infection control, whether adequate prophylactic antibiotics and anti-thromboembolic measures were given for surgery, medical personnel burn out, incompetent hospital employees, out-dated surgical techniques and surgical team competency / incompetency account for the variation.   If a hospital can manage, under worst case scenarios, to have no adverse events it is logical to infer that quality hospitals with competent surgical teams can handle planned cesareans in healthy women routinely and consistently with little or no adverse events.  Any research that does not consider these variations in quality of care adds nothing meaningful to obstetrical research or to the discussion of relative merits of PVB and PCB.  Very rarely does obstetrical research consider all confounding variables.   Planned elective cesareans in healthy mothers are predictable and quick.  These surgeries always involve senior, experienced obstetrical care providers – anesthesiologists and obstetricians.  There is no chaos in the OR.  No lives are hanging in the balance.  With planned cesareans, you start with the most skilled and best trained obstetrical professionals.  You aren’t transferred to them when things are dire. 

CIHI and the Canadian Patient Safety Institute (CPSI) released information that preventable harm is experienced in 1 of every 18 hospitalizations, with 20% involving more than one occurrence of harm.  This, by their own admission, is an underestimation.  Similar harm is common in other countries including Australia, Spain and the U.S. This study did not separate obstetrical harm done by PVB or PCB.  It listed A) non-instrumental harm done (associated with vaginal births) and B) the harm done relating to cesarean and instrumental births.  One can infer, given Canada’s ‘normal’ birth policy, that the majority of these CS incidents are related to emergency CS or planned CS for medical complications.  Very few (if any) would have been associated with elective CS in healthy mothers.  Certainly, the proportion related to instrumental deliveries in category B are PVBs.  In category A, the number of harm incidents were 7,109.  In category B, the harm incidents were 6,911.  The rate of harmful events in mothers was 4.2% (11.7% of all admitted patients) and 1.0% of newborns (11.9% of all admitted patients). 76 Clearly, more work is needed in hospitals to address the preventable harm done during maternity care in many hospitals.  Business as usual, with a ‘normal’ birth policy, is not working.  A ‘normal’ birth policy, in Canada and around the world, makes the most dangerous and expensive birth option – a planned vaginal birth – the default standard of care.   

More honest information about the true risks and benefits of different modes of birth and empowering women to make their own choices would save health care systems billions and would drastically reduce maternal and child morbidity.  More elective cesareans would allow more effective staging of births during normal working hours reducing peak times when maternity staff is over taxed and unable to provide adequate care.  Respecting the basic human right of women to make their own choices would inevitably lead to an increased planned cesarean rate in healthy women and decreased market share for those who do not have the education or skills to provide PCB.  Those who make their living exclusively from PVB and the damage they cause will see a reduction in revenue.  That is the real “disastrous social and financial consequences for health internationally” the normal birth advocates are referencing.  

It is unlikely allowing increased access to planned cesareans in healthy mothers will negate all need for quality midwifery service.  Some women will always prefer the service a competent midwife offers.  Surgery, especially when hospital and surgical team quality is kept secret, remains a frightening prospect for many women deciding to have children.  Early, honest and proper antenatal assessments will identify those pregnant women with risk factors.  Refer any case with risk upwards.  Midwifery credibility suffers when they take these cases and fail.  Similarly, refer pregnant women upwards if they do not want a vaginal birth and do so without judgement, inflammatory rhetoric or sanctimony.  Midwives who set barriers to these women are setting themselves up for failure and subsequent loss of credibility.  Midwives or doctors have nothing to gain by denying maternal autonomy in terms of credibility.   It is also extremely important to provide full and honest disclosure regarding risks associated with PVB.  Whitewashing those risks is denying informed consent.  When women ask ‘Why wasn’t I told?’ when things go wrong it reflects badly on both doctors and midwives.  Pregnant women have the right to know.

“Why wasn’t I told?” is a common refrain from mothers dealing with physical and psychological damage caused by childbirth.  Full disclosure, informed consent and the right to autonomy about medical options are basic tenants medicine is built on.  The exception is obstetrics.  That may be changing. On appeal, in 2015 after a 16-year battle before the courts, the Supreme Court of the United Kingdom powerfully affirmed women’s right to autonomy in childbirth and awarded £5.25 million to a woman who was not offered the choice to deliver by planned cesarean.77   Her son was left brain damaged.  The obstetrician responsible for Ms. Montgomery’s care decided not to fully inform about the risks of a planned vaginal birth because “then everyone would ask for a cesarean section”.  

 Once taboo to talk about, social media and the internet have made it easy for women to share their stories and warn other women.  More and more women refuse to remain silent.  Mothers who have negative childbirth experiences warn their daughters.  Friends warn friends.  Sisters warn sisters.  Women increasingly forego the motherhood journey.  Self-preservation is understandable with the added benefit that the ‘none and done’ never risk seeing their daughters treated as badly as they know they would be. 

Cesarean section is an advancement in a medical specialty that has zealously undermined evidence based improvement.  Obstetrics can’t remain a medical specialty that is ideologically driven by many working in the field.   Cesarean is worth improving and they are the only way to avoid the permanent damage ‘normal’ birth causes, and which millions of mothers and children live with.

 

 

 

 

 

 

 

 

 

 

 

 

 

1.        Joint Policy Statement on Normal Childbirth, J. Obstet Gynaecol Can 2008; 30(12): 11163-1165

2.       The Skeptical OB. Poor Dr. Klein; the evidence does not support his claims about epidurals.  March 2, 2012; www.skepticalob.com 

3.       Position Statement on Elective Cesarean Section, CAM June 2004 and Position Statement on Midwifery Care and Normal Birth.  Jan 2010.

4.       Appropriate Technology for Birth. No authors listed. The Lancet, Vol. 326, Issue 8452, August 24, 1985, pgs. 436-437

5.       Monitoring Emergency Obstetric Care: a handbook.  World Health Organization 2009.

6.       Hull, P. Cesarean rates don’t indicate quality of care and targets are dangerous.  National Health Executive, Health Service Focus, October 19, 2016. http://www.nationalhealthexecutive.com/Health-Service-Focus/caesarean-rates-dont-indicate-quality-of-care-and-targets-are-dangerous

7.       Millennial Development Goals 5– Improving Maternal Health, World Health Organization, Reviewed May 2015. 

8.       Dietz HP, Wilson PD, Milsom I.  Maternal birth trauma: why should it matter to urogynaecologists? Urogynecology, October 2016. Vol 28, 5: 441-448

9.       Discharge Abstract Database and Hospital Morbidity Database; Canadian Institute for Health information; Fichier des hospitalisations MED-ECHO, ministère de la Santé et des Services sociaux du Québec.  Highlights of 2010-2011 Selected Indicators Describing the Birthing Process in Canada. June 21, 2012

10.   Anonymous, Hospital episode statistics – England. Health and Social Care Information Centre. 2015

11.   Anonymous. Safe prevention of the primary cesarean delivery. American College of Obstetricians and Gynecologists; 2014; http://acog.org/Resources-And-Publications/Obstetric -Care-Consensus-Series/Safe-Prevention-of-the-Primary-Cesarean-Delivery.

12.   Dietz HP, Pardey J, Murray H.  Pelvic floor and anal sphincter trauma should be key performance indicators of maternity services. Int Urogynecol J 2015; 26:29-32

13.   Anonymous. Limitations of perineal lacerations as an obstetric quality measure. Obstet Gynecol 2015; 126: e108-e111

14.   Inpatient Hospitalizations, Surgeries and Childbirth Indicators in 2012-2013, CIHI, (sources are the Hospital Morbidity Database (HMDB))

15.   Leading Hospitalization Costs in Acute Inpatient Facilities in 2012-2013, CIHI (sources are the Hospital Morbidity Database and Canadian MIS Database)

16.   CIHI, Patient Cost Estimator, 2014-2015

17.   Allen, VM, O’Connell CM, Farrell SA, Baskett TF (2005) Economic implications of method of delivery. American Journal of Obstetrics and Gynecology. 193. 192-197

18.   Caesarean Section, National Collaborating Centre for Women’s and Children’s Health, Commissioned by the National Institute for Health and Clinical Excellence, RCOG Press, September 2011.

19.   Planned Cesarean Delivery Offers Protection Against Pelvic Floor Disorders, electivecesarean.com Dec 29, 2009

20.   Dietz H, Lanzarone V; Levator trauma after vaginal delivery, Ob Gynecol 2005; 106: 707-12

21.   Delancey J The hidden epidemic of pelvic floor dysfunction: achievable goals for improved prevention and treatment. Am J Obstet Gynecol 2005; 192:1488-95

22.   Gyhagen M, Bullarbo M, Nielson TF, Milsom I.  Prevalence and risk factors for pelvic organ prolapse 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery; Br J Obstet Gynaecol 2013; 120: 152-160

23.   Weber AM, Richter HE, Pelvic Organ Prolapse, Am Col Obstet and Gynecol; 106: No. 3 September 2005

24.   Farrell, SA, Allen VM, Baskett TF; Parturition and urinary incontinence in primiparas; Ob Gynecol, 2001 March; 97 (3):350-6

25.   Burgio, et al, Risk Factors for fecal and urinary incontinence after childbirth: the childbirth and pelvic symptoms study

26.   Sichuan Da, Xue Xue Bao, Yi Xue Ban. Three-Dimensional Ultrasound of the Pelvic Floor in Early Postpartum after First Delivery; Ultrasound Obstet Gynecol, 2016 Mar; 47(2) 253-6

27.   MacArthur C, et al; Urinary incontinence persisting after childbirth: extent, delivery history, and effects in a 12-year longitudinal cohort study; BJOG 2016 May; 123 (6)

28.   Gyhagen M, Bullarbo M, Nielson TF, Milsom I. The prevalence of urinary incontinence 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery.  Br J Obstet Gynaecol 2013; 120:144-151

29.   Gyhagen M, Bullarbo M, Nielson TF, Milsom I.  A comparison of the long-term consequences of vaginal delivery versus caesarean section on the prevalence, severity and bothersomeness of urinary incontinence subtypes: a national cohort study in primiparous women; Br J Obstet Gynaecol 2013; 120: 1548-1555

30.   Multi-million Dollar Lawsuit over Vaginal Mesh, April 17, 2012, CTV News

31.   Obstetrical Anal Sphincter Injuries (OASIS): Prevention, Recognition and Repair; SOGC Clinical Practice Guideline, No. 330, December 2015

32.   Wegnelius G, Hammarstrom M, Complete rupture of anal sphincter in primiparas: long term effects and subsequent delivery.  Acta Obstet Gynecol Scand 2011; 90:258-63

33.   Schwab W, Marth C, Bergant AM, Post-traumatic Stress Disorder Post Partum, Geburtshilfe Frauenheilkd, 2012 Jan; 72(1) 56-63

34.   Hsu C, Medical Daily, August 8, 2012

35.   Strous R, Sackler Faculty of Medicine, Tel Aviv University, PTSD Can Affect New Mothers, Israel Medical Association Journal, August 8, 2012, https://psychieblog.wordpress.com/tag/professor-rael-strous/

36.   Lim G, et al, Easing Labor Pain May Help Reduce Postpartum Depression in Some Women, American Society of Anesthesiologists 2016 annual meeting, October 26, 2016.

37.   Reynolds JL, Post-traumatic stress disorder after childbirth: the phenomenon of traumatic birth. Can Med Assoc J; Mar 15, 1997; 156(6) 831-835

38.   Garthus-Niegel et al. The influence of women’s preferences and actual mode of delivery on post-traumatic stress symptoms following childbirth: a population based, longitudinal study, BMC Pregnancy and Childbirth 2014, 14:191

39.   Centre for Maternal and Child Enquiries (CMACE). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006-2008.  The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom.  BJOG 2011;118(Suppl. 1): 1-203

40.   AIHW: Humphrey MD, Bonello MR, Chughtai A, Macaldowie A, Harris K, Chambers GM, 2015.  Maternal Deaths in Australia 2008-2012.  Maternal deaths series no. 5. Cat. No. PER 70. Canberra: AIHW

41.   Saurel-Cubizolles MJ, Romito P, Lelong N, Ancel PY:  Women’s health after childbirth: a longitudinal study in France and Italy.  BJOG 2000. 107 (10): 1202-1209

42.   Garthus-Niegel S, Ayers S, Martini J, von Soest T, Ebehard-Gran M, The Impact of maternal postpartum post-traumatic stress disorder symptoms on child development: a population based, 2 year follow up study.  Psychological Medicine 29 Sept 2016.

43.   Jacobson B, Bygdeman M, Obstetric care and proneness of offspring to suicide as adults: case control study.  BMJ 1998; 317:1346-1349

44.   Salk L, Lipsitt LP, Sturner WQ, Reilly BM, Levat RH, Relationship of maternal and perinatal conditions to eventual adolescent suicide.  Lancet 1985; i:624-627

45.   Verdoux H, Geddes JR, Takei N, Lawrie SM, Bovet P, Eagles JM, et al. Obstetric complications and age at onset in schizophrenia: an international collaborative meta-analysis of individual patient data. Am J Psychiatry 1997; 154: 1220-1227

46.   Van Os J, Jones P, Lewis G, Wadsworth M, Murray R. Developmental precursors of affective illness in a general population birth cohort.  Arch Gen Psychiatry 1997; 54: 625-631

47.   Factsheet: Women and Alzheimer’s Disease, March 2014, www.alz.org

48.   Ptok U, Barlow K, Huen R. Fertility and number of children in patients with Alzheimer’s disease. Arch Women Ment Health 2002;5(2):83-86

49.   Sobow T, Kloszewska I. Parity, Number of Pregnancies, and Age of Onset of Alzheimer’s Disease. J of Neuropsychiatry &Clinical Neurosciences. 2004.Vol.16; Issue1:120-a-121

50.   Li FD, Chen TR, Xiao YY, et al. Reproductive History and Risk of Cognitive Impairment in Elderly Women: A Cross-Sectional Study in Eastern China. 2016. Journal of Alzheimer’s Disease; Vol. 49; No. 1:139-147

51.   Wilson RS, Arnold SE, Schneider JA, Kelly JF, Tang Y, Bennett DA. Chronic psychological distress and risk of Alzheimer’s Disease in old age. Neuroepidemiology 2006;27(3):143-153

52.   Bloom BS, de Pouvourville N, Strauss WL.  Cost of illness of Alzheimer’s Disease: How Useful are Current Estimates? The Gerontologist 2003; Vol. 43; No 2:158-164

53.   Statistics Canada, Perinatal Deaths, CANSIM Table 102-0508, 2011.

54.   Eichenwald EC, Stark AR, Management and outcomes of very low birth weight. N Eng J Med. 2008 358(16): 1700-1711

55.   Pasupathy D, Wood AM, Pell JP, Fleming M, Smith GCS; Rates of and Factors Associated with Delivery-Related Perinatal Death Among Term Infants in Scotland; JAMA, 2009, 302(660-668

56.   Puza S, Roth N, Macones GA, Morgan MA.  Does cesarean section decrease the incidence of major birth trauma? J Perinatol. 1998 Jan-Feb; 18(1):9-12

57.   Alexander JM, et al, Fetal injury associated with cesarean delivery. Obstet Gynecol. 2006 Oct; 108(4): 885-90

58.   The Economic Impacts of Stillbirth in Australia; Stillbirth Foundation Australia; September 2016.

59.   Toronto Star, The High Cost of OB/GYN mistakes in Ontario.  November 28, 2015

60.    http://www.citizen.org/publications/publicationredirect.cfm?ID=7497

61.   Milne V, Schin P, Nolan M, Is Canada’s medical malpractice system working? www.healthydebate.ca November 20, 2014

62.   Martin ST, Canada keeps malpractice cost in check, Tampa Bay Times, July 26, 2009

63.   Kirkey S, Millions Paid to Canadian families for ‘catastrophic’ baby deliveries, malpractice insurer finds.  National Post, September 9, 2016

64.   Windrim R, Ehman W, Carson GD, Kollesh L, Milne K, SOGC; The ALARM Course: 10 years of Continuing Professional Development in Intrapartum Care and Risk Management in Canada. J Obstet Gynaecol Can 2006; 28(7): 600-602

65.    NHS Litigation Authority, Extract from Ten Years of Maternity Claims: An Analysis of NHS Litigation Authority Data; October 2012.

66.   NIH State-of-the-Science Conference Statement on cesarean delivery on maternal request. NIH Consens State Sci Statements 2006; 23:1-29

67.   The American College of Obstetricians and Gynecologists, Committee Opinion, Cesarean Delivery on Maternal Request, Number 559, April 2013

68.    Bodur S, Gun I, Ozdamar O, Babayigat MA, Safety of uneventful cesarean section in terms of hemorrhage.  In J Clin Exp Med. 2015; 8(11): 21653-21658.

69.   Kirkup B, The Report of the Morecambe Bay Investigation; An independent investigation into the management, delivery and outcomes of care provided by the maternity and neonatal services at the University Hospitals of Morecambe Bay NHS Foundation Trust from January 2004 to June 2013., March 2015

70.   Silver RM, Landon MB, Rouse DJ, Leveno KJ, Spong CY, Thom EA, et al. Maternal morbidity associated with repeat cesarean deliveries. National Institute of Child Health and Human Development Maternal-Fetal Units Network.  Obstet Gynecol 2006;107: 1226-32

71.   Bujold E, et al. Inter-delivery interval and uterine rupture. Am J Obstet Gynecol 2002; 187:1199-2002

72.   Esposito MA, et al. Association of interpregnancy interval with uterine scar in labor: a case control study. Am J Obstet Gynecol 2000; 183: 1180-1183

73.   Shipp TD, Inter-delivery interval and risk of symptomatic uterine rupture.  Obstet Gynecol 2001; 97:175-177.

74.   CIHI Snapshot, Inpatient Hospitalizations, Surgeries, Newborns and Childbirth Indicators, 2014-2015

75.   Mullins M, Menaker R, Esmail N, The Fraser Institute Hospital Report Card, Ontario 2006

76.   Canadian Institute for Health Information, Canadian Patient Safety Institute. Measuring Patient Harm in Canadian Hospitals. With What can be done to improve patient safety? authored by Chan B, Cochrane D. Ottawa, ON: CIHI; 2016.

77.   UHSC_2013_0136_Judgement.  Montgomery v Lanarkshire Health Board, [2015] UKSC 11.


 

 

 

Media contact:  Penny Christensen, Birth Trauma Canada,

                                mail@birthtraumacanada.org