Two articles from Age re: c/s inc. comment from Lionel Steinberg

[BellyBelly]

Here you go...

Rise in caesarean births should be examined
May 31, 2007

MOST parties to the sometimes rancorous debate about women's birth practices agree that our high caesarean rates warrant investigation. But trying to unpack the trend, and its varied implications — be they for maternal and child health, doctors, insurers, the public purse and so on — tends to open a Pandora's box of dogma, prejudice, hyperbole and myth.

And so when another worrying statistic comes to light, as in a recent State Government report finding a rise in healthy young women undergoing caesareans in private hospitals, it inevitably provokes more questions than answers. Why are more than one in four young women in private hospitals undergoing a caesarean despite good health and uncomplicated pregnancies? The Department of Human Services figures show that the proportion of women under 35 who had a low-risk first pregnancy and went on to have a caesarean in a private hospital rose from 23.4 per cent in 2001 to 27.5 in 2005. The correlating rate in public hospitals has been a fairly stable 19 per cent since 2003.

Some doctors concede there may be more women electing for caesareans without medical reason in the private hospital system, but believe the overall number is small. And yet the "too posh to push" woman is regularly evoked in this debate, along with the obstetrician favouring surgery out of personal convenience. It's time to drop the caricatures and find the truth. Health Minister Bronwyn Pike said her advisory committee on maternity services would investigate whether hospitals with higher caesarean rates need extra help.

The report reiterates there's "no agreed or optimal or clinically appropriate (caesarean) rate," and experts caution against policies that would lead to different birthing options in private and public hospitals. We need to take this step by step.

Mothers' wishes, legal fears push up caesar rate
Carol Nader
May 31, 2007

THE rate of caesarean sections is higher in private hospitals because women ask for them and because doctors are worried about being sued if a natural birth goes wrong, leading obstetricians say.

Of the women under 35 with uncomplicated first pregnancies who give birth in private hospitals, 27.5 per cent had a caesarean in 2005, up from 23.4 per cent in 2001.

For young first-time mothers giving birth in public hospitals, the figure has remained stable at about 19 per cent.

The obstetrics committee chairman at St Vincent's Private Hospital, Lionel Steinberg, said 5 to 7 per cent of women who had caesareans in private hospitals asked for them without any medical need.

"The reasons the caesarean sections have increased in first-time mums in the private sector are patient requests for caesareans, too many inductions of labour and the medico-legal risk related to each individual obstetrician in the private sector," he said. "In my practice, which is a low-intervention practice, there is an increased demand for caesarean sections … I spend a third of my time trying to convince women to give it a go naturally."

Dr Steinberg said women asked for caesareans because they feared labor pain, for convenience and because they thought it was safer. But it was not safer for the mother, as anaesthetics and surgery were associated with more risk, he said.

St Vincent's Private delivers about 3500 babies a year, more than any other private hospital. Its caesarean rate is 36 per cent. At Frances Perry House, another private hospital with a major obstetrics service, the rate is about 40 per cent. Obstetrician Ross Pagano, senior medical staff chairman at the hospital, said the higher rate was because women with more complicated pregnancies were referred to the hospital.

He said about 5 per cent of his patients asked for a caesarean. "An easy vaginal birth is very safe for the baby, but particularly in complicated cases caesareans are safer," he said. But Dr Pagano said a caesarean was not the safest option for mothers.

He said the increasing use of caesareans had nothing to do with doctors scheduling patients around their social calendars. "We get really annoyed when we read in the paper that obstetricians do caesareans because it's better for your golf game. It's absolute nonsense," he said. "We do caesareans these days because we want the best outcome … Nowadays, if a baby gets distress, even mildly, we will opt to get that baby out swiftly."

Dr Pagano said doctors were worried about being sued for problems, sometimes out of their control. He said some doctors had been sued for labours that had complications that "in retrospect could have been prevented by caesarean section".

[Janet]

Onya Lionel! Finally a surgeon who reads studies and talks fact instead of myth. He'll be very unpopular with his colleagues this week

[BellyBelly]

He always speaks like this though LOL. He quite openly tells his clients

[blackbird]

The Age has been running quite a lot of articles on this topic lately. I think it's good to get a public discussion going. I wonder what the breakdown is between scheduled/planned and emergency c/sections? And how you distinguish btn a c/s that is done after labor has commenced and a 'true' emergency? And does it matter? Me thinks my c/s might be playing on my mind more than I thought...

[Janet]

The perinatal data defines them as prelabour or during labour but that can be a very blurry way to distinguish. In Australia it's roughly 50/50 booked/in labour. Most caesareans in Australia are not performed for genuine evidence based reasons but because of previous surgery, or because it's the end result of unnecessary inductions and other interventions. Birth is a massive event in a woman's life and all women need to debrief from their experience with love, validation and support. One thing I've learnt from supporting birthing women is that over time our feelings always change around our births. I hope you can access good support to help you debrief and heal, if that's what you need, or at any rate to move forward from your experience. Recovering from my surgery took about two years on the emotional side, and I still feel some sadness over parts of it. I always will. Birth doesn't end when the baby leaves our bodies, it ripples through our lives, our relationships and our families for the rest of our lives. I wish you much strength and healing I'm sure Kelly has birth trauma well covered in her articles

Kelly I think the mark of a REALLY good surgeon is one who refuses to take on healthy women as clients. That would be providing evidence based care.

[Morgaine]

I think the mark of a REALLY good surgeon is one who refuses to take on healthy women as clients. That would be providing evidence based care.

Then he would be a very poor surgeon indeed with only a small number of women to care for. You do make a good point there, never quite thought of it in that way before!

This might interest you blackbird - The perinatal statistics show a consistent rate of around 15% caesareans are considered elective with emergency cs rates being anywhere between 11% and 14%.

In Victoria, the data breaks down the main reported reasons for both elective and emergency cs. I LOVE VIC's perinatal data, they provide really extensive data compared to the other states.

The three main reported indications for elective caesareans in VIC were:
Previous caesareans (57%), malpresentation (18%) and Other reported indications. (12.5%).

The three main reported indications for emergency caesareans in VIC were:
CPD/failure to progress(32%), fetal distress (31%) and malpresentation (12%).

And this is the part where my eyes just fall out of my head.

Women who plan homebirths have a caesarean rate of 7% (0.2% elective, 6.8% emergency)
Women who plan birth centre births have a caesarean rate of 11.9% (2.1% elective, 9.8% emergency)
Women who plan hospital births have a caesarean rate of 29.4% (15.6% elective, 14.3% emergency)

Look at the rates of emergency cs for homebirth! Clearly if you're looking to reduce your liklihood of ending up with surgery in place of a birth, you're best served by planning a homebirth.

[BellyBelly]

They are great stats Morgaine, thanks for the detailed post. Do you mind if I post them with my other stats from the homebirth conference?

[Morgaine]

Sure, the state perinatal data is public access, you can easily find that data by looking at the most recent perinatal data for VIC and other states. Unfortunately the data is for 2004 and some 2005. I wish they'd hurry up and publish 2006 and 2007. It is absolutely ridiculous theres a two year lapse!

[BellyBelly]

Yes I do have a printed copy of it, but I never seem to get time to go through it all... I wish it was annual too.