Hannah listening to Joshua’s heartbeat
Have you ever wondered whether the caesarean you had, or the one you’re being told you need, was or is really necessary? I know many women who’ve been told that they require a caesarean because their baby is too big or hasn’t engaged, etc. Recently I’ve been wondering again whether these reasons are really valid and why so many of us are now having medical intervention to get our babies out. Then, quite coincidentally, a study was reported on in the Sydney Morning Herald last week. It exposed the increasing trend of women who are receiving inadequate consultation on medical interventions, including caesareans. The study reports some very d isturbing statistics:
- 10% of women are uninformed about the risks of emergency caesareans and epidurals
- 25% of women are not consulted before having an episiotomy
- 60% of women are not adequately informed about vaginal examinations
- 22% of women are not consulted or informed before having an ultrasound
The study also shows that despite there being an equal number of women in both public and private Australian hospitals wanting a natural birth, more women in our private hospitals are saying they were only allowed a caesarean. About 41-50% of births in our private hospitals are cesarean, compared to 28% of those in our public hospitals. (WHO recommend 10-15%). In Australia, however, our caesarean rate is really high. According to an Australian Institute of Health and Welfare report, almost one-third of all births in Australia in 2011 were delivered by caesarean. This is a huge increase from 1991 when the statistic was 18 per cent. The results of these kind of studies are partly what drove me to seek out a private midwife and a home-birth when I was pregnant. Professor Hannah Dahlen was one of my two private midwives. To find out whats behind these statistics I decided to interview Hannah. Hannah’s been a midwife for more than 20 years, is an executive member of the Australian College of Midwives, NSW Branch and has researched women’s birth experiences at home and in hospital and published extensively in this area. I couldn’t think of anyone better to turn to for answers …
Prof. Hannah Dahlen
Interview: Professor Hannah Dahlen on Caesarean Sections
Megganmamma: Why are caesarean rates so high in first world places like Australia and America? In Australia, it seems that as soon as you have an obstetrician and plan to birth in a public hospital your chances of having a caesarean are hugely increased and your chances of birthing without intervention are slim. Surely it’s the women who check into private hospitals who should be healthier and more likely to birth naturally, not less. What’s really going on?
Prof. Hannah Dahlen: The argument often of private obstetricians has been that, “Well yes, but we look after older, sicker women,” which is actually not true. Yes, the women tend to be a bit older in the private sector, but they’re certainly much healthier and they have a higher socio-economic status, so they have a whole lot of social advantages. In a study we did in 2012 we looked just at low risk woman. We made sure they were all under 35 years of age, (between 20 and 34 years), that their babies were not too small and not too big, that they were giving birth between 37 and 41 weeks (not too early and not too late), and we got rid of all the population where they were high-risk, or where there were risk factors and then we matched them. If you gave birth as a first time mother who was low risk in the private sector, compared to a women of similar risk in the public sector, you were 20% less likely to have a normal vaginal birth and your chances, as a first time mother, of having a normal birth without intervention sat at around 15%, which was shockingly low.
There are a couple of issues:
One of the major problems is that these private obstetricians have 200 to 300 women a year. It’s not sustainable to a lifestyle to be on call and to be called out every night of the week, which is when most women go into labour and give birth. So there’s an incentive for private obstetricians to schedule in woman to have elective births, whether that’s inducing them or doing a caesarean section. So that’s one of the problems; it’s the way the model’s set up – it provides an incentive to try and get women to birth during more reasonable hours.
The second problem with the model is that it’s led by obstetricians working under a medical model. This model views pregnancy and childbirth generally as a problem waiting to happen, not as a normal physiological process. The lens that an obstetrician looks at birth through is very different to that of a midwife. The obstetric lens tends to look for problems while a midwife is always looking for the fact that this will go well and when problems arise – deal with them. The medical model means that obstetricians take a much more negative view and a much more precautionary view, which means they intervene earlier. Not all obstetricians of course – there are some really great ones out there.
Also, a lot of the problem is around the language used. An obstetrician uses language around woman like, “Oh your baby’s a bit on the big side” and of course, all the woman hears is, “I’ve got a huge baby and how am I ever going to get it out?” That’s the common one. Then the next week when she sees her obstetrician she might hear something like, “Well, it’s still quite on the big side.” Then when they tell her that one of her options is to have a caesarean she will jump at it gratefully because the thought of all the terrible things that might happen to her body and the thought of her baby getting stuck have been seeded. On the other hand, a midwife might say, “Your baby’s growing beautifully and you are beautifully strong and healthy and your body is designed to be the right size for your baby.” That midwife would certainly be aware if the baby was growing big but they wouldn’t assume that you couldn’t have a normal birth. They would be vigilant, but not negative. Midwives work like swans – they appear serene on the surface but under the water there’s a lot of activity going on. We try to keep fear out of the room. I think the language we use reflects our paradigm on birth. Is your paradigm that birth is powerful, triumphant, transforming and physiological? Or is your paradigm that birth is potentially flawed, that women’s bodies are potentially flawed and that they need the expert in order to make sure it’s a safe event. They are very different paradigms in view of birth. There are private midwives in Australia with caesarean rates of 3%, while the New South Wales rate is now around 33%. The reason for this is not really because there’s anything special about what we do, except that we surround woman with arms of love, trust and encouragement and the woman finds the potential that’s always there. We put our arms around those women and tell them they are magnificent. Once they believe it, they actually are magnificent. That’s always there; it just needs to be believed.
Never in history have woman been stronger, taller and fitter. These days women’s haemoglobins are fantastic, our diets have improved, we don’t have the tiny little pelvises we used to when we didn’t have enough vitamin D or enough healthy food and were birthing multiple babies with low haemoglobins. Today’s women live healthier and longer than ever before. And yet we have somehow enabled this belief in woman – that their bodies’ are fundamentally flawed. The fact that more women are now overweight and giving birth is a modern problem we are grappling with and we need to support women to reduce the risks associated with this and most importantly to get healthy before they have babies.
Megganmamma: Is it also a financial thing, this huge increase in caesareans?
Prof. Hannah Dahlen: Look, there are some financial benefits, but that’s not the major driver. If you could schedule an operating day where you did say 10 caesarean sections, each taking around half an hour, back to back, and then you go home and sleep through the night, it’s very different to being woken up in the night worrying about somebody’s fetal heart rate trace, being called in, being patient, waiting, coming back and having that happened multiple times. So yes, of course it’s financially beneficial because you can put more women through your practice and have a quality of life – the incentive around it is that ‘why would you not?’ I think we’ve almost incentivised birth towards intervention because of convenience and the ability to therefore generate more income. The more caesareans a doctor does, the more income they can generate. It’s not that caesareans are necessarily more lucrative than other forms of intervention, but a doctor can take on more women by putting them through the system on a orderly schedule and indirectly they make more money from this approach. So it’s more around the fact that they can actually schedule births to happen within business hours which enables them to put more women through their practice. Yes, ultimately there’s a financial gain, but there’s also a quality of life gain that’s probably more powerful.
Another factor that you can’t ignore is that litigations have played a major role in this. Litigations in some ways support this move because rarely do you get in trouble for doing a caesarean section, but if you don’t and something goes wrong you’re often asked “why didn’t you do one?” So it’s almost as though litigation says to doctors, “You are doing the right thing,” which reinforces this whole non-evidence based approach. Also in America and Australia we’ve got a very adversarial litigation system. We’ve got a system that enables you to sue quite readily. In New Zealand, for example, and in many of the Scandinavian countries, there’s compensation when there are problems. This stops the targeting of health professionals and consequently there’s a much lower intervention rate in those countries. We still need to make health professionals accountable for poor practice, but that’s done by the professional regulatory body.
Megganmamma: Many women I know have been told they absolutely had to have a caesarean. Reasons have included their babies being too big or their baby having not yet engaged when they are barely 38 weeks along. Are any of these reasons valid?
Prof. Hannah Dahlen: No they are not. You do not know if a baby is too big unless you have a labour and at some point in the labour things start to slow down and not progress. That’s when you get your indication about whether a baby’s too big. Women can push out 5.5 kg babies without blinking an eye and they can have real trouble with 3.5 kg babies. Being told your baby’s too big has got to be one of the most misused excuses and the least evidence-based excuse used today. It’s probably responsible for the majority of unnecessary caesarean sections. If I could explode one huge myth out there it would be that your baby is NOT TOO BIG. Nature is very clever in designing mums and babies to be the right size for each other. We haven’t evolved over millions of years to get it wrong now. It’s not sensible and it’s not true. Some of the biggest babies born interestingly are in home-birth and Birth Centre practices and they have the highest rate of normal birth. Let’s get past the ‘poor big baby’. A big baby is a healthy baby as well; it’s not such a negative thing. Yes, there are some cases where babies are too big and the labour will tell you that, but there are a tiny number and mostly it’s not a problem with today’s tall, healthy women.
As far as babies not being engaged, babies engage when they are approaching the labour and birth. With your first baby that may be a week or two before, but it may not happen until you actually go into labour. Every woman is individual. For example, if you are an African-American woman you have what we call a ‘high inclination of your pelvis.’ Those women often have a different angle on their pelvis and their babies engage later. It doesn’t mean that they give birth any less ably. Also, women think that because the magic due date has ticked past they are due, but if you’re not engaged at 38 weeks it’s highly likely your body is telling you you’re possibly going to go to 42 weeks. That may be your normal time of give birth. Engagement should never be used as a reason for caesarean section. It’s an absolute no-no.
Also, 38 weeks is not full term. You have just reached it, but full term goes until 42 weeks. Saying that 38 weeks is full term is ridiculous. It’s like saying that everyone is going to hit puberty and menopause at the same point in their lives. There are variations in all of us and for some women babies who come out at 38 weeks are truly immature – they have breathing problems and they have feeding problems and they are just not ready to be in this world – not to mention they have lots of brain development left. Making babies come out at 38 weeks for no good reason and no evidence to support it is actually, I think, outrageously unethical. There are too many ‘early term births.’ These are births that are brought on at 37/38 weeks. There’s a lot more morbidity with them, a lot more admissions, a lot more feeding problems, a lot more crying and behavioural problems and a lot more jaundice. That then impacts on the baby’s early adaption, on their early breastfeeding, and how mothers feel about being a mother and this continues a terrible cycle that you began life with. We are creating massive problems by bringing babies into the world who are not ready to be here.
Megganmamma: Why do obstetricians place such a huge amount of emphasis on getting the baby out by 38 weeks?
Prof. Hannah Dahlen: The recommendation from New South Wales Health and from all of the world authorities now, is that caesareans that are needed should not be done earlier than 39 weeks. And more and more evidence is now coming out to support this. I read a paper recently which said we should move it to 40 weeks, because even between 39 and 40 weeks there’s a lot of maturity that happens to a baby.
The reason why obstetricians place such a huge amount of emphasis on getting the baby out by 38 weeks is this: 1. It’s convenient because you schedule the woman in and they don’t go into labour and therefore you still have your caesarean and 2. You eliminate the very small risk of a stillbirth happening between 38 and 39 weeks. That’s the reason, however, what we’re showing in our research is that you don’t eliminate the risks, you actually create other risks. And those risks are very real. Early delivery is not saving babies lives but is creating a whole bunch of misery in early motherhood that doesn’t need to happen, not to mention the long term health consequences.
Megganmamma: Under what circumstances would a woman genuinely need to have a caesarean?
Prof. Hannah Dahlen: The only real indication for caesarean, like the number one absolute, is when your placenta has grown across the front of your cervix – it’s called placenta praevia. Basically the baby can’t get through and you can have a massive haemorrhage when the cervix starts to open up. If you had your very first herpes outbreak within a couple of weeks before or when you were having labour then that’s a fairly good indication for a caesarean section. We are now saying that there’s much less absolute around breech babies, even though the big breech trial came out saying women who have an elective caesarean have less adverse effects on the baby. We are now realising there were many problems with that trial. If we are selective and have experts who know what they are doing then vaginal breach is very safe. In NSW now we have Breech Centres Of Excellence, which is great. We need more.
Really there are about one or two absolute reasons why you would have to have a caesarean section. The majority of caesareans are for very soft and very debatable reasons. The number one reason for a caesarean in our country is a repeat caesarean. If we’re going to target anything, let’s first keep the first-time mothers safe from intervention and let’s stop the first caesarean, but if they have a caesarean let’s increase the vaginal birth after caesarean (VBAC) rate. We have very good evidence that we can do that safely and that you can successfully have a vaginal birth after a caesarean – up to 70% to 80% of women will. So we need to take previous caesarean section out of the ‘absolute’ list. The repeat caesarean rate in the private sector is about 98%, which shows women are just not being given an option.
Megganmamma: What does having a caesarean birth mean for the baby in the long run?
Prof. Hannah Dahlen: This is probably the most important question that we will answer in the next decade. We may look back on today in 10 years’ time and see this as a terrible era when we did terrible things for which we had no idea of the ramifications.
For women who have caesarean sections (and this has been shown through several studies now), their children have a 25% increase in type 1 diabetes, around 25% increase in asthma and allergies and atopic disorders, so all of those allergic responses. We’ve had several studies showing a relationship between obesity and caesarean section. Some studies show that there are links between caesarean section and behavioural disorders like ADHD and autism and some of the worrying auto immune disorders like multiple sclerosis and even cancer. What that’s telling us is that being born is good for you. We haven’t been programmed for a millennium to come out through our mother’s vaginas for that not to be important. And there are two mechanisms in this: one is in labour, which triggers hormones that stimulate the baby to be ready to be out in the world and to connect with its mother, but 2. The bacteria that line the vagina are really important in colonizing the baby’s gut so that when the baby is born it sets up what we are now calling a microorganism of its own, a system of bacterial defence that’s healthy. When you don’t have a gut lined with bacteria from your mother’s vagina, which is then topped up with healthy bacteria that grow when breastfeeding occurs, you are essentially setting down an imperfect defence mechanism and that defence mechanism may react to stress or to bacteria or to events in your life in either an overstimulated or an under-stimulated way. So it may respond dramatically, which would give you allergic responses, it may give you diabetes from the attack on your pancreas, or a virus or something that comes into your life … and it may also mean that it dampens your defences which may make things like cancer more likely. What we are increasingly discovering is that during the first couple of weeks of life following a normal birth through the vagina, (provided the baby breastfeeds early and only breastfeeds), the baby’s bacterial defence mechanism for life is set down. That’s why being born is good for you. However, antibiotics are a major problem and can disturb that even if you have a vaginal birth. We still have lots more research to do before we can say it is causal, but we can see there is an association. Surely then we should be cautious until we are proved either wrong or right.
Megganmamma: What about those women who, for example, who have their placenta covering the cervix and for whom a normal vaginal birth is not an option? What can be done?
Prof. Hannah Dahlen: We can do so much. I think we will increasingly find the valuable use of probiotics, but we are in early days of looking at how that can help us. What can help is skin to skin in theatre. Currently the recommendation for all women is that when their baby is born there should be skin to skin with the mother and we should not interfere. That first hour is probably the most magical and powerful in a human’s life and yet we do all these things to babies that can wait: we weigh them, we measure them, etc. They should go straight to mum and we should leave them alone so that they can bond and connect and so that baby can find the breast and have their first breastfeed. In theatre currently in Australia there are some hospitals that do it, but others who don’t. Sometimes some women get it, others don’t; it depends on whether the midwife agrees with it or if there are staff around to support it. For mothers who need to have caesareans: the baby should be put straight onto the mum’s skin and mum and baby should not be separated. Getting breastfeeding set up really early will go a long way to helping it work well.
We have some really interesting research from animal studies which show what happens when you take a baby rat, away from its mother and then return it. Their mothers instinctively lick them and give them more attention than the other baby rats – almost trying to repair the damage. So we in hospitals can make sure that the mother and baby overcome a lot of the damage by making sure that what we can facilitate we do. Don’t separate mothers and babies – that’s the key message here.
The problem is that babies born by caesarean are much more likely to have things done to them. We are much more likely to take their blood sugars and to give them artificial formula feeds. They are more mucousy and tend to have more vomits because they haven’t had the mucous literally squeezed out of them through vaginal birth. They may also have the drugs in their system from the anaesthetic and be a bit sleepier and less likely to feed as well. So we’ve got to put extra effort into making sure we do what we can to compensate for that.
Megganmamma: If a woman really wants to birth naturally, what would you advise her to do?
Prof. Hannah Dahlen: Firstly, I would advise her to find a midwife that she could get to know and trust. Then I would say she needs to think about the environment she would feel safest in. If she really wants the protection of a hospital then a birth centre is ideal, one with a caseload midwife program. If hospitals make you feel fearful and worried and you are a low risk woman who’s healthy and well then I would say find a midwife and have a home-birth. We know that the best outcomes for women, as far as interventions go, are at home. We also know that the outcomes in birth centres are very good, but the outcomes with continuity of midwifery care are absolutely supreme compared to all other models and can occur for women of all risks, not just low risk women.
Megganmamma: As far as birth centres go in New South Wales, do you recommend any as being particularly supportive of natural birthing?
Prof. Hannah Dahlen: They are all very good. We also have two midlife-led units – one at Ryde and one at Belmont. They are stand-alone units run by midwives. I hope we see an expansion of them occurring, but some birth centres (and this is an important thing for women to know) don’t have continuity of midwifery care, so I would suggest looking for a birth centre where you get to know your midwife. While relationship and environment are both important, if you had to trade one for the other, I’d say relationship is the most important. You wouldn’t have strangers in there watching you make love, so why have strangers at birth? Giving birth is incredibly intimate and incredibly finely balanced, so you want your brain to be able to go into that primitive space that it needs to feel safe and trusting. You can only do that when you know your providers and your providers know you.
Megganmamma: If a woman can’t afford a private midwife, what’s her next best option?
Prof. Hannah Dahlen: Find a caseload model of midwifery which gives you your own midwife or midwives throughout your pregnancy, birth and postpartum period. If that caseload model is part of a birth centre that’s ideal. Then there are publicly funded Home-birth programs. We currently have twelve of these across Australia, so if you are lucky enough to live near a hospital which provides the option of publicly funded home-birth that’s even more perfect because then you can do that without having to pay. Women shouldn’t have to pay for something that leads to better outcomes and saves the nation money.
Megganmamma: I feel as though I couldn’t trust a private obstetrician. Do good obstetricians exist in spite of the system?
Prof. Hannah Dahlen: There are lots of great obstetricians out there and many of the ones who work in the public sector are committed to best practice and evidence-based care. Sadly in the private sector it is hard for women to know which obstetricians have low intervention rates because none of the individual rates are published. If this would happen then women could make an informed choice. Women should demand that obstetricians publish their intervention rates. This would help make private obstetricians accountable and I think choices for women would then increase. It is time we had a MyBirth website like the MySchools website. Let’s make our health professionals accountable to the women they serve.
Megganmamma: Is there anything else you would like to add?
Prof. Hannah Dahlen: A really under recognized source of women getting through labour is the use of water. I would so encourage women to seek out environments and providers which will enable them to use water (baths, showers, etc). Even if you don’t want a water birth, the use of water reduces your need for pain relief and in particular epidurals. And epidurals are often the beginning of the cascade of interventions. If we could reduce the epidural rate in this country we could reduce the intervention that we see in childbirth. So, find somewhere with water, find a provider who believes and supports it. Water in labour is so comforting and the benefits that come from it will help us move towards normal birth.
Megganmamma: A woman I met told me that during her birth in one of our public hospitals, the doctor said that to increase her chances of a normal birth they where going to give her an epidural. What would you say about that?
Prof. Hannah Dahlen: We rank scientific evidence in terms of levels – level 1 (systematic review) being the highest in the world, down to level 5. Level 1 evidence is when you amalgamate randomised controlled trials where women are randomly allocated to having an epidural or randomly allocated to not (and we can debate the ethics of all of that). When you amalgamate all of those results it’s very clear that epidural doesn’t facilitate normal birth, it hinders it. Epidural leads to higher rates of intervention and in particular to more forceps and vacuum birth. And forceps and vacuum birth are much more likely to lead to surgical cuts to your perineum (episiotomy) than not having one. And cuts to your perineum, especially when combined with forceps and vacuum birth, are much more likely to lead to the most severe form of perineal trauma where your tear extends down into your anus. There are very few evidence-based professionals who could say that epidural facilitates normal birth. However, some women have abnormal labours where their baby gets into a posterior position (head and back lying against your spine) who are in significant pain (not normal labour pain). These women need to have their labours augmented (sped up) using artificial hormones and some may need to have an epidural. So I’m not against epidural. I think epidural has a fantastic role to play, but we overuse it and overusing any intervention is not a wise thing to do. However, we know from level 1 evidence and from randomised trials, that water reduces epidural. That’s why I’m saying we should get the water out. Let’s get woman into a nice warm bath. If we do that we will use epidural far less than we are today.
Megganmamma : If a woman decided that the only place she felt safe to birth was in a hospital, would you advise her to check into a public hospital rather than a private hospital in Australia?
Prof. Hannah Dahlen: The only option in a private hospital is a private obstetrician, so in a private hospital you can’t have a midwife who you know and having a midwife you know will lead to the best outcomes. Currently no private hospitals have allowed private midwives in. There is one model of care in the private sector and that is the private obstetric model. I’d suggest she find a public hospital and a caseload midwife program (continuity of midwifery care). Women also really need to know that because these programs are so popular they fill up very quickly. To be accepted into one you have to get in almost the moment you are pregnant. The waiting lists are very long. Don’t hang around thinking, “Oh, I’ll just go in around 12 weeks.” No, as soon as you see the blue line on that pregnancy stick, ring up and find out what options are available.
Megganmamma: Is it possible to have a normal birth if you’re booked in with a private obstetrician in a private hospital?
Prof. Hannah Dahlen: Of course it’s possible, but it’s much less likely and that is a scientific fact which even obstetricians don’t debate. Women who birth rapidly and easily, or women who are very informed and forceful, do well in private hospitals. The problems start when you’re pregnant and feeling vulnerable and people are making suggestions or using negative language around you. Your number one instinct as a mother is to protect your baby; we all have that instinct within us. So you will defend and protect your baby and if you have negative language around you, language of risk and vulnerability for your baby, you will become vulnerable to that.
Megganmamma: What are the most important preparation steps for a woman to take if she wants to birth normally?
Prof. Hannah Dahlen: 1. Find a midwife who you will get to know through your pregnancy and birth, who you know will be around for your antenatal, birth and postnatal birth period. Birth is about relationships and we know birth works best where these are in place. This is probably the most important thing. We have level 1 evidence which tells us that if women have midwife-led continuity (ie. a midwife who they know throughout the childbirth continuum) they will end up with less intervention and be more satisfied, not to mention it costs less.
2. We investigate when we buy a fridge or a car – we research and we read Choice Magazine or look for reviews, but when we have a baby we don’t seem to question much. Do your own research. Don’t just listen to your friends and family – remember that’s their only experience and probably not scientifically based.
3. Think about what kind of birth you want. If you really want to have a normal birth and you want to have birth as a life changing and transforming event, then you need to seriously think about finding providers that hold that same view and go and choose them. And generally where you’ll find that type of care is through a birth centre or homebirth program that provides you with continuity of midwifery care.
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