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“Don’t underestimate what your body can do,” says new mum Libby Nathan, who gave birth to her baby boy this week at the Royal Hospital for Women. Photo: Louise KennerleyIt was picture-perfect: Intense, emotional and “excruciatingly painful” but also everything Libby Nathan hoped it would be. This week the 36-year-old gave birth in the Royal Hospital for Women to her little boy – the first baby for her and husband Jeremy.
“It was a very empowering experience and I’m proud that as a team we were able to do it,” she says.
The team Nathan is referring to didn’t involve a doctor. It consisted of her, her husband, midwifery practice at the Royal, and her privately hired doula, or birth support companion, who, she said, was “agreed to and embraced by” her midwives.
Nathan is the face of a shift in obstetrics in NSW. She delivered her baby without medical intervention, which is what she had wished for, but she also benefited from the high level of care available from the hospital, which is leading the push towards natural birth among the state’s major hospitals.
Ten days before giving birth she was knocked over, and needed special monitoring in the lead-up.
“It was a good lesson in things not always going to plan,” she says. “We always knew things don’t always go to plan, but we wanted to maximise our chance of a natural birth.”
As it happened, she was in hospital getting test results when midwives suggested she might be in labour. By 3pm her waters had broken and by 7.45pm her baby was born.
She says despite the fact she had coped with the pain and felt positive about the birth, she doesn’t judge woman who seek medical intervention.
“Even with my shorter labour it was just exhausting,” she says. “With my holistic philosophy I believed I was capable of it. But every situation is different, and I know women who were also so geared for a birth like that. But then they are in labour for 30 hours and it’s just not progressing.”
Amid spiralling use of medical interventions such as caesarean section, and a continuing fight from women’s rights advocates to give women more control, five years ago NSW’s Towards Normal Birth policy was launched.
Its aims were ambitious – expecting more than 80 per cent of women to give birth vaginally, and 60 per cent of women who had already had one caesarean to give birth to their second baby vaginally by 2015 – and signalled a landmark policy change to birth in NSW.
But today, on paper at least, the policy has not achieved its goals. Data released by Health Statistics NSW on birthing outcomes in NSW to 2013 (the most recent year for which information is available) show under 57 per cent of mothers in NSW have a normal vaginal birth, down from 58.2 per cent five years previously.
Only half of all first-time mothers now have a spontaneous vaginal birth, while there has been a large spike in women being induced to nearly 39 per cent of first-time mums, a 15 per cent increase on 2009, and more women are having major haemorrhages after they give birth.
The community of people involved in birth, from mothers to midwives, doulas to doctors, is divided over the right response. Why can’t we meet the targets, and should we even try?
It’s a minefield. Every woman’s experience is different and so are her values. Beliefs vary from wanting a vaginal delivery more than anything else, to deciding the pain and potential side-effects are an unnecessary evil best avoided.
Language drips with normative value – from talk of risk and choice, to words like “achieving” and “natural” – that seemingly politicises every aspect of birth.
Against this background, debate can be difficult. But the head of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, Michael Permezel, says the fact NSW has not met its targets is not necessarily bad.
“The most important thing is it’s not health administrators who write policies that are determining the mode of birth, it’s really the women themselves,” he says. “The reality is in Western countries the rates are remarkably similar, and women are voting for caesarean section rates of around that 25 to 30 per cent mark mostly.”
He says women are becoming more risk-averse, so as they get older and heavier, which makes birth more risky, they are less likely to opt for a vaginal birth.
For example, while NSW has seen spiralling rates of labour induction, NSW Kids and Families, the ministry in charge of Towards Normal Birth, says one explanation could be that in NSW the percentage of mothers aged over 35 years (24 per cent in 2012) was almost twice that of the national average (14 per cent).
“If a vaginal birth is completely safe, of course most women will chose that option, but the surveys are very clear that where there is added risk from vaginal birth, most women will choose a caesarean section,” Permezel says.
He fears insisting on strict targets could be dangerous.
“When health services perhaps decide on the caesarean section rate first, and then try and fit the women to that caesarean section rate, it might lead to some inappropriate decision-making,” he says.
St George Hospital in Sydney’s southern suburbs stands as an example of how targets that look good on paper can be difficult to achieve.
The rates of women there who had a vaginal birth for their second baby after previously having a caesarean were low – only about 17 per cent of cases – compared with the Towards Normal Birth target of 60 per cent by 2015, when the hospital set out to make a change.
But Trent Miller, the clinical director of obstetrics and gynaecology, says it wasn’t the target that motivated them as much as feeling their low rates meant women were not getting the best possible care.
“We went into it being quite pro vaginal birth … we wanted to be pretty liberal in offering it to everyone because most women can have a go,” he says.
The team found despite strong evidence it is safe to have a vaginal birth after a caesarean (and that repeated caesareans put both mother and baby at risk), many women were reluctant.
“A lot of the time it is the poor experience from the last birth – they are scared. They were traumatised by what happened and they don’t want to go through that again,” he says.
“And then there was another group of women who had had a caesarean, but didn’t really mind that was what had ended up happening – and that second group is actually much harder to convince.”
Smaller teams, ensuring the advice given was consistent, and helping those women deal with their bad experiences, did have strong success – increasing their VBAC (vaginal birth after caesarean) rates to 27 per cent.
But there were also some tragedies. Two women had uterine ruptures, and in one of those cases the baby died. Another woman had a stillbirth.
The relatively high number of terrible events in that time was a statistical aberration – Miller says there have been no such deaths since they published the results of their efforts in the Australian and New Zealand Journal of Obstetrics and Gynaecology last year.
But it highlights the high stakes. The team needed to warn women clearly about the risks, but make it clear they are very rare and outweighed by the benefits.
“There are some women who will take that and say ‘that’s not for me’, and for some women that is absolutely fine,” he says. “We are not there to convince women to do something they don’t want to do”.
But the truth is, Miller says, that without forcing some to have vaginal births, it simply would not be possible to reach the 60 per cent target in Towards Normal Birth. Stop ‘blaming women’ for systematic failures, midwives say
Hannah Dahlen is on the front lines of the push towards normal birth in NSW. The spokeswoman for the Australian College of Midwives and professor of midwifery at the University of Western Sydney was involved in the development of the NSW policy, and rejects the idea it is unachievable.
She says smaller hospitals that tend to have lower-risk patients in particular are seeing incredible results, citing Fairfield Hospital as just one success story, where vaginal births were above 78 per cent in 2013.
But the private sector, she says, has got “so much worse”. Induction in private hospitals is also high, at around 50 per cent.
“We are doing it all to save babies apparently, but there has been no change in the perinatal mortality rate over the past decade – none,” she says. “But we have escalated and escalated and escalated the intervention.”
“We are ending up with so many women who are traumatised by their birth. Then these women say ‘I’m not walking back into a hospital’ and they make dangerous decisions like deciding to freebirth.”
Dahlen says there is still not enough support available to ensure women can give birth naturally, particularly first-time mothers, which then triggers more intervention down the track.
“I agree mothers are older, women are overweight, but it’s not enough of an excuse for us to keep blaming mothers,” she says.
Nordic countries have similar rates of maternal risk factors but manage to have much lower caesarean rates, she adds.
Dahlen says private obstetricians should be forced to publish their individual caesarean section rates, and women should use the NSW health statistics to research what hospital they give birth in.
“If you go out and buy a fridge or a washing machine you would do research, so why wouldn’t you do it when you are having a baby,” she says.
Dahlen believes an increased number of dangerous bleeds which appears to be occurring recently could be related to a lack of respect for the “third stage” of labour when the placenta is delivered, with research showing increased interventions such as induction can lead to haemorrhage.
But the haemorrhage issue provides just one case study of the divided opinions about what is happening in NSW. NSW Kids and Families says that the apparent rise is small enough that it might not be a trend.
And while Dahlen believes it is likely linked to increasing intervention and medicalisation, Professor Hans Peter Dietz has a different idea.
The obstetrician and gynaecologist spends his days fixing the pelvic floor damage women have experienced in childbirth.
He worries that the increasing push towards natural birth is having the unintended consequence that more women are having longer, more difficult labours.
“In the past it was two to three hours of unsuccessful pushing before obstetricians intervened, now it may be six,” he says. “It has the advantage that some women will push their baby out, but the risk that some will be left with a post-partum haemorrhage.”
(NSW Kids was unable to say what proportion of caesarean haemorrhages occurred after the type of situation Dietz is describing, which would have required an emergency, rather than elective caesarean.)
Dietz is also concerned by an increasing trend towards doctors using forceps.
As an example, he cites the Royal Hospital for Women, one of the only major hospitals that has lowered its caesarean rate, by 10 per cent between 2007 and 2013, and is considered a leader in the field in NSW. But in that same period, its forceps rate increased by more than 50 per cent. He estimates that for every 10 caesareans prevented, it is likely that four additional tears to a woman’s levator muscle – which holds the pelvic organs and bowel in place – occur, and four additional sphincter tears.
“Of those eight additional tears (in about 6 women), it is very likely that only one or two are even diagnosed at birth, and even when diagnosed, such tears are often not well repaired, which means the damage is major and permanent in about five women for every 10 caesarean sections saved,” he says.
“Obstetricians and midwives are often blissfully unaware of the additional damage done in the quest to reduce caesarean rates, especially as most of the damage only causes symptoms, [such as] urinary and fecal incontinence, prolapse, sexual dysfunction, years or decades later.”
Dietz says the goal of vaginal birth is important, but to achieve it as mothers get older and more overweight you have to shift the goalposts of what you think is an acceptable level of risk. And, he says, the goalposts are clearly placed differently depending on what hospital you give birth in.
“It’s as if there are two different philosophies, and we are making decisions for these women without ever informing them properly,” he says.
“In my entire clinical life, how many women with major later life health problems due to caesarean have I ever seen? I can’t remember a single one. How many after forceps will I see? Several a week, at least 100 a year, maybe 200 a year,” he says. Balancing fear vs information
Let’s get one thing straight: you are probably going to be fine. Most women can come through a vaginal birth (or a caesarean section) relatively unscathed.
But what happens to those who don’t? For women who feel robbed of natural birth by hospital interventions, the disempowerment and painful memories can last a lifetime.
But there is also another, largely silent group of women: those who may “achieve” a normal birth, but at great physical and emotional cost.
Liz Skinner is a registered nurse and midwife of more than 20 years’ experience.
As part of her PhD project undertaken with Professor Dietz, Skinner has interviewed 40 women who experienced major pelvic floor trauma.
Her findings paint a disturbing picture of the care given to women with birth trauma.
Two-thirds of the women showed symptoms of post-traumatic stress disorder, and many couples were experiencing sexual and emotional problems.
Every woman interviewed had had her pelvic floor muscles pulled entirely off her pubic bone and pelvic side wall. Yet not one had been identified as suffering this major trauma after their birth.
Only five of the 40 had been diagnosed with major anal sphincter tears, yet further examination revealed 55 per cent had them.
“Health professionals were not attentive to any of this – I felt alone, I still do,” one respondent said.
Two-thirds said their doctors and midwives had dismissed the symptoms they experienced after birth, while nearly 90 per cent said they had got confusing and conflicting information from their treating team before, during and after the birth.
Skinner says she was shocked by both the suffering, and lack of support.
“It’s a hidden issue and they are not talking about it because it’s women’s business to have babies,” she says.
While feminists previously fought to return control to women giving birth, Skinner sees the new feminist issue as ensuring that women are correctly assessed for their risk of complications, given full and frank information and support if things go wrong.
“This issue of scaring women is the elephant in the room. But if you were going for heart surgery they give you lots of information before you go into the room, including the risk you might have a heart attack or stroke. Should we not tell you that? It’s the same with any medical intervention, so why is information about complications not given to mothers?” So what are hospitals doing to lower intervention?
But Andrew Bisits, the medical co-director of maternity services at the Royal Hospital for Women, says in his hospital, encouraging women towards normal birth is never about encouraging them at any cost.
“It’s really about responsible, appropriate use of intervention,” he says.
He credits the Royal’s success in decreasing intervention to ongoing, systematic reviews of every birth.
But he believes all interventions at the hospital, including its forceps use, should still be lower.
Even the Royal is a long way off meeting the state targets, but Bisits thinks they are achievable, if a little ambitious.
“I think there is a substantial quantum of enthusiasm in this area for women to have natural birth,” he says. “I can’t really say that has increased [over the past five years] but I think our enthusiasm for it and willingness to support that in a responsible way has become more explicit.”
Yet the team often comes up against a high degree of fear, and a lot of misinformation promoting caesareans.
“People forget that a caesarean is a relatively major operation. It’s an instant trauma to the body. It’s anything but keyhole surgery,” he says. “I think that fact sometimes gets lost and people forget that you can get through a normal birth with no scratches or just a few scratches.”
There is also increasing evidence that the process of childbirth is important to the child’s long-term wellbeing, as it transfers vital bacteria to the baby, decreases the risk of conditions such as asthma, and encourages bonding between mother and child.
For new mum Libby Nathan, who spent a few days at the Royal bonding with her new baby, the key is confidence – she avoided all negative stories about birth and focused on positive thinking.
“The only thing I would say is, don’t underestimate what your body can do,” she says. “But also don’t be too proud or hard-headed to change the plan if you need to.”