Wednesday, September 5, 2007

Caesarean section rates - a marker of quality?

Attended a presentation by Mike Robson, who is the Master of National Maternity Hospital, Dublin. His presentation was about cesarean section rates and the way they are categorized and recorded. There were a number of salient points that resonated with me. Mike's over arching message was: the issue is not whether cesarean section rates are too high or too low, but whether we know what the rate is; why it is at the level it is; how is it changing and what are the consequences. I am particularly concerned about that last question. As far as I am aware, there is no longitudinal research that is looking at what the long term effects of cesarean are for women, and we certainly do not know what the implications are for subsequent generations. There is already evidence that women are encouraging their sisters and friends to have cesareans. And we do not know the effect that media has on women's choices-how influential are the actions of Hollywood stars when they are open about their choice to have elective cesarean.

As yet we really do not know about maternal request for c/s. There is a general feeling that it is increasing but there is no concrete evidence to prove it. What was worrying was Mike's statistics which showed that it is women who have had babies and labored before who mostly request elective c/s. This emphasizes the importance of getting it right for women in their first labour and birth. Mike also contended that there is not the interest in normal labour and birth by midwives and obstetricians, which I would suggest is actually where we should be concentrating our efforts. The thing is: it is time consuming and emotionally wearing supporting a woman in labour - delivering a baby via ceasearen section is relatively quick and 'easy' in comparison.

I would go one step further and ask whether we are losing our skills at supporting women in normal birth. There has been lots of discussion about this in relation to breech birth, but I would suggest that it is also true of so-called 'normal' birth. How much easier it is to organize an epidural than to walk the corridors with a women, talking her through each contraction; rubbing her back; filling and emptying warm baths; driving to her home to assess her in the middle of the night and so on. Alongside with that loss of skills is loss of confidence and faith in normal birth. Much has been written about this so I will not rant on. Suffice to say, I agree with Mike that we need to carefully collect data about c/s and ask ourselves about the ongoing implications of an increasing c/s rate. But we also need to get back to basics and ask ourselves what we are doing to promote normal birth in an ever increasing complex social context.

1 comment:

Carolyn McIntosh said...

I think you have said it all here Sarah. One of the important messages for me as well was that it is important how we collect data so that we can make accurate comparisons. While health profesionals debate the veracity of differing statistics it is the public who bear the consequences. Certainly the concern about increasing caesarean rates has to be predominantly for future pregnancies and future generations.