Overmedicalization of Childbirth is a Breach of Women’s Human Rights

Reblogged from Girls Globe
written by Julia Wiklander
Published 13 May 2016

Professor Cecily Begley opened the second day of the Nordic Midwifery Congress with a challenging speech, asking the midwives in the audience what they will be criticized for when women and health professionals look back at them in 30 years time. Yet, Begley shared heartwarming research results showing the importance of evidence-based, natural, midwifery care during childbirth.

Begley mentioned that medicalization in childbirth is a growing problem everywhere, and although the Nordic countries have lower levels of C-sections and instrumental vaginal deliveries, there is still a rising trend, which needs to be halted. She inspired the sea of midwives from Nordic countries and beyond to use the latest research in their work and to share it with their colleagues. She also mentioned the importance of informing and educating women, so that we, together, can improve childbirth practices for all women in our communities.

I had the privilege to speak with Cecily Begley after her keynote address. After our interview she also asked me about my birth story and left me encouraged and told me that if I ever have the opportunity to give birth again, I will have a natural and strong experience. Her passion for childbirth is palpable and her leadership encourages midwives and women to team up and be powerful agents of change. Listen to her explanation of why overmedicalization is a problem and what she believes needs to be done to combat it.

Be your own inner champion

This fabulous little video has just been released. The information below is the news release from the team. I've reproduced it in full because I think it is so important and such a good move to remove barriers to women speaking up about what concerns them.

What do you think about it?

[Collaboration for Leadership in Applied Health Research and Care South London (CLAHRC South London)]   [National Institute for Health Research]

26 April 2017

King's Improvement Science film at heart of campaign to empower pregnant women to voice health concerns

An animated film developed as part of a King’s Improvement Science [KIS] project is at the heart of a new campaign launched today by Tommy’s charity, King’s College London and the BabyCentre website to empower pregnant women to overcome fears about speaking to professionals about their health concerns.

Each day in the UK, 10 babies are stillborn and 152 babies are born preterm. A body of research led by Jane Sandall, professor of social science and women’s health at King’s College London, and lead of the CLAHRC’s maternity and women’s heath theme, has shown that women’s knowledge about their own changing body is invaluable in contributing to safer pregnancies, but that they often struggle to voice their instincts and concerns.

The ‘Always ask’ campaign centres around two animations (a longer and shorter version) developed out of a project that builds on Jane Sandall’s research, which was led by Dr Nicola Mackintosh, formerly a King’s Improvement Science fellow at King’s College London (now at the University of Leicester). ‘The Re-Assure’ project brought together women, health professionals, a writer and a digital artist to create an animation that follows a pregnant woman through her pregnancy journey. It encourages pregnant women who are worried about their health, or their baby’s health, to take their concerns seriously and ask for help.

The film was developed with the help of 34 women who have previously experienced serious complications in pregnancy or birth. It was made with the support of a £10,000 grant from King’s College London’s Cultural Institute, and co-produced by the women, Nicola Mackintosh, KIS fellow James Harris, writer Claire Collison and animator Patrick Beirne. Professor Jane Sandall was also involved. Fifteen staff – midwives and obstetricians – from maternity services at Guy’s and St Thomas’ NHS Foundation Trust contributed.

Trusting your own instincts in pregnancy is an important theme of the ‘Always ask’ campaign. Pregnancy information often focuses on specific red flag signs and symptoms such as stomach pain or bleeding. Dr Nicola Mackintosh said, ‘Our research has shown that many women who seek help for concerns about potential complications in pregnancy and the postnatal period, do not present with ‘classic’ warning signs and as a result, struggle to have their concerns taken seriously. The wider literature suggests that a change in attitude is often what is required, rather than just the provision of information about specific red flags.’

This is why the ‘Always ask’ campaign does not talk about specific symptoms; instead it encourages women to trust their instincts and ‘look out for changes that don’t feel right’. It also gives practical tips on appointments, getting listened to and being taken seriously.

The ‘Always ask’ campaign has been endorsed by the Royal College of Midwives, the Royal College of Obstetricians and Gynaecologists, and NHS England.

 Read more about the animation in the King’s Improvement Science 2016 annual report

Thirty years of the World Health Organization’s target caesarean section rate. It’s time to take it seriously.

Australia, like much of the western world faces burgeoning numbers of women having caesarean sections along with increasing rates of postpartum haemorrhage, postnatal depression and other morbidities. There are many who argue for surgical birth, saying childbearing women are older, fatter and sicker and therefore require the life-saving operation. Others are critical of the increase. Then there are those who examine the literature and seek the truth of the matter.

Today's blog post is by Dr Kirsten Small, an Obstetrician and Gynaecologist who teaches in the School of Nursing and Midwifery at Griffith University in Queensland, Australia. 

Kirsten has a research interest in examining the mismatch between the evidence base and what happens in clinical practice in maternity care.

In line with her research interest, Kirsten provides the following thought provoking lens on a recently published review of the World Health Organisation's target caesarean section rate. Read on, I think you'll find what she has to say fascinating.

The Medical Journal of Australia recently published a narrative review, titled “Thirty years of the World Health Organization’s target caesarean section rate: It’s time to move on.” (link: https://www.mja.com.au/journal/2017/206/4/thirty-years-world-health-organization-s-target-caesarean-section-rate-time-move).

Authors Stephen Robson and Caroline DeCosta argue that the “ideal” caesarean section (CS) rate proposed by the World Health Organization in 1985 is “too low” (Robson & DeCosta, 2017, p 184).

By selective use of published literature, they generate a narrative to support this argument, and somewhat obtusely recommend that “in Australia, we should be aiming to provide CS to all women in need” (Robson & DeCosta, 2017, p 184). It is difficult to disagree with this point, but the high Australian CS rate would suggest that we are also providing CS to women who have no need for it, and who may not desire it.

The key points of their paper are presented in a summary as Figure 1 below. 

 Figure 1: Summary Robson & DeCosta, 2017, p 181

It is possible however, to use the published literature to create a different narrative, one that supports the contention that Australia’s CS rate is not appropriate.

An alternative summary of the evidence is:

• It has been two years since the WHO reaffirmed its longstanding position that the ideal CS rate is under 20% (Betran, et al., 2015).
• CS rates, particularly in wealthy industrialised countries continue to rise, with no evidence of associated improvement in perinatal outcome (Betran, et al., 2015)
• The strongest predictor of CS birth for the first infant is birth in a private hospital (Dahlen et al., 2012).
• Women whose first baby is born by CS find it difficult to access a care provider who will support them to achieve a vaginal birth in subsequent pregnancies (Toohill, Gamble, & Creedy, 2013).
• Outcomes that interest the patriarchal medical model typically exclude those that reflect women's experience of their care (Parry, 2008).
• Longer term outcomes for the neonate are better following vaginal birth rather than CS (Hyde, Mostyn, Modi, & Kemp, 2011).
• Pelvic organ prolapse and incontinence are not strongly correlated with mode of birth (Bozkurt, Yumru, & Şahin, 2014). Surgical procedures for these conditions are increasingly safe and carry low risks of complications (Ogah, Cody, & Rogerson, 2011).
• Serious complications of CS such as placenta accreta, while rare, are of increasing concern to health care systems, given the large number of operations performed annually (Cheng, Pelecanos, & Sekar, 2016).
• We should aim to provide all women with evidence based care that achieves high rates of vaginal birth (Caughey, Cahill, Guise, & Rouse, 2014). All women should be involved in decision making regarding their birth options, to the extent that they wish to be.

Conclusion: There are ingrained systemic reasons why the medical model presents CS as the safe, easy option for women (Bryant, Porter, Tracy, & Sullivan, 2007). The evidence is clear – there is no population benefit for a CS rate of over 15%. Clinicians should focus on applying evidence to the care of individual women in order to achieve the best outcomes for them and for their infants.

References

Betran, A.P., Torloni, M.R., Zhang, J., Ye, J., Mikolajczyk, R., Deneux-Tharaux, C.,Gülmezoglu, A.M. (2015). What is the optimal rate of caesarean section at population level? A systematic review of ecologic studies. Reproductive Health, 12(1), 57–57. http://doi.org/10.1186/s12978-015-0043-6

Bozkurt, M., Yumru, A. E., & Şahin, L. (2014). Pelvic floor dysfunction, and effects of pregnancy and mode of delivery on pelvic floor. Taiwanese Journal of Obstetrics and Gynecology, 53(4), 452–458. http://doi.org/10.1016/j.tjog.2014.08.001

Bryant, J., Porter, M., Tracy, S., & Sullivan, E. (2007). Caesarean birth: Consumption, safety, order, and good mothering. Social Science & Medicine, 65(6), 1192–1201.

Caughey, A. B., Cahill, A. G., Guise, J.-M., & Rouse, D. J. (2014). Safe prevention of the primary cesarean delivery. American Journal of Obstetrics and Gynecology, 210(3), 179–193. http://doi.org/10.1016/j.ajog.2014.01.026

Cheng, H. C., Pelecanos, A., & Sekar, R. (2016). Review of peripartum hysterectomy rates at a tertiary Australian hospital. Australian and New Zealand Journal of Obstetrics and Gynaecology, 56(6), 614–618. http://doi.org/10.1111/ajo.12519

Dahlen, H. G., Tracy, S., Tracy, M., Bisits, A., Brown, C., & Thornton, C. (2012). Rates of obstetric intervention among low-risk women giving birth in private and public hospitals in NSW: a population-based descriptive study. BMJ Open, 2(5), e001723–e001723. http://doi.org/10.1136/bmjopen-2012-001723

Hyde, M. J., Mostyn, A., Modi, N., & Kemp, P. R. (2011). The health implications of birth by Caesarean section. Biological Reviews, 87(1), 229–243. http://doi.org/10.1111/j.1469-185X.2011.00195.x

Ogah, J., Cody, D.J. & Rogerson, L. (2011). Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women: A short version Cochrane review. Neurourology and Urodynamics, 30, 284–291. doi:10.1002/nau.20980.

Parry, D. C. (2008). “We wanted a birth experience, not a medical experience”: exploring Canadian women's use of midwifery. Health Care for Women International, 29(8), 784–806. http://doi.org/10.1080/07399330802269451

Robson, J., & de Costa, M. (2017). Thirty years of the World Health Organization's target caesarean section rate: time to move on. The Medical Journal of Australia, 206(4), 181–185. http://doi.org/10.5694/mja16.00832

Toohill, J., Gamble, J., & Creedy, D. K. (2013). A critical review of vaginal birth rates after a primary Caesarean in Queensland hospitals. Australian Health Review, 37(5), 642–7. http://doi.org/10.1071/AH13044