C-Sections

There is no doubt that the number of C-sections has increased in the UK, even in the last five years. The caesarean rate has risen from 25% in 2013-2014 (NCT, 2014) to 27.1% in 2015. Interestingly, mothers over 45 accounted for 59.3% of these C-sections in 2015-2016 (NHS, 2016), which could indicate that it is not perceptions of childbirth leading towards higher intervention rates, but the fact that more older women are becoming pregnant due to advances in technology. Older women are more likely to require a C-section; in women aged 20-24, the C-section rate is 19%, compared to a rate of 42% in women aged 40-44 (NHS, 2016). However, of the 59.3% of women aged 45 and over who had a C-section, 55% of these were elective procedures (NHS, 2016). I would speculate that social stigma against older mothers may have rendered them unconfident in their abilities to have a natural birth. In any case, the current figure of 27.1% for birth by C-section is too high; the World Health Organisation has stated the ideal rate for C-sections would be 10-15% (WHO, 2015), and yet elective C-section rates are ever increasing.

Why is this? Dr Terrie Inder, who is a neonatalist at Brigham and Women’s Hospital in Boston said, “Without any evidence at all to suggest continuous foetal monitoring improves outcomes, it has become a standard of care. And when there’s a blip in the reading-  if a baby’s heart rate goes up or down- that can trigger a C-section, even if it’s not clear if the baby is truly in distress” (Thielking, 2015). This indicates that unnecessary medical intervention can then cause further unnecessary medical intervention. Although there are some factors which can increase the risk of C-section- for instance, rising obesity rates (Dodd, 2011), it seems clear that a rise in medical intervention, and women opting for a C-section, as well as C-sections caused by other medical interventions, such as foetal heart monitoring or inductions, are on the increase.

This leads us to the question: why does it matter than the C-section rate is 12% higher than it should be? There are numerous reasons why this is problematic. Firstly: the consequences for the human race. There is evidence to suggest that the rise in C-sections is actually affection evolution, in that bigger babies are being born (Briggs, 2016), whereas in the past bigger babies would likely have died during childbirth. Whilst it is amazing that technological advances have allowed more babies to survive, this is problematic as it means that more and more C-sections will be necessary in the future due to the increasing size of babies. When the other risks of C-sections are considered, this increase is worrying. There are obvious risks that are always present with a major surgery, but some of the damage is more insidious. For example, there are studies to show that babies born via C-section are more vulnerable to intestine issues and allergic diseases later in life, which is due to the baby not being exposed to the right bacteria as it is born. (Rushing, 2011) A solution to this may be vaginal seeding, but there is mixed evidence on this. Reducing the number of C-sections is a difficult task, as it is important that women keep their right to choose. A potential solution could be better educating women so they can make a truly informed choice.

 

New Survey

https://www.surveymonkey.co.uk/r/QD7KJW6

This is the link to my new and improved survey. Unlike my last survey, it will produce both quantitative and qualitative data. I have got rid of the ambiguous questions, and phrased things slightly differently to avoid acquiescence bias. Overall, this survey should produce much more valid results than my last one.

500 Words On Induction

Firstly I will be looking at inductions: whether induction rates have gone up in the last 50 years, whether there are valid reasons for this, and if this is safe. The methods of induction I’m looking at is rupturing of the membranes, and chemical induction via oxytocin.

In 1965, induction rate was only at 15%, which rose to 40% in the 70s due to the belief that it reduced infant mortality caused from allowing babies to mature beyond full term. The induction rate in 2013-2014 was a mere 25%, significantly lower than in the 70s, which could indicate that childbirth is not medicalised in the same way that it was then, when technological advancements took over midwifery practise. However, this is an increase from previous years; in 2011-2012 the induction rate was 22.1%. There is a clear increase in inductions between the years 2011-2014, and quite a rapid increase given the timeframe. In fact, these kinds of increases have been reported across Europe, with Belgium and Lithuania having an induction rate of 33% in 2016.

These increases are a serious matter, because inducing a birth increases the risk of an emergency c-section by 67%, which is a traumatic surgery that carries its own risks for both mother and baby. The use of pitocin (synthetic oxytocin) to induce birth also carries with it a plethora of risks; it is slow acting, so it is easy for too much to be administered as it’s impossible to precisely check the effect on the uterus. Risks to the baby include: cerebral palsy, fetal distress, increased blood pressure, slow and fast heart rate, whereas maternal risks include: strong, painful, prolonged uterine contractions, hemorrhaging, impaired uterine blood flow and strong nausea. These complications usually arise when doctors administer pitocin rather than performing emergency c-section. This could indicate that too much focus on vaginal birth could be dangerous for women.

Given that induction can be dangerous, it would be expected that it would only be administered if entirely medically necessary. However, in a survey of US women that had been induced, 44% said that there was no medical reason for the induction; for example 19% wanted to get the pregnancy over with. Only 18% had a maternal health problem that required quick delivery. The most common medical reason for induction was that the baby was overdue. This is extremely problematic as a reason for inducing labour, even though it is technically a medical reason.

A baby is considered full term at 39-40 weeks, and women are assigned a due date 280 days after their last period. However, only 4% of women deliver at 280 days. This would indicate that our current method of calculating due dates is wrong. Therefore, it would be wrong to risk inducing a labour purely because a woman has reached her due date. Many women are induced at 38-42 weeks, which means it is hard to tell how long a natural pregnancy should last. Smith speculates that most inductions are too early, as his study found that the due date should actually be 40 weeks and 5 days after the last period. Evidence has been found that chemicals in the baby’s lungs dictate when labour happens, which I would argue is proof that we don’t yet know the delicate mechanics of birth, and should therefore only intervene when absolutely medically necessary. The evidence that I have found shows that induction is not being used as sparingly as it should.

All these statistics are sourced in my copy of the essay. 

Itinerary

This is my plan so I’ll have my first draft completed before Christmas. The word counts are approximate, but the finished first draft should be 5000 words.

16/11/17: 1000 words on labour inductions and episiotomies. Complete second survey

23/11/17: 1000 words on perceptions of childbirth, looking at the survey and media texts.

30/11/17: 1000 words on epidurals and fetal heart monitoring. Complete one interview

7/12/17: Another 500 words on perceptions of childbirth, focussing on the interview.

16/12/17: 1000 words looking at if perceptions of childbirth are causing more medical intervention

23/12/17: Conclusion, introduction and bibliography

Unnecessary Induction of Labour

• Evidence to suggest that chemicals in the baby’s lungs dictate when labour happens; therefore it could be dangerous to induce labour before the baby is ready. https://www.sciencedaily.com/releases/2015/06/150622162023.htm
• Pitocin (synthetic oxytocin, used to start contractions) can cause many health issues for both baby and mother. https://www.abclawcenters.com/practice-areas/prenatal-birth-injuries/labor-and-delivery-medication-errors/pitocin-and-oxytocin/
• Failed induction can often lead to the need for a Cesarean birth. Therefore it should only be used when medically necessary. https://www.ncbi.nlm.nih.gov/books/NBK53624/
• In a survey done on US women, 44% said that labour was induced for no other reason than because they had reached their due date. Inductions for non medical reasons are on the rise in the UK, and as I found earlier, this can be harmful. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3894594/
• Only 10% of women go into labour on their own by 39 weeks. Therefore, perhaps it is normal for women to give birth past their due date and they should not be induced. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3777570/
• It is difficult to tell how long a normal pregnancy should be because many women are induced at 38-42 weeks.
• Smith says the estimated due date of 40 weeks is wrong- it should be more like 40 weeks and 5 days after the last menstruation. Therefore induction is often too early. https://academic.oup.com/humrep/article/16/7/1497/693431/Use-of-time-to-event-analysis-to-estimate-the
• Buckley suggests that there are hormonal benefits to waiting for a spontaneous labour http://transform.childbirthconnection.org/reports/physiology/

 

HOWEVER: 

• Studies have found that many there are many risks associated with a higher gestational age, which could mean that induction at 40 weeks is safer. https://www.ncbi.nlm.nih.gov/pubmed/17306661

 

I got all of these resources from this article: https://evidencebasedbirth.com/evidence-on-inducing-labor-for-going-past-your-due-date/

It is important to note that none of these studies looked at the preference or personal experiences of the women involved. I should maybe talk about induction either in my own survey or interviews.

This indicates that spontaneous births are declining and intervention in the UK is on the increase. Is this a good thing? Just over a third of births in 2013-14 included some form of induction. http://content.digital.nhs.uk/catalogue/PUB16725/nhs-mate-eng-2013-14-summ-repo-rep.pdf

 

Focusing In

To make sure my research is focused, I am going to look at a set definition of “the over medicalisation of childbirth”.

 I would define this as two things. Firstly, childbirth being perceived as a medical procedure in society and the media. Secondly, excessive unnecessary medical intervention being used during childbirth. I would argue there is an increase in both of these things, and as a result, childbirth is becoming over medicalised in our society.

I will be looking at these two factors separately, and trying to see if there is a cause and effect relationship. I am of the opinion that it is our perceptions of childbirth as a dangerous and medical event that causes excessive medical intervention.

I’ll be able to do surveys on people’s perceptions of childbirth to see if people generally see it as a medical procedure. I can also look at specific media texts, like the show One Born Every Minute to see if shows like this portray a medicalised and sensationalised view of childbirth. There are also a few studies on this topic which will be interesting to look at, for instance the article in my last post.

I will also do a few interviews on women’s experience of childbirth and if they found doctor’s intervention necessary, or welcome. However, for this part of my research I will be more heavily relying on statistics and scientific findings. For instance, is there any harm in additional medical intervention? How many women felt pressured to accept this intervention? Has intervention increased in the last 10 years, and has this caused positive results?

 

Perceptions of Childbirth

https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-016-0827-x

This article talks about how the media, especially reality television can make people see birth as more dangerous than it actually is. Interestingly, this links back to the original question I wanted to ask: how the media affects women’s perceptions of childbirth. The article suggests that the media actually perpetuates the medicalisation of childbirth.

It says “media representations often portray technology and interventions as contributing to the medical profession’s success in reducing the risk and uncertainty associated with childbirth“. However, it also claims “leading women to believe that maternity care is designed to ‘manage’ or avert the risks for mother and baby, but often risk management is merely ‘covering’ the hospital/staff in case of litigation“. This implies that extensive intervention in labour often isn’t for the benefit of the woman, but for the hospital in the case of something going wrong. Since too much intervention can often actually cause problems in and after labour, this is extremely problematic.

https://www.nice.org.uk/guidance/cg132/evidence/full-guideline-184810861

This is an article about the use of Caesarean sections. According to the article, women who are eligible for a vaginal birth but opt for a Caesarean section are significantly more likely to suffer cardiac arrest, and the infants born this way are more likely to require intensive care. This indicates that perhaps, where possible, a natural birth is better for both mother and baby, despite advancements in technology. It also suggests that there is a strong correlation between women opting for a Caesarean and fear of childbirth (page 96). Is it our perceptions of childbirth that is leading to over medicalisation? However, according to the article “Obstetricians estimate that they agree to perform a CS for about half of the requests they receive”. This could indicate that many women desire the medical model of childbirth, but many don’t actually receive it.

http://www.europeristat.com/reports/european-perinatal-health-report-2010.html

This article has a lot of really useful statistics which will be useful for looking at the risk of childbirth. I need to look at this in more detail and perhaps check the validity of it.

http://www.bmj.com/content/324/7342/892?sort_by=field_highwire_a_epubdate_value&sort_order=DESC&items_per_page=10&page=1&panels_ajax_tab_tab=bmj_related_rapid_responses&panels_ajax_tab_trigger=rapid-responses

This article argues that childbirth is NOT becoming too medicalised and critisises studies that claim it is. It’s important that I look at this in detail so I can form a balanced and nuanced argument. I’ll also be trying to find similar articles to this.

http://www.open.edu/openlearn/body-mind/health/nursing/why-childbirth-medical-procedure

This article provides a balanced and informative discussion on the debate which will prove very useful when I am starting to form my own argument.

 

Thoughts on my Survey

The statement “Childbirth is dangerous” really intrigued me. I am curious how dangerous people think childbirth is, and how this compares to how dangerous it actually is- for instance, is it more risky than crossing the road? I would like to compare this perceived risk to the practical risk, and how this in turn compares to the measures doctors put in to prevent this risk eg. fetal monitoring etc.

This links to my title because if the medicalisation of childbirth is essential to prevent a high risk, this would answer my question in that, no, childbirth is not becoming too medicalised as this medicalisation is saving lives. But if childbirth is comparatively non-risky, surely all this medical intervention is unwarranted, and only used to pander to a perceived risk.

I will be conducting further surveys on perceptions of childbirth, and then I will use other resources such as Spiritual Midwifery by Ina May Gaskin to look at the actual risk of a labour with little medical intervention. It will be interesting to see how these results compare.

Survey Evaluation

Although there are some interesting findings from my survey, there are multiple flaws with it.

Firstly, my second statement “There is no non-medical reason why a woman should refuse pain relief during labour” was very confusing to some people due to the double negative. In fact, 3 people told me that the question confused them, and 2 participants skipped the question. When looking at the results for this question, I should bear in mind that some people may have misunderstood the question, causing unreliable results. In my next survey, if I were to ask a similar question I would phrase it as “Women should always accept pain relief during labour. Do you agree?”

Secondly, my scales all go the same way. Any “strongly agree” result means a person is more pro-medical than natural birth. Acquiescence bias means that people are more likely to agree with statements than disagree with them, and this could mean that my survey has skewed the results to be more pro-medical birth.  To improve this, I should either mix up how pro-medical my statements are, or use a different questioning method ie. “Medical intervention during birth is: a) essential, b) quite important, c) not very important or d) not important at all.

Thirdly, I have only collected quantitative data. My participants did not have the opportunity to explain why they felt as they did. Since childbirth is such a personal matter, it is essential that I allow my participants to express their feelings on specific topics. Although quantitative data is easy to put into graphs, I’m likely to get more detailed information from qualitative data. For this reason, if I do another survey, I will include “explain why” boxes, and I will also be conducting some interviews.

Fourthly, my sample is very biased towards people from the UK aged 16-20. Ideally I could do some kind of stratified sampling for people of different ages, genders and ethnicities. I am unsure how possible this will be, as there are so many subcategories within Western culture. I am also curious how perspectives of women who have babies compares to those who haven’t. Next time I should try to take a less biased sample; since I just posted the survey on social media, all I have done is take the opinions of those within my circle, which may mean my results lack ecological validity.

Survey Results

I managed to get 32 participants for my survey, which I am very pleased with as a larger sample means my results are more reliable and have more ecological validity. The majority of the participants were from England, but I also had responses from Northern Ireland, America, Australia, Yemen, Norway and Canada. This is fantastic as I can compare the attitudes of different Western countries. Although it is interesting, I’ll be discounting the result from Yemen as it is not a Western country.

77.42% of my participants were aged 16-20 meaning this survey predominately measures young people’s attitudes to childbirth. However, 4 of my participants were aged 41-50, 2 were 21-30 and 1 was over 50. This gives me a broad range of ages to study.

For the statement “Childbirth should always happen in a hospital”, the average rating on the scale was 61 out of 100, where 100 is strongly agree and 0 is strongly disagree. This indicates that generally, people feel that hospital is the best place to have a baby. Notably, the only person who marked 100 (strongly agree) was aged 16-20 and was from England. Interestingly, the other participants who marked more than 80 on the scale were also in this demographic. This could indicate that UK teens are more likely to see hospital as an essential part of childbirth. 4 participants marked 20 or less on the scale. Only one of these participants was aged 16-20; the rest were older, and all but one was from the UK. One participant was from Canada. This may mean that there is a more liberal attitude to childbirth in Canada, and that adults are more likely to see home-birth as an option.

For the statement “There is no non-medical reason why a woman should refuse pain relief during labour”, agreement was at 41 out of 100. This indicates that people generally think that pain relief is not necessarily essential during childbirth, a key staple of the natural birth movement. The majority of participants marked their answer as below 35. However, there were two exceptions, who marked their answer as over 90. They were both aged 16-20, one from Australia and one from England.

For my statement, “If doctors think labour isn’t progressing fast enough, labour should be induced using artificial hormones”, agreement was at 52 out of 100. This only means “slightly agree” and in fact 5 people indicated they didn’t know their opinion on this. 5 people indicated that they strongly agree with the statement (a score of 80 or above). Of this sample, 3 were aged 16-20. All of these participants were from the UK. Could this mean that people from the UK are more likely to favour medical intervention? 5 participants strongly disagreed (a score of 20 or less). 4 of these were aged 16-20 and 3 were from the UK. The other two were from Canada and the UK.

For the statement, “Giving birth at home is dangerous for both the mother and the baby”, agreement was at 48 out of 100. This is only an average result of “slightly disagree”. 3 participants of a variety of ages strongly agreed, all of whom were from the UK. 6 participants strongly disagreed. Ages ranged from 16-50+ and these participants were predominately from the UK, except for one from Canada.

For the statement “Doctors always know what is best for pregnant women” agreement was at 54 out of 100: slightly agree. 3 participants strongly disagreed. The ages were all different (ranging from 16-50+) and these participants were predominantly from the UK, although 1 was from Canada. 6 strongly agreed, all of whom were under 30. Does this mean young people have more faith in doctors?

“Childbirth is dangerous” was the statement I was most interested in, and agreement was at 60 out of 100. 4 participants strongly disagreed. All were from the UK bar the one participant from Canada, and ages again ranged from 16-50+. However, older people seemed more likely to disagree with this statement- perhaps because they have experienced, or witnessed childbirth themselves? 4 participants strongly agreed, all of whom were under 30. This indicates younger people are more likely to see childbirth as risky.

The statement “The conditions of a woman’s labour (eg. if she can have a water birth) should be up to the doctor not the woman” got an agreement rating of 27 out of 100, indicating that most people disagree with this. 15 participants strongly disagreed, with a variety of ages and nationalities. This indicates that the idea of women having choice is fairly universal. 3 participants strongly agreed. Interestingly, 2 of these were aged 41-50, a demographic that in previous questions seemed to prioritise the autonomy of the woman.

My final statement was “It’s a doctor’s decision if a woman should get a Cesarean birth or not”. The average agreement rating was 42, indicating that most people feel it is the woman’s decision. 5 participants strongly agreed. 2 of these were aged 16-20 but the rest were aged 40+. Perhaps older people only feel a doctor’s decision carries more value in emergency situations. 9 participants strongly disagreed, all of whom were under 30. This seems to contradict previous questions in which young people valued the doctors more so than older people.