A Conversation about Caesarean Births

I did my doula training with Michel Odent, world-renowned obstetrician and champion of natural birth. I was struck by something he said once- that it's better to have a non-traumatic, elective (planned) caesarean rather than a birth process interrupted by intervention after intervention. This advice really opened my eyes- that there isn't such a thing as a 'perfect birth'. Each situation is unique. Caesarean births (c-sections) can be a complex issue.

As a pregnancy and baby osteopath I frequently treat women after c-sections and see many women experience a myriad of feelings including shock, shame, anger and sadness on top of a number of physical symptoms related to the delivery. Many women talk about being made to feel lesser if they have had a c-section, implying it's an easier option. Since when is surgery easy?!

The caesarean rates in many economically advanced countries is much higher than less economically developed countries.  In Brazil, the rate is 55.6%, in China it's now 47%. The UK has a caesarean rate of 26.2%. Countries such as Iceland, Finland and Norway have managed to contain their c-section rates down to 15%.

The reasons for the rise in caesareans can be linked to the medicalisation of birth, fear of pain, convenience, lack of investment in midwifery care and belief that it might be the least traumatic option.

It's a huge topic, especially when considering additional issues such as VBAC (vaginal birth after caesarean), the microbiome effect, gentle or natural caesarean.

I interviewed Clare Goggin, founder of 'Caesarean in Focus', a change platform for caesarean sections.

Thank you Clare for taking the time to speak with me.

Thank you so much for inviting me to chat to you on your blog! I’m really excited to connect with you and your readers. You have asked some really insightful questions, and I apologise now that brevity is not always my strong point!

What motivated you to share this topic and create a movement?

My interest in caesarean birth is rooted in my own birth experiences, as well as a long-standing interest in maternal health (I’ve worked both in NHS maternity commissioning and in charities that support pregnant women and new mothers).

Prior to having children (and birth experiences) of my own, I was very familiar with the evidence base surrounding the impact of pregnancy and early infancy on wider public health and social outcomes. I even spearheaded a project designed to bring down caesarean section rates at our local hospital.

However, seeing the healthcare system through the eyes of a service user gives you a completely different perspective. My caesarean births brought me not only my two babies, but also my own ‘voice’. I learned how important it was to speak up for myself and really wanted to support other women to do the same.

I set up Caesarean in Focus because I wanted to raise awareness of the choices women can make surrounding caesarean birth—knowing that, for many women, if you don't know your choices, then you don't have any. I also wanted to help make woman-centred approaches to caesarean birth the norm in the NHS, as this could help make women's negotiations less stressful at an individual level as pregnancy and birth are a really vulnerable time for women.

We have set up a Facebook group that to specifically talk about caesareans: why they happen; how they happen; to whom they happen; how they impact women and families; and how we can improve the outcomes of caesarean section (across NHS themes of experience, efficacy and safety). Our aim is to involve all interested parties in developing solutions that are embraced across the system rather than imposed.

I am also writing a book about caesarean birth, which will be released in Autumn 2017, which I am very excited about!

What do you think is the current situation with caesareans in the western world?

The current situation with caesareans in the western world is complex and I feel that it is really important not to simplify my (and other women’s) experiences of it. The most important thing that I think we can do is talk about it in all its complexity.

Undoubtedly caesarean birth saves the lives of many mothers and their babies: recent research shows that countries with caesarean birth rates of up to 19.1% have lower maternal and neonatal mortality rates. However, as the caesarean rate in England is now over 26%, it is important to remember that caesareans are also associated negative outcomes, such as an increased likelihood of post-natal depression and post-traumatic stress disorder, as well as reduced likelihood of initiating breastfeeding.

To date, the predominant Government policy and birth campaigner response to rising caesarean section rates has been to focus on improving “woman-centred” vaginal birth. However, there has been very little campaigning or policy attention given to how caesarean sections are performed and how this impacts on health outcomes for families, despite the fact that more “natural” caesarean techniques are available with potential to improve families’ experiences of caesarean birth (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2613254/).

I whole-heartedly support the efforts surrounding increasing access to woman-centred vaginal birth. There are huge challenges in this arena at present with the changes to the Supervisor of Midwives role and the NMC’s position on independent midwifery.

I see the work that Caesarean in Focus is doing as a necessary complement to the existing work on vaginal birth, we are extending the woman-centred philosophy, not challenging it. In particular, I am passionate about advocating for pregnant women and women who have birthed by caesarean to ensure that they:

• Feel at the centre of decision making about their birth;
• Experience their moment of birth in theatre via ‘gentle’ caesarean techniques; and
• Feel supported in the postnatal period as they adjust to motherhood and recover from major surgery.

What are the common misconceptions about caesareans?

This is such a tricky question to answer, as the terrain of caesarean birth is so contested!

There are the obvious clichés about caesarean birth, which in my view, only serve to cause pain to women:

“All that matters is a healthy baby”

“she was too posh to push”

“she took the easy way out”

“Caesarean birth= failure”.

The more I think and read about caesarean birth, the more I realise that the way we talk about caesarean birth is really messed up: it is filled with fear, confusion and disconnection. The evidence that we have about caesarean birth is much more contested and incomplete than many realise. I am really passionate about encouraging women to focus on what their own intuition is telling them about their pregnancy and birth and raising their voice as much as they can. I want women to feel a mix of peace, confidence and connection about their birth, whether or not it occurs via caesarean.

Caesarean birth can be a truly beautiful rite of passage for women and their babies. This is true for women who seek out a planned caesarean and can be true for women who have unplanned caesareans when their feelings are placed at the centre of what happens.

What are your three top tips for a smoother recovery?

1. Get as much help as you can!

Caesarean birth is major surgery. It is probably the only major surgery, where the ‘patient’ is expected to take responsibility for the nourishment of another human being within a couple of hours of delivery!

With this in mind try to line up as much help and support as you can. How you do this will depend on your individual circumstances, but could include a mix of:

• Making the most of your partner’s paternity leave
• Saving up annual leave for your partner (so there is a gentle transition back to work after paternity leave)
• Inviting friends/ family who you trust and feel comfortable with to come and clean for you (or take older children to and from school)
• Engaging a postnatal doula to help with practical tasks and provide emotional support
• Talking to your health visitor or midwife about other help available locally (e.g. Home Start)

1. Rest

Closely linked to getting help, is the importance of taking it easy! I know it can be hard. I was so excited after my first son was born that I was about to head out to the park with my son in his pram two days after my caesarean, when my midwife arrived and told me off for leaving the house! It wasn’t long before I realised that I’d been hugely over ambitious!

In our culture, there is a huge focus on productivity above all else, and with many women working right up to the day their baby is born, the idea of 40 days of rest in bed is an anathema. Even more so when their partner goes back to work after a few days and they are not geographically close to supportive family and friends to visit and care for them.

For me, I spent a lot of time in the first few weeks sitting propped up on the sofa, cluster feeding for what felt like hours on end and watching seven seasons of The West Wing while eating chocolate HobNobs (I’d read something about oats being good for breastfeeding and decided to make the most of it)!

I’d also suggest you check out this lovely blog about caesarean recovery which has lots of detailed practical tips.

1. Be patient with yourself

It takes time to heal, both physically and emotionally from a caesarean birth. How long it takes varies from woman to woman and surgery to surgery, but it is rarely immediate and virtually every woman will benefit from giving themselves a little longer to recover than they think they need.

There is so much pressure on new mothers to get back to normal (including pressure we apply to ourselves), but pushing yourself in the early days can become counterproductive.

How influential has social media been in raising awareness of best practice for caesareans?

Social media has been a hugely important way to connect with others working in a similar area and to hear a lot of different women’s perspectives on caesarean birth. It is particularly useful for connecting with mothers and healthcare professionals in ways that would be impossible to do in person.

I am currently the primary carer for a 3 and 2 year old and social media makes it so much easier to connect to a fab obstetrician in Nottingham or a wonderful midwife in Liverpool, than it would ever be if I needed to travel to each of these places.

It has also meant that we’ve been able to canvass the views of nearly a thousand women for our caesarean birth experience survey, as well as talk to women who are spending most of their time looking after their young children, but still feel that the voices of pregnant women and mothers matter hugely.

I saw online that you recently spoke to a group of obstetricians about caesareans. How did they receive your views? Have you seen much collaboration between professionals in this way?

I did indeed. I was invited to speak at an internal training session by a friend of mine who was doing a rotation in obstetrics. I spoke about my own caesarean birth experience and shared some of the preliminary findings of our birth experience survey. The main points that I made were:

• A healthy mother and baby is not all that matters (that the emotional impact of birth is vital too)
• Small changes in practice make a huge impact on birth experience (particularly skin to skin)
• We all need to talk about caesarean birth more often so that women are prepared for all potential birth outcomes.

The response was really good overall, there was a mix of enthusiastic agreement and defensiveness (mostly relating to time pressures). I think there is definitely more work to be done in making it easier for healthcare professionals to provide genuinely woman-centred care, particularly by looking at how continuity of care can be made a reality and how we support healthcare professionals who support women who want out of guideline care (a position that can feel very vulnerable in today’s litigation focused healthcare environment).

Overall, I thoroughly enjoyed talking with them (and the midwives who attended) and would absolutely love to do it more often!

Can you tell us a little about the trend for gentle caesareans? What do they involve and how would you suggest a woman find an obstetrician who performs them?

Gentle caesareans reclaim caesarean birth as a rite of passage for women, who (for a variety of reasons) need or want to birth their babies by caesarean section.

Each gentle caesarean birth is as unique as the family concerned, but the gentle caesarean approach encompasses:

1. Greater involvement of the parents in the moment of birth: This could be by lowering the surgical drape so the parents can watch the baby emerge, and/or enabling parents to video or take photos of the baby being born. Some parents choose a musical playlist to be played in theatre and request that the lights are dimmed as the baby is born. Others ask that they discover the baby’s sex themselves rather than being told.

1. A slower birth: The obstetrician facilitates the baby’s birth, allowing the baby to emerge on its own rather than being “delivered”, mimicking more closely a vaginal birth, and helping to compress fluid out of the baby’s lungs. The clamping of the umbilical cord is also delayed, allowing the baby to get the full benefit of the nutrients in the placenta.

1. Immediate and prolonged skin-to-skin contact: In a traditional caesarean birth, the baby is cleaned, weighed and dressed immediately after being born, and often taken into the recovery room while the surgery is concluded.

By contrast, in a gentle caesarean, the baby is passed to the mother to be held against her skin while all checks take place and remains with the mother until they are both ready to be transferred into the recovery room. Some babies are even ready to initiate breastfeeding in theatre, others are still sleepy from birth, but are able to enjoy the closeness with their mother until they are ready to feed.

In terms of finding an obstetrician who will perform a gentle caesarean, I would suggest the following:

• Write out your wishes in a birth plan, you may find this article helpful to share with your caregiver.
• Discuss your gentle caesarean wishes with the midwife or obstetrician who is providing your antenatal care.
• In this meeting:
• I’d start by explaining what each of the elements of your birth plan mean to you and why you want them (e.g. you want your birth to be a life affirming rite of passage and want to do all you can to ensure that you and baby are able to bond)
• Then, go through the plan point by point, allow them to ask questions about what you are asking for and if necessary, ask them to explain the concerns they have.
• Its important to note that while there is still a RCT on natural caesareans underway, key elements such as skin to skin and optimal cord clamping are evidence based.
• Remember that a gentle caesarean can be a plan B if complications start to arise in your pregnancy or labour. Most of the elements (particularly skin to skin, photos and lowering the drape) are not limited to a planned caesarean (indeed I got those elements in crash caesareans).
• If you experience difficulty negotiating your wishes, you can ask for a supervisor of midwives to help advocate for you (this role is in the process of being phased out) or ask to speak with the clinician in charge of caesarean guidelines and/or the Patient Advice Liaison Service.
• Stand your ground! There is really no reason for them to refuse you (assuming both you and baby are well).

Thank you for your practical suggestions, resources and for sparking a wider conversation about Caesarean births with your platform Caesareans in Focus, Clare.