DEBATE: “Are government efforts to reduce the C-section rate a good thing?” A doctor argues 'No'

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We've asked the professor of midwifery and the professor of obstetrics featured in the short documentary above to each respond to the debate topic in 600 words, then provide a 200-word rebuttal to their opponent's opening statement.

Opening Statement by Prof. Hans Peter Dietz

Professor in Obstetrics and Gynaecology at Sydney Medical School

The short answer is: ‘No’. The long answer goes like this…

Caesarean Section (CS) rates continue to rise around the world, making this procedure the most common operation on Earth. In NSW, that rise has slowed, but CS rates have still gone from 30.4% in 2010 to 32.9% in 2016. Many people think this rise is a bad thing, due to sloppy, greedy or incompetent doctors. That’s nonsense. The main causes are increasing age at first birth, obesity, and medical problems. Women are bigger and have fewer and bigger babies, later in life. It would be astounding if this did NOT push CS rates up. In fact, it’s remarkable that childbirth has been getting ever-safer in Australia despite all those changes. Until recently.

Childbirth has become increasingly dangerous in the UK and Australia as a result of unwarranted interference with medical practice. The best local example was the ‘Towards Normal Birth’ policy directive in NSW in 2010, which mandated a CS rate reduction to 20% by 2015 – an impossible target. Such policies are produced by midwives, administrators and political activists, with marginal involvement of doctors. A recent ‘National Framework for Maternity Services’ was entrusted to a committee of a dozen, with a majority of midwives, and not one obstetrician. After protests by obstetricians the process was hurriedly cancelled and re-started last year.

This kind of meddling does serious harm. Authorities in the UK and New Zealand have performed experiments on entire populations since the early 90s. In the UK, the Morecambe Bay Report shows how dangerous an obsession with natural childbirth can be, and there are other similar scandals. An obsession with natural childbirth, i.e., an obsession with reducing the CS rate, can literally kill. In New Zealand, the site of the most comprehensive population experiment in maternity care ever, women are almost three times more likely to die in childbirth compared to Australia.

Many sensible people feel we should keep an eye on the CS rate. And indeed there are good reasons to try and avoid Caesareans because they are, after all, major surgery. Unfortunately, options are limited. It’s just not realistic to expect natural childbirth if the preceding 20 years of your reproductive life have been anything but natural: rising obesity rates and delayed childbearing explain a large proportion of the problems women face in childbirth.

Government bureaucrats are not the right people to tell obstetricians how to deliver babies. They are not qualified or licensed to decide on the need for (or indeed to perform) caesareans. But they’re doing exactly that, with dire consequences. Forceps rates in England have more than doubled since 2005, likely causing over 100,000 additional cases of major maternal birth trauma such as pelvic floor muscle and anal sphincter tears. Forceps rates in Sydney have increased to over 10% in some places, in order to avoid CS. I see more and more young women with often incurable anal incontinence and pelvic organ prolapse and/ or post-traumatic stress disorder as a result of birth trauma, much of it caused by forceps.

Obstetricians are bullied into using obsolete, dangerous practices to placate activists or bureaucrats who have no idea of the damage they’re doing, and who will not share in the blame when things go wrong. In a legal climate that increasingly emphasises patient autonomy, more and more doctors and hospitals are sued because they increasingly do unnecessary harm or fail to warn women of the dangers of childbirth, and rightly so.

Since the Hippocratic Oath was written in ancient times, our job as doctors has always been to cure sickness and prevent death. But when an army of midwives with a fixed idea of ‘the way things should be’ dictates government policies, and patients threaten to sue us if we use our years of experience to make a decision that isn’t on their birth plan, our priorities are skewed. Make no mistake – driving down the CS rate will lead to more disability and death.

Rebuttal by Prof. Hannah Dahlen

  1. Scandinavian countries with the lowest CS rates and best outcomes (ranked as best place to be a mother) have similar demographics to Australia. Midwives are central to their success and promoted by WHO.
  2. New Zealand (>90% midwife care) has little difference in maternal mortality (MM) (9 versus 7 per 100,000). NZ has high suicide rates (25% of deaths). America (>90% obstetric care) has the highest MM in developed word (26:100,000). States with more midwives have better outcomes. 
  3. Doctors outnumbered midwives on Towards Normal Birth Committee.  
  4. The National Strategic Approach to Maternity Services is co-chaired by an obstetrician and midwife. There are more obstetricians than midwives on the Advisory Group.
  5. Australian women are most negative if they had a CS or hospital birth and most positive if they have a normal birth or birth in a birth centre or at home.
  6. Over 36% of midwives report lack of respect by doctors in recent global survey (93 countries).
  7. Sydney study found urogynaecologists most risk adverse (42% would request  CS).
  8. Trials of CS versus vaginal birth (for twins and breech babies) showed no difference in incontinence or sexual problems at 3 month and two year follow up.
  9. Having a baby is not a ‘sickness’
  10. We are all accountable - first and foremost - to women

Read Prof. Hannah Dahlen's opening statement here