DEBATE: “Are government efforts to reduce the C-section rate a good thing?” A midwife argues 'Yes'

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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. Hannah Dahlen

Professor of Midwifery at the University of Western Sydney's School of Nursing and Midwifery 

The continued rise of surgical intervention during birth is not a good thing. But don’t just take my word for it…

FIGO (world’s leading obstetric body), ICM (world’s leading midwifery body) and the WHO (world’s leading health policy body) have all flagged concerns about the rising caesarean section (CS) rate. The President of FIGO stated recently that FIGO believes there should be a focus on delivering "naturally and normally as far as possible. In 2015, the WHO stated that there was no evidence of benefit when the CS rate went above 15%.

The latest evidence suggests 34% of women who give birth in Australia have a caesarean section CS. That’s higher than the OECD average (28%), and a lot higher than Iceland, Finland, Sweden and Norway (15-17%), a set of countries with the lowest maternal and perinatal death rates in the world.

In NSW in 2010, following a significant rise in CS rates, the Towards Normal Birth Policy (TNB) was introduced. The aim was to support clinicians to reclaim lost skills (due to medicalization of birth) around supporting normal birth.

The rate of instrumental birth (forceps and vacuum) has remained unchanged since 2006 (11-12%). Only the normal vaginal birth rate has decreased over the past decade. The TNB policy in NSW had no impact on the CS rate and likewise did not impact on instrumental birth rates. Forceps have declined from 13.9% in NSW in 1990 to 4.7% in NSW today. The forceps and vacuum rate is higher in the private sector at 13.6% (CS 42.1%) compared to 9.4% in the public sector (CS rate 27.9%) and this is not without morbidity for the baby and the mother.

Using forceps, in particular, can increase the chance of pelvic floor morbidity. However, the argument that in order to prevent one intervention, we should embark on a more radical intervention (CS) is illogical and against current recommendations. Undertaking a CS at full dilation to avoid a forceps birth is the most dangerous time to undertake this surgery; so this is not the solution. 

Several studies have shown a link between birth by CS and an increase in a variety of health disorders in children, such as asthma, eczema, diabetes, obesity etc. The fact that babies miss coming through the bacteria-rich vagina when born by CS may influence the seeding of a healthy microbiome (the good bacteria in your gut). CS may also switch off or silence (epigenetics) certain genes associated with immunity in the child. There are also cumulative health effects for women in subsequent pregnancies and later in life.

Arguments are often made that the rate of CS is rising due to increase in the age of women giving birth. However, there is a threefold variation in rates across the nation for women in the same age groups. Women who give birth at home are often the oldest of all women giving birth yet they are three times more likely to have a normal birth and less likely to have a severe perineal tear when compared to similar low risk women birthing in hospital. 

Today, we have strong scientific evidence to help us understand how to reduce forceps and vacuum birth and this is through: continuity of midwifery care (a midwife providing all your care through pregnancy, birth and postnatally); reduction in the use of epidurals (as these prolong second stage and increase forceps and vacuum); reduction in continuous fetal monitoring (CS reduced when monitoring intermittent); continuous support during childbirth; upright position for labour and birth; homelike environment; birth at home or in birth centre and avoid private obstetric care.

As practitioners, we need to look at the whole picture when informing women, including by ascertaining what is important to them in their particular circumstances. This is the process of getting informed consent and should be the cornerstone of best practice. It’s time for providers to work with women to ensure birth is emotionally and physically safe for them and their babies.

Rebuttal by Prof. Hans Peter Dietz:

It’s not surprising that Prof. Dahlen defends government intervention in maternity care - she was heavily involved with the failed 2010 NSW policy directive Towards Normal Birth. In my opening statement, I asked ‘Who benefits?’, and it’s time for an answer. We’re seeing the latest episode in a 400-year turf war. Obstetricians, that is, those best-qualified and trained for at least 12 years to provide care in pregnancy and childbirth, have been on the losing side. Midwives have acquired an historically unprecedented degree of control over maternity care. Prof. Dahlen is open about the issue of control: She wants government to force obstetricians out of obstetrics. I thought we were all about patient choice. 

Government interference in maternity care has done enormous harm - nowhere more so than in the UK. There have been so many examples of natural childbirth ideology killing women and babies in the NHS that it’s finally going out of favour. A few days ago, The Times of London quoted a senior NHS bureaucrat as follows: "It is absolutely not our view that trusts [NHS Local Health Districts] should be encouraged to reduce caesarean rates." Pauline Hull of Caesareanbirth.org went on to say, "Caesarean rates targets have been a huge problem. They are dangerous." I agree. No degree of obfuscation and no amount of pseudo-science will change that.

Read Prof. Hans Peter Dietz's opening statement here.