Maternity care in Ireland has very much been in the spotlight in the last few weeks. Aja Teehan’s High Court case has been to the forefront of this but we’ve also had some interesting studies published including this one that says Irish women have more C-sections than their European counterparts and this one that says women fare better in pregnancy and birth when they are under midwife-led care.Strong and conflicting opinions are being expressed on all sides. Some are fervently in favour of women choosing a home birth after a Caesarean section (HBAC) if they feel it’s right for them. Others are just as passionately opposed to the concept concerned for the perceived risk to mother and baby. That’s all fine. Everyone is entitled to their opinion whatever their reasoning may be. You’d like to think their opinion is informed but that’s really the best we can hope for.
However some people’s opinion is more important than others. It’s importance lies not in the bias of the opinion itself, but on it’s influencing power. Specifically, I’m talking about the opinions of female journalists who are writing in this space. Whether you agree with a journalist or not, the fact remains that anything they write has a hugely influencing factor on their readers and as we all know, with power comes responsibility. This is something that has been deeply lacking in media commentary on maternity care, and specifically Aja Teehan’s case, in recent weeks.
I’ll pull out two examples for you: Sinead Ryan in the Evening Herald a couple of weeks ago and Fiona Looney in yesterday’s Daily Mail (I can’t link to them for you as neither are available online). Both women are known for their intelligent, witty takes on life and have many years’ journalism experience between them. Yet on this particular subject, their professionalism and journalistic skills were thrown out the window. Both women are opposed to the idea of HBACs, which of course is fine as they are entitled to their opinion however both women cite their own birthing experiences as reasons to not go down this path.
Fiona told us about her first emergency C-section which saved her preterm baby’s life and how a subsequent birth ended in another emergency C-section because she had been deemed to have “failed to progress”. A third pregnancy was an elective C-section. Sinead Ryan also had an emergency C-section and implied that she had suffered a uterine rupture – a terrifying and extremely rare occurrence. My heart goes out to both women. Those of us who have been pregnant and/or given birth know how vulnerable women are at this time and when something goes wrong it is a deeply upsetting experience with potentially long term emotional and psychological implications. It is easy to see from reading both columns how much their birth experiences affected them. But – and this is a very, very big but – this does not excuse them from their responsibility to properly research their subject matter and present the facts of the situation.
An opinion piece is exactly that but it CANNOT be peppered with factually incorrect information to suit a purpose. In this specific subject, where expectant mothers, women who have recently given birth and women who are trying to conceive are soaking up everything they can get their hands on, journalists have an even greater responsibility to ensure they have the right information. Women will make choices based on what they read. They need to make sure they’re making the right ones based on the correct information.
So, here I’d like to correct the inaccuracies that both women reported in their articles in the hope that other women might read this and it will correctly inform their decisions. Sinead cited that uterine rupture occurs in 1 in 100 women. (It is worth saying here that this figure is grossly incorrect). Fiona Looney’s headline said C-section “is better than being dead” (!). Fiona also said that she was told that attempt a vaginal birth after two Caesareans (VBA2C) was “dangerous”, “risky”, “reckless” and the word “rupture” was mentioned. She was also advised that after three babies born by C-section, she should have no more children despite wanting more. Fiona made her decisions based on the information she received and she can’t possibly be blamed for that. But the information she received was incorrect. Here are the facts:
- The rate in Ireland is 2 per 1000 women overall, or 1 per 1000 for women in spontaneous labour who did not receive oxytocin augmentation (Turner et al, 2006).
- Of the small percentage of women who do rupture, even a smaller percentage of women will lose their baby or require a hysterectomy. In the rare instance of rupture, 94% of babies survive. (Guise et all 2004 via Midwife Thinking)
- Uterine rupture is associated with women whom have had a previous caesarean section, however, uterine rupture can occur with women with no previous Caesarean history.
- The risk of uterine rupture during a VBAC is actually lower to those of other possible birth complications of which are present in all vaginal births. First time mums are at risk for complications that are equally serious to uterine rupture and occur at a similar rate. For example, placental abruption, (Deering 2013) cord prolapse, (Beall 2012) and shoulder dystocia. (Allen 2011)
- VBAC is safe. Overall, around 70% or more of women who try VBAC will give birth vaginally. If a woman has given birth vaginally previously, this rises to 90% (9 out of 10 VBAC women will birth vaginally)
Regarding Fiona’s comment on C-section being better than being dead and a general perception that C-sections are extremely safe, here are some facts:
- While the risks are relatively small, as with all major surgical procedures, there is a risk of death. The risk of death in a woman following a Caesarean section is believed to be less than 1 in 2,500. The risk of death in a woman following a vaginal birth is believed to be less than 1 in 10,000. There is a higher risk for emergency Caesarean Sections vs planned Caesarean Sections. Cunningham FG, et al. (2005).
Looking at the questions around VBA2Cs and the number of pregnancies a woman can have:
- The clinical practice guidelines from the Institute of Obstetricians and Gynaecologists and the HSE state: “in individual circumstances where a woman strongly desires a trial of labour after two previous CS, it may be considered. If the head is engaged, if the cervix is favourable, if there is a history of a prior vaginal delivery and if labour starts spontaneously the risk of a successful VBAC may be high and the risk of UR may be low. However, the risks and benefits of a TOLAC (trial of labour after Caesarean – my addition) in such cases should be documented antenatally in the notes. There is also a case for not using oxytocic agents either to induce or augment labour in such circumstances (Turner, 2002). Women with >1 previous CS should also be advised to attend their maternity hospital early if they experience any abdominal pains or signs of labour.”
- The NICE guidelines in the UK recommend that practitioners should “inform women who have had up to and including four CS that the risk of fever, bladder injuries and surgical injuries does not vary with planned mode of birth and that the risk of uterine rupture, although higher for planned vaginal birth, is rare”
Finally, Fiona states that HBACs don’t happen in the UK because they’re not allowed. They are and they do. In the UK, the place of birth is ultimately left to a mother to decide. I think I’ve covered all the inaccuracies that both women mentioned in their articles. If I’ve missed one, please let me know and I’ll add it. Personally, I don’t care where anyone gives birth just as long as they have made an informed choice and it is the place that they feel the most comfortable and safe. Also, when I write about this subject, I like to include the data to back up my arguments. Sinead and Fiona, in fairness, it would have taken you five minutes to Google the correct information. References: AIMS Ireland Cuidiu Birth Statistics per unit in Ireland: http://www.bump2babe.ie/statistics/ Midwife Thinking: VBAC: Making a Mountain out of a Molehill:http://midwifethinking.com/2011/02/23/vbac-making-a-mountain-out-of-a-molehill/ Deering, S. H.; Smith, C. V. Abruptio Placentae, 2013. Medscape.http://emedicine.medscape.com/article/252810-overview#a0199. Beall, M. H.; Chelmow, D. Umbilical Cord Complications, 2012. Medscape.http://emedicine.medscape.com/article/262470-overview#a30. Allen, R. H.; Chelmow, D. Shoulder Dystocia, 2011. Medscape.http://emedicine.medscape.com/article/1602970-overview#a03