The emotions of cesarean birth.

Paulin e Dillard announced that she is beginning a research project on the long-term emotional reactions to cesarean sections. With the c-section rate in the United States rising every year it is important to not just consider the physical aspects for the mother and baby, but also the emotional aspects and how they affect parenting and marital relationships.

"Every day women are subjected to surgical birth without any real understanding of why. This often leads to emotional difficulties later that are ignored by the current obstetrical environment," Pauline stated. Pauline is looking for volunteers to answer an extensive survey about their birthing experience. She needs women who have had true natural childbirth to respond as well as those who have had a cesarean section.

Pauline was a childbirth educator and birth assistant for 12 years. She is currently an unlicensed psychotherapist in the state of Colorado. She is working on her MS in psychology through South Florida Bible College and Theological Seminary. This research project is designed to fulfill her thesis requirements as well as bring understanding to the general public about this important issue. She is also the author of Woman of Birth: A Novel and The Discerning Childbirth series of workbooks.

If you would like to be a part of this important research project and contribute to the future of birth practices please go to Pauline's website www.dunamascomm.com and request a survey form.

RELATED ARTICLE: Women's health care professionals issue warning about cesarean section on demand.

The American College of Obstetricians and Gynecologists (ACOG) recently released opinion that deems physicians ethically justified to perform elective cesareans without a medical reason has caused alarm for major women's health organizations. The opinion may deny women access to fully informed consent regarding one of the most controversial obstetrical procedures. With a U.S. cesarean rate exceeding 26 percent, and no definitive study on the benefits of cesarean delivery, it is startling to give physicians the go-ahead to perform nonmedically justified surgery on women with normal pregnancies.

A group of women's health care organizations, including Lamaze International, American College of Nurse-Midwives (ACNM), Doulas of North America (DONA), Coalition for Improving Maternity Services (CIMS) ** , and the Association of Nurse Advocates for Childbirth Solutions (ANACS), believe this opinion downplays the risks to mother and baby when non-medically necessary cesareans are performed. "No evidence supports the idea that cesareans are as safe as vaginal births for mother or baby, and pregnant women should be given all of the facts they need to make an educated decision," said Barbara Hotelling, president of Lamaze International.

"The World Health Organization recommends no more than a 15 percent cesarean rate. With a million women having cesarean sections every year, this means that 400,000 to 500,000 may be unnecessary," warned CIMS Executive Director Rae Davies.

Research shows that the risk of maternal death following cesarean section is five to seven times higher than vaginal birth. Complications during and after the surgery may include injury to the bladder, uterus and blood vessels, hemorrhage, anesthesia accidents, blood clots in the legs, pulmonary embolism, paralyzed bowel, and infection.

Citing additional concerns about the risk of placenta previa, placenta accreta and uterine rupture during subsequent pregnancies, prominent obstetrician-gynecologists Ingrid Nygaard and Dwight Cruikshank stated, "Given the absence of rigorous scientific evidence, we believe that it is currently ill-advised to routinely give all prenatal patients the choice of their desired mode of delivery."

The American College of Nurse-Midwives stated, "Regrettably, the opinion issued by the ACOG Committee on Ethics may lead to an increasing level of distrust between health care professionals and the women who seek our services. The purported benefits of cesarean section on demand are unproven and the known risks place the woman's life and reproductive future on the line. This is the message women must receive."

The baby also is at risk. With planned cesareans, some babies are inadvertently delivered prematurely. Studies show that babies born even slightly before they are ready may experience problems breathing and are five times more likely to be admitted to intermediate or intensive care. Premature babies also have more difficulty breastfeeding.

"Contrary to the ACOG statement, fear of pain in labor need not force women to have cesareans. All women benefit from emotional, physical and most importantly, educational support in labor and when making decisions about the birth of their child. Studies have shown the value of doula services in lowering the cesarean section rate," added DONA President Ann Grauer

Lamaze, ACNM, DONA, CIMS ** , and ANACS believe that all caregivers should respect the birth process and not intervene without compelling medical indication, Carolyn Rafferty, executive director of ANACS reported, "A growing number of obstetric nurses are deeply concerned at the prospect of placing increasing numbers of women at unnecessary surgical risk. We implore obstetrical nurses around the country to speak up for women and fulfill the nursing obligation of patient advocacy."

--Collectively, Lamaze, ACNM, DONA, CIMS **, and ANACS speak on behalf of nearly 15,000 childbirth professionals and reach approximately three million expectant parents each year.

** ALACE is a founding member of the Coalition for Improving Maternity Services (CIMS) and endorses this press release.

RELATED ARTICLE: Cesarean section quadruplets the risk of maternal death.

The Coalition for Improving Maternity Services views with alarm a recent study showing that U.S. women having cesarean sections are four times more likely to die compared with women having Vaginal births. (1) Investigators reported a maternal death rate of 36 per 100,000 cesarean operations versus nine per 100,000 vaginal births. This is the difference attributable to the surgery itself, not any complications that might have led to the need for surgery Based on calculations of what constitutes a reasonable cesarean rate versus the actual US cesarean rate *, 135 women die every year as a result of having surgery they did not need. Moreover, the difference in mortality rates between cesarean section and vaginal birth is almost certainly larger than it appears. Investigators only considered deaths occurring up to one year after delivery Some surgically related deaths--scar tissue causing a twisted bowel, for example--may occur after the one-year cut-off.

In a press release entitled "Weighing the Pros and Cons of Cesarean Delivery," the American College of Obstetricians and Gynecologists offered the theory that cesarean section benefits mothers by protecting against pelvic floor prolapse as a counterbalance to the fact that it was associated with an increased maternal death rate. (2) The research, however, does not support this theory,

While some studies do report a short-term benefit with cesarean section for a few women, (3) none find long-term differences in symptoms resulting from pelvic floor weakness or injury to maternal tissues. (3-7) Other studies report considerable percentages of women with urinary or bowel problems in the early weeks and months after cesarean surgery. (8-9) The finding that cesarean section offers no long-term advantages holds true even without taking into account that many features of standard obstetric management cause or contribute to weakness or damage, and the use of these features could be greatly reduced or eliminated. These include episiotomy, fundal pressure (pushing down on the woman's belly to expel the baby), vacuum extraction, forceps delivery, and how and in what positions women are directed to push. (10) Indeed, the ACOG press release acknowledges that vaginal instrumental delivery produces the worst results.

Epidural analgesia also contributes indirectly by increasing the need for vaginal instrumental delivery and episiotomy. (11-12) Had women birthing vaginally received optimal care, the incidence of pelvic floor laxity and genital injury would likely have been much smaller. CIMS contends that reducing the use of injurious practices would do far more to improve maternal health and well-being than substituting major abdominal surgery. Increased risk of maternal death is but one of the many hazards of cesarean section.

--CIMS, Press Release, October 1, 2003; (888) 282-C[MS (phone); [phone] (fax); [e-mail].

* The 2002 cesarean rate was 26 percent. This means that about one million of the 4 million US women giving birth every year have cesarean sections. (13) The World Health Organization recommends no more than a 10 percent to 15 percent cesarean rate. (14) If the US cesarean rate were halved, 500,000 fewer women annually would have had cesarean sections. The death rate among them would have been nine per 100,000 (45 women) rather than 36 per 100,000 (180 women)--a difference of 135 lives.

References

(1.) Harper, M.A., et al. 2003. Pregnancy-related death and health care services. Obstet. Gynecol. 102(2):273-8.

(2.) ACOG, 2003. Weighing the pros and cons of cesarean delivery. ACOG News Release, Jul 31; http//www.acog.org/from_home/publications/pressreleases/nr07-31-03.cfm.

(3.) Rortviet, G., et al. 2003. Urinary incontinence after vaginal delivery or cesarean section. N. Engl. J. Med. 348:900-7.

(4.) Gordon, H., and Logue, M. 1985. Perineal muscle function after childbirth. Lancet 2:123-5.

(5.) MacLennan, A.H., et al. 2000. The prevalence of pelvic floor disorders and their relationship to gender; age, parity and mode of delivery. Br. J. Obstet. Gynaecol. 107:1460-70.

(6.) Nygaard, I.E., Rao. S.S.C., and Dawson, J.D. 1997. Anal incontinence after anal sphincter disruption: A 30-year retrospective cohort study. Obstet. Gynecol. 89(6):896-901.

(7.) Viktrup, L. et al. 1992. The symptom of stress incontinence caused by pregnancy or delivery in primiparas. Obstet. Gynecol. 79(6):945-9.

(8.) Declercq, E.R., et al. 2002. Listening to Mothers: Report of the First National US Survey of Women's Childbearing Experiences. New York: Maternity Center Association.

(9.) Lydon-Rochelle, M.T., Holt, V.L., and Martin, D.P. 2001. Delivery method and self-reported postpartum general health status among primiparous women. Paediatr. Perinat. Epidem. 15:23-40.

(10.) Goer, H. 2003. Preserving pelvic floor, genital, and anal sphincter integrity in childbirth: Elective cesarean is not the solution. Medscape Ob/Gyn & Women's Health, in press.

(11.) Carroll, T.G., et al. 2003. Epidural analgesia and severe perineal laceration in a community-based obstetric practice. J. Am. Board Fam. Pract. 16(1):1-6.

(12.) Robinson, J.N,, et al. 1999. Epidural analgesia and third- or fourth-degree lacerations in nulliparas. Obstet. Gynecol. B;94(2):259-62.

(13.) Hamilton, B.E., Martin, J.A., and Sutton, RD. 2002, Births: preliminary data for 2002, Nat. Vital Star Rep. 51 (11).

(14.) World Health Organization. 1985. Appropriate Technology for birth. Lancet 2(8452):436-437.