Category: csections commentary

A recent study from the US suggests that women do not know enough about their birth options prior to making decisions about the way in which they will attempt birth following a previous caesarean. No surprises there.

But what is particularly worrying is not simply that women don’t know even basic information  but that a significant number are having to go ahead and make life changing decisions regardless.

As Berstein points out “they [VBAC and repeat CS] are both safe options” but each mode has risks these are different and need to be weighed up by Mum. They can only do this if they have all relevant information.

For example the likelihood of achieving a VBAC (Vaginal Birth After Caesarean)  is around 75% but nearly three quarters of the women interviewed in this study couldn’t hazard a guess at the VBAC success rate. Despite this over half had already opted for a VBAC regardless. (Incidentally a 75% success rate is interpreted by many as great odds, but it is worth remembering that for others, particularly those who have experienced a traumatic birth previously, it might leave enough uncertainty to lead them to request a repeat caesarean).

Unfortunately Bernsteins advice to women for tackling such gaps in their knowledge is to “have a really good discussion of your options with your OB…Don’t just read about it online or listen to your friends.” I have a several problems with this. Such an approach assumes:

• That the practitioner has sufficient time to spend giving the mother all the information she needs to make a truly informed decision
• That the mother can take in all the information during the appointment. That she can ask useful/probing questions pertinent to her specific concerns as the information is revealed
• That the practitioner is willing and able to give the mother an unbiased account of her options. It is unfortunately the case that both personal opinion and hospital/surgery policies sometimes get in the way of this

In addition, while this study is important for highlighting the poor level of information support some women are getting during the antenatal period, this is yet another study that takes as it’s starting point the idea that poor education is causing women to plan a repeat caesarean. Despite Berstein’s comment that “they are both safe options” there appears to be the preconception that caesarean birth would be avoided if only women were better educated. There does not appear to be any space for the idea that with balanced information about comparative risks some women might actually choose a caesarean.

While I am in danger of banging on about this too many times I think I will probably continue to do so for the foreseeable future. Knowledge is power and with that comes a feeling of control.

Feeling in control is a key component in retrospectively perceiving an event as positive. If we felt out of control, that things were just done to us without our consent or without a feeling that we participated in the decision-making, we are significantly more likely to view that event negatively.

This is never more true than during birth where things can quickly change and our feeling of control disappear in a breath. I believe it is essential that women are armed with as much information going into birth as they feel they can cope with. It is great therefore to be able to tell you about another book aiming to support women in just that…

‘Choosing Cesarean’ by Magnus Murphy MD and Pauline McDonagh Hull

It focuses on caeasrean birth as the title suggests but does not set out to advocate caesarean birth for all women. Instead it simply proposes that it is legitimate for women to make an informed choice in favour of a planned caesarean even where there is no medical need. They argue that all vaginal births are essentially a ‘trial of labour’ (traditionally this term has been used only in relation to VBAC) and that being prepared for a variety of outcomes is essential. They believe that information and understanding options is key to decision-making and key to coping if the plan needs to change.

“Women are being sold the natural approach as though it is something tangible they can have-just as long as they follow advice, prepare for the big day, and avoid any unnecessary medical interventions that might derail this most desirable outcome. But no matter how good the birth preparation and no matter how ideal the birth setting, doctors and midwives are still only able to optimize women’s chances of spontaneous vaginal birth-not predict or guarantee them. An injection of realism wouldn’t go amiss sometimes.”

New research, suggests that the opinion of the practitioner strongly influences the decision a woman will make about the mode of birth she will request.

BERNSTEIN, MATALON-GRAZI and ROSENN wanted to investigate why it was that so many women were choosing to undergo a repeat caesarean rather than a ‘trial of labour’ also known as a VBAC (Vaginal Birth After Caesarean).

They found that “When patients perceived their providers as having a preference for ERCS [repeat caesarean], very few chose TOLAC [VBAC] whereas the majority chose TOLAC if this was their provider’s preference.”

Even though the sample size was relatively small (155 women and 3/4 were educated to degree level and over the age of 30) the trend was very clear. Practitioner opinion still heavily influenced the decision the woman then went on to make. Interestingly when the woman was not aware of the practitioner expressing any particular preference the split of who chose what was exactly 50:50.

More alarming perhaps is that researchers found that regardless of which birth mode the woman chose she had a woefully inadequate level of knowledge about both the benefits and the risks of her preferred choice.

The multi-choice questionnaire assessed the woman’s level of understanding of the mode of birth they were to undergo and despite the fact that they had all received prenatal care and counselling they were unable to accurately answer such questions as:

• If I were to try for a trial of vaginal labor, my overall chances of success are…
• If I try for a vaginal delivery (VBAC), the risk that my uterus will rupture (opening of the uterine scar) is…
• The reason for my previous cesarean section is an important factor in determining my chances of a successful vaginal delivery…

ACOG (American College of Obstetricians and Gynecologists) clearly define informed consent and this study reveals that women are not being given the level of unbiased, informative material they require in order to be able to genuinely make an informed decision.

As researcher point out “Informed consent, is defined as a process of communication whereby a patient is enabled to make an informed and voluntary decision about accepting or declining medical care and has become a mainstay of contemporary medical practice. It is viewed by many as a collaborative process between physician and patient intended to facilitate the patient’s autonomy in the process of ongoing choices. Our respondents showed insufficiencies in the area of comprehension, a major tenet of informed consent. They lacked awareness and understanding of their situation and possibilities. From our data, it appears that provider bias may affect the opinion of some patients, with undue influence on patient’s voluntary decision making.”