Written to mark National Caesarean Awareness Day, 2005.

I recently came to a decision about my next birth. I’m not planning a HBAC, I’m not planning a VBAC, I’m planning a birth. To quote Henci Goer, “Frankly, VBAC should be a nonissue by now. You should be no more choosing whether to labour this time than you did before you had a caesarean.

Based on 2 decades of studies, totalling many thousands of women, the consensus of experts [both of the medical model and the midwifery model] is that in the absence of a specific reason for caesarean section, the routine policy for women with prior caesareans ought to be labour.”

Certain groups central to the pursuing and upholding of the medical model are changing their view on this, despite the unchanging evidence, and this seems to be where the problems lie.

Now the logical, academic side of me feels terribly confused then by what I see happening in our hospitals to birthing women, and not only those who have had prior caesareans. We all know that vaginal birth is safer for babies, the evidence is well documented and persuasively presented by many people.

Spontaneous labour, followed by normal physiological birth, ie the midwifery model, produces the best outcomes regardless of prior surgery. But in Australia, fewer than 1% of women access this optimal care.

Even those who could afford it without much difficulty, mostly choose to hire a careprovider from the medical model despite the worst outcomes being associated with disastrous notions like active management of labour and elective repeat caesarean with no actual medical indication for it.

Of course, if you were to survey most of the people walking past in the street today, no doubt a large percentage could tell you that birth is dangerous and difficult, best confined to the walls of hospitals, and almost certainly requiring the services of a surgeon in some capacity.

The advertising of their business by those who promote the dangerous and poorly evidenced medical model is thorough and buys into larger myths in our culture around women and women’s bodies.

And their continuing promotion, through ridiculously elevated levels of first time mothers experiencing unnecessary caesareans leading to further surgery as VBACs are refused, means that they are safely both capturing and creating a market share via an unethical monopoly.

If you doubt that this is a policy, and in collusion with our media, you need only think of the recent release of a very faulty study in Australia which alleged that induction at 39 weeks gestation led to a lowering of stillbirth rates.

In the same week, a study demonstrating yet again, the efficacy of the midwifery model, now largely the domain of independent midwives practicing in our homes, was completely ignored in favour of the footage of women clutching small infants praising their obstetricians early intervention in saving them from the dangers of normal, physiological birth and timely gestation.

The very language we use reinforces this clash between the well evidenced, and the poorly evidenced but predominant culture – Trial of labour, trial of scar, hoping for a VBAC, successful VBAC, failed VBAC, uterine rupture which rather conjures images of catastrophic bursting culminating in a spewing forth of blood and baby.

For most women, any issues with their scar results in a small pulling apart and cessation of labour, provided you haven’t had your labour augmented with chemicals which stretch the uterus beyond it’s normal capacity. And let’s not forget other terms like incompetent cervix and failure to progress.

The United Nations 4th World Conference on Women, in Beijing 1995, said this in relation to healthcare for women. Countries need to:-
"Reinforce laws, reform institutions and promote norms and practices that eliminate discrimination against women and encourage both women and men to take responsibility for their sexual and reproductive behaviour; ensure full respect for the integrity of the person, take action to ensure the conditions necessary for women to exercise their reproductive rights and eliminate coercive laws and practices."

The World Health Organisations, report “Safe Motherhood: a guide for care in normal birth” states that “The uncritical adoption of a range of unhelpful, untimely, inappropriate and/or unnecessary interventions, all too frequently poorly evaluated, is a risk run by many who try to improve the maternity services. And also warns that “Women and their babies can be harmed by unnecessary practices.

Staff in referral facilities can become dysfunctional if their capacity to care for very sick women who need all their attention and expertise is swamped by the sheer number of normal births which present themselves.

In their turn, such normal births are frequently managed with "standardised protocols" which only find their justification in the care of women with childbirth complications.” The report states, crucially that “The aim of the care is to achieve a healthy mother and child with the least possible level of intervention that is compatible with safety.

This approach implies that: In normal birth there should be a valid reason to interfere with the natural process.” Too few women are achieving this kind of care and that is only too evident in our soaring rates of unnecessary surgeries.

So what happens to women and our community in all this? For a start, the money spent by governments on supplying highly priced, poorly evidenced careproviders is money which could be spent more judiciously on programmes preventing violence against women or abuse against children.

Hospitals are performing unnecessary surgeries on perfectly healthy women and leaving women at far greater risk of postnatal depression and, the little mentioned but frequently experienced, post traumatic stress disorder.

Women who have caesareans frequently have difficulty breastfeeding, which not only leads to the high dollar value of formula being used, but the resulting drop in the health of that baby leading to further draining our health budget because we know that formula fed babies are at far higher risk of being hospitalised from illness

. And women unable to breastfeed are also missing out on valuable protection from reproductive cancers, particularly breast cancer, which is in almost epidemic proportions nowadays. There go more health dollars which could have been more usefully and economically spent on midwifery care.

Given that the safety of midwifery has been demonstrated over and over around the world ad nauseam, yet still midwives are asked by obstetricians to demonstrate their worthiness to care for women in normal, physiological labour, something is very wrong.

We need to step up to the community and be proactive with information, to go on the offensive with the superior outcomes and satisfied clients of midwifery care. We need to stop allowing surgeons, ill qualified for the care of healthy pregnant women, to dictate the terms of the discourse because women are losing out to it.

We need to ask obstetricians to demonstrate their safety outcomes and justify their capacity to care for women who require nothing from their impressive skillset as surgeons. As Michel Odent said, “Imagine the future if surgical teams were at the service of the midwives and the women instead of controlling them.”

We need to retain our obstetric services for the few women who need this admirable and life saving technology put to the use for which it was intended. We need caesareans to be treated again as major surgery, and not performed without good reason after a woman has used other less invasive methods at her disposal.

We need for women who have this necessary surgery to have their experience honoured, and not treated as a run of the mill, every day occurrence, with no regard for their emotional state or physical needs.

And those of us who have experienced caesareans need to be firm about our future decisions and base them on evidence and not let the medical model steer us into unnecessary further surgeries.

According to a newly published Canadian study of 308,755 mothers who gave birth from 1988 to 2000 after a previous Caesarean section, maternal in-hospital death was significantly higher in elective repeat caesarean group (5.6 per 100,000) than the trial of labour group (1.6 per 100,000). This means that maternal death is 3 1/2 times greater with elective repeat C/S.

Today is a day for us to honour ourselves and our experiences. We are grateful for the mothers who are with us today, and their children, who might not be if it weren’t for emergency surgery in a developed country.

We are grateful for the journey which our births take us on, because birth is a journey and not a destination. Our courage and experience can lead us into the betterment of birth for all Australian women, if we let it.

References available from the author on request.

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