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A woman's right to choose how she gives birth has come a long way, but is allowing the choice of a planned caesarean a step too far?
On a book cover on Rachel's* coffee table, a woman cradles her baby bump and beams. The book is teetering at the top of a thick stack and, while visiting family bustle in the kitchen behind her, Rachel reaches from the couch to pick it up. Angling it away from anyone who might glance over her shoulder, she skims past the chapters on labour to the section about caesareans. Rachel's family and friends already know her baby will be born by caesarean section - but they don't know the truth about why.
Rachel has done the research. She's delved into the risks and benefits of caesarean section versus vaginal delivery and decided she doesn't want to risk the mental or physical injury that she has so often seen marr the experience of mothers around her. She's heard the stories of friends' long labours, followed by emergency caesareans or traumatic births and tearing; and says she wants a predictable, calm birth, left in the hands of a surgeon.
"I've always had comfort in the fact that I would make a decision to have a C-section. And it made me feel calmer about it all," she says. "As this baby makes its arrival in the world I do not want to hear the word 'emergency' anywhere near me." Yet, although she knows her mind, it's still too taboo to risk talking about, even to those she loves and trusts.
In March, while most New Zealanders were fixated on Covid-19 coverage, reproductive health in New Zealand reached an important milestone: a new law was passed removing abortion from the Crimes Act. While caesarean on request is legal, reflecting on the liberalising of abortion law Rachel says having to shop around for a doctor who will sign-off your caesarean or having to say you are mentally unwell to get one, sound familiar to Rachel - she's been through a similar experience in her fight to choose a caesarean birth. She wonders how many people who have fought for a woman's right to choose abortion could also say they would support a woman's right to choose a caesarean.
Shifting on the floral-patterned futon as she tries to accommodate her growing bump, Rachel shakes her head, exasperated that it's not yet a choice women can make freely or openly. "I think the rhetoric certainly sounds really similar [to the abortion debate]. You're made to feel like you don't know your own mind. And that you don't have a choice over your body, and that everyone has an opinion."
Grabbing her phone out of her bag, she pulls up articles she's read about birth fear. "A few years ago I was reading an article talking about tokophobia, which is a fear of giving birth. And there were so many points where I was like, that's me, that's me, that's me; putting off having children even though you want to have them, preoccupied with the thought of giving birth."
Rachel believes her fear is rational, given birth is painful and can be both dangerous and traumatic for mothers and babies. Scrolling through the articles she's convinced those concerns are often ignored - including by other women. "It's like there's this attitude, 'I had to go through it [labour], so so should you.'"
The kind of caesarean Rachel is having is what's known as 'caesarean section on maternal request'. Unlike an emergency or elective caesarean, there is no medical reason for it.
Is Rachel's choice unusual? Both the Royal Australasian College of Obstetricians and Gynaecologists and the New Zealand College of Midwives say the practice is uncommon. However, the true extent is unknown because the Ministry of Health does not collect clinical data on how many people ask for, or undergo, this kind of caesarean. Doctors say there is no specific ministry code they can use on patient notes that would allow the information to be recorded in health statistics.
This hole in the data caught the attention of Emily Dwight in 2015, when she was researching for her medical honours degree at Otago University. Now a doctor working in health, innovation and improvement in Auckland, Dwight interviewed midwives and obstetricians about how often women asked for a caesarean, how the request was handled, and whether a woman's right to choose should be allowed. "It's very difficult to section off this particular cohort of patients because often, they're just lumped together with all the elective caesareans, which are actually a different group," Dwight says.
Resourcing pressure in hospitals also means planned caesareans might be left off the records in some cases. One of the doctors Dwight spoke with said staff did not record it as "maternal request" because the practice was frowned upon by their hospital unit, and they had got "into trouble".
Dwight also found some doctors and midwives felt "there were instances where the caesarean section would be recorded as being performed due to an obstetric or medical complication, when in fact the decision was made almost entirely because of the pregnant woman's request. They said in these cases that it was more likely that they would find a medical indication that they could 'pin it on' and record this as the reason for performing the caesarean section. In turn, the records would not be entirely reflective of the truth."
At Rachel's house, it's a tight squeeze in the baby's soon-to-be bedroom. She's been racing all over town these last few weeks, collecting second-hand purchases and hand-me-down clothes from friends. "I got that for a fiver," she says, pointing to a baby gym resting on a chipped change table she bought on TradeMe.
While the baby's room is still in chaos, the actual birth has been in the planning for years. Worried there was no obvious pathway to getting a maternal request caesarean, early in her pregnancy Rachel saw a private obstetrician. She wanted the certainty that she would get the procedure, so she didn't have the worry hanging over her throughout her entire pregnancy.
The thought of a vaginal delivery had already led Rachel to delay having children, but that gave her and her partner time to save $6000 to pay the obstetrician to care for her throughout the pregnancy and then perform the C-section.
It nearly didn't happen though: the obstetrician already had too many patients. In a last-ditch effort, Rachel got her partner on the phone, while she paced the room, listening in as he pleaded with the doctor. When the doctor told him yes, she felt a wave of relief and her anxiety instantly disappeared.
That relief remains tinged with guilt, though. Her choice is possible because she can afford to go private, and she worries about those who can't.
Should the public pay for medically unnecessary surgery, though? The Ministry of Health says caesarean sections that do not have a clinical indication and are undertaken solely based on request are not publicly funded.
Rachel thinks they should be, and that a patient's right to choose that option needs to be taken seriously. "How do I know there are not other people out there who come from backgrounds where they have not as much money available to them, who feel exactly the same way? Why the hell should they be forced to do it?"
That's a question Otago University bioethics Professor John McMillan finds fascinating. Attempting to balance imaginary judicial scales in his hands he says there are two sides to the autonomy argument: the pregnant patient's bodily autonomy and the doctor's professional autonomy. He says what is critically important is that patients feel they have access to an open and independent discussion with their doctor or midwife about their reasons for wanting a caesarean.
However, he believes there is an argument for allowing doctors to exercise their professional autonomy. "If, at the end of the discussion, the midwife or the obstetrician wasn't convinced that there was an acceptable balance of risks and benefits professionally, or they thought it wasn't within their scope of practice or how they interpret their duty of care, they could say, 'I understand that, but it's not something I can agree to for these professional reasons.'"
There is some 'contestable space' within that discussion, he says. "There's [also] an argument to say that the balance here should be much more towards the autonomy end [for the woman], which is if there's a full exploration of, you know, 'Why is it that you'd like to do this?' then who is the professional to say, 'I'm not happy for you to take on these risks and benefits'?"
McMillan says, putting aside the cost difference, it's arguable that other non-medical birth plans - including birthing suites, pools, and home births - are publicly funded and focus on accommodating a woman's preferences to make her comfortable while she delivers her baby. The question is 'how far do we go?' to make women comfortable with the delivery process.
When it comes to choice, the cost of a caesarean to the health system is considerably more, as the procedure requires a surgical team and usually a longer hospital stay. However, British research has found that is only the case if everything goes right. Once vaginal birth injuries resulting in urinary incontinence were accounted for, the cost difference was just £84 ($NZ164). In 2011, the UK made maternal request caesareans free via the public health system. Should New Zealand follow that example?
The head of Otago University obstetrics and gynaecology department, Michael Stitley, says the system wouldn't cope. Sitting in his office at Dunedin Hospital, his ID badge hangs over the v-neck of his blue scrubs. It's late afternoon and he's been operating for the past eight hours. His obstetrics operating list was so over-subscribed today that some women's surgery had to be postponed. 'Not enough beds,' he says. Soon, he'll head off on his post-operative ward round, visiting the bedsides of the patients he's operated on today, before starting a night of on-call back-up.
The overall cost argument is a difficult sell to individual district health boards trying to manage a busy surgical service on a day-to-day basis, he says. "Not all resources are truly money[-based] or financial - there are limited hospital beds on a postnatal ward or surgical ward. There are limitations to getting access to theatre."
He's also concerned about equal access, saying even if maternal request caesareans were available free through the public system, there would still be a 'postcode lottery', with obstetricians or services spread unevenly around the country and women living outside the main centres likely to miss out.
Despite having to deal with the daily resource constraints, he still believes women have the right to ask for caesareans. "I don't think it's inappropriate [for an obstetrician] to say, 'Look, you know, I sat down and had a long discussion with this woman and went through her reasons behind this.' And I don't think it's anybody's job to judge whether those reasons are valid to you or not. They're valid to the woman and that's the person that is important in that discussion."
When women have asked him for a caesarean, there is usually a reason behind it. "A number of those situations are someone who has had a traumatic experience with a previous birth, [with] ongoing either psychological or physical pain."
Mental health issues or prior sexual abuse may also come up. Stitely believes the most important thing is that a woman's reasons are heard, so she and those caring for her can make a decision together.
College of Midwives midwifery advisor for quality assurance Jacqui Anderson says a midwife would want to get to the crux of why a woman doesn't want to give birth vaginally. "The evidence shows that the majority of reasons relate to women's fear around birth or their beliefs that, for some reason, they're not able to labour and birth naturally."
Anderson says sometimes women will be concerned there is a family history that might impede a vaginal delivery, because a mother or aunt has struggled in childbirth. It is not a midwife's role to decide if a woman does or does not get to have a caesarean, she says - the procedure can only be signed off by an obstetrician. The midwife's role is to listen, reassure and refer the woman to an obstetrician, or in some cases a psychologist or counsellor, to talk further about her concerns. Women have a right to a referral to an obstetrician and midwives will always support women through their concerns, Anderson says.
For Rachel, the idea of talking to a midwife about her decision was daunting. Her birth plan veered so far from midwifery philosophy, which opposes unnecessary medical intervention, she worried the discussion would result in a midwife trying to talk her out of her decision, or invalidate it by telling her she needed to see a counsellor. "I was worried I'd be forced to fight tooth and nail and then there would be no guarantee at the end, that I wouldn't be able to deliver how I wanted to. And then I was worried that I'd be made to feel unsupported, not capable."
Emily Dwight's research notes a potential conflict of interest for those helping women to make their decision. Three of the midwives she spoke with during her research said the delivery makes up the largest part of a midwife's fee and they could lose some of their income if more women chose caesareans.
Anderson, who is a practicing midwife, says it is completely false that midwives don't let women have caesareans because it affects their income. "If a woman has a caesarean section and she doesn't labour, the midwife still gets a fee. She is still paid."
She does admit, though, that the midwife does not receive as much as she would if she looked after a woman in labour for a number of hours and then had a caesarean section.
Anderson says midwives get very concerned about "this myth out there" that some women don't get caesars because it meant the midwife didn't get paid.
Dwight's research also found potential conflicts of interest with doctors signing off the procedures. One medic pointed out how it helped to reduce doctors' workloads: "It's much easier, honestly, to go and do a caesarean at nine o'clock in the morning than it is to do a vaginal birth... I don't think it's right, but it is much easier."
For Rachel, this first challenge of motherhood will soon be over. As she unfolds and admires a small knitted jersey from a pile, she imagines the tiny hands she will thread through its armholes in a few months. She's had to fight for this feeling of calm but she hopes that one day - whether it be at home, in a hospital, with or without pain relief - all women will be able to choose a birth plan they feel comfortable with. She wants a planned caesarean to become part of a suite of choices that respect and uplift women as they bring the next generation into the world.
*Not her real name