"The grass isn't necessarily greener in Holland's maternity landscape, and more care please when reporting on 'The Business of Being Born'"

This has been another busy month for me. Every spare minute has been spent preparing my upcoming press release with the results of ec's first round of surveys (thank you to everyone who completed them) and spare minutes are becoming increasingly scarce as our darling little girl spends less time asleep during the day and more time playing. Still, I wouldn't have it any other way, and what a perfect excuse for a screen break! Anyway, on with a look at the latest cesarean news.

As we know, the World Health Organization's suggested ideal cesarean delivery rate of 10-15% is frequently cited in articles or discussions in the many countries whose rates far exceed this range. That's despite the fact that this ‘ideal' is reportedly unsubstantiated by research (see Hale, RW and NIH statement) and highly criticized by many in the medical profession (see Medical views).  

Well this month, I spotted a very interesting article about the current situation in The Netherlands, which highlights the conclusions of a research paper that's just been published in Medisch Contact: "New choices needed in the care of pregnant women, Visser et al, 2008".

The report warns of a Dutch midwife system 'under pressure' with (avoidable) perinatal mortality no longer one of the lowest in Europe and a maternal death rate that has risen in the last 20 years (due to 'substandard care' in 50% of cases). The problem appears to rest with the fact that skilled obstetrical staff only work Mon-Fri, 8am-6pm, which means perinatal mortality is 23% and 7% higher at night and weekends. Homebirth is still popular, and although only 10% of women choose this in cities, half are reported to need hospital treatment. The report authors also talk about the existence of 'conservatism in midwifery with the prevailing belief in a happy ending without too much intervention, even if there are complications', but they say that this is now clashing with the ‘changed expectations' of pregnant women and their partners, who ‘no longer want to tolerate complications or prolonged labors.'

Why is this so interesting? Well because for many years, The Netherlands (and countries similar to it) has been praised for its maternity care system, and held up as an example of how cesarean rates can be safely reduced. (2003, 2001, 1993) Yet despite having achieved the ‘ideal' cesarean rate of 15%, questions on safety are being asked in the report, such as: "Does this ‘unique' Dutch system comply with the 21st century?"

This is not the first time Dutch maternity care has been called into question in recent years (see our Netherlands page) and in fact, when I began to look into the Dutch cesarean rate a little further, I found another interesting article that may explain one reason why its rate has remained lower than many other Western countries - that is, less litigation. According to midwife and author Beatrijs Smulders, 'if a client is unhappy with the care received from a doctor or midwife, she can attend a special committee, comprising midwives, obstetricians and GPs, who will review the case and the medical evidence. Financial compensation is not a consideration and usually if a mistake has been made this is acknowledged as something that does occasionally happen and the midwife or doctor will receive a warning. After three warnings court proceedings may be commenced. This approach is made possible because of the social support system in Holland, which provides fully for parents who have a handicapped child through the national insurance system and other community facilities. There is no need to sue the doctor or midwife to obtain money to pay for this care.' 

I may be proven wrong, but in my opinion, the cesarean rate in The Netherlands will not only continue to rise but, as we're finding in many other countries, maternal request will account for some part of that rise (see Caesarean section on request: a survey in The Netherlands, Kwee et al, 2004). 

Two other things worth mentioning this month. There was a disappointing article in Newsweek covering the Rikki Lake documentary ‘The Business of Being Born.' It said of the film: "one of their messages is that c-sections should only be performed when needed to guarantee the well-being of the mother and infant, and should not be a first choice for healthy mothers. New research into the risks associated with elective caesareans supports their view." If you look at the 'Comments' section at the bottom of the article, you'll be able to read what I posted in response to this statement.

And finally, in another article, two doctors offered very different views on the protective benefits of cesarean delivery:

Jenny King, a urogynaecologist at Westmead Hospital: ‘Most women who give birth vaginally do not develop urinary incontinence, faecal incontinence and prolapse' ...And women who deliver only by caesarean section can have pelvic floor dysfunction, as may some women who have never been pregnant.'

Tim Wilson, a colorectal surgeon at Sydney Hospital and Mona Vale Hospital: ‘I see sphincter disruption after vaginal delivery as well as tears in the immediate post-partum period, but most commonly we see the effects of that damage ... when women are in their 50s and 60s. ‘The most common thing we see is symptoms related to a tear ... in the muscles between the anus and the vagina.' Many women who had a caesarean section were ‘saving themselves a lot of discomfort and pain later in life', he said. ‘The birth process is anything but optimal. It is tearing, bruising, and very traumatic - a lot of women do not come forward about it [incontinence] because they feel shamed.'

As is often the case, the article headline reflected the ‘no protective benefit' view: Caesareans unlikely to spare mothers grief of incontinence, Sydney Morning Herald. I can only suggest that you draw your own conclusion after reading the available research on this issue - see our Birth injuries pages.