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Are we now at a point in maternity care where we are causing harm?

Despite the fact that support for childbirth is one of the most common and predictable health care needs in any community, it is surprisingly difficult for consumers to find objective data on the outcomes of different birthing practices.

Part of the reason for this is that childbirth is a very ideologically driven area and supporting women to make an informed choice about their birthing options is often not the highest priority when research in this area is reported and disseminated.

This is why studies such as the one reported below are so important.  This study, conducted by Hannah Dahlen, Professor of Midwifery at Western Sydney University and Lilian Peters, Post-Doctoral Research Fellow, Vrije Universiteit Amsterdam (and colleagues), confirms previous research findings that birth interventions, such as inductions and caeesarian sections, increase the risk of both short and long term health problems for the baby.

On the basis of this research, and other studies overturning previously accepted views about the natural progression of labour, Dahlen and Peters argue that Australia may now be at the point where the negatives of birth interventions outweigh the positives.

To address this issue they call for increased support for evidence-based birthing practices, such as continuity of midwife care, which are known to reduce the rate of potentially harmful birth interventions.


Hannah Dahlen and Lilian Peters write:

Medical and surgical intervention during birth continues to rise in much of the world. The latest data suggests around one in three women in Australia have a caesarean section and around 50 percent have their labour induced and/or augmented (sped up with synthetic hormones).

But is there an effect in the longer-term on children’s health associated with the way they are born?

In all reality it is only recently that we have been looking at this question. There is no doubt that a certain level of intervention during childbirth improves outcomes for women and babies but is that rate now too high in the developed world and could there be other consequences we are less aware of?

A five-country study

We have published a study in the latest edition of Birth with an international team based in five countries looking at the short (first 28 days) and longer term (five years) impact of medical (induction and/or augmentation of labour) and surgical (caesarean section and forceps and vacuum delivery) intervention in birth compared to spontaneous vaginal birth.

In this study we analysed routinely collected data in New South Wales between the years 2000-2013 for 491,590 healthy low risk women giving birth and their children. We examined child health in the first 28 days and up to 5 years of age.

We found that babies who experienced a forceps or vacuum birth (instrumental) following induction or augmentation had the highest risk of jaundice and feeding problems needing treatment in the first 28 day. We also found that babies born by caesarean section had higher rates of needing treatment for having a low temperature.

In the first five years, the incidence of respiratory infections (like pneumonia or bronchitis), metabolic disorder (diabetes, blood sugar issues, obesity) and eczema were highest amongst children who experienced any form of birth intervention compared to a birth where there was a spontaneous onset of labour and a birth with no medical or surgical intervention. The odds of most of these health issues were highest with caesarean section.

Mounting scientific evidence

The study adds to the mounting scientific evidence which suggests that children born by spontaneous vaginal birth, without commonly used medical and surgical interventions, have fewer short and long-term health problems even when you control for risk factors that might pre-empt the intervention. We intend to undertake even longer term follow up studies to confirm these findings.

Recently a systematic review analyzing 80 papers that compared short and long-term outcomes from caesarean section and vaginal birth was published in PLOS Medicine.

This review showed some similar findings to our study, showing that children born by caesarean section compared to vaginal birth had higher rates of asthma and obesity, with some of the studies showing these health differences well into adulthood.

Recent birth recommendations from WHO

Recently the World Health Organization (WHO) has released recommendations on birth care, titled: Intrapartum care for a positive childbirth experience.

The first four recommendations were that women should have respectful maternity care, effective communication, a companion of their choice and continuity of midwifery care.

We know both continuous support during childbirth (i.e a doula) and continuity of midwifery care (a midwife who provides the care all the way through pregnancy, birth and postpartum) reduces interventions in birth and improves outcomes for women and babies.

WHO recommendations also overturned nearly 70 years of established practice regarding how fast women should progress in labour.

They presented new research that shows women progress much slower than the previously recommended 1cm an hour and they should not be considered in active or established labour until around 5cm dilated. This is a massive change in the way progress in labour will hopefully now be approached.

It is evident that during the past decades when intervention has escalated one of the main reasons has been to make labour progress according to old, and now apparently flawed research.

Introducing a more evidence-based approach to care during labour and birth can increase the rates of physiological birth and this is now strongly recommended by WHO.

Implications for health services and providers

As the evidence mounts about the long term implications of intervention in childbirth, it is time to have a serious discussion about how we inform women and their partners and where we focus future research.

Currently much of the information we give, based on the research we undertake, is focused on short term outcomes and this may be only part of the picture.

While intervention in childbirth has increased significantly in Australia in the past decade, there has been little change in maternal and perinatal mortality.

What if we are now at a point in maternity care where we are causing harm?

The USA is currently grappling with how it can spend more money than any country on earth on health care, have high rates of childbirth intervention and lose more mothers during childbirth than any other developed nation. Even more worrying, the maternal mortality rate is increasing in the USA.

There will always be a need for intervention and a certain level of intervention saves lives and improves the health of mothers and babies; however, it appears we have gone too far.

There are countries with equally good outcomes for mothers and babies as we have in Australia yet they have half our intervention rates (i.e Scandinavian countries). WHO still recommends rates of caesarean section should not exceed 15% as there is no evidence of additional benefit after this and some evidence of harm. Australia has double this rate and it is rising every year.

Stop blaming women

A familiar discourse offered as explanation for the rise in intervention is that women are older, larger, have more medical issues and are asking for caesareans. In part this is true, but it is not the whole picture. Blaming women obfuscates the issue and stops health providers from examining their own contribution to the intervention rates.

A study we published in 2014 found only 10 percent of low risk women in private hospitals and 15 percent of low risk women in public hospitals had a birth with no medical or surgical intervention and these high intervention rates were not without morbidity for the baby.

Less than 8 percent of women are able to access continuity of midwifery care despite high level evidence showing reductions in intervention, better outcomes for women and babies and cost savings under this model of care.

One has to ask why is there such slow progress on making continuity of midwifery care a number one priority in maternity care.

Do we simply not understand the benefits of relationship-based care or does a significant change in service delivery like this threaten powerful vested interests?

Comments 4

  1. Ruth Armstrong says:

    It is important to note that the study under discussion only reports associations.
    Although the authors have presented plausible mechanisms, there is no evidence from the study that birth interventions have caused any of the outcomes mentioned here. It may be that the conditions leading to birth interventions also led to some of these outcomes.
    We are not told about the indications for the birth interventions, and the lack of a control group (understandably not available in this study) means we don’t know what the outcomes would’ve been without intervention.
    Also, the study does not report outcomes for high risk pregnancies.
    A post from the same authors (about the same study) in the Conversation, garnered some important observations in the comments section about potential biases in the study.
    https://theconversation.com/how-birth-interventions-affect-babies-health-in-the-short-and-long-term-93426
    Re the headline: Really?
    Can we compare an altered microbiome with the possible damage for a baby who has become hypoxic due to prolonged or obstructed labour? What is the acceptable number of interventions to prevent one catastrophic outcome?
    There are undoubtedly unnecessary birth interventions in Australian hospitals because the risks are hard to pick and the stakes are high. Continuity of care from an experienced, competent midwife is a great place to start, but while we’re in the mood to stop blaming people, let’s not get too carried away about vested interests either. In the end, I think doctors, midwives and parents all want the same thing.

  2. Hannah Dahlen says:

    Thanks for your comments Ruth and I agree with many of them. This study does indeed show association and not causation. Intervention when undertaken appropriately and with the informed consent of the woman can and does save lives. Having said that a recent systematic review published in PLOS Medicine (link above) of 79 large studies including thousands of women and children show something is going on. What the mechanism is is less clear and we have proposed two possible explanations where the evidence is mounting (epigenetics and microbiome). What we also know is certain models of care (continuity of midwifery care) lead to better outcomes for women and babies by reducing intervention and improving the health and wellbeing of mothers and babies. This is level one scientific evidence and yet we continue to choose to ignore it. Why? We also know there are countries beyond our shores that have half our intervention and equally good or better maternal and perinatal outcomes. We all need to work together to make sure women in the 21st century get both safe and satisfying care.

  3. Andrew Watkins says:

    Can we compare an altered microbiome with the possible damage for a baby who has become hypoxic due to prolonged or obstructed labour? What is the acceptable number of interventions to prevent one catastrophic outcome?

    It is not a straight 1:1 comparison – altered microbiome v. catastrophic injury

    What we are comparing is an altered microbiome etc for 30-60% of babies, depending upon which hospital they are born in, with the incidence of catastrophic brain injury due to perinatal asphyxia ( rough incidence of severe encephalopathy 10/1000LB, or 1% , an overestimate for good centres in Australia)

    When one then factors in the relative paucity of evidence that urgent caesarian section and other interventions make an appreciable difference to this rate on a population basis, the Dahlen argument has some force.

    It is also worth noting that the private hospitals with CS rates of 40-60% care for the lowest risk women in the community – they dump most high risk women to the public sector, which is appropriate, given their abilities, but it further underscores the question about whether there may be other cultural factors and conflicts of interest driving the intervention rate.

  4. Mikayla Smith says:

    Despite mucho natural birth propaganda, only 1% of women want homebirth.

    More & more women want control of their birth – increased safety, the date secured so arrangements can be put in place, adequate pain relief, and choice.

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