LIKE most first-time mothers, Faye Wong (not her real name) was incredibly excited when she got pregnant. She read baby books and magazines voraciously, signed up for ante-natal class and bought out "half of Mothercare" (baby brand retail shop) to prepare for baby's arrival.
When she was 38 weeks pregnant, her obstetrician said the baby's head had engaged and his size was quite big. The doctor suggested inducing her labour.
In the labour room, her "nightmare" began. The pain from the drug-induced contractions was a rude jolt to her system. Then she was jabbed and prodded with painkillers, IV tubes and the works.
"I was shocked, confused, and in absolute terror," recalls Wong, 35. Finally, the induction failed and she had to be wheeled in for emergency caesarean. Thankfully, she delivered a healthy baby boy weighing 3.9kg. When she got home, she struggled with breastfeeding and suffered a severe bout of post-natal blues.
"I felt 'cheated' by having to undergo a C-section," Wong admits. Her son is now seven. "I was a newbie to the birthing process and was meek as a lamb led to the slaughter," she adds.
"If I'd known then what I know now, I probably would have been better prepared, stood my ground and not undergone early inducement."
Wong's experience isn't unique.
"We see a fair amount of women who are unhappy about the outcome of their deliveries," says Jennifer Hor of Jenlia Maternal Services. The UK-trained midwife has been running antenatal classes and post-natal home visits for 17 years. "Some felt they had a C-section even though they didn't want it. Or, some felt they didn't get enough information from their doctors."
So, are women less assertive when it comes to childbirth? Are they getting or finding the information necessary to make informed choices and decisions? And have we forgotten that childbirth, an age-old practice, is meant to be natural?
Birth trends
Over the years, the medicalisation of childbirth means what used to be a straightforward, natural process is now treated as a high-tech medical procedure.
Caesarean rates are on the rise in both developed and developing countries. In countries like the US and UK, caesarean rates average around 25 to 32% (2007 figures) while developing countries like China has a 40.5% rate (2000).
In Malaysia, a survey of the C-section rates in major government hospitals in 2008 showed a figure of 20 to 25%, according to Dr Hj Mohamad Farouk Abdullah, President of Obstetrical and Gynaecological Society of Malaysia.
"Until five years ago, the C-section rates in government hospitals was 10% to 15%," says Farouk also the head and senior consultant at department of obstetrics and gynaecology, Tengku Ampuan Rahimah Hospital, Klang. "In private hospitals, you can say one in four births are delivered through C-section (30 to 40%), based on interactions with my colleagues from the private sector. (There is no official figure for C-section rates in Malaysia's private hospitals). The World Health Organization (WHO) states, "there is no justification for any region to have a higher rate (of caesareans) than 10 to 15%."
In government hospitals, maternal request is one of the top five indicators for C-sections. Other indicators are foetal distress, poor progress, and previous C-sections, Farouk added.
"Women say they want to take ownership of their bodies, yet we have healthy, low-risk women who said they had a C-section for their first births because they listened to their doctors," says Farouk, who also sub-specialises in reproductive medicine. And because of the risks from the first surgery, these women are requesting for repeat C-sections. "Ironically, women are pushing the trends that way.
"We are also seeing the use of more technology to manage pregnant mothers, for example using CTG (cardiotocography) to monitor foetal heartbeat and uterine contractions and ultrasound scans," says Farouk. "It's not all bad, but if you monitor too much, you might pick up something and wonder if you don't take action, there might be consequences, hence the interventions."
Doctors come with their beliefs and agendas, based on experiences. Some underplay certain risks and amplify others. For instance, placental calcification (ageing of the placenta) is not a major issue for some obstetricians if the woman is near term and foetal growth is normal. But for a different doctor, a few specks on the ultrasound scan is reason enough for labour induction.
"There can be grey areas in medical investigations. I tend to be more conservative with placental calcification and continue to monitor foetal health and growth parameters," says consultant obstetrician and gynaecologist Dr Choong Kuo Hsiang of Pantai Hospital Kuala Lumpur.
Also, fear of litigation is scaring obstetricians into defensive and often interventionist practices.
"An obstetrician is more likely to be subjected to litigation because a caesarean section was not performed or was perceived to have been performed too late for complications of surgery," explains consultant obstetrician and gynaecologist Dr T. Chow from a private hospital in Klang Valley.
In Asia, including Malaysia, the culture of using caesarean delivery to manipulate the horoscope of the baby is one of the factors for the rising numbers of caesarean section performed for non-medical grounds, she added.
Medical interventions
Clearly, it's not always true that C-sections or epidural blocks are being foisted on reluctant women. The fact is, some women don't question their doctors, or they themselves are asking for interventions.
Labour induction, elective caesarean, epidural jabs, and routine episiotomy are some of the common medical interventions during childbirth.
Induction of labour, the use of medication or other methods to bring on labour, is usually done when the mother's or baby's health is at risk. Pre-eclampsia (pregnancy-induced high blood pressure), reduced amniotic fluid, or intrauterine foetal demise (stillbirth) at a late stage of the pregnancy are some of the reasons for induction.
"For such cases, studies have shown that caesarean section rate has been unchanged or lower among the induced group as compared with expectant mangement ofpregnancy (no intervention)," explains Chow, who has been in practice for more than 15 years.
"But induction of labour at 37 to 41 weeks on non-medical grounds is linked with an increased risk of caesarean section for nulliparous women (a woman who has never given birth) and an increased risk of instrumental delivery," Chow adds.
No doubt, medical interventions can be a lifesaver for mothers and babies. Improved surgical techniques and anaesthetics, and advances in medicine have ensured that women with high-risk pregnancies get the best possible care.
However, once the natural process of labour and birth has been disturbed, if there is no actual emergency, there is risk that the side effects of the treatment will trigger more intervention necessary to fix the problem. This sequence of events is called the "cascade of interventions".
"Pitocin (Syntocinon), a synthetic form of the hormone oxytocin used to induce or speed up labour, often results in a rapid increase in the intensity and strength of the woman's contractions. As a result, she may opt to use pain medications such as pethidine, a form of narcotic, or epidural anaesthetic. Babies sometimes don't react favourably to the sudden increase in the intensity of the contractions, which may result in irregularities of the heartbeat. Thus in turn may necessitate delivery by caesarean," explains Choong.
"Many women who use epidural do not experience the urges to bear down which help them to birth their babies. Often, in this situation, the doctor will use forceps or vacuum to deliver the baby, which means he needs to do an episiotomy (a surgical cut to enlarge the vaginal opening). Many women experience long-term perineal pain following episiotomy."
A failed induction (when labour doesn't started after the first cycle of treatment) can either require a rescheduled induction or emergency C-section.
"Women should received accurate information about the risks, benefits, and alternatives of induced labour and understand the possible side effects and interventions, " advises Chow.
The big 'C'
Most women also come with the preconceived idea that C-sections are safer than vaginal delivery, Choong said.
"When there are complications in the pregnancy or during labour, doctors will deliver the baby by C-section," says Choong. "In fact, C-section, which is classed as a major surgical procedure, carries with it the risk of complications and shouldn't be viewed as an alternative option to normal birth."
Some of the C-section risks include bladder injury, bleeding, womb infection, and an increase in the risk of placental accreta (abnormal deep attachment of the placenta to the womb that can result in severe haemorrhage upon removal of the placenta from the womb) and placental praevia in subsequent pregnancies.
"Babies delivered by elective caesarean section at 37 to 39 weeks' of pregnancy are at two to four times more likely to suffer from respiratory morbidity compared with babies delivered by vaginal delivery," Chow adds. WHO global maternal survey also finds that women who choose elective caesarean with no medical indication are at increased risk of maternal death and serious complications.
"C-section shouldn't be seen as a harmless option," says Chow. "Women who choose caesarean for lifestyle choice or for fear of childbirth pain should be counselled." Studies have linked depression and distress after birth, which affect up to one in five women, to forceps and caesarean births. (Boyce PM. Risk factors for postnatal depression: Arch women Ment Health. August 2003)
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