Dr Raoul Goldberg queries whether the rising incidence of caesarian section (CS) is a cause for concern. Faced with this alarming increase in caesarian deliveries, especially in the private sector, we need to consider what effect this might have on the child’s overall health and indeed on the community when one in two children are born by CS. We need to ask what is truly in the best interests of the child when there is the choice to have a normal vaginal delivery. Factors influencing the rising incidence are examined and both the conventional obstetrical point of view and midwife’s point of view are described. With this as background, what insight can we gain into the effects of CS on the newborn child?

Dr Raoul Goldberg[/cl]
[cl=wqual]BSc (Med), MB ChB (Wits), CEDH (Hom)

[just]In recent years there has been a progressive increase in the rate of caesarian section (CS) deliveries worldwide. In the USA the overall rate increased from 5.5% in the 1970s to 21% in the year 2000; in Brazil, the increase was from 30.3% to 50.8%.[sup]1[/sup] There is growing consensus that medical indications alone cannot explain these increases.[sup]2[/sup] Based on the rates of CS with the lowest perinatal mortality, the ideal rate is widely accepted to be in the region of 15%. Currently, however, the rates vary greatly in different settings depending on a variety of factors. In all countries, CS rates in private hospitals are higher than in public or social security hospitals. In South Africa the rate for the public sector is between 10% and 20% depending on the area. This still lies within the World Health Organisation’s (WHOs) accepted range. However, in the private sector the rate is over 50%. This cannot be justified on clinical indications alone. It is difficult to obtain precise information about the other non-clinical factors involved because all CS are ostensibly done for clinical reasons; the non-medical reasons are usually not stated. There are many obstetricians around the world and in South Africa, who only deliver babies by CS, citing the safety of mother and child as the reason for this policy.

Articles in the “Naturally Healthy Children” ™ section of the Journal have been looking at an approach to optimal child health.[sup]3-8[/sup] Faced with this alarming increase in caesarian deliveries, especially in the private sector, we need to consider what effect this might have on the child’s overall health and indeed on the community when one in two children are born by CS. We need to ask what is truly in the best interests of the child when there is the choice to have a normal vaginal delivery. Before we try to find answers to these difficult questions, let us first try to understand the reasons for this increased frequency.

[cl=spurple]Factors influencing the rising incidence[/cl]
Maternal and perinatal risk factors have always been and will continue to be justifiable reasons for performing emergency or elective CS. There are definite medical indications for CS accepted worldwide, e.g. failure of labour to progress, fetal distress, and breech presentation to mention a few. Advancing technology may give the clinician earlier warning of risk to mother or child and therefore increase the caesarian rate. Yet these factors alone do not explain the increased prevalence. For instance, women with low income or socio-economic status are at higher obstetric risk, yet women of higher income and social class, where the risk is low, are associated with higher CS rates.[/just]

A host of other factors are associated with higher rates of caesarian delivery:[sup]9-11[/sup]

[bul][b]Socio-economic factors[/b]: high income/high level of maternal education/private insurance/urban residence
[][b]Demographic and reproductive factors[/b]: older maternal type/first pregnancy/previous miscarriage/previous stillbirth/low or high birth weight
[] [bi]Health service factors[/bi]: private hospital/delivery in non-academic hospital/high number of prenatal visits/early initiation of prenatal care/recently graduated physician/male physician/individual obstetrician/solo practice setting/antenatal care under obstetrician working in the same hospital/request by patient or offer by obstetrician/delivery on Friday/medico-legal considerations[/bul]
[just]If one tries to find among these associated factors the underlying causes for this increase, one is led to two main reasons: choice by the mother or pressure by the gynaecologist/obstetrician.

Maternal choice appears to be influenced by intellectual sophistication and higher socio-economic status which permits greater health choices, i.e. private gynaecologist/private insurance/private hospital/more comprehensive antenatal care. These factors as mentioned above will increase the chances of having a caesarian delivery (over 50% of births are by CS in the private sector compared with 10 – 20% in the public sector). The more informed the woman is, the more likely she will know that normal vaginal delivery has a greater risk of incontinence in later life and caesarian delivery may avoid complications for mother and child. The more sophisticated the woman, the more she may wish to preserve her figure and youthful appearance and to undergo the least amount of inconvenience and discomfort in delivering her baby.

[b]Apart from the few radical obstetricians who would deliver all babies by CS, most gynaecolgists/obstetricians would agree that a normal vaginal birth would be the first prize.[sup]13[/sup][/b]

The psycho-emotional status of the pregnant woman will also strongly influence the birth process and thus also the chance of delivery by CS. Most women choose the ‘safety’ of the controlled hospital environment. And many women will choose not to go through the natural birthing experience for fear of the physical and/or emotional pain or discomfort of the birth.[sup]12[/sup] Parents today have greater freedom to choose how they wish their babies to be born. Whatever their choice, which needs to be respected, they should always be as well informed as possible about all factors concerned, both the overt physical risks to mother and child as well as the psycho-emotional consequences.

Gynaecological pressure may influence the mother to choose caesarian delivery and is more frequent if the gynaecologist is male, recently graduated, in solo practice and if the due date is on a weekend. Add to this the ever-present threat of litigation for damage to mother or child incurred in the normal delivery. In the UK, 70% of all litigation relates to obstetrical practice and therefore obstetricians pay more for medico-legal insurance than any other medical specialty. In Ireland, an obstetrician will pay more than R400 000 per year for such coverage. In the USA some cities have no private obstetricians as a result of the pervasive practice of litigation for the smallest damage to mother or child.

[cl=spurple]The conventional obstetrical point of view[/cl]
Apart from the few radical obstetricians who would deliver all babies by CS, most gynaecolgists/obstetricians would agree that a normal vaginal birth would be the first prize.[sup]13[/sup] This is because CS delivery is not without its complications, especially in developing countries or where medical facilities are lacking. They will have to admit there are more maternal deaths with CS (9/100 000) than with normal vaginal birth (2/100 000).2 The overall complication rate for CS is between 11% and 14%, the most common complications being uterine lacerations, blood loss and infections. Elective caesarian delivery has significantly less risk of complication. Recent research indicates that caesarian delivery has been associated with unintended adverse maternal health outcomes.[sup]9-15[/sup] Caesarian section will also impact on future pregnancies: such mothers will statistically have fewer children due to lessened desire for or reduced ability to have children, and the next pregnancy is more likely to be complicated through repeat CS or placental problems. There is also evidence that caesarian mothers experience less immediate and long-term satisfaction with the birth, are less likely to breastfeed and have greater difficulty interacting with their babies after birth.[sup]16-18[/sup] It has also been documented that lung function in the newborn baby is weaker when born by CS compared with normal deliver.[sup]19,20[/sup] If there is any perceived risk to mother or child, most obstetricians would not hesitate to perform a CS and would prefer to do an elective rather than an emergency caesarian delivery since the complication risk in the latter is higher.[sup]21[/sup] The worst scenario would be a bad vaginal birth with perineal tearing and fetal distress. Most gynaecologists believe that the increase in CS is associated with reduction in maternal and neonatal risk (R Goldberg – personal communication with practising gynaecologists). Obstetricians evidently differ in their use of caesarian delivery, suggesting different practice guidelines and expectations for doing CS.

This would suggest that other factors such as the risk of malpractice litigation, women’s vanity, convenience for both obstetrician and the pregnant woman and financial considerations, may sometimes be more important than the obstetrical indications to operate.

[cl=spurple]The midwife’s point of view[/cl]
Most private midwives are dismayed at the high incidence of caesarian delivery in the private sector.[sup]22,23[/sup] The rate of CS is much lower in women who are delivered by midwives. Why is this the case? The midwife generally is able to provide a variety of options and benefits to a pregnant woman that the gynaecologist cannot offer. They have the time and dedication to provide a warm, maternal and nurturing support system which engenders mutual trust, less anxiety and more insight and understanding for the parents. They feel that gynaecologists are orientated more to solving obstetrical problems than carrying out routine deliveries, have less time to support the individual psycho-emotional needs of their patients and are usually not fully available for the mother in labour. It is probably this more personal relationship and relaxed environment in which the midwife functions that accounts for the much lower incidence of CS, perineal tears and the need for epidural anaesthesia. (R Goldberg – personal communication with practising midwives in private practice).

There are a number ways in which a pregnant woman can work with a private midwife. She may choose a midwife to accompany her through a part or all of the pregnancy and opt to have her baby at home, in a birth centre or in a hospital where the midwife may still be active in the birth process. Or she may choose to have an obstetrician deliver the baby or be on call for an emergency that the midwife cannot deal with. All midwives would certainly choose to have a good working relationship with an obstetrician as they see this as the optimal support for pregnancy and birth.

[b]It is a totally different experience for a baby to be born naturally through its own labour down the birth canal, or to be removed unnaturally from the mother’s abdomen through a surgical incision through the womb.[/b]

[cl=spurple]Effects on the newborn child[/cl]
With this as background, we can try to gain insight into the effects of CS on the newborn child. In previous articles on child health we looked at the child as a physical/spiritual being whose spiritual life journey begins long before conception and whose earthly existence begins to be shaped at conception when the child’s spiritual I-nature is clothed in the physical/material substance provided by mother and father. In the last article, ‘Where do I come from?’ we saw how the stellar forces of the universe, at the moment of fertilisation/conception, imprint into the sensitive living substance as the conceptual horoscope. We traced the development of the embryo and saw how its material substance is organised with awesome perfection and synchronicity to provide an appropriate vehicle for the spiritual content. And after 40 weeks, the physical birth takes place – an exquisitely sensitive cosmic moment when the forces of the stars and planets imprint themselves anew on the newborn child as its birth horoscope.

Physical birth is the start of the child’s life journey on earth where the I of the child is given many opportunities to unfold its fullest potential. Every life experience has meaning for the child and has an effect on the child’s wellbeing. The energetic, vibrating life matrix of the child absorbs every impression that it meets – physical, chemical and psychological – imprinting it indelibly through specific resonance into its ‘memory bank’. These stored impressions will have an effect on physical as well as psychological functions. It is a totally different experience for a baby to be born naturally through its own labour down the birth canal, or to be removed unnaturally from the mother’s abdomen through a surgical incision through the womb. Try to imagine the natural birth experience: Imagine the approach to birth as a passage from a warm, light-filled, buoyant and protected place towards a dark narrow door into the unknown. The child’s core being is actively involved in the whole process. Far-reaching changes begin to take place in the environment, the surrounding fluid is suddenly sucked away, and pressure begins to increase over the whole body pushing the baby downwards head first into the birth canal. Gravity presses down powerfully on the head and body, forcing movement through a compressed and very narrow passage. The child squeezes through the tight darkness, against the firm resistant tissues and then suddenly the head pops through into the air and light-filled space. In a moment of crowning glory the child takes its first breath and emerges through hard-earned labour as a citizen of the earth. How different is the experience for the child who is removed surgically from the womb by CS! Plucked in a moment from the warm, buoyant enclosed space and thrust into the harsh glare of the cold fluorescent light without preparation or participation. This is a very different experience, with a very different impact on the life of the child.

Is the child a passive partner in the birth process, without any choice in the way it is to be born, to be manipulated by the personal wishes of mother or doctor? Or does the child actively participate in the natural birth? Does it have a right to some choice in the matter? Does it perhaps know better than anyone else when it is ready to be born? And what do we take away from the child by depriving it of the opportunity to be born in the natural way? These questions cannot be answered intellectually and no research will provide clear-cut answers to the long-term impact that unnecessary caesarian delivery will have on the life of the child. Nor will we gain insight in this way to the long-term effects on society when every second child is born by CS. Speaking to insightful individuals born by caesarian delivery, gives a common picture that there is something unborn in their lives, that they struggle existentially to go through the birthing process that they missed as a newborn baby. Yehuda Tagar, the founder of Psychophonetics, who was born by CS, tells me that he only finally completed his birthing process at the age of 33 years when he was able to ‘give birth’ to Philophonetics. I believe the only way to hear for oneself the answer to these questions is to allow them to resonate in the listening heart.

For when we give the child the respect and reverence it deserves as a spiritual being, then it is hard to imagine that it is not actively involved as the central player in its own birthing process and birthing experience. And when we, as the parents, doctors and nurses involved in the destiny of this child, allow the child to determine its own future, then we become the true midwives for this child’s journey into life.[/just]

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