While pregnant with her daughter in 2013, first-time mum Amy Dawes was focused on a vaginal delivery. No drugs, no intervention; she was “all set to breathe her out”.
Yet when the contractions began, it became clear her plan had been scuppered. After more than 12 hours of pain so intense she was vomiting, an epidural was administered. And when it eventually came time to push, her little girl wasn’t delivering.
The obstetrician gave Dawes two options: C-section or forceps.
“At that time I just burst into tears because they both sounded really scary to me, but the cesarean was the thing I’d heard most about, a lot of negative stuff. In my eyes, it was just something I wanted to avoid,” the now-Brisbane resident told Mamamia.
The forceps delivery that followed left Dawes with a third-degree perineal tear and a bilateral levator avulsion, which means her pelvic floor muscles had been pulled off the bone, leaving her pelvic organs exposed. She now requires a splint just to keep them in place inside her body.
“I always thought I was going to be a really fit mum, you know, chasing around after my kids. I now often wonder whether my children will ever get the best of me,” she said.
Pockets of the medical community are renewing their concern that a concerted effort to reduce C-section operations is influencing the decisions pregnant women make about their birth, women like Amy Dawes.
The debate is most heated in NSW where the state’s health department has a policy in place that explicitly aims to lower C-section rates by increasing the number of women who have vaginal births. That policy is called 'Towards Normal Birth', and seven years, four premiers and a failed target deadline later, it's still active.
The choice of that phrase - 'normal birth' - has been widely pilloried since the policy's launch. It's one used by the World Health Organisation to refer to vaginal delivery with minimal or no medical intervention. But critics argue that it carries a value judgement. One that suggests alternatives, no matter how medically necessary, are 'abnormal', and therefore may influence a woman's decision about her delivery.
Debate around Towards Normal Birth has been renewed recently after the UK’s Royal College of Midwives abandoned its own 'normal birth' campaign, amid accusations it was leaving women who'd chosen or required intervention in their delivery feeling "like failures".
The decision followed a 2015 inquiry into the deaths of a mother and 11 babies at University Hospitals of Morecambe Bay NHS Foundation Trust in England, which concluded that "over-zealous" pursuit of natural childbirth "at any cost" led to unsafe care.
Hans Peter Dietz, Professor of Obstetrics and Gynaecology at University of Sydney Medical School, believes NSW could be heading for a "maternity scandal" of its own. He argues that policymakers have become “obsessed” with ‘normal’ vaginal birth as an indicator of successful obstetric practise, and it’s leaving his colleagues on labour wards “stuck between a rock and a hard place”.
"It's a fundamental shift in how we deal with our patients. Because in the past - for the last 2500 years - doctors have focused on curing sickness and preventing or delaying death,” he told Mamamia. “Now, suddenly, the absolute numbers of a certain intervention [C-section] is supposed to be a key performance indicator? That's new, that's revolutionary, and it does fundamentally conflict with how we traditionally measure success or failure of patient care.”
Former head of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, Michael Permezel also previously expressed concern about the umbrella nature of this top-down dictum.
"When health services perhaps decide on the caesarean section rate first, and then try and fit the women to that caesarean section rate, it might lead to some inappropriate decision-making," he told The Sydney Morning Herald.
What to expect on delivery day. (Post continues below.)
Hannah Dahlen, Professor of Midwifery and spokesperson for the Australia College of Midwives, was on the NSW Health Maternal and Perinatal Health Taskforce that endorsed the policy. Speaking to Mamamia, she said the directive is based on research and existing international practices that indicate "facilitating normality" is the optimal way to approach birth.
"Towards Normal Birth was about looking at the scientific evidence and making sure that we support women in the best way possible that they have optimal birth outcomes, and that when intervention is required they have it but when intervention is not required they're not having it unnecessarily," she said.
"It's not midwives rubbing a couple of incense sticks together and going, 'Oh wouldn't that be a nice idea'. We're talking about the top scientific evidence in the world."
As well as being costlier to the public health system, C-sections involve long recovery, can impact subsequent pregnancies, and carry risks including organ damage and blood loss.
And there is no arguing that rates of the operation were on the increase. By the time the policy was introduced in 2010, C-sections constituted 30.4 per cent of deliveries in NSW public hospitals, up from 23.5 per cent in 2001.
But Towards Normal Birth has so far failed to curb that.
It had aimed for an 80 per cent increase in 'normal' vaginal births in public hospitals by 2015, but NSW Health Data for that year shows that they were two per cent lower than in 2009. Also, C-section rates climbed two per cent higher in the same period.
The policy directive itself points to ‘consumer demand’ and ‘fear of litigation’ on the part of medical staff as possible reasons for increasing C-section rates.
But Professor Dietz notes that it's also come at a time when first time mothers are older and more overweight than before, and statistically more likely to require intervention.
He and Amy Dawes are among those who argue that, despite an ideological push away from C-sections, women are not being adequately warned of the risks associated with alternative interventions, including forceps.
While their use statewide has increased marginally (from 3.6 per cent of all deliveries in 2009 to 4.7 per cent in 2015), in some hospitals figures are at "historical highs" (11.3 per cent at Royal North Shore, for example).
The risks include genital tears and wounds, short or long-term urinary or faecal incontinence and prolapse. (There is no clear data on how frequent such injuries are in NSW, as they are often diagnosed years after delivery.)
Dawes said she had been told "nothing" about such possibilities prior to her delivery, and has since spoken to countless other sufferers who have said the same.
Without giving patients access to appropriate information, Prof Dietz said, doctors are not meeting their obligations to obtain informed consent.
"We should treat [pregnant] women exactly the way we treat anybody who requires surgery or any kind of major form of treatment - we ought to consider them competent adults," he said. "It doesn't mean that they have to be force-fed all those things that can go terribly wrong. But women need to at least have the choice to obtain this information, as much as they want. At the moment that is not the case.”
This is why Dawes is helping to establish the Australasian Birth Trauma Association. The Association's function will be to raise awareness of the physical and psychological effects of birth trauma, and to support affected women and their loved ones.
"I think there needs to be a more balanced approach," she said. "We don't want to scare women out of vaginal birth, but we want to empower women to make the best decisions for their body."
In a statement issued to Mamamia, NSW Health confirmed the Towards Normal Birth policy is still active despite being based on 2015 targets.
"Updated guidance for maternity care in NSW will be developed during 2018, to align with the recently published NSW Maternity and Neonatal Service Capability Framework," a spokesperson said.
"The review process will include a robust consultation process with clinicians, academics and consumers and be informed by the latest evidence."