Maternal-Assisted Caesareans: a cut above?

photo by Alan Light [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons
photo by Alan Light [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons
If you follow ‘birth interest’ pages in social media, you could be forgiven for thinking that there is a sudden epidemic of ‘Maternal-Assisted Caesareans’ (MACs) in Australia. As an Aussie with connections to birthing women, let me firstly assure you that this is not the case.

So, now that we know there’s no reason to fear of an army of Sigourney Weaveresque Aussie mothers taking over the birthing world (yet), let’s take a long, hard look at the MAC and what it does and doesn’t do to improve birth.

What is the Maternal-Assisted Caesarean?
Unlike some of the headlines which misrepresent this birth as a ‘DIY Caesarean’, the MAC is essentially like any other Caesarean until the baby’s head and shoulders emerge from the womb. At this point, instead of the baby being pulled out entirely by the OB, and then handed to other theatre staff, the baby’s own mother completes the delivery process by lifting the baby from her open incision up onto her chest.

There are some other practical differences between a MAC and a standard Caesarean. The mother must be scrubbed and gloved before the procedure begins, the drape between the mother and the operating space (which usually represents the boundary of the operating space) is lowered, and the mother may be shifted or inclined from the usual supine position in order to more easily reach her baby. Beyond all of this, and most importantly: the mother has to have the full support of her OB and his/her theatre staff to be able to proceed with a MAC.

Bargain Power
Before I go any further with this discussion, I want to briefly take a tangent (which will become relevant later, I promise!). As many Australians looove going bargain hunting in places like Bali, I’m going to use this kind of as my backdrop for an analogy.

Let’s say we hit the markets and find a rad stall selling t-shirts. In this marketplace it is accepted and expected that customers will haggle over prices with stall holders. The t-shirts are advertised at $10 each. In your mind, you think $5 is a reasonable price. So, setting that as your goal, you offer the stallholder $2 apiece. He scoffs at your offer, and suggests $8 instead. You raise your offer to $3; he brings his down to $6 – a generous gesture. But, you know you can do better. You express dissatisfaction, and even threaten to walk away and find a new supplier. He then suggests $5 a t-shirt, and even throws in a small key-ring for free. Winner, winner – chicken dinner.

(We’ll come back to more on this marketplace exchange later…)

For whom is the MAC likely to be most appealing?
Remembering that my experience (or bias!) is dealing predominantly with women who have birthed by Caesarean and had a negative or traumatic experience, what women usually report feeling during such a birth goes like this:

– I was scared for my life, scared for my baby’s life.
– I was forgotten, insignificant, like a ‘vessel’.
– I was powerless, voiceless and passive.
– I was disconnected from the experience.

Given that ‘previous Caesarean’ is the leading reason for all Caesareans performed in South Australia (that’s elective and unplanned combined), it is my belief that the MAC will be a birth choice predominantly considered and made by women having subsequent Caesareans. Of course, it is possible that a woman birthing by Caesarean for the first time may have a particularly strong stomach (pun intended, I think) and opt for a MAC, but I feel that, statistically at least, it is likelier that MACers will be mothers having second or third Caesareans.

So, if a mother opting for a MAC is the same mother who had a previous Caesarean in which she felt all of the above things, it is no wonder a MAC might appeal.

How a MAC is different to a Standard Caesarean from the woman’s POV
Returning to my experiences of working with women who have had less than desirable Caesarean births, let’s consider why a woman with this kind of birth history might choose a MAC.

Instead of the woman being an object of surgery, easily forgotten and disconnected from the experience, the MAC places the spotlight on the mother from the moment she starts scrubbing up till the moment she pulls her baby from her body. It gives her a role in Caesarean birth where currently there is none. It forces the care providers around her to engage the mother in the process of the birth. And, for mother and baby, the MAC reduces the separation time after birth and sets up skin-to-skin straightaway. In this sense, the MAC is a revolution for Caesarean mothers – what we are currently witnessing is a groundswell which may change Caesarean birth forever.

But, is it really going to change Caesarean Birth?
There are still some facts about Caesarean birth which remain, regardless of who lifts the baby from the mother’s womb:
– Caesarean birth is major abdominal surgery which comes with all the risks inherent to any major surgery.
– Caesarean birth increases risks to future pregnancies and births, including complications like uterine rupture and placenta accreta.
– Caesarean birth fails to ‘seed’ the baby’s gut flora like a vaginal delivery does.
– Caesareans which are performed in unplanned circumstances, by care providers unknown to the woman and/or in true emergencies are unlikely to be able to accommodate a MAC.

By Dbmayur (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons
By Dbmayur (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons
Let’s go briefly back to Bali…
To be honest, I have no experience of haggling at a market in Bali (perhaps you already suspected this!). However, I do know that it is *possible* to haggle at these markets, I know that generally you have to ask for a greater discount than you are expecting to receive, and I know that I need someone experienced in marketplace haggling to show me the ropes.

Birth is no different.

The most exciting and realistic change the MAC represents for a woman is increased bargaining power, particularly if she knows in advance that she will be birthing by Caesarean. Let’s assume here that the $10 t-shirt you want to buy is your decision to birth by Caesarean, and your $5 goal price is your desire for an empowered birth.

Asking for a MAC might be like asking the stallholder to give you that t-shirt for $2. Sometimes, you might be lucky and get a generous stallholder (or OB, to explicitly make the parallel) who agrees to this from the outset – if this is your experience, awesome! Probably, and more realistically, however, it is likely that your initial request will be denied. The trick here is to anticipate this response and thus use it to your advantage. If you were secretly prepared to pay $5 all along, your $2 request is a means to an end which brings you closer to your $5 goal, particularly if you don’t really mind about missing out on the $2 deal.

In birth, this currently exists as women requesting a lotus birth at hospital when what they actually want is delayed cord clamping. By requesting the lotus birth, it forces care providers to consider not cutting the cord at all and – if they do cut it – might ensure true delayed cord clamping if not the lotus birth (i.e. no cord clamping). The MAC might work for women in a similar fashion, giving them a boundary to work back from as they fight for the Caesarean birth they deserve.

What Qualities Do You Want a Caesarean Birth to Have?

If you choose to birth by Caesarean and you want this experience to offer you a chance to:

– Have as active a role as possible;
– Connect with the ‘actions’ of the birth;
– Be the first person to hold your baby;
– Discover the sex of your baby for yourself;
– Have immediate skin-to-skin facilitated;
– Avoid the routine cleaning and swaddling of your child;
– Remain connected with your body and baby during your Caesarean;

… then talking to your OB about a MAC is a fantastic way to get this ball rolling. You might be denied the opportunity to truly assist in your Caesarean delivery, but you may instead end up getting the drapes lowered and being able to observe more of the birth (if this is what you want). It may be that, instead of witnessing the birth ‘first hand’ with a MAC, you negotiate for a photographer to be in theatre in order to document the birth so that you can look at the photos later if you choose. Perhaps, and most importantly, the MAC discussion may prompt you to clearly explain the importance of feeling involved during the birth and thus lead to your care provider to simply adopting a more empathetic tack during the procedure. These are the things which can make the difference between a negative or traumatic experience and a more empowered one. It just depends on what your goal point is.

So, what is the point everyone is missing?
There is a lot of good that the MAC can do, especially for women who genuinely have no choice but to birth by Caesarean and for women who have a desire to roll up their sleeves and be this actively involved in a surgical delivery.

But, in the hype surrounding the MAC, there is an important question we’ve failed to ask:

Why do women need to pull their babies out of their own stomachs in order to feel better about Caesarean birth?

I suspect the long answer to this question will reveal much about our birth culture, our social values, long-ingrained power structures and how we routinely view women and their bodies as a society… But, the shorter answer is that it is about the desperate desire for women to ‘take birth back’.

With a third of all women now birthing (and potentially only ever birthing) by Caesarean, this is a response to the systematic denial of an active birth experience for our generation. We need to very carefully think about what women are really asking for when they request a MAC – when the answer includes words like ‘respect’, ‘connection’, ‘trust’ and ‘I did it!’, we know that the situation is not as simple as, “Throw the woman a MAC bone, STAT!” and that the real solution can likely be applied to all births for common good.

Where does the Big MAC Debate leave us?

Lastly, let’s return to my marketplace haggling idea one last time. If we allow ourselves to be too quickly swept up in the ‘superior’ qualities of the MAC and what makes it better than a ‘crap’ birth, we run the risk of forgetting the true value of the ‘t-shirt’ we’re bargaining for – birth shouldn’t be disempowering by default, and we must accept (and demand!) this as a truth so that we know the high value we place upon it is reasonable. In fact… *whispers*… If I may be quite frank with you, I’m not even sure a good birth is something for which we should have to ‘bargain’ in the first place.

(Also… *slides in closer and whispers again*… There is the question of whether choosing a MAC over a normal vaginal delivery in order to feel empowered is a medical veto wrapped up in the illusion of empowerment – the MAC is intrinsically tied up with care provider permissions in a way that normal vaginal delivery is not… But, I think that’s another blog post for another day.)

In my opinion, the MAC is the current manifestation of a birth culture needing attention, and, because Caesarean birth is so prevalent, it makes sense that this kind of birth has become a platform for change. Like the $2 offer in the t-shirt exchange, the MAC can be a means to an end for the birth movement – it won’t stop women having unnecessary Caesareans (and, let’s face it – the MAC might even make Caesarean birth more appealing for some), but it does, at least, begin the more general discussion about ‘how can we make birth better for women and babies?’ and ‘what do women want?’… And, hey – if, while we’re working out the meaning of the MAC for our generation, this approach to Caesarean birth spares individuals from disempowering experiences in the meantime, well, I guess that’s the key-ring thrown in for free. 🙂

A Love Affair with VBAC Stats

At some point during a VBAC journey, it is likely you will start a love affair with stats. I know, because I’ve been there. I’ve courted stats, I’ve had lover’s tiffs with stats and, I’m pretty sure, I’ve even taken them to bed.

So, here follows a lengthy discussion which – if you choose to read it – may mean you won’t be able to read another VBAC success stat again without picturing a dancer on a pole. (And yes, you can thank me later.)

The Love Story Begins

While you’re waiting for the retails stores to have crystal balls on special, having facts and figures upon which to base your decisions is the next best thing, right? And, who doesn’t love a sexy stat or two, especially when they tell you what you want to hear.

In fact, I think stats can do even more – with the right stats, you might gain some credibility in your discussions with a care provider, for example. Stats might even lead you to make a critical choice which is the difference between the birth outcome you desire and the alternative. And, in this day and age, we plebs have even more stats at our fingertips than ever before – this is perhaps our greatest time of empowerment. Repeat after me: COLLECT ALL THE STATS!

But, stats – like all forms of information (and indeed all new relationships) – need to be approached with certain level of caution. Like any meticulously constructed Instagram account, the best looking stats have possibly been cropped and filtered to create a certain outcome. And, like that Instagram pic which crops out your ‘shagbuster’ trackies, stats only tell you part of the story you want – it is your job to gather the rest of information you need to give these numbers *context*. (Because, let’s face it, everyone secretly only wants to see the stuff that is cropped *out* of Instagram pics, right?)

Let’s take a popular general statistic like ‘women have a 75% chance of VBAC success’. This might fill you with confidence for your planned VBAC. Indeed, it *should* give you confidence in your decision to plan a VBAC, because it sounds pretty darn good. Crikey, if I were told I had a 75% chance of winning lotto, I’d be actually getting dressed today (and that’s saying something!) and heading out to my local newsagent to buy myself a ticket.

However, here’s the catch: this statistic is the promise of an outcome, not a guarantee. (Darn it – I might have just gotten dressed a little prematurely! Never mind – Instagram will help me to crop my shagbusters out.)

And, here’s a harsh fact: Not all women have an equal 75% chance of successful VBAC, just like not every punter has an equal chance of winning lotto. This is an average, a OSFA number. It is a handy number to know, but it is not necessarily your Magic Number. We logically know that my chance of winning lotto goes up and down depending on which numbers I choose (if i do indeed choose my own numbers), and how many tickets I buy. In a similar way, some women are more likely to VBAC than others.

Harsh Fact #2: The effect of your choices on your Magic Number is really only ever known retrospectively. This is the awful truth about stats – sometimes they’re all talk. But, sometimes they turn out better than you thought.

So, while you’re in the thick of it and don’t yet have the benefit of hindsight, let’s at least try and make this stat work a little better for you. And, how do you do that? You need to work it, baby! Think of yourself as the RuPaul of the VBAC Stat World! You need to go forth like the fierce mama you are and get more information to frame this number within your own context (feel free to leave the killer heels and spandex to RuPaul, however – I much prefer ugg boots and jeans!). Don’t leave this stat standing there, naked, shivering and pleading for a coat – dress it up in the important stuff, like ‘who is my care provider?’ and ‘where am I birthing my baby?’

As you start adding details to the 75% stat, watch your Magic Number bounce up and down. Truthfully, I have a dance pole in mind here with this… And now so do you. (I did warn you!).

Think of 75% as the sweet zone on the pole. When you jump on, you might be a bit rusty and find yourself at about 45%. That’s okay – the beauty about VBAC is that you have at least nine months to do something about that. So, you start researching, making choices and asking questions. This is you climbing a little higher. You go back to your obstetrician and hear that they have an 80% VBAC rate. You beauty! You climb higher. But, after reading about the difference between VBAC rates and success rates, you ask your obstetrician how many VBACers they oversee – their answer is five in the past year. Uh oh, your Magic Number just slipped a little. You then get to your 36 week review and your care provider starts mentioning ‘big baby’, ‘small baby’, ‘low amniotic fluid levels’, ‘high amniotic fluid levels’, ‘due dates’, ‘going over’… Yikes, suddenly you feel like you’re at risk of face-planting on the tacky floorboards beneath you. (Actually, so is the landlord – they’re stepping in to stop the show lest it becomes a public liability claim.) (And yes, this landlord is a metaphor for a ‘bait and switch‘ care provider – they do exist.) So, you quickly change tack, get a second opinion or two and make some new decisions… Phew! You might have just avoided a repeat Caesarean (and an insurance claim).

You see, the VBAC success rate is not guaranteed until *after you give birth* (and you jump down from the dance pole). This is actually good news!

Don’t think of a VBAC success stat as a static number – it is a fluid thing. The birth choices you make, the preparation you do, and the support you have around you all shift this number up and down. Stats are great to help you understand what are reasonable expectations – they help you to make the best decisions possible when the crystal ball you bought online from China is caught up in the Australia Post Christmas rush. But, at the end of the day, stats are numbers which can be sliced and diced numerous ways for various agendas – like any good relationship, it is important to remember that you have control over what you bring into the picture, too.

Digesting VBAC Stats: Know What You’re Eating

Chocolate by André Karwath aka Aka – Own work. Licensed under CC BY-SA 2.5 via Wikimedia Commons – httpcommons.wikimedia.orgwikiFileChocolate.jpg#mediaviewerFileChocolate.jpg

If you’re a South Australian mother researching VBAC, chances are that you’ve stumbled across the Pregnancy Outcome Unit’s ‘Pregnancy Outcome in South Australia’ reports. (If you haven’t already, you just did.) Seriously, if you love stats which are actually *relevant to a local context*, these publications are to the World of VBAC Stats what Pana chocolate is to the world of cocoa-based confectionery. (And, if you haven’t yet stumbled across Pana chocolate, make sure you do – it will help you stay up late reading stats.)

Whet your appetite!

Now, these documents are really a bit of a beast. There is so much information in them that they are best consumed piece by piece (a bit like Pana chocolate). It pays to pace yourself – take notes, highlight things, digest them. Come back in the morning with fresh eyes and re-read them again. Take more notes and eat more chocolate.

One of the tastiest pieces of information for a VBACer is found under ‘Clinical and Maternity Performance Indicator: Vaginal Birth following Caesarean Section’ (shortened to ‘VBAC’ when ‘VBFC’ would actually be correct in this case… I guess it makes it sound like VBACers have their own footy club, though). This is where you will find the magical number which answers the question: ‘How many women VBAC in SA?’

Let’s hold that thought – how far through that block of Pana are you right now? Is it still tasting sweet? Is it melting in your mouth and slipping down your throat like a silken river caressing your insides? Well, enjoy that, because what I’m about to say will leave a bitter taste in your mouth.

For years, the VBAC rate in South Australia has consistently been at about 17%. (And, if you’re playing from interstate, the national rate is usually around 16% – you can track this in the Australian Mothers and Babies reports.)

I can hear you suddenly choking on your chocolate. What?! Did I read that correctly?! Only 17% of VBACers actually VBAC? And, because you’ve read them: Don’t the South Australian Perinatal Practice Guidelines cite a VBAC success rate of 72-76%??

STOP!

In the name of (stat) love, I want to make a really important point whilst you catch your breath…

The reported rate of VBAC in these cases IS NOT A VBAC SUCCESS RATE. This is simply the rate at which women in a defined cohort VBAC. Assuming these two things are synonymous is like thinking you can subsitute Cadbury for Pana (which, I assure you, you cannot).

A hypothetical

Take a group of 100 women who are potential chocolate connoisseurs. Sarah Wilson has successfully reached 66 of these women, so they have no interest in eating chocolate. 34 of them are after a sugar-fix and indicate they’d like to eat Pana, but 17 of them get Cadbury and the other 17 get Pana. The overall rate of Pana chocolate distribution is 17%, but the rate of successful distribution to the women who wanted it is 50%. So, whilst Pana sales aren’t as great as they could be, it’s maybe not so bad because half of the women who wanted Pana got their fix. (And, from Sarah’s perspective, these stats are looking pretty damn fine.)

Alternatively, here’s the chocolate-/sugar-/dairy-/gluten-/caffeine-/ramble-free breakdown:

Take a group of 100 women, 34 of them plan a VBAC and 17 of them go on to have a VBAC, this means:
– The VBAC rate for this group of 100 women is 17%
– The VBAC *success rate* for this group of women is 50%.

To make my point – taking the VBAC rate of 17% and describing it as a *success rate* is categorically incorrect. VBAC rates and VBAC success rates are *two different sets of stats*.

Furthermore, the group of women in this cohort are “women giving birth vaginally following a previous primary (first) caesarean section and having NO intervening pregnancies greater than 20 weeks gestation.” Do you fit the bill? If you’re having a VBA2C, this stat might be of little relevance to you. If you’re planning a second or third VBAC, you might also feel the need to find this information via other avenues.

So, how do we find out more about VBAC success rates? Well, until our health bureaucrats start recording how many women *attempt VBAC*, we will not know what the success rate is. The best thing you can do here is to ask your care provider AND hospital two questions:

– What is your VBAC rate?
– What is your VBAC success rate? (Otherwise known as ‘How many women in your care attempt VBACs? How many of these go on to VBAC?)

Further Food For Thought

Once you have a VBAC success rate, is it going to satisfy your craving for reassurance? Possibly, but maybe not.

Think about this: if an obstetrician has an 80% success rate, he/she sounds like a keeper, yeah? What about if this obstetrician only oversaw 5 attempted VBACs in one year, 4 of which were successful (hence the 80% success rate)? Does the stat indicate this care provider is skilled and experienced at attending VBAC, or does it simply suggest that this care provider lucked out? And, just whose ‘success’ is this stat, anyway?

The message you can take home in a foil swan

Stats are great to help us get our heads around the unknown, to get a feel for birth culture and to play to our best odds. But, it is really important to read the fine print – adding the word ‘success’ to what is simply a VBAC rate creates a BIG difference. Having the confidence to question stats, care providers and ‘birth experts’ takes intestinal fortitude, but seeking accurate information from a variety of sources makes for a balanced diet… Even if it is predominantly made up of Pana chocolate when you do the number-crunching!