Last month I attended a protest in London over an incident on the other side of the world. It concerned a woman named Adelir Carmen Lemos de Góes, who was forced to have a caesarean section in Torres, Brazil at the beginning of April.
The 29-year-old mother of two had initially been advised by her obstetrician to have the operation, but decided this was not appropriate for her and her baby. The doctor then obtained a court order, on the rationale that it was necessary to protect the lives of Lemos de Góes and her baby.
The outrage against the prospect of someone having an operation against their will led to protests both across Brazil and outside Brazilian embassies across the world. I hoped that this horrible event might finally be the catalyst triggering the changes needed to make maternity care more humane in many countries.
Yet as I stood there on that street in London on April 11 with just three other women and four children, it was hard not to wonder if people in the UK felt this protest did not apply to them.
Maybe people felt this was only a Brazilian problem or an issue only for women who choose to have children. Some passers-by took a press release but many, mainly tourists, were uninterested. Clearly it is time for a reality check regarding both the risks of caesarean section and issues around bullying in maternity care.
A caesarean section is major abdominal surgery whose risks include blood clots, bladder or bowel damage, endometriosis, haemorrhage, blood poisoning and anaesthetic-related complications. Some caesareans do save lives and some women need them for the benefit of themselves or their babies. There are also sometimes grave consequences when women are unable to access caesareans.
Having said that, the WHO recommends that caesarean section rates do not exceed 15% as mortality rates are no longer improved when the proportions are any higher. Yet caesarean rates in the US are 30.3%, while the UK is also well above the useful rate at 22%. As for Brazil, the rate is a whopping 45.9%.
This is happening at a time when maternal death rates are improving worldwide, as confirmed earlier this month by a World Health Organization (WHO) report highlighting a 45% global decrease in maternal mortality rates between 1990 and 2013. This drop reflects improvements in maternal health over the last two decades, even if it falls short of the UN Millennium Development Goals’ targeted 75% decrease between 1990 and 2015.
One reason for missing the goal is the US, where recent WHO and Amnesty International reports show that the maternal death rate has doubled over the past 25 years to become the highest in the developed world. Factors including poverty, ethnicity, obesity and the increased age of mothers all played their part. Interestingly, this increase also occurred during a period where US caesarean rates rose by more than 50%.
Maternal deaths have decreased by 20% in the UK and 40% in Brazil over the same period. But if there was more reliable data on maternal morbidity, meaning serious physical and psychiatric illnesses from complications linked to childbirth, it would probably better highlight the risks of too many caesareans. Fewer maternal deaths in Brazil would also be attributed to the creation of a public healthcare system in the late 1980s.
So why so many caesareans? The prevalence can be linked to beliefs that it is safer than vaginal birth. In Brazil, some women choose caesareans for reasons related to appearance and body changes. Other women may have difficulty opting against caesareans because physicians see them as convenient and sometimes receive financial incentives.
In the UK the situation is more subtle, but bears comparison. The medical advice is not always up to date. Women with breech babies are often told they will need a caesarean for instance, when this is now seen as doubtful. It can often seem that caesareans are recommended because the midwifery skills to deliver babies where there are complications have been lost on the back of declining natural birth rates.
And while many healthcare professionals listen to patients’ wishes and talk them through a range of options in a sensitive manner, some patients feel that they must adhere to their advice and are not always told about all the alternatives.
Practitioners can appear inflexible as a result of issues like time pressures, policy constraints, fear of litigation or job loss, available resources, bullying in the workplace, previous negative experiences and strenuous work demands. Some women end up being pressured into having caesareans when there may not be any need for them.
The risk of having a caesarean should always be weighed against the risks of giving birth vaginally based on individual circumstances. In the case of Lemos de Góes, a risk assessment was required because she had had two previous caesareans and her baby was thought to be in a breech position.
Her obstetrician obtained the court order in the belief that she was putting herself and her baby at risk and that a caesarean section was a safer option. But it may not have been. The risks of Lemos de Góes having a third caesarean may not have been fully considered – such things are sometimes overlooked in Brazil. Even in the UK, vaginal birth risks are sometimes explained to women without reference to caesarean risks.
In addition to physical risks, obtaining a court order potentially introduced emotional risks as she was not involved in the decision-making process. This lack of involvement may be important as the potential causes of post-traumatic stress disorder following childbirth include women feeling out of control.
It boils down to a question of patient choice. We live in a culture where the doctor is seen to know best and people often feel they must comply with the medical advice. This compulsion is likely to be even stronger when the health of a baby is involved.
The protest against Lemos de Góes’s forced caesarean could be seen as an opportunity to reaffirm and protect our rights to make healthcare choices and question medical advice in the face of healthcare system problems.
Respecting women’s rights around childbirth is an important factor to consider in programmes aimed at decreasing maternal morbidity and mortality rates. If the outrage in the Lemos de Góes case was over her coercion, particularly linked to medical reasoning that appeared shaky, we need to recognise that our situation in the UK is not entirely different. It is time people woke up to what is really going on.