Knife's edge

PUBLISHED : Tuesday, 23 August, 2011, 12:00am
UPDATED : Tuesday, 23 August, 2011, 12:00am


To avoid damage to her pelvic floor muscles and the risk of incontinence, Panda Chu decided to have her first child delivered by Caesarean section. 'I was more interested in the product than the process,' the physiotherapist says. 'But I can understand other women's sense of achievement in wanting to go through labour.'

These days, both mother and doctor are able to propose elective Caesarean sections, even without medical indications. 'At the time, my obstetrician asked if I wanted more than two children and whether the second one would be within a year of the first,' Chu says. 'Since my answer was no to both, she was fine with my decision.'

A 'yes' would have increased the risks and complications associated with Caesarean sections. As it stands, the risk of maternal death or severe complications increases by up to 14 times when Caesarean sections are done without medical reason, according to a World Health Organisation (WHO) study last year.

For every 10 women in Hong Kong who give birth, four have Caesarean sections, a rate nearly double that of other developed countries. In private hospitals, the rate rises to six in 10, the study says. Caesarean section delivery accounted for 16.6 per cent of all Hong Kong births in 1987, but 27.4 per cent in 1999.

This rising trend is a global one that is causing concern. Suthit Khunpradit, a researcher from the department of obstetrics and gynaecology at Lamphun Hospital in Thailand, points out that while reported rates vary, studies have shown that, in England, Scotland, Norway, Finland, Sweden and Denmark, Caesarean section rates rose from between 4 per cent and 5 per cent in 1970 to between 20 per cent and 22 per cent in 2001.

Some medical experts are critical of patients and their doctors opting for the procedure without medical reason. In a recent HealthDay report, Dr Alan Fleischman, medical director of the March of Dimes, a US non-profit body aimed at improving the health of mothers and babies, said: 'Caesarean sections should be done at the right time and for the right reason ... convenience for the woman or her doctor isn't the right reason.'

According to the United States National Library of Medicine, the operation has existed since ancient times and originated from attempts to save the soul, if not the life, of a fetus whose mother was dead or dying. Efforts to save the mother bore fruit in the 19th century when systematic improvement of Caesarean section techniques eventually led to lower mortality for women and their babies.

Planned, or elective, Caesarean sections may be due to medical reasons, such as small birth canal, abnormal position of the baby, placenta previa (placenta too close to the cervix), medical conditions (such as heart problems or diabetes), or small or premature babies. Women over the age of 35 are more likely to need the surgery as they are at a greater risk of certain complications during pregnancy.

In a study published in July in Obstetrics & Gynecology, Yale School of Medicine researchers analysed indications for Caesarean delivery on prospectively collected data from more than 30,000 births at Yale-New Haven Hospital from 2003 to 2009.

'We found that more objective reasons, such as the baby being in a breech position and placenta previa, remained stable over time, while less objective reasons, such as slow progress in labour and concerns about fetal heart tracings, contributed large proportions - greater than 50 per cent - to the increasing primary Caesarean delivery rate,' says lead researcher Dr Jessica Illuzzi of the department of obstetrics, gynaecology and reproductive sciences.

In Hong Kong, one news report cited a doctor saying that at least a quarter of pregnant women request the operation for non-medical reasons, of which about 70 to 80 per cent are due to fung shui. Actress Michelle Reis, for example, scheduled the birth of her first son on February 8 this year, which was said to be an auspicious date on the Chinese lunar calendar.

A 2007 study by Dr Selina Pang Man-wah and her team from Chinese University's department of obstetrics and gynaecology, Prince of Wales Hospital, found that women reported 'safety of the baby', 'fear of vaginal birth', and 'pain associated with vaginal birth' as important reasons for choosing an elective Caesarean section. 'Because of the increasing emphasis on patients' participation in medical decisions in recent years, women's demands for Caesarean sections have become a main reason for the abdominal route of delivery,' says the study published in the Hong Kong Medical Journal.

The increasing strain on obstetric services, in large part due to mainland mothers wanting to give birth in this city, is not helping either. Births are tightly packed to deal with the demand, with the Caesarean section the route of choice since it guarantees deliveries run on schedule, and controls the time and cost of the mother's stay. Some operations are booked for as early as 36 weeks for convenience.

'Some of my patients rather go with an elective Caesarean section to avoid the risk of an emergency Caesarean section and be hit with even higher fees,' says Dr William So, a local obstetrician who specialises in fertility treatments.

While going under the knife can save the life of both the mother and the unborn child, a Caesarean section is still major abdominal surgery and, like any operation, carries risks. These include maternal infections, haemorrhage, other organ injury, anaesthetic complications and psychological complications. 'In some settings, maternal mortality associated with Caesarean section has been reported to be two to four times greater than that associated with vaginal birth,' says Suthit, whose study, 'Non-clinical interventions for reducing unnecessary Caesarean section', was published in the Cochrane Database of Systematic Reviews last month.

In addition, babies born before term can also experience problems, such as 'wet lungs' syndrome (fluid retained in the lungs), and are four to seven times more at risk of respiratory problems as babies born naturally. Death is also possible.

Fleischman points out in the HealthDay report that women need to understand the importance of going full term. 'Fetuses are not just getting fatter in the last month,' he says. 'Their lungs and brains and kidneys are developing.'

In her 2007 report, Pang says that changing attitudes towards Caesarean sections among staff and patients could be adding to the trend. 'It has been shown that a significant number of obstetricians would agree to perform an elective Caesarean section without an obstetrical indication upon maternal request,' she writes.

Clearly, there needs to be more scrutiny of women planning to have a Caesarean section, and doctors and hospitals.

In Britain, for example, the National Collaborating Centre for Women's and Children's Health has created clear clinical guidelines for Caesarean sections. Firstly, when considering the operation, its benefits and risks compared with vaginal birth, specific to the woman, should be discussed.

Secondly, maternal request is not on its own an indication for the operation and specific reasons for the request should be explored, discussed and recorded. When an identifiable reason is absent, the overall benefits and risks of a Caesarean section should be discussed and recorded.

According to Suthit's findings, the use of Caesarean sections can be reduced by requiring not one, but two doctors to agree on the best way to deliver a baby; providing internal feedback to doctors on the number of operations performed; and seeking support from local opinion leaders.

A previous Caesarean section delivery convinced Hong Kong resident Grace Southergill to have her second child by Caesarean section - although she admits convenience, a fear of pain and an auspicious date also played a role.

'The first time round, my doctor advised a Caesarean section at 37 weeks because the baby was too big and I had gestational diabetes,' says the stay-at-home mum.

Looking back, Southergill, who had wanted a natural delivery, wishes she had better researched her doctor and waited longer before having the first Caesarean section. 'I am still in pain from my second delivery. The surgery took really long, largely in part because of the scarring from my first Caesarean section.'

Dr Leslie Lo Siu-fai, a local obstetrician, believes that mothers seeking to have a natural birth often pick an obstetrician by word of mouth. He notes that doctors performing more than 20 to 30 births a month may have less time for vaginal births, and that doctors' fees for either mode of delivery should be the same so that there is no financial incentive to push for medical intervention. Getting a doctor's delivery statistics could help - a useful indicator would be the success rate of patients wanting a natural delivery.

'The delivery mode should be a free choice for the mother, as long as the doctor explains the pros and cons in either situation,' says Lo.

Birth choices


per cent of requests in Hong Kong for Caesarean section deliveries are motivated by fung shui considerations