Wednesday, May 21, 2014

What’s wrong with what Lamaze has to say about Cesareans?

Those that have read this blog for a while should know that beyond being a proponent of Cesarean by Choice – I believe in every woman being empowered to make the birth choice that best meets her needs and those of her family. I don’t believe any specific birth choice should be demonized or glorified (they each have their respective risks and benefits) – and that women should have access to care that best meets the individual needs of both themselves and their families. This means being given information on the risks and benefits of the options available, being given information on the likelihood of those risks and benefits materializing, being given information on what would happen should those risks materialize, being able to ask any questions that should arise, and being respected in whatever choices are made.

I loathe misinformation – and I particularly loathe misinformation that can result in significant harm to both women and their children or undermines their ability to make an informed choice in conjunction with their care providers.

As such, I’m really not a fan of what Lamaze has to say on the topic of caesareans (btw they’re hosting a twitter chat at 9PM ET, 6PM PT (#LamazeChat, #Cesareans, #CSections) ) – particularly if the following video is any indication of what they have to say on the matter.

First, let me say that listening to Lamaze on the topic of Cesareans seems as wise as listening to Similac on the topic of breastfeeding. Lamaze is a big company – and what does it sell: vaginal birth – or more specifically childbirth education classes to prepare women for planned vaginal deliveries. Planned Cesarean birth is in direct competition to planned vaginal birth – and those who choose Cesarean have no need for childbirth preparation classes that focus on vaginal birth. So it’s a wise business strategy for Lamaze to sell the idea that a caesarean birth is a bad birth and that taking their classes can reduce your risk of having a Cesarean birth. Unfortunately this strategy harms women and their babies in a myriad of ways and is based on a foundation of misinformation, half-truths and outright lies.

The video that Lamaze has produced – illustrates beautifully how Lamaze uses misinformation, half-truths and outright lies to sell vaginal birth (this may take a while). The video produced begins with the declaration that Cesareans can save lives….BUT…then goes on to decry the fact that one in 3 women have Cesareans in the US. This is where the web of lies and misinformation begins. It is true that upwards of 1 in 3 BIRTHS are via Cesarean, however, this does not mean that 1 in 3 women who give birth will have Cesareans. The rate of Cesarean birth in the US is roughly comparable to the rate of Cesarean birth in British Columbia, where approximately 31.4 percent of all live births were Cesarean sections in 2011. (Source: BC Vital Statistics Agency 2011 annual report, Figure 11). However, the headline rate of Cesareans masks important differences between different groups of women who are giving birth. In December of 2011, the Perinatal Services of BC produced a report that looked more closely at caesarean delivery rates in British Columbia using the Robson Ten Classification system. ( ) The report provides some important insights into which mothers are having Cesarean sections in British Columbia (and is probably pretty comparable to who are having Cesareans in the US). Among Rookie moms (first time mothers or nulliparous) – there are three distinct Robson 10 groupings – those with a single head down baby at term who go into spontaneous labour (Robson Group 1), those who have a single head down baby at term who are either induced or delivered by caesarean before labour (Robson Group 2), and those who have a single butt first (breech) baby (Robson Group 6). Among moms in group 1 (rookie mom, head down singleton baby, spontaneous labour at term) one in 5 delivered by Cesarean (19.8 percent), those in group 2 (rookie mom, head down term baby, induction or CD before labour) nine in 20 delivered by Cesarean (44.5 percent) and among first time moms with a breech baby 19 in 20 were delivered by Cesarean. Among those who had given birth before and did not have a uterine scar and had a head down baby: fewer than one in 38 (2.6 percent) of those who went into spontaneous labour at term (group 3) delivered by way of Cesarean, and among those who either had labour induced or caesarean delivery before labour (group 4) the caesarean rate was 13.1 percent or slightly more than 1 in 8 . Among those with a head down term baby who had given birth before via caesarean (group 5) nearly 8 in 10 delivered by way of caesarean (78.9 percent). Those who had given birth before, including those who had a uterine scar and had singleton breech (group 7) had a caesarean delivery rate of 87 percent. The Cesarean delivery rate among moms of multiples (group 8) was more than 7 in 10. All those with a transverse or other abnormal presentation had a Cesarean rate of 80.6 percent or more than 8 in 10. Women who had a single vertex pregnancy that was delivered prior to term (less than or equal to 36 weeks gestation) had a caesarean delivery rate of a little less than 3 in 10. Those who couldn’t be categorized into the Robson 10 system, either due to incomplete information or otherwise had a Cesarean delivery rate in excess of 9 in 10 (93.1 percent).

Ideally, it’d be nice if the Robson system would distinguish between those who elected caesarean, and those who did not as important information is unavailable when the treatment plan is unknown. Many women might have elected for or chosen Cesarean and as a result this table does not give a good indication of the percentage of planned vaginal births that result in vaginal deliveries. It would also be nice if nulliparous moms who were expecting multiples were separated from those who had been to the childbirth rodeo before. Further, an even better understanding of Cesarean rates (and a woman’s individual risk of having one) could be had if rates were further stratified into other variables like age, maternal BMI, expected large baby, small maternal stature, etc. But atlas I digress.

At any rate – the use of the Robson 10 groups clearly illustrate that there is a lot of variation at work beneath the headline Cesarean rate, and that the use of the headline rate likely over-estimates the risk of having a caesarean for many women, particularly those who have been deemed to be “low-risk” pregnancies (singleton, term, head down with healthy mothers). The take home message for moms to be is the following: your risk of needing a Cesarean during labour and delivery is an individual risk that is a function of a variety of individual factors and to better understand the likelihood of YOU needing a Cesarean, you need to have a detailed conversation with a qualified maternity care provider.

The Lamaze video then goes on to declare that the rate of Cesareans is “Double what Unicef and the World Health Organization” recommend. This is one of those zombie statistics – it simply refuses to die. In 2009, the World Health Organization retracted its recommended rate of 15 percent because “there is no empirical evidence for an optimum percentage” and “what matters is that all women who need Cesarean sections get them.”

Lamaze in their video then proceeds to delineate the risks of Cesarean birth to moms (post-operative infections, complications from anesthesia, blood clots, injury to organs, infertility and placental complications in future pregnancies) and babies (including accidental surgical cuts, intensive care admissions, premature delivery and breathing difficulties at birth and beyond). I’ve got call a very loud foul on how this information is presented for a few reasons: 1. Lamaze does not distinguish between planned and unplanned caesareans, and I should note that most unplanned caesareans are the result of trials of labour that were abandoned. The risks to mom and baby are very different depending on if the caesarean is planned or unplanned. 2. Lamaze does not put the risks into any kind of context – is the risk being described a near certainty or a rarity? 3. Lamaze does not detail any of the benefits of caesarean delivery. 4. Lamaze does not detail any of the risks of vaginal delivery. All this part of the video seems to do is to motivate women to avoid caesarean delivery (note I’m only 39 seconds in at this point).

Then comes the hard sell: Lamaze tells women that they can reduce their risk of Cesarean in the following ways and that doing so is “pushing for better care”:

1. Get educated – take a Lamaze childbirth education class.

This is where women should just stop listening to what Lamaze has to say because it’s abundantly clear that Lamaze is not in it for the benefit of mothers and babies, Lamaze is in it to sell their product: childbirth education…and more specifically education on “natural childbirth”. The video encourages women to find a class near them, to get facts and support from a “certified educator” and to “learn from other moms”. No evidence is provided that shows a woman’s individual risk of having or needing a Cesarean is modified as a result of taking a childbirth education class – Lamaze or otherwise.

2. Choose a provider and birth setting with low caesarean rates. The video encourages women to ask about their provider’s caesarean rate, the caesarean rate of the hospital or birth center and that if the rate “sounds too high” to shop around and switch providers.

Here is where Lamaze’s advice takes a potentially dangerous turn. I have a major issue with using Cesarean rates as an indicator of quality obstetrical care. Encouraging women to choose a provider or birth setting based on rates of Cesarean can lead women away from quality care and towards outcomes that are utterly tragic. A provider or location with a high Cesarean rate might be an excellent choice – even for a woman who desires to avoid a caesarean and to give birth vaginally if doing so is safe for herself and her baby. Conversely, a provider with a low caesarean rate might be an excellent choice even if the mother wishes for a maternal choice caesarean. Providers and facilities with high Cesarean rates might be caring for a high-risk population, they might be respecting maternal choice caesarean, and/or substituting Cesarean for instrumental (forceps or vacuum) delivery. If a provider or facility has a low Cesarean rate it might reflect inadequate access to Cesarean delivery that could put mothers and babies are risk of serious and life threatening situations (death and long term disability). Mothers need to choose a provider who they can trust and who is qualified to advise them on the best care for both themselves and their babies – and facilities that are equipped to ensure that access to the best care is available. The best providers, likely don’t really give a damn about their Cesarean rates but care deeply about making sure their patients (both moms and babies) make it through the process as safely as possible. The best care providers also care a great deal that the women they serve do not feel violated as a result of their birth experience and are bound by professional ethics and standards.

The video then goes on to encourage women to hire a doula for labor support – as it will shorten labor, reduce pain, and help the father or birth partner support the laboring mother.

I have mixed feelings about doulas – I’m sure some are great, and are a tremendous resource to women as they go through the birthing process. But some are ideological zealots who frustrate the relationship between a woman and her care provider. Ultimately, I have a hard time seeing how the presence or absence of a doula would mitigate an individual woman’s risk of needing a caesarean section. An epidural on the other hand, does do many of the things that Lamaze claims doulas do: it can shorten labour, is a proven method of pain relief, and if you aren’t in pain, you likely aren’t cursing out the father of your child, which probably helps him to support you. Further, with an epidural in place, if you ultimately do need a caesarean it can often be topped up and allow you to avoid a general anesthetic…I’ve even heard that an epidural can be placed but not dosed until the mother feels it is necessary.

I’m now at 1:37 in the video – the point where Lamaze encourages women to “let labour start on it’s own”. It claims that induction carries health risks, that you’ll know baby is ready to be born, and that your body will be ready for birth.

Generally speaking, I do not believe that care providers recommend induction unless they believe that the risks of induction are less than the potential benefits of induction. Further, there is recent evidence that labor induction might be tied to a lower risk of C-section ( according to a review published in the Canadian Medical Association Journal. The same review found that there were also significant benefits for the fetus including a lowered risk of fetal death and admission to a neonatal intensive care unit. I’m also going to criticize the video for failing to indicate what the risks of induction are, or the magnitude of those risks.

At 1:50 the video encourages women to avoid “routine” interventions. It claims that continuous monitoring can falsely signal trouble leading to a caesarean, that being confined to a bed can make it harder to deliver, and that water and food restrictions can leave you weak and exhausted. The video encourages women to ask their care providers about the interventions used.

Here are my problems: 1. I’d be far more worried about trouble not being detected and falsely believing that everything was okay with my baby when it wasn’t. 2. Many hospitals do not require that mothers be confined to beds, some have “walking epidurals”, and 3. Experiencing hours of unrelenting pain can also leave you feeling weak and exhausted. I agree that women should ask their providers about the interventions or procedures that are used, and that they should be apprised of the associated risks and benefits.

At 2:09 the video encourages a woman to question a Cesarean if either mother or baby are in no immediate danger. It encourages women to ask what the alternatives are and what the risks of waiting are and to understand the short and long term risks of surgery and that long labor is not a medical reason for a Cesarean.

Again, in my experience – qualified care providers generally do not recommend proceeding to a Cesarean unless they feel that the risks of continuing with a vaginal delivery outweigh the risks of proceeding to a caesarean. There may be benefits to either the mother or baby to avoiding a situation where the mother has been utterly exhausted by labour and a real risk to the health and safety of the baby has materialized. In some facilities – OR resources are not continuously available and if the probability of vaginal delivery is low, it may not be worth the risk of having the resources be unavailable should they prove to be needed. Further, recovery from a Cesarean may be more difficult if labour has be unnecessarily prolonged. Lastly, the short and long term risks of Cesarean delivery (and vaginal delivery) would ideally be discussed and understood long before the day of delivery arrives.

The video then goes on to discuss Vaginal Birth After Cesarean, declaring it is a reasonable option for most women with previous caesarean, that routine bans are not based on evidence, and that VBAC success is as high as 74 percent.

Lamaze fails to provide the risks and benefits of VBAC – and fails to mention that in the event of the most serious complication of VBAC, uterine rupture, that immediate access to surgical care is needed to avoid lifelong disability or death for either mother or child. Further, the VBAC success rate of 74 percent is in an ideal case – where the woman had the prior Cesarean for a non-recurring reason, has a low-transverse scar, and is carrying a singleton pregnancy.

The video ends with the statement: “push for the safest, healthiest birth possible”.

Too bad that what Lamaze is advocating for likely is not “the safest, healthiest birth possible” for many women - and might lead many women to distrust their care providers, feel tremendous guilt should they ultimately need or choose cesarean and might result in birth trauma, lifelong disability or death for some women and their babies.


  1. Have you ever considered doing your PhD and using your research to get answers to those questions about the difference between those who have elective Cesarean and those who have emergent Cesarean?

  2. Hi Anon- the idea of doing a PhD is attractive to me, however, that idea has to be in the context of what it is I want to do and what I need to do in order to do that and life in general. I have a strong background already - with a Masters in Economics and a decade as a government Health Economist. In order to do a PhD - I'd have to find the right program and the right advisor, and I'd have to be willing (or financially able to) to give up paid employment for the time it would take to undertake the PhD. Moving from Victoria is not an option at this point in my life. Further - my husband's career is exceptionally demanding - and requires a large amount of support to enable his success while maintaining the demands of the family.

    If I could undertake research in this area - and in the process get a PhD, while maintaining or experiencing a minor reduction in my income, while still being able to meet the needs of my kids and the family in general, that would be great (dream job of sorts).

    That being said - there's a lot I could do, to meet some broader goals with the qualifications and background that I already have. A PhD is not a pre-requisite to starting-up an organization focussed on maternal health and well-being, an independent foundation or community contribution company that could undertake the same research. A PhD is also not a pre-requisite to writing a book - or maintaining/fostering a community. A PhD is not a pre-requisite to affecting change. In which case, I have to think about the doors that a PhD would open, that are not already open (but merely require the choice to walk through).

    I know that right now - my career and where it is at right now, is the least sustainable part of my life. But I also know that despite my cynicism, despite my lack of enthusiasm for my current employment (for a whole myriad of reasons) - I am passionate about health, and health policy and women's health and maternity care. There's good work to be done in this area (not just research) - and if possible, I intend to do it, the challenge is in figuring out how.

    That being said - there's already an excellent book on elective cesareans written by Pauline McDonaugh-Hull and Dr. Magnus Murphy - "Choosing Cesarean: A Natural Birth Plan"

  3. That all makes sense. I was just curious because it seems like so many of your posts comment about how much of the useful information is unavailable. And you seem so passionate about the subject I thought you might be the one who could help fill the gaps in the information available. I can see that a PhD isn't the only way to make it happen, it was just the first thing that came to mind for me.