Once again I sit in awe as another obstetrician mouths half truths to an unsuspecting public about the benefits of cesarean section as an equal or better "alternative" to vaginal birth.

I'd like to address the following points and hope that you publish to correct Dr. Gifford-Jones misinformation. Considering the maternal death rate for cesarean section is 2-4 times higher than that for vaginal birth, lives could be saved.

1. "There is no pain during birth and less discomfort following surgery than with labour".

This is simply not true. As a member of a local VBAC support group I have met DOZENS of women who experienced excruciating pain and resultant post traumatic stress disorder from epidurals that did not work, and whose caregivers ignored their cries for help. You'll find thousands of their stories on bulletin boards and chat rooms, and at International Cesarean Awareness Network meetings all over North America. I myself underwent a cesarean, and during the first half of the operation I felt everything. As far as less discomfort following surgery ... I can not believe how anyone could think this could logically be true. A cesarean section is MAJOR ABDOMINAL SURGERY! It is only because cesarean is so common that it is no long considered major - is there any pain after an hernia operation? An appendectomy? I was barely able to walk for a week after my cesarean. After my totally unmedicated homebirth I got up and WALKED to my bed by myself 15 minutes after giving birth. I am NOT an isolated case. Ask around Dr. Gifford-Jones. Also increased with cesarean and proven by 40 years of research, besides maternal death, which Dr. Gifford-Jones makes so light of later in his column, are rates of infection and hemorrage, which make sense considering that cesarean is SURGERY.

2. "For instance, it's illogical to expect a narrow vagina to return to normal after passing an eight-pound baby through it" ..... and "Vaginal tissues... are often injured ... this may result in surgery to correct urinary incontinence"

Who defines "normal"? How do we know that the tissues are not supposed to give a bit after the first baby to allow the second baby to come through? Is this definition of normal based on a man's view of what is tight enough to give a man pleasure during sex or actual scientific data? Does Dr. Gifford-Jones actually believe that if someone attached a penis-lengthening device to his penis, that it would get longer? Why does it follow that my vagina gets ruined by birth? And secondly, the huge problem of urinary incontinence is due to the medical managment of the second stage of labour the pushing stage, where the vast majority of women have epidurals, so they can't feel their own bodies telling them what to do, or stand up to use gravity to help, and a team of medical staff pull the woman's legs up around her ears and scream at her to push. They tell her to hold her breath for 10 seconds or more at least 3 times during a contraction, depriving her baby, and her tissues, of oxygen. They put her mostly on her back, so she has to push up-hill. The practice of getting women to hold their breath, the Valsalva technique, was developed as a method of expelling pus from infected ears, NOT for labour. The logic of putting woman on their backs to push babies out escapes me. Do people defecate on their backs? NO, we sit on a toilet because gravity HELPS! The only reason women are made to recline is because it is easier for the doctor - they don't have to bend over or otherwise inconvenience themselves in anyway to assist at a birth. There is no medical evidence to support the practice. With all this pressure, the mother pushing like crazy because the staff have scared her or shamed her into doing it, and total lack of support for the tissues of the mother's perineum, the doctors complain the women tear. Or, like at many hospitals in the Toronto area, 30% of those babies are yanked or sucked out by a vacumm extractor or forceps, usually requiring an episiotomy resulting in further damage, because it is too hard to push against gravity with an epidural. If there is no instrument involved, usually an episiotomy is given to "prevent" a tear (which research shows actually CAUSES the worst tears - whole other story). And, in my mother's generation, EVERY SINGLE WOMAN in birth was given an episiotomy - perhaps that has something to do with the statistical occurance of incontinence. Cut muscles don't heal very well. Women forcing their babies out against gravity, holding their breath, might have something to do with the rates of injury.

3. "It's interesting to note what happens in Brazil .... In some Brazilian private clinics, the cesarean rate is 75%!"

Dr. Gifford-Jones, along with many OB's in the United States, is holding this up as some kind of wondrous achievement! The real reasons 75% of women in Brazil have cesareans are not because it is safer for mothers or babies, it is because of cultural beliefs which are: a) only poor Indians have their babies vaginally, like savages. b) If my vagina stays tight, my husband won't leave me. It is for this same reason wealthy women in Brazil smoke cigarettes and eat like birds - to stay thin so their husbands won't leave them. Go there and ask the women what they think if you don't believe me. And, if those women's labours had never been managed in the above mentioned ways, maybe they wouldn't believe that vaginal birth would damage them! And what about the babies? Has anyone ever done any research, long-term, on the affects of cesarean section on such vast proportions of a society? Perhaps Dr. Gifford-Jones should contact a peri-natal psychologist for information, or Dr. Michel Odent of the Primal Health Research Institute, in England.

4. "Who can best answer this controversial question? I would suggest it's female obstetricians."

This is the part that really makes me angry. Obstetricians are SURGEONS FIRST. Obstetrics is a surgical subspecialty. Obstetricians are not educated in normal birth. They rarely, if ever actually see a woman labouring for more than five minutes at a time. Obstetricians, female or otherwise, are experts on nothing except surgical techniques to help when there are bona fide problems, which if women were left to labour as nature intended them to, would happen in less than 10% of births. In London, England, normal births are handled by MIDWIVES, and the UK has better maternal and infant mortality rates than we do, and certainly better than Brazil. Statistically, if women want to avoid the problems Dr. Gifford-Jones seems to think are the big issue - vaginal tearing and urinary incontinence, they should see a MIDWIFE for their care, since in most cases, midwives respect natural birth as a normal biological event that a woman's body was designed for, not a medical emergency waiting to happen based on a faulty design. Thier episiotomy rates, and the resultant rates of tears, are far lower than that of any obstetrician, on average. Those statistics are easily available on the Internet - anyone can look it up.

Who can best answer this controversial question? WOMEN! Women, given they are informed of ALL the risks and benefits of cesarean section, which Dr. Gifford-Jones only touches on - not even mentioning the risks at all. Most people don't chose cesarean because they think it will prevent cerebral palsy (as if that's the worst thing that could happen and in the vast majority of cases is NOT birth related - look it up!) or will save them from a tear. They chose it because they never get the full picture. Yes, women have to get informed, but obstetricians have only a part of the picture. Women need to get information on NORMAL birth - hard to find in our culture. As a doula supporting women birthing in the hospital and at home, I can tell you normal birth definitely doesn't happen in the hospital - it can't, and that is the only place where obstetricians see women labouring. The known risks of cesarean section are many and varied - I list them below. Current medical practice does not even acknowledge that unknown risks could exist. I highly recommend your readers do some research before they accept any information in Dr. Gifford-Jones column as truth.

Your sincerely,

Ellen D. Newman

Birth Doula and Childbirth Educator

Risks of Cesarean Section over Vaginal Birth:


- 2-4 times high maternal death rate

- increased risk of endometriosis

- 1/3 of women experiencing cesarean will develop wound infection

- 5% of women experiencing cesarean section will develop womb infection

- 5-10% will develop urinary tract infection

- 1000 millilitres of blood loss vs. 600 millilitres (averages)

- .2% will have injury to the urinary tracts (repeat cesarean carries a higher risk - .6%)

- thrombphletbitis is 10 times more likely in cesarean birth than vaginal birth

- in subsequent pregnancies 25% of those who develop placenta previa will also develop placenta accretia (compared to 5% for those with unscarred uteri)

- risks of anesthesia

- possibly more difficulty nursing

- possible negative effect on future fertility

- definate psychological/emotional issues: post-partum depression rates and rates of sexual dysfunction are higher


- jaundice

- fewer quiet, alert periods

- neonatal acidosis due to maternal hypotension

- sluggishness, depressions and interference with suckling reflexes due to anesthetic crossing of the placenta

- low Apgar scores

- high incidence of asphyxia

- lower blood volumes

- lower plasma levels

- 3-7 times high fetal mortality in scheduled cesareans

- hyaline membrane disease due to iatrogenic prematurity (misdiagnosed or inaccurate determination of due date by caregivers)

- respiratory problems in the premature baby

- respiratory problems in the term baby as fluid is not expelled from the lungs as the baby passes over an intact perineum

- baby's face cut by the scalpel.

I also include this for your interest:

(Mode of Delivery and Risk of Respiratory Diseases in Newborns, Elliot M. Levine <[email protected]> , et al. Obstetrics & Gynecology 2001;97:439-442) PPH (formerly termed persistent fetal circulation) is a life-threatening problem of neonates. Women undergoing elective Cesareans sections had a rate of PPH of 3.7 per thousand live births, versus 0.8 per 1000 live births for women having vaginal deliveries. I.E. the Cesarean risk of PPH was 4.6 times that of vaginal birth. From the authors:

"Conclusion: The incidence of persistent pulmonary hypertension of the newborn was approximately 0.37% among neonates delivered by elective cesarean, almost fivefold higher that those delivered vaginally. The findings have implications for informed consent before cesarean and increased surveillance of neonates after cesarean."

Copyright 1997-2006 Mother Care. All photos Mother Care & Terri McKinney Photography. All rights reserved. Revised: Wednesday, January 04, 2006.