Issue link: https://maltatoday.uberflip.com/i/516462
maltatoday, SUNDAY, 24 MAY 2015 News 11 TIM DIACONO MALTA'S high rate of Caesarean sections has been criticised by both the World Health Organisa- tion and, among others, local mid- wives, the latter partly attributing the blame to doctors. The WHO recently repeated its long-standing recommendation that a country's rate of Caesarean sections – which in Malta stands among the highest in the EU – should hover between 10-15% of its total births. In a statement from its Geneva headquarters, the WHO warned that C-sections can cause signifi- cant complications, disability or death, particularly in settings that lack the facilities to conduct safe surgeries or treat potential compli- cations. For years Malta's C-section rate has been among the highest in the EU – in 2013, 31.2% of births in Malta were carried out through C-sections, higher than in most EU countries. In the EU only Italy, Cyprus, Portugal, Romania, and Slovenia had a higher rate. Midwives are all too aware of the situation and some have ascribed a shocking factor to it. "Sometimes, doctors advise preg- nant women to induce their preg- nancies and undergo a C-section on the pretext that, for example, their babies will be born with large heads," an experienced midwife who chose to remain anonymous told MaltaToday. "In reality, the C-section opera- tion will simply be more conven- ient for the doctors themselves. Maltese women need to become more assertive and not simply treat their doctors' words as law," the midwife said. A European Perinatal Health Report published in 2010 found that 28% of Malta's births were induced, giving Malta one of the highest rates of inducement in Eu- rope. A second anonymous midwife, a representative from the Malta Midwives Association, claimed that this trust in doctors has now become part of Maltese culture. "It has become part of our cul- ture now – if you get pregnant, you visit a doctor. Yet, people don't visit a doctor unless they're sick, and pregnancy isn't a sickness. The vast majority of pregnancies don't have any complications, and midwives should be entrusted with low-risk mothers. "Unfortunately, for many Maltese women, a doctor's word is sacred. While C-sections are major opera- tions, natural childbirths are natu- ral and hence a better option." The Malta Union of Midwives and Nurses has long sounded warning bells about these persist- ent figures, and union president Maria Cutajar has repeatedly called for an independent audit on obstetrics to ascertain its cause. "I recently attended a meeting of the European Midwives' Asso- ciation and Malta's high C-section rate was criticised," Cutajar told MaltaToday. "Look, the numbers are there, they have been for a while, and they're reflecting badly on Malta. I cannot stick my head in the sand and say that it isn't a problem, both health-wise and as a financial burden to the Health De- partment. However, we can only start finding ways to decrease the numbers once we have the facts in front of us." She said that a number of factors could have a role to play in this high rate – such as the high labour inducement rate, women giving birth at a later age, the majority of breech babies and twins being delivered through C-sections, and people becoming more trusting of technology. "If we find out that it is the wom- en themselves who are choosing to undergo C-sections, then we could start focusing on educating moth- ers of the benefits of natural child- birth," Cutajar said. "However, I'm not an extremist and we must be careful not to portray mothers who had undergone C-sections in a negative light. Mothers have the right to make their own decisions after all." 'C-sections a poor price to pay for newborn morbidity' Despite the WHO's warnings, obstetricians see another side of the coin. Professor Charles Savona-Ven- tura, head of the University's De- partment of Obstetrics, pointed out that the WHO's 15% recom- mendation does not take newborn morbidity into account. "The effects of a difficult pro- longed birth process causing birth anoxia results in significant life changing morbid conditions such as learning disabilities, ADD, cer- ebral palsy, epilepsy, visual impair- ment and significant cognitive and developmental disorders," Savona- Ventura told MaltaToday. "A C- section is a poor price to pay to safeguard the newborn from these complications." He added that Maltese women are the most obese in Europe and have the highest rate of diabetes. "These factors promote foetal growth, resulting in big babies, prolonged labour, and a higher risk of the foetus being deprived of oxygen," Savona-Ventura said. "This becomes even more relevant when one considers that Maltese women than average are shorter than their Central and Northern European counterparts. "These women have an option – to persist in achieving a vaginal delivery and risk a severely dam- aged child or to intervene with a Caesarean Section. I know what option I would choose in those circumstances." He added that Maltese women are delaying having children into their 30s and that this, coupled with the "generally increased pro- miscuity of the modern genera- tion" has resulted in a rise in infer- tility, requiring the use of artificial means of reproduction. "This itself carries an increased risk of multiple pregnancies and the obstetric problems that this situation brings about," he said. He criticised the WHO for set- ting a blanket target without tak- ing local realities into account and called for detailed, scientific, mul- tifactorial studies to properly audit Malta's situation. "Until then, emotional state- ments by pro-natural birth sup- porters will remain simply that – irrelevant emotional outbursts," he said. Apart from the modern preg- nancy delay and Malta's high obes- ity and diabetes rate, obstetrician Yves Muscat Baron also believes that Malta's C-section rate has been pushed up by the increasing number of foreigners giving birth in Malta. "Around 13.8% of the babies born in Malta in 2013 were for- eign, when that figure only stood at around 1.8% in 2001," he said. "A lot of them cannot speak Eng- lish or Maltese, making coop- eration between themselves, mid- wives and doctors during labour a difficult task. Also, a lot of them, particularly Libyans at the mo- ment, would have a high anxiety level after having had traumatic experiences. To make matters worse, they don't have their ex- tended family to support them as Maltese women often do, further increasing their anxiety." He dismissed criticism by mid- wives that obstetricians are en- croaching on their professions. "I respect midwives, but the truth is that there are limits of safety to both mother and child that must be considered," Muscat Baron said. "Around 50 years ago, 25% of ba- bies used to die in labour. In parts of Africa, one in every 20 pregnant women dies in labour. The truth of the matter is that nature kills." WHO criticises Malta's high Caesarean birth rate Prof. Charles Savona Ventura: "Emotional statements by pro- natural birth supporters will remain simply that – irrelevant emotional outbursts."