Theresa Judgeexamines the emerging childbirth trends which are highlighted in the latest ESRI report
More detailed statistics are needed to establish why the rate of Caesarean sections is continuing to increase, according to one of the State's leading obstetricians.
Michael Robson, the master of the National Maternity Hospital in Holles Street, says he believes the issue warrants closer examination.
"Some of us are very concerned because we don't know why it is going up," he says.
Robson was speaking after the publication of the latest report on perinatal statistics from the Economic and Social Research Institute (ESRI). It shows that 24.2 per cent of all live births were by Caesarean section in 2003 compared with under 12 per cent in 1991 and 20.4 per cent in 1999.
The 2003 figures are the latest available. It is generally believed that the Caesarean rate is now at about 25 per cent. The World Health Organisation (WHO) recommends a rate of 15 per cent.
Robson believes hospitals here need to adopt a classification system that is used internationally which would provide more detail on the various groups of women having Caesareans. This would establish, for example, the rate among first-time mothers who went into labour spontaneously.
"We all know there is a problem, but let's find out more information, and look at the individual groups who are contributing to the rate, and then we can have a real discussion about it," he says.
He says Holles Street now uses a 10-group classification system, based on the category of pregnancy, the woman's previous obstetric record, the type of labour and delivery, and the gestation of the pregnancy.
Robson says the use of such a system may not result in fewer Caesareans and may not even aim to do so, because at this point no one can say what the ideal rate should be without more accurate data on the categories of women having them.
He says the rate in Holles Street last year was 18.9 per cent but he is aware that rates vary significantly across different maternity units.
Caesareans, he says, are increasing among first-time mothers and once a woman has her first baby by Caesarean she is more likely to have later babies by Caesarean. Factors such as the woman's age and her body mass index appear to influence the rate, he adds.
The master of the Rotunda Hospital, Mike Geary, believes "we should not get hung up on a specific figure". What is important is that hospitals engage in "constant critical evaluation" of Caesarean sections, he says.
Geary says the rate of Caesareans in the Rotunda has not risen very significantly in the past eight years. "We reached 24/25 per cent about eight years ago and there has been no dramatic change since. I think that is the kind of level we will hold at."
He says there is "a critical evaluation" of all Caesareans every week with a more comprehensive review every month and argues that there is "no solid substance" to the 15 per cent rate recommended by the WHO.
Geary says there are "a whole host of reasons" why the Caesarean section rate has risen.
There are proportionately more first-time mothers in the statistics because more women are having their first babies later and the incidence of Caesareans is higher among first-time mothers so this would account for some of the increase, he says.
Another factor is the practice now of delivering breach babies by Caesarean. Geary says the number of big babies over the past 10-20 years has also increased and this is likely to be contributing to the rise in Caesareans.
He says the number of women who come in to the Rotunda with a specific request for a Caesarean when there is "absolutely no clinical indication" is only about 10-20 a year. Such a request would then be "fully discussed with the couple".
Geary says that in some cases he thinks it is reasonable for a woman to request a Caesarean, particularly if she is nearing 40 and has been through fertility treatment and may feel that she does not want to take the risks associated with a labour.
He does not believe the increase in Caesareans is linked to a fear among obstetricians of being sued but acknowledges that "at a subconscious level it may be influencing people".
However, a lecturer in midwifery in NUI Galway who also works as a domiciliary midwife in Galway and Mayo, Christina Engel, says she is very concerned that medical intervention in childbirth is increasing all the time.
She is concerned that we are so far above the WHO recommended rate for Caesareans, and believes this figure reflects the proportion of women who actually need the surgery. She points out that our rates are more in line with those of the US and UK rather than those of Holland and Sweden and that this is likely to be due to the way births are managed in hospitals.
The ESRI report finds that the number of home births fell from 288 in 2002 to 236 in 2003. In 1999 there were 246 home births.
Engel believes many women are denied the choice to have their babies at home because there is no support for independent midwives, who usually have to work alone and be on call 24 hours a day. She has had to turn down requests from women in Sligo, Leitrim and Donegal where there is no domiciliary midwife service. A HSE-run service in the northwest has closed down.
"Independent midwives are not supported by anyone, they are very much on their own," she says.
While health insurers cover the cost of home births, there may not be a midwife available.
Women, she says, are being "socialised into thinking that induction and epidurals are quite normal and a necessary part of childbirth".
The most important thing during labour is for a woman to have good support from a midwife who believes in her ability to give birth and who helps the woman believe in herself. "Midwives feel their role is being taken over by the medical profession," she says, while also stressing that midwives need obstetricians. She points out that midwifery is now a four-year qualification.
Engel believes the increase in procedures such as rupturing the membranes (breaking the waters) and inducing labour, when there are no clear health reasons for doing so, are preventing women from experiencing natural childbirth. She says there is a need for greater detail about births classified as "spontaneous".
From her experience as a midwife for more than 30 years, she believes a successful labour can be a hugely positive experience and can give a woman strength and confidence throughout her life. "It can give a woman belief in her own body, a huge sense of achievement and can help her to be a strong mother."
The ESRI report also confirms that the age at which women are having babies continues to rise. Geary says this is in line with other developed countries and that there is "no need for panic".
While risks of complications are higher for women aged over 40, they are not greatly increased and most women over 40 have very healthy pregnancies, he says. Older women are often better prepared and more motivated to take folic acid and eat healthily.
He says that generally a woman's fertility starts to "fall off dramatically after 37" but it is up to each couple to decide when they should have a baby.
While Irish women are having their babies older - the average age increased to 30.6 years in 2003 from 30.1 years in 1999 - Ireland's birth rate is still the highest among 25 EU countries. In 2003 the rate was 15.5 per 1,000 population, while the next highest was France at 12.7.