Navigating C-Sections, Natural Birth & Informed Choices S6|7

Birth Your Way: Navigating C-Sections, Natural Birth & Informed Choices S6|7

 

Welcome to Sense by Meg Fora. If you are a parent or a parent-to-be who are navigating the whirlwind journey of pregnancy, birth, and those early days of parenting, and you’ve got questions about birth options specifically, then this episode is tailor-made for you. Join me as I sit down with the incredible Dr. Mama Asu Prepra.

She is a pioneering gynae obstetrician who is really transforming women’s health, and she has the most incredibly compassionate approach. It was just an episode that I loved recording, and it’s a thorny topic, and it’s one that she handles just incredibly. So she has had quite an experience personally with her own challenging birth and postnatal period, but today is not so much about that.

It’s really about the C-section rate and what we can do as we deliver our little ones to ensure that we can have natural deliveries whenever possible. So the things that you’re going to hear about today, the first is why South African C-section rate is one of the highest in the world, and how can you navigate your birth journey with confidence. Secondly, we’re going to look at how to empower yourself to chart your own path during childbirth.

You deserve a voice, and Mama Asu is going to go through exactly how you can hear that voice and also convey it as well. We’re also going to understand a little bit about the issues that come in terms of the mental health journey and how that contributes to whether or not you have a C-section as well. So whether you’re expecting your first baby or you’re adding to your brood, or if you’re just curious about birth options and specifically birth options in South Africa, this episode is absolutely packed with valuable insights and some heartwarming stories too.

So tune in for an engaging conversation that promises to enlighten, support, and inspire you throughout your parenting journey. Welcome to Sense by Meg Fora, the podcast that’s brought to you by Parent Sense, the app that takes guesswork out of parenting. If you’re a new parent, then you are in good company.

Your host Meg Fora is a well-known OT, infant specialist, and the author of eight parenting books. Each week we’re going to spend time with new mums and dads just like you to chat about the week’s wins, the challenges, and the questions of the moment. Subscribe to the podcast, download the Parent Sense app, and catch Meg here every week to make the most of that first year of your little one’s life.

And now, meet your host. This podcast is brought to you by Next Biosciences, the local leaders in reproductive health. Their goal is to empower couples during the reproductive health decisions that matter the most.

And it’s also brought to you by Huggies, which is South Africa’s number one nappy brand. Huggies, we’ve got you baby. Welcome back mums and dads to Sense by Meg Fora.

I am always delighted to have you join me here and to explore those incredible topics of early parenting from pregnancy through to preschool. And today we are joined by a wonderful guest. It’s my first time having her on the podcast and I’m really excited because I know this won’t be the last.

And we are welcoming Dr. Mamasu Pepra to the podcast today. And I’m really excited to have her here. She’s been impacting the life of women’s health for over a decade.

And she’s not just your average gynecologist. She also has a passion for tackling those often unspoken about and sometimes taboo issues that women face about their hormones, intimacy, or mental well-being. So she combines both a preventative and conventional medicine approach to really cater for her patients’ needs.

So Mamasu, welcome to you today. Thank you so much for having me Meg. It really is a pleasure.

And hello to all your listeners. It’s awesome to have you join us. So you’re joining us from Hilton, which is very close to my heart because my family lived down there as well.

And you actually run not just a practice, but you have a, I think I’d call it almost like a network called the Nurture Hub. Is that correct? Yes. The Nurture Hub is a platform in the community of mothers.

And we basically talk about the hard stuff. You know, people who are struggling with pregnancy or the postpartum, whatever that looks like for them. So yeah, I like to have real honest conversations and not just the superficial, hello, how are you? I’m fine.

Oh, your baby’s so cute. Often we find that mothers are struggling, you know, and I think, yeah, it’s good to talk about it. No, absolutely.

And does the Nurture Hub only occur in person or is it online as well? I mean, how do the moms who are listening to us here actually find out about it? Yeah. So in Hilton, if you’re based in KZN Hilton, we do offer in-person services. We have a support group and we do consultations, but then we also offer online consultations if needed.

So yeah, we’re available everywhere. We even once had a couple from Vietnam, which was really, yeah, so. That’s incredible.

And you know, when you and I first met, I was just so fascinated by your journey. So first of all, you are this incredible OBGYN, obstetrician and gynecologist for South African listeners. But don’t practice currently as an obstetrician.

You practice more as a gynecologist. And that had its roots in your journey. So you’ve got two little boys, a two-year-old and a six-year-old.

And I think it’s your little one. Your two-year-old gave you a really hard time in the early days. And that journey actually kind of led to the fact that you needed to stop obstetrics for a while.

Is that right? Yes, that’s right. I had preeclampsia when I had Ezra. And, you know, I happened to be the two percent that ended up with multiple medical complications.

It took me a while to get back on my feet afterwards. And with that, I decided that I needed to take a break and just, you know, spend time with my family. You know, as a woman working, it’s not easy.

I think I may have chosen one of the hardest professions as a young mother. But, yeah, it was a real challenging time. But I’m really happy where I am right now in the space and helping so many other women.

Well, when we first chatted, I said to you, we will definitely spend a whole episode just going through what help syndrome is and what that journey looked like. It’s highly unusual and rare, but when it happens, moms, it is really, really severe and can be, well, is life-threatening. And we’ll definitely go and explore an episode on that sometime in my But for now, we’re going to be talking more about birth.

And the specific topic I wanted to explore with you is birth your way, which is the topic for today. This episode is also brought to you by Haggy’s Extra Care. That’s their best nappy yet.

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The umbilical cord cutout on size zero is also perfect for cleaning this delicate area. And the reason why this is a topic that also is very close to my heart is because we live in South Africa where we have pretty much the highest C-section rate in the world. And so it has always been a passion of mine to talk about why that is, what we can do about it, and when is it that women should be actually having C-sections versus not.

And many years ago, I was actually driving in the car and I was listening to, it was Cape Talk in 702 at the time. And they were having a discussion about these, the C-section rates. And, you know, I pulled the car over and I phoned in and I said, you actually need to know some facts here.

And I had written Pregnancy Sense at the time and we had actually pulled some research on the exact numbers out of the private hospitals for the preceding 12 months. And the numbers at that time were around about 73% of caesarean, of babies born in private hospitals were born by caesarean section. And in actual fact right now, it’s even slightly higher than that.

And what’s staggering about that is that what, and what a lot of people don’t know is that the World Health Organization recommends rates of around about 15%. And that, moms, just so you know, that means that if a country is having, or region is having caesarean section rates below 15 in 100, less than 15 babies in 100 are being delivered by C-section, it means that either the mom or the baby or both are under threat because there is a time where a C-section is an incredibly important surgical procedure and it’s life-saving. But for anything over 15%, it starts to become a little bit questionable.

So when you’re hitting numbers of 75%, you’re definitely in a space that needs to be questioned. And so that’s what we’re going to be chatting about today a little bit. So I guess to kick that off, Momashu, is why is it that we have got these radically high numbers in our private sector? Yeah, you know, South Africa is quite interesting because if you look at the rest of Africa, the caesarean section rate typically ends up being less than 10%.

But in the South African setting, you know, we’ve got our private sector and our government sector. In government, the general caesarean section rate is about 25%, but it depends where you give birth. So if you give birth in a highly specialized hospital, where most mothers will be referred if they’re sick, the rates typically become much higher, ranging from about 60% to 80%.

But if you get delivered in private practice, and as you’re saying, as high as 78%, 80%, there’s so many reasons. And I think it’s a multitude of a group of many things. So I’ll start with the mothers that we have and how, you know, I feel that women are losing the confidence in themselves and their bodies and the ability to be able to give birth.

I think with all the information that’s out there, people love to share their horror stories, that people are actually scared. They’re scared of having poor complications, outcomes with their babies. They’re scared of having damage to their pelvic floor that they can’t repair.

Then when you think about healthcare professionals, you know, a caesarean section, specifically, if it’s a planned caesarean section, is something that’s quite controlled. You know exactly where it’s going to happen, when it’s going to happen. And a vaginal delivery is uncontrolled.

You don’t know the outcome and you don’t know how things are going to go. So often what happens is that doctors would feel more comfortable in their priority being the safety of a mother would opt for a caesarean section versus a vaginal delivery. Other things like the increased litigation in our country, I mean, South Africa, you know, cases are going for, I don’t know, 30 million rand with medical legal fees if they’re poor outcomes.

And often those are because of someone having a vaginal delivery that became complicated. And then the baby has a poor outcome. So those are the main reasons why I think it has increased in South Africa.

What the question and issues and what you’re inferring is that, you know, a lot of the caesars that we are doing, yes, there are many that are medically indicated and lifesaving, but there’s a gray zone where a lot of those caesars that are done have soft indications, meaning that, you know, actually maybe if it was in the hands of a different doctor, perhaps they would have done it differently. So mainly things like common reasons for caesarean sections would be prolonged labor, you know, the labor took too long or induction of labor took too long, and then someone will end up with a caesarean section. So much has changed in terms of, you know, how we manage and monitor labor.

So if you don’t mind, I’ll just go a little bit deeper into, for example, what we call a labor that’s long. So usually when someone is in labor, we have a graph and we plot how they progress according to this graph. If you are below the graph, then, you know, we say the labor is slow.

If you’re above the graph, we say, I mean, well, we call that a quick labor, that’s a precipitous labor, or you’ve hit the mark. And what they found is that that graph that was made, it’s made by a guy named Dr. Friedman, that actually, because of modern times, the way our labor progresses now has changed. And actually, where that graph used to say an average woman needs to dilate every one centimeter per hour, that’s the average or more, what new information is saying is that actually we progress with labor much slower.

So, you know, 0.5 centimeters, 0.6 centimeters an hour is actually normal for the modern woman in this day and age. But we’re using a graph from, you know, the 1950s to still determine how we progress and monitor labor today. I mean, I still use that graph.

That graph is everywhere. So, you know, sort of catching up with the information that we had from the past and making it align with new information now is also quite an important thing we need to do. Yeah, absolutely.

And, you know, you’ve named the two big drivers there. The one is the woman herself and the other one is the doctor. So, you know, the doctor will have a multitude of push factors to recommend a C-section, including predictability, lower risk of litigation or of things going off-piste and not being predictable.

And then, of course, there’s also the golf game on a Friday afternoon, which we don’t want to interfere with. So there are a number of things that I do think that there is a driver from gynecologists and then potentially also from the hospitals, of course, who make more money when people give birth by cesarean section. And, you know, so I think there are drivers from the medical system and they’re definitely drivers from the mother’s side as well.

And I think, I mean, I definitely want to explore in quite a bit of detail drivers from the mom’s side. Before I get into the mom’s side, I just want to touch very briefly. Do you think that there are specific practices or policies that could be advocated within a health care system that would help to reduce our C-section rates across South Africa? This episode is brought to us by ParentSense, the all-in-one baby and parenting app that help you make the most of your baby’s first year.

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Do you think that there are specific practices or policies that could be advocated within a health care system that would help to reduce our C-section rates across South Africa? Yes, I do. I think something that’s really important is actually to help the mother prepare for labor. It’s a lot of education, preparing their bodies, their minds for what to expect during labor, how to cope with pain, how to push a baby out correctly.

What I think a lot of women are doing, and I think again, you know, I think the depiction from social media is that, you know, your body will take over. Just go with the flow. Let’s see how things go.

And as much as that is true, there are very much things that, you know, the body takes over. The reason women in the past used to be able to do these things correctly is that they actually got to watch other women give birth. But now the way we give birth is, and specifically if you live in a medical institution, is private.

You know, people don’t really get to watch you. So people don’t have an idea of what to expect until it’s their time. Yes, we have videos, but these videos are often horrifying to people and they’re not often that, you know, that helpful.

So I think, you know, women getting to see the labor in the past and how they’re not able to see it now is such an important thing that we actually need to talk about it and teach it and talk about it and teach it some more. I also think things like, you know, having health care systems that are more open to having birth partners, doulas, actually come into a hospital because some hospitals are actually, you know, quite hostile to doulas. And maybe some health care professionals would also be because there may be a conflict between the doctor or the nurse and the doula.

And so some institutions just don’t support that. But we know evidence shows that having a doula present can increase the chances of you having vaginal delivery and having a better experience. So I think those are the two main parts that we can, the main factors we can use to help mothers with this.

Of course, we have to change the culture. Of course, we have to, you know, decrease the fees and the payout from these litigation cases. But this is going to take a very long time.

And that’s a huge cultural shift in an organization, societal shift that we need that will take a much longer time than actually addressing the mothers and what they ask for. Yeah, it’s interesting. I mean, I do think there’s got to be shifts, probably at a regulatory level.

Medical aides probably have to put some pressure on hospitals as well. Because obviously, you know, money is always the thing that talks. But as you say, I think the thing that you and I can impact most strongly is, of course, the mom’s attitudes.

And, you know, I was really interested in when you and I first chatted and obviously you don’t practice obstetrics now anymore. But when you were, your C-section rate was actually really low. And so I think that, you know, I think it was, did you say it was in the 20s, I think, percent? I was doing about 65 to 70 percent natural births.

So yeah, about 30, 30 percent. Yeah. Which is quite extraordinary.

And what do you put that down to? So mom comes into your rooms and she goes into different obstetricians rooms. How are you handling it differently? What are you saying to her that makes her feel like she can do it and that this is part of her journey? You know, I have one thing to say, and that is that it was personal experience. I had a vaginal delivery for my first born in 2018.

And I saw firsthand the obstacles, the barriers. I had to navigate it as well. And, you know, it was almost like having vaginal delivery was a privilege.

I actually remember one colleague saying to me, wow, like people don’t actually do that anymore. You know, and from then I realized that actually it’s such an empowering time. It is difficult.

I will not lie. And I will say I was definitely not as prepared as I thought I was. I assumed that as a health care professional, that I had enough information, but there’s so many other parts that you need to learn before you can actually do it successfully.

So for me, I’ll say it was personal experience. And when I say I believe in a vaginal delivery, I did it myself. I had to do this, do that.

I’ve been there. I know exactly where to go, what to do, which nurse to look for. I would give my patients that advice.

And it worked. Yeah. And yeah, I was on their side and tried to make it as, you know, have as little intervention as possible.

I also used to tell them one other thing, which was as much as they could, if they could delay going to the hospital and go a little bit later than sooner, that would also increase the chances because then you had a higher chance of being advanced in your labor and have less intervention. That’s so interesting. So I remember when I wrote the book Pregnancy Sense, that was something that came up.

We actually had a whole section, one of the chapters on interventions. So there are interventions that happen, medical interventions that happen in the labor process that can increase your chances of ending up having a cesarean section. And that’s probably what you’re talking about.

So could you take us through what are the type of medical interventions that actually increase your chance of a C-section versus those, you know, having a less interventions that actually, you know, kind of have more of a capacity to end up with a vaginal delivery? So, you know, there are various interventions that, and I would say it’s more because of the medicalization of giving birth, that there are all these interventions that we do to ensure the safety of a mother, but it comes to the detriment of, you know, interfering with the natural process. So typically things like the position of a mother, you know, because of safety, we don’t want mothers to fall off beds or fall anywhere. So we generally, specifically in the more latter part of the labor, want a mother to lie down rather than move around and be in whatever position they want to be.

We like to monitor the baby’s heart rates. We need to make sure that the baby is fine. So we put a machine, we attach the mother to a machine that’s a belt.

Once you attach, it’s very difficult for you to walk up and down. Sometimes we may put a catheter in the mother, specifically if there are issues, if you want to do any interventions, for example, during an epidural. Other things like the analgesia that we give.

So something like pethidine is almost like morphine. It’s a sedative. It can, you know, sort of take your mind to a if you’re in a sort of altered state.

So it would be safer for you to, you know, stay put. An epidural, that’s, you know, the sweet spot for a lot of women and how they manage labor. But an epidural typically will numb your legs.

You are definitely not encouraged to move. You have a drip inserted and you’re stuck to the bed. So essentially any medical intervention that is done that makes you, will limit your natural movements and how you’d use gravity and the movement of your body to help the baby adjust and come out of your body.

So interesting because I think, I mean, it’s exactly, you know, the picture, whenever you picture somebody in labor, they’ve got their feet up in the air and they’re lying flat on their back. And just that in and of itself and everything you spoke about there leads to that position is part of what can inhibit. I was very lucky in that I had a super progressive obstetrician and she had me walking and moving.

And two of my three babies were delivered by vaginal delivery. And the third, my last baby was delivered by C-section. It was quite interesting.

You know, often when you’ve had a C-section, you do look back and I’m sure a lot of moms will be listening to this and thinking this. You look back and you go, I wonder if I could have avoided that. I wonder if that could have been a natural delivery.

And I often do think that with Emily, because I did end up having a C-section with her. The reason for the C-section with her was, and I wanted to ask you, so my waters had broken. I was actually standing in a takeaway shop on a Friday night and my waters broke just like you see in the movies.

I looked down and I knew that I felt like I wet my pants. I got in the car and then there were these little leaks coming through. As I sat there, I thought, okay, this is not me weeing.

This is something more than that. And it was a day later in the evening that they then said to me, I must have a C-section, 24 hours. And the reason that was given was that it was 24 hours since my waters had broken.

A little bit of context, because I have got two questions about this, is that my sister-in-law, who I was quite close to, had given birth exactly a month almost to the day before me and had had the most horrific delivery in the UK in which they actually used forceps to take her baby from her without being fully dilated. And so it was obviously a young registrar or whatever, so he ruptured her uterus and she really, really, really did nearly die. It was touch and go for a few days.

Now that I think was in my head and I had heard the story, I knew her well and I was completely shell-shocked. And I personally think that my body just went, I got to eight centimetres dilated, my body went, nips, I’m not going any further. And that was it because that happened at about 10 in the morning on a Saturday morning and at six in the evening, I had gone nowhere, like tried everything and I was still eight centimetres dilated and so they decided to c-section me.

So I guess a couple of questions come out of that. The first one is just a little bit more scientific and medical. Is it true that a baby should be delivered if the mum’s waters have broken 24 hours before? Can we actually wait a little bit? So yeah, you know, the concern with the water breaking is that the water is what protects the baby and the mother from any infection.

And if that sterile environment is exposed to the external, well if that sterile environment is exposed to the external, that you have a higher chance of having infection. And that typically happens after 24 hours. So yes, that is generally true.

Typically what happens is that if a woman hasn’t then gone into labour and is not contracting after that 24-hour period, we start antibiotics and we will induce the mother. That’s generally how… That’ll be handled. Yeah.

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So if you’re thinking about what you can do to protect, preserve and defend the health of your children in their lifetime, one of the most actionable and easy ways to access this is to store your baby’s stem cells at birth with NexCells. But I actually wanted to say to you Meg that it’s interesting that, I mean, your daughter, she’s now an adult, is she not? Yeah, she’s 19. And so, you know, the fact that that still plays on your mind 19 years later, it actually never leaves you.

You know, those questions, what if, what if, what if? And it’s such an interesting thing. Yeah. Yeah.

And it’s super interesting because what did happen was that they did do me a pick toe drop. They gave me, they tried to induce the labor. I was put on antibiotics and nothing could kickstart that labor.

And that kind of speaks to, and you’ve kind of alluded to it there, that the fact that this still sits with me is fascinating on a psychological level. But what also sits with me is that actually there’s a big psychological impact on the way that labor progresses that comes from, yeah, fear. You know, and I think because birth is so foreign to us, we don’t give birth, we don’t see birth, it’s something that has become medicalized.

There is a big fear driver that will inhibit labor from actually progressing, because I’m convinced that’s what happened with mine. It was, I got to eight centimeters, fear kicked in and my body went like that, you know, Impala is running through the field and sees a line. She just stops, the labor just stops because this is too dangerous a place to give birth.

And I feel like fear plays a big factor in the cesarean section rates as well. Yeah. You know, when you talk about fear and the science behind it, I mean, the hormone cortisol is what, you know, is the hormone that’s released when you’re stressed.

And the hormone that causes contractions and allows your labor to progress is oxytocin. And actually, if your levels of cortisol are significantly high, it can interfere with the oxytocin receptors in your uterus and your body receiving the oxytocin. And yes, so that’s literally how it interferes with the labor process.

So a lot of it is, you know, at your mind. And that’s why people say, you know, your breath, you need to breathe, you need to breathe, because that helps counteract a lot of the stress and anxiety that you have. But yeah, literally your body will clench and tighten up, and that will also interfere with the birth process.

So yeah, I’m not, I’m actually not surprised that you got to that point and then thought of your sister and it was like, no, I don’t want that. Because I mean, your body showed that it’s able to do it because you gave birth to two babies before. But the only thing that was different was what had happened to your sister and her trauma.

And definitely, I think there’s certainly a place that would have played. Very interesting. Well, you know, you and I have spoken about doing more and more work together, and I feel very passionate about, you know, giving you the space to access moms through my platforms, because I think that this is, I mean, it’s definitely your calling, but I think it is part of my calling as well to help moms to be able to deliver their babies their way and be empowered to do so.

And that’s why I’m super excited that you’re going to be joining me on the 19th of February, which is just coming up now. I’m in a webinar called Birth Your Way. And moms, we’re going to be talking about two aspects of birth and delivery.

I’m going to be talking about having a baby your way. So the first few weeks and hours after your baby’s born. So everything from, you know, why are they crying? How do we, how do we establish good feeding? So just everything around that newborn.

But my master is going to be talking about what to expect in your birth and how do we actually remove fear from that room? How do we take back control? How do we really become masters of our baby’s birth? So I’m super, super excited to be sharing that platform with you. Is there anything that you want to, a couple of little tidbits that you wanted and tell moms that you’ll be talking about or where you’d like to focus your energies in that webinar? Yeah. So what I think is important is for people to know what a vaginal delivery looks like, not the actual process, but the things around you, where you go, what you need to do versus a cesarean section.

Cause I think a lot of people also have not ever seen what the theater looks like and what to expect from that. What else? The other things that I’m going to do is talk about, I would say evidence-based strategies to decrease the chances of you having a cesarean section, because there are things that moms can do to decrease the chances of them having it. I want to focus on helping a mother feel confident in a space where she’s at her most vulnerable.

So those are soft skills of advocacy, negotiation, knowing how to make an informed decision, how to pick the right healthcare professional to lead your birth. And hopefully, you know, by the end of that webinar, they’ll have some, a few actionable tips that they can use and implement immediately to help prepare them for the birth that they want to have. Oh, I absolutely love that.

I am so excited. I’m excited for that webinar. I’m excited for what comes in the future with us and moms, this is going to be a real treat.

So don’t miss this webinar with us. And how do they get hold of you? How do they get hold of the Nurture Hub? Are you on Instagram? Is there a website? Yeah, we have a website. It’s www.thenurturehub.co.za. And we have an Instagram handle, it’s the underscore Nurture Hub.

So either way, you can contact us and we’ll get back to you as soon as we can. That’s wonderful. Well, thank you so much.

This has been an absolute treat. So many fabulous facts and also delivered so gently. I think it’s, I think often, it’s also how the message is delivered that, you know, moms don’t want to be made to feel guilty and that they’re doing something wrong if they go one way or the other, but they need to feel empowered in a really gentle way.

And that’s really what you do. So thank you for bringing your voice to this. I really appreciate it.

No, thank you so much for having me on your show, Meg. I look forward to this webinar. It’s going to be awesome.

What a fabulous episode. A big thank you to our sponsors, NEXT Biosciences and Huggies for their support of this podcast. And you can find more information on NEXT Biosciences Stem Cell Banking and their reproductive health journey at nextbio.co.za. That’s nextbio.co.za. Your baby deserves the very best and Huggies delivers every time.

And for more information on Huggies, visit huggies.co.za. Thanks to everyone who joined us. We will see you the same time next week. Until then, download ParentSense app and take the guesswork out of parenting.