OBGYN.net Conference CoverageFrom the 24th Annual American Urogynecology Society Meeting, Hollywood, FL - September 2003
Barbara Nesbitt: “Hi, I’m Barbara Nesbitt, I’m at AUGS and I have the pleasure of sitting here today with Dr. Magnus Murphy from the University of Calgary. I think you are all familiar with him, he has written a book that we’ve had on OBGYN.net for quite a while, “Choosing Caesarean Birth” and it’s been a little controversial with people that don’t want to choose that way.
But we’re at an Urogynecology conference and obviously we’re talking about incontinence and prolapse and all the things that come from, a lot of times, vaginal birth. We have Dr. Murphy’s new book, “Pelvic Health and Childbirth” and we’re going to discuss it and the reason he wrote this as a follow-up to his first book. It will also be available to us to buy and to read sections of. Dr. Murphy is also a member of the Editorial Advisory Board of OBGYN.net, Urogynecology. Nice talking to you doctor.”
Magnus Murphy, MD: “Well, thank you Barbara. It’s my pleasure, and the privilege is entirely mine. Especially sitting here and looking at this beautiful view out here, all the birds out in the woods. Thank you for having me.”
Barbara Nesbitt: “You wrote the first book, and then you were telling me that there was a whole area left that you wanted to explore in this second book.”
Magnus Murphy, MD: “Yes, the first book, I started working on that in 1998, and as you mentioned, called “Choosing Caesarean Birth”. It basically focuses on caesarean as a possible preventative measure for preventing urinary incontinence and other pelvic floor disorders. What really led to this book is the perceived need, specifically in my own practice, and I’m sure in many of my colleagues’ practices, of education. Educating women on, firstly, what the pelvic floor actually is. I usually get a blank stare when I start talking about the pelvic floor because it’s this esoteric part of our bodies that many people don’t have any idea that even exists. Secondly, to explain what is actually going wrong.
For instance, to give an example, one of the comments I often hear from patients is that they have a bulge in the vagina and so I’m trying to explain what this bulge is, where it came from, why it happened, what can be done about it through various ways; non-surgical, including surgical, and then also what could possibly have been done to prevent it.
So the book will be hopefully, of enough use to women who already have problems, but also for those who still have to decide, specifically then, in terms of how they are going to have their babies.”
Barbara Nesbitt: “So this is something that I think is important because we’re seeing more older women having a first child. We’re not talking about 20 or 30 years ago when it was 18 or 19 year-old girls who didn’t even think to ask the question. Now we’re into 35-year-old and older women having infertility treatments and there’s a plan there. Now they don’t want or need to ruin a bladder system that’s been working fine for years.”
Magnus Murphy, MD: “The other thing is also, not only are women postponing pregnancies, but they are also having fewer babies. Obviously I can’t generalize, it’s a certain section of the population, but in general in western countries anyway, the fecundity, that means the number of babies women are having, has dropped remarkably. Now there has been a slight rise again in certain countries but still it’s incredibly low. The point is that women are having fewer babies, maybe one, or two, at the most three, later in life.
They are also living a lot longer and living more active, productive lives. They want to be able to enjoy life after childbirth, whereas you know in the older days women were either having babies every two years, or life expectancy basically ended at the time when fertility wasn’t an issue anymore. That’s certainly not the case now fortunately, and therefore the long-term effects of childbirth and pregnancy are today a major issue and it’s of prime importance in my view. Whereas in previous centuries and previous years, obstetrics focused specifically firstly on, whether the mother was going to survive childbirth because that was the main issue, and the fetus really was of secondary importance.
In the previous century it all evolved regarding saving the fetus and making obstetrics and delivery and having babies safe for the baby because, to a large degree, we’ve overcome the immediate life-threatening risks to the mother. We’ve gotten to a point where having babies is relatively safe, not only for the mother but also for the baby. My point is that it’s now time to think about the mother’s morbidity, meaning the health of the mother and the effects of having children on their future quality of life. So, it’s not only survival that’s of importance anymore, but now quality of life, and that is to a large degree what this book is about.”
Barbara Nesbitt: “I think we can say that, as you said, in the different generations, this is a generation of a more educated woman who knows to ask questions; maybe more than 20 years ago, ten years ago but they don’t always know what options are available for them. So is this something that they should go to their obstetrician and say, ‘I want to look at having a c-section?’”
Magnus Murphy, MD: “That’s a very good question. I think the important thing is that I fully believe in the principle of not only informed consent but complete understanding of the implications of decisions. The days of paternalistic medicine are long past. I believe women should educate themselves about decisions made, and not have the physicians make decisions completely on their own. Therefore, yes, I think the book discusses childbirth, the pros and cons of vaginal birth and caesarean. The caesarean choice doesn’t necessarily come without risks attached, and it’s important to note that I am not suggesting that women should have a caesarean. What I’m suggesting is that women educate themselves about the choices, about the risks of the different choices, including those risks of caesarean; there are many. And then go to their physicians and discuss this with the physicians.
I’ll give you an example. My sister lives in Pennsylvania and she is a highly educated professional woman. She’s 37-years-old, she’s having her first baby. She asked her obstetrician for a caesarean. This was a few weeks ago. According to her, this person almost fell off his chair. I want to educate women that it’s their right to discuss this, and also physicians that it is their duty to discuss with patients the implications on childbirth of vaginal delivery and also discuss the risks of caesarean.
I think one of the problems with pre-natal care is that we don’t have time. We don’t have the time to discuss many of these things and because of that it becomes neglected. There was this well known study that’s being talked about a lot at these conferences, where in Britain, female obstetricians and female obstetrical senior residents were asked what they would like for themselves for a first baby. More than 30% actually indicated they would like to have a primary, preventative, elective caesarean section. Eighty-five percent of those indicated that they would want this specifically for protection of the pelvic floor. A minority indicated they would want it because caesarean is arguably, although I think there is enough proof of it, safer for the baby.
The point is I am quite sure that very few of those female obstetricians will then go to their offices and discuss this with their own patients. It is something that’s neglected and I think that women have the right to know and have the obligation to educate themselves. Then discuss it and then make their own decision jointly with their physician.”
Barbara Nesbitt: “You and I have been emailing back and forth and you certainly have submitted access to your first book. Anyone who wants to can go online and read chapters from it. You have answered questions. You freely let women write to you and you answer them. Some are very upset with you, some are very glad to hear what you have to say. Controversy is always good. It opens minds, doesn’t it? Makes people think.”
Magnus Murphy, MD: “Yes, I think so. I don’t know if you’ve actually noticed, in this book I have abstracts from certain comments that were posted on my own personal website, which is www.pelvicfloor.com. There was one particular posting that was very poignant, and this lady just tore into me about how dare I make comments like this. And it illustrated to me what a passionate topic this is, and of course, it’s bringing a new life into the world, it is very passionate. This is why I want to again stress that I and Carol Wasson, my co-author, whom I’d really like to acknowledge here, has made a large contribution to the project, we are not suggesting what women should decide. We’re not telling them what they need to do; we are trying to educate them about the fact that they should make a choice.”
Barbara Nesbitt: “You are giving them the option to learn both ways and then make the choice, which they feel is the right one.”
Magnus Murphy, MD: “Exactly, but of course, as you mentioned, it is a continual source of controversy, and I think as women become more knowledgeable, it will be even more so.
I have been told, and this is second-hand information, but I have been told that Germaine Greer, who is a well-known person in feminist circles, has made a comment in Australia where she has said that “the battle for vaginal delivery has already been lost.” Now I apologize if I have this wrong but this is something that I heard second hand. There was also a very, very good lecture by Mrs. Margaret Summerville, who is a well-known ethicist in North America, in Toronto last November 2002. She gave one of the seminal lectures on ethics regarding elective caesarean, and basically indicated that the whole evolution of law and medical ethics, is developing in a direction where physicians may actually be found negligent not having informed people of these issues. That is quite a frightening thought as you can imagine. It is not being done today, and it is very problematic because it is almost like opening a can of worms.
But I do believe that the tide is turning and it’s unstoppable and I wanted to do my part in educating.”
Barbara Nesbitt: “So, come on the website, read the excerpts from this book.* There will be a few chapters on it to begin with before we get the whole thing. Read the whole first book, “Choosing Cesarean Birth.” And write to Dr. Murphy if you have anything that you want to ask him because he has his email address on there, readily available.
I thank you. I was from a day when you just had a baby and you didn’t ask any questions. I like this new way very much.”
Magnus Murphy, MD: “Thank you Barbara.”
*Editor's note: The publisher has not yet released the chapters for on-line publication. As soon as we get them they will be available on OBGYN.net Urogynecology. For purchasing information, please see the listing on Amazon.com.