Is it a good idea to reduce the caesarean rate?

Caesarean section rates in western countries have been rising for a long time – but the rate varies widely between different countries. In Sweden, for example, it’s 17%, while in Cyprus it’s 52%.

It’s not at all clear why rates differ so much. Reasons often cited for high caesarean rates include: the increase in older first-time mothers (for whom pregnancy and labour is riskier); the increase in overweight mothers (ditto); the fact that babies are getting bigger; a trend for women to request a planned caesarean section; increased medical management of labour, which sets labour on a path culminating in emergency caesareans; and a cautious approach by doctors who fear litigation.

This is informed speculation, however: the only way to know for sure would be to record and collate the reason for every caesarean section, and that doesn’t seem to happen. I am slightly sceptical of the idea that the increase is down to women requesting the procedure. It provides a handy narrative and another pejorative term for women (“too posh to push”) but the truth is that the majority of caesarean sections are performed as an emergency procedure, and there are often medical reasons for planned sections (breech presentation, placenta praevia).

Does it matter?

This is the interesting question. In Australia, one in three babies is born by caesarean, one of the highest rates in the world. There is pressure to reduce the rate: caesareans, it is argued, pose an increased risk to the mother and baby. An article in the Sydney Morning Herald quotes Andrew Bisits, the medical co-director of maternity services at the Royal Hospital for Women in New South Wales:

“People forget that a caesarean is a relatively major operation. It’s an instant trauma to the body. It’s anything but keyhole surgery. I think that fact sometimes gets lost and people forget that you can get through a normal birth with no scratches or just a few scratches.”

In New South Wales, a policy to reduce the c-section rate and increase the “normal” birth rate has been unsuccessful, with c-section rates remaining fairly static. According to the Herald article, there has even been an increase in the number of women having induced labour and forceps deliveries. More women “are having major haemorrhages after they give birth.”

One obstetrician, Professor Hans Dietz, argues that the “increasing push towards natural birth is having the unintended consequence that more women are having longer, more difficult labours”. He says:

“In the past it was two to three hours of unsuccessful pushing before obstetricians intervened, now it may be six. It has the advantage that some women will push their baby out, but the risk that some will be left with a post-partum haemorrhage.”

The article goes on:

“He estimates that for every 10 caesareans prevented, it is likely that four additional tears to a woman’s levator muscle – which holds the pelvic organs and bowel in place – occur, and four additional sphincter tears.”

Dietz is also sceptical about the oft-cited dangers of caesareans:

“In my entire clinical life, how many women with major later life health problems due to caesarean have I ever seen? I can’t remember a single one. How many after forceps will I see? Several a week, at least 100 a year, maybe 200 a year,” he says.

So, is the drive to push down the caesarean rate misguided?

The short answer is: I don’t know. I suspect that nobody else does either. The Herald article demonstrates that people who work in maternity services have vastly differing views on the subject.

For women, it’s bewildering. Few, I imagine, are delighted at the prospect of surgery to deliver their baby; but even fewer want what Dietz describes as the potential consequences of a difficult vaginal birth: “urinary and fecal incontinence, prolapse, sexual dysfunction, years or decades later.”

What we need is more data: why caesareans are performed; the health consequences for women (and their babies) who deliver this way; whether reducing the caesarean rate results in better outcomes for women and their babies; the particular factors that lead to an assisted delivery; the physical and mental health consequences for women and their babies who have an assisted delivery; the correlation between factors such as age, weight and social class and method of birth.

Until we have that data, women will continue to be the unwitting victims of an argument that rages between professionals without coming to a satisfactory conclusion.

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