A caesarean can be a lifesaving procedure and is vital and medically necessary in about 10-15% of births.
Across Australia 35% of all births were by caesarean section. That’s more than one in three.
That means there are a lot of caesareans performed that may not be medically indicated.
Why is it so common? And importantly, does it matter?
Grab a cuppa, this is a long one.
Who is this article for?
Are you pregnant? Or trying to fall pregnant? Is your partner pregnant? If yes, then this article is for you.
My aim is to give you information so you can have better conversations with your health providers.
I hope this information can empower you, and help you get the best outcomes for you and your baby. Knowledge is power, after all!
Why do the high numbers of caesarean births matter?
Let’s talk about that first.
There is a common perception that caesarean section is safer for mum and baby than a vaginal birth. A caesarean can be a lifesaving procedure when medically indicated, and is vital in a range of circumstances but, when it is used in more than 20% of births it does not improve health outcomes.
Risks to mum’s health after a caesarean
What we do know is that there is a greater risk of issues with mum’s health after a caesarean, including:
Greater risk of bleeding, and the need for a blood transfusion
Greater risk of adhesions forming between pelvic organs, and of surgical injury
Greater risk of hysterectomy in the future
More likelihood of experiencing uterine rupture with future pregnancies
Greater likelihood of abnormal placentation (issues with the placenta) with future pregnancies
Greater risk in future pregnancies of ectopic pregnancy, including caesarean scar ectopic pregnancy (CSP), preterm birth and stillbirth
Multiple caesareans also carry a greater risk of menstrual issues, bowel obstruction, chronic pain, sexual dysfunction and subfertility.
There also tends to be less satisfaction with birth experiences expressed by women who had undergone caesarean sections.
Risk to baby’s health after caesarean
The potential long-term health impacts on babies are still being investigated but there are known subtle but significant effects on the child’s physiology.
They include things like:
Altered immune development
Greater chance of allergy and asthma
Links to the development of metabolic syndrome later in life
Lower intestinal microbiome diversity (less range of different bacteria in your gut, which is important for digestion, immunity, and possibly mood)
There has been some speculation as to whether there are any long-term effects on brain function and educational outcomes.
A recent review of existing studies demonstrated that “caesarean delivery births are associated with an increased risk of autism spectrum disorder and attention-deficit/hyperactivity disorder, irrespective of caesarean delivery modality, compared with vaginal delivery” (Sandall J, 2018).
The good news about caesareans
All of that may be a lot to take in and can even seem a bit scary! My apologies. I’m really not meaning to cause fear or anxiety.
It still remains true that there are circumstances when a caesarean section is the best option.
When medically indicated, caesareans can be lifesaving!
In the interest of presenting a balanced view, there is also some evidence that caesareans may give some benefits with regards to urinary incontinence and urogenital prolapse after birth, but it’s not conclusive.
We all want to make the best decisions for our health and the health of our kids, and an accurate understanding of the risks and benefits of the options being presented to you is necessary if you’re going to make an informed choice.
Why are caesareans so common?
This all begs the question: if a non-medically indicated caesarean section carries all the risks outlined above, and it’s not actually providing better health outcomes for mum or baby, then why is it so common? And why does it seem to be becoming more common?
The answer to that is complex. It’s partly about demand, but it’s also about the culture that exists in health care in Australia and most of the western world. It could also be said that caesareans are presented in the media as being controllable, convenient, fashionable and modern, and that this leads to a less-than-accurate perception of the realities of the procedure.
Reasons for having an elective caesarean section
We know that when we ask women, most do not show a preference for a caesarean section in the absence of complications. We also know that the majority of women who request a non-medical caesarean do not do so for reasons of convenience! Some of the reasons women do give are:
The perception that a caesarean is safer for them and their baby
Fear of labour pain
Fear of pelvic floor damage and urinary incontinence
Fear of the negative effects of vaginal birth on their sexuality and sexual function
Previous negative experience of vaginal birth, which includes less than ideal quality of care from health professionals, and experiences of disrespect, neglect and even abuse.
I will say that it’s my impression (and that of many others) that the fears named above are contributed to by the way labour and birth are viewed in our culture and presented in our media. And that stuff is hard to get away from.
Why do so many health professionals recommend caesareans?
Women also say, in addition to the reasons given above, the greatest influence on their decision was their health professional. I think that is significant.
Interestingly, most health professionals say that the greatest influence on their willingness to recommend caesarean sections are the women in their care.
Some studies suggest that this is partly due to a fear of malpractice and litigation. Some health professionals fear that they are more likely to be sued after a vaginal birth than after a caesarean. And, if we’re being honest and compassionate, I think that may be a legitimate fear.
We also know that many young doctors have received inadequate training in vaginal birth, and because of the culture within hospitals and health services, are understandably afraid of looking incompetent. And people will naturally be biased towards something familiar and comfortable.
Is there a gender bias in health care?
Other factors affecting health professionals include their views on pregnancy and birth – do they see it as a natural physiological or an inherently pathological process? Associated with that can be their attitudes and beliefs around women’s preparedness to birth vaginally. This last brings up the entire issue of the gender bias that exists in health care – the evidence is that women still frequently receive substandard care compared to men, and their health complaints are more likely to be regarded as emotional or hysterical than are men’s, for a start.
Do doctors regard elective caesarean sections as more convenient?
Then there’s the issues around financial benefits and convenience. Around the world caesarean sections are more common in private facilities than in public ones. And a private caesarean generates more revenue for a hospital. It makes sense that this could therefore give rise to a top-down cultural pressure from hospital management on doctors to perform more. And doctors do regard elective caesarean sections as more convenient. I’m not suggesting that a doctor’s sole reason for suggesting a caesarean is so they can play golf on the weekend. But if you combine a belief that caesareans are not that risky with the huge work demands placed on most doctors, which will often include having to juggle work in both public and private facilities, then suggesting an elective caesarean in circumstances that allow it may actually make sense to them from the broader perspective.
Most health professionals believe they are doing the right thing
I want to state that I believe that most professionals believe that they are doing the right thing. We are all trying to do the best we can in the situations we find ourselves, and with the information we have at the time. But doctors and other health providers are just people too, and have beliefs and biases, and are, after all, well… human!
I think keeping this humanity in mind is a key to changing this issue.
How do we reduce the number of caesareans?
If we prioritise positive human relationships with regards to pregnancy and birth, particularly between women and their health providers, we have a chance to make a positive difference.
There needs to be some cultural changes, including at the institutional and clinical levels as well as in clinicians’ beliefs and practices. Perhaps if hospitals paid as much for a vaginal birth as for a caesarean, rates would come down. Perhaps if clinicians were taught to value vaginal birth more, and were taught skills to facilitate it, including dealing with VBACs (vaginal birth after caesarean) and breech presentations, caesarean rates would come down.
There is ample evidence of what is called a “cascade of interventions”. What that means is that once an initial intervention is applied, whatever it may be, you are more likely to continue down the path of more interventions, and more likely to end up with an emergency caesarean. Initial interventions can include medications to induce or speed up labour, breaking the membranes to induce or speed up labour, giving medications for pain relief, and requiring women to labour in bed instead of upright and moving around.
In contrast, we know that when women experience midwife-led continuity of care, such as is provided in numerous birth centres around Australia and here in the ACT, and when women have continuous labour support (historically provided by other women), they are more likely to have a spontaneous vaginal birth (they weren’t induced), and less likely to have a caesarean or instrumental vaginal birth. Their babies are more likely to have immediate positive health outcomes. And the women are more likely to report satisfaction with the experience.
Is a caesarean the right choice for you?
What about for you, though? What can you do right now to help improve your chances of a good outcome for your birth?
First, it needs to be said that the choice of an elective caesarean is a personal matter. If, after weighing up the alternatives, you still choose to do so, that is absolutely your right. I hope this article has helped in that choice.
If this article has contributed to a decision to avoid a non-medical caesarean where possible, then as I said before, knowledge is power. Most women say that this kind of information is useful, welcome and empowering, and can help them to have more meaningful dialogue and a more equal relationship with their health care providers.
You can insist on a good, respectful relationship with your provider. You can have open conversations about these matters with them. Talk about your wishes and your concerns. Most people will respond well to that. And if they don’t, if you feel uncomfortable or disrespected, or if you feel that their values around pregnancy and birth don’t match yours, you can find someone who does.
Perhaps if these conversations are being held more often, it will help turn the tide. Perhaps it will help to push back the overuse of caesarean section and other interventions in labour and birth. Perhaps it means women will have better support during birth in the future. Better health for them and their babies. And more satisfaction with what should be a truly wonderful and transformational moment in any mother’s life.
Contact us if you have any questions or book an appointment at our clinic in Canberra.
References
Australian Institute of Health and Welfare
Betran AP, et al., Optimising caesarean section use 3: Interventions to reduce unnecessary caesarean sections in healthy women and babies, The Lancet, vol 392, Oct 13 2018, 1358-1368
Bohren MA, Hofmeyr GJ, Sakala C, Fukuzawa RK, Cuthbert A. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2017, Issue 7. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub6.
Boerma T, et al., Optimising caesarean section use 1: Global epidemiology of use of and disparities in caesarean sections, The Lancet, vol 392, Oct 13 2018, 1341-8
Sandall J, et al., Optimising caesarean section use 2: Short-term and long-term effects of caesarean section on the health of women and children, The Lancet, vol 392, Oct 13 2018, 1349-57
Zhang T, et al., Association of caesarean delivery with risk of neurodevelopmental and psychiatric disorders in the offspring: a systematic review and meta-analysis, JAMA Network Open. 2019;2(8):e1910236