There’s no doubt that caesarean sections are an essential procedure that can save the lives of women and babies. But around one in three Australian women will give birth by caesarean section – and that’s not just to save lives.
The problem is that once a procedure becomes this prevalent, there’s a risk it will become normalised as the usual way to give birth. And we certainly haven’t reached a point where one in three women needs a surgical procedure to deliver her baby.
The rising caesarean section rate in most of the developed world has not resulted in reduced rates of stillbirth or infant death – quite the contrary.
One Australian study showed that babies were more likely to be admitted to a neonatal intensive care unit if they were born by elective caesarean section than other types of delivery. A previous caesarean section also increases the risk of stillbirth.
In terms of outcomes for women, those who have emergency and elective cesarean sections are less likely to exclusively breastfeed. And there is growing evidence that caesarean operations increase the risk of the mother dying or becoming ill with blood loss, blood clots, abdominal organ injury and the need for a hysterectomy.
It’s important to consider the risks of caesarean births. But rather than just focus on the polarised “vaginal birth vs caesarean birth” debate – which pitches doctors against midwives, and doesn’t help women who are stuck in the middle – we need to focus on the ways we can support all women to have the best outcome from childbirth.
It seems that one of the driving forces behind the rising caesarean section rate is fear – from other women about labour and birth, and from doctors and midwives who are themselves fearful of the birthing process.
Rather than design studies that compare a fundamentally normal experience with a surgical procedure, we should be examining why women are fearful of labour and birth and what our health system can do to reduce this fear.
Our health system is generally an unfriendly one for pregnant women and it’s likely that this compounds the fear of birth. It’s common for a pregnant woman receiving care in the public system to see up to 30 different caregivers through pregnancy, labour and birth and the postnatal period.
The opportunity for pregnant women to develop a meaningful relationship with her health care provider, discuss her fears, affirm her needs and develop confidence in labour and birth are minimal.
Even in the private sector, a woman will generally know their obstetrician (unless she/he are off call that weekend), but she will meet a multiple of midwives and nurses through labour and the postnatal time.
The birthing environment impacts on women’s capacity to give birth and may contribute to her fear. Birth is a powerful event for women, and memories and perceptions last decades.
One of the disturbing elements of birth in the 21st century is the lack of respect for privacy for labouring women. The entourage of people appearing uninvited into labour rooms in most hospitals is astonishing. Each labour and birth can have a multitude of spectators, including a midwife, obstetrician, registrar, resident, student midwife, medical student and on it goes.
The response to high caesarean rates in some countries, such as Finland, has been to establish “fear clinics” to address the underlying cause of childbirth fear and identify means for women to cope with it, rather than opting for a cesarean section.
To address this problem and encourage Australian women to give birth normally, many states in are embarking on impressive campaigns. In NSW, the Towards Normal Birth Policy was released last year and provides 10 steps towards supporting more women to go into labour and ultimately have a normal birth.
The policy recognises that ”some women will have, or develop, certain risk factors that require attention. But unnecessary interference in the natural process may disturb the expected course and may lead to a cascade of intervention."
The challenge is to redesign the health system to facilitate women’s confidence and trust in birth. Fundamental changes need to occur to ensure all women are supported during pregnancy and feel confident in their ability to give birth, including:
Continuity of caregiver;
Increased options for the style of birth, with access to a birthing pool;
A positive environment, free of disruptions; and
One-to-one midwifery care in labour so women are never left alone or fearful.
I welcome research that seeks to improve outcomes and experiences for birthing women. But rather than study what happens to women who choose childbirth with intervention, let’s concentrate on supporting women to give birth normally without fear.
Join the conversation
Comments (19)
Joy Johnston
(logged in via LinkedIn)
Thanks Caroline for this article on a fascinating topic. I often remind myself and others that 'usual' is not necessarily 'normal'. The physiological norm for pregnancy, childbirth, and nurture of the infant will always engage the woman's and baby's sensitive hormonal systems and deep intuitive knowledge.
I have worked as a midwife providing one-to-one primary materntiy care for women for many years now. When I started, I thought I knew about normal birth. I had given birth 'naturally' to my…
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Keely Boom
(Research Fellow, THINKK, the Think Tank for Kangaroos at University of Technology, Sydney)
A fascinating article, Caroline. The WHO recommends an 'ideal' caesarean section rate of 10-15% yet we are far beyond that.
I'm currently reading Birth Matters by Ina May Gaskin which includes the Mother-Friendly Childbirth Initiative (http://www.motherfriendly.org/MFCIb). I would like to see this initiative widely adopted in Australia. Do you have any views on this initiative?
electivecesarean.com
(logged in via Twitter)
I'm afraid it didn't get very much publicity at the time, which is why so many people don't know, but the WHO revised its original (1985) cesarean recommendation in 2009:
http://www.prlog.org/10388884-who-admits-there-is-no-evidence-for-recommending-1015-caesarean-limit.html
and
http://www.bbc.co.uk/news/10448034
It now says that there is "no empirical evidence for an optimum percentage" of 15% and that an "optimum rate is unknown". Therefore, WHO suggests that users of its handbook "continue to use a range of 5-15% or set their own standards."
Byron Smith
(PhD candidate in Christian Ethics at University of Edinburgh)
Excellent article, thanks.
It would be interesting to know what else drives the high caesarian rate. The article identifies fear (both that of the mother's and of the health professionals) and I'm sure it is a or the major trigger, but have studies investigated what proportion of c-sections are the result of convenience (for either mother or doctor)? Anecdotes of birth rates shooting up in the days leading up to Christmas and New Year, if true, suggest more may be going on. Of course, a certain number are truly needed for medical reasons (though even here, there are serious questions about what level of medical risk justifies surgery). I offer no condemnation about the choices of labouring women in stressful situations, but this article does raise timely questions about a system with such high rates of intervention.
Iain Murchland
(logged in via Twitter)
You probably saw it, but there was a recent article here at The Conversation arguing that a large proportion of the increase in caesarian rates is due simply to the changes in the age profile of mothers and its interaction with how risk profiles vary with age. I think they suggested that something like 70-80% of the increase was consistent with this explanation.
The other thing that I think is likely to explain some of the residual increase in the change in BMI of mothers, the rate of gestational diabetes and their impacts on the rate of suspected macrosomia. But that's just a gut feeling, I haven't looked into the literature to see if there's evidence to support it.
Byron Smith
(PhD candidate in Christian Ethics at University of Edinburgh)
Thanks for pointing out that earlier article. I had missed it.
electivecesarean.com
(logged in via Twitter)
Unfortunately, this article talks about what might be reducing women's chances of achieving a spontaneous vaginal birth outcome without mentioning obesity or advanced maternal age. The truth is that we can support women, give them continuity of care, give them a birthing pool and try to talk to them out of their fears, but unless you are also honest with them about the fact that their weight and age are two of the most important risk factors for adverse birth outcomes, it won't be enough.
Also…
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Regan Forrest
(logged in via Twitter)
May I suggest that fear is also exacerbated by countless anecdotes of midwives who obfuscate and delay the delivery of pain relief - all in the (in my view, misguided) belief that letting women languish in agony is in some way 'beneficial' for the subsequent mother-child relationship.
While people may be entitled to this view, women should be entitled to a choice - and if they choose pain relief it should be delivered in a timely manner. Smokescreening in this regard should not be countenanced.
electivecesarean.com
(logged in via Twitter)
Unfortunately, this article talks about what might be reducing women's chances of achieving a spontaneous vaginal birth outcome without mentioning obesity or advanced maternal age. The truth is that we can support women, give them continuity of care, give them a birthing pool and try to talk to them out of their fears, but unless you are also honest with them about the fact that their weight and age are two of the most important risk factors for adverse birth outcomes, it won't be enough.
Also…
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electivecesarean.com
(logged in via Twitter)
Also, you mention Flenady et al's stillbirth study in the context that stillbirth risk is associated with a previous c-section. Now I haven't read the study in full, but based on the study authors' Summary (which you link to), c-sections are not mentioned at all (they may appear in the Full Text, but even so, were not deemed important enough to appear in the Summary). Rather, the authors state:
electivecesarean.com
(logged in via Twitter)
"Large disparities (linked to disadvantage such as poverty) in stillbirth rates need to be addressed… Overweight, obesity, and smoking are important modifiable risk factors for stillbirth, and advanced maternal age is also an increasingly prevalent risk factor… Identification of ways to reduce maternal overweight and obesity is a high priority for high-income countries."
Amie Steel
(logged in via Facebook)
It is so great to see the discussion around fear towards birth highlighted by your wonderful article. As much as all of the biomedical reasons proposed by so many of the above comments are real, it may be that by focussing on issues of obesity and maternal age we miss the big picture.
It may also be that as health professionals it is easier, and more quantifiable, to focus on these fixed and tangible health issues, rather than dealing with a nebulous emotive response like fear. What would we do…
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Jenny Mountford
Community Nurse (logged in via email @sghs.com.au)
I think you hit the mark with the fear factor, but it is only part of the story. Professionals are very quick to take the "safe" alternative as it is deemed the right thing to do if there is appears to be a risk. A live health baby is the prime objective in any delivery as it should be, however there is always the fear of litigation if the "safe' delivery is not chosen as an option.
As an ex-midwife in a country hospital I saw lots of CS but really the reason was for the positve outcome not convenience. It is no good waiting until the last minute if it will take an hour to get staff ready for an operative delivery.
I now work in the community and don't have that stress anymore, and I don't miss it one little bit!!
Robyn Thompson
(logged in via email @gmail.com)
It’s a pleasure to read your challenging article Caroline. Sensible and respectful debate that includes women is long overdue. So overdue that abdominal surgery is already the delivery ‘norm’. May I take this opportunity to reinforce that birthing places and professionals require major change to accommodate and protect the mammalian woman during labour, while giving birth, and breastfeeding.
A positive environment, free of disruptions where she can rely on her mammalian skills, requires the experience…
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electivecesarean.com
(logged in via Twitter)
Other areas of your article refer to a mixture of emergency and elective cesarean birth risks, and also elective cesarean risks that include births at gestational ages as early as 37 weeks (which would normally only be done out of necessity, not choice). I think it's important that we stopped treating different cesarean birth risks as though they are all the same, when they're not.
electivecesarean.com
(logged in via Twitter)
Please know that I am completely supportive of efforts to help women who WANT to give birth naturally. What concerns me is when women are given the idea that regardless of their individual risk factors, if they adopt the right mental approach, if they choose the right birthing environment, and if they trust their bodies (you don't mention the latter, but this often appears in maternity literature) then everything will be ok.
electivecesarean.com
(logged in via Twitter)
And of course it also concerns me that women who WANT a cesarean are often criticized for or worse still, refused what is a legitimate birth choice at 39+ weeks' gestation with plans for a small family.
electivecesarean.com
(logged in via Twitter)
I think that both cesarean and vaginal birth are "normal" today, and that what's important is that we try to reduce the number of UNWANTED cesareans without impacting on those that are very much WANTED. As you say above, what matters is that "we need to focus on the ways we can support all women to have the best outcome from childbirth", and that's not the same as assuming that all women should or would want to plan a vaginal birth.
electivecesarean.com
(logged in via Twitter)
Apologies for my single comment appearing as multiple posts but the "show full comment" link doesn't appear to be working on my first attempts.