The Caesarean Epidemic

By Bruce Teakle

Caesarean section as a “lifestyle choice” has had a lot of attention lately, but are women really to blame for sky-rocketing caesarean rates?

Late last year morning viewers of Channel 9 were treated to a “live caesarean on TV”, with presenters claiming that this was the birth of Australia’s 20 millionth citizen. “How do you feel?” the peppy interviewer asked the post-operative mother. “Just numb” was her reply.

The Sydney mother had become part of a steady stream of publicity promoting caesareans. Television interviewers, super-models, and rock stars are increasingly being shown in the popular media as having chosen a caesarean without a safety need. Recently a high profile Brisbane obstetrician wrote in the Courier Mail that “Modern, emancipated women are increasingly exercising their right to choose by deciding that a planned caesarean section is their preferred mode of delivery.”

The pressure is on to normalise caesarean birth – and it’s about time to put some facts into the discussion.

Rising Rates
Certainly an increasing proportion of births are by caesarean section. Currently 31% of Queensland’s roughly 50,000 annual births are by caesarean, and the rate has been rising at 1 to 2% per year. To put this into perspective, New Zealand and Britain have rates of around 21%, and The Netherlands has a rate of 12%, all with excellent outcomes. Even the US has a lower rate, at around 25%.

What’s The Difference?
While caesarean section is being promoted as “just another way of giving birth”, there are important consequences to consider. A range of risks to mothers and babies are increased by caesarean section, including death of the mother (4 x risk), need for neonatal intensive care (5 x normal birth) scalpel cuts to the baby (2% of caesarean births), and a range of complications in subsequent births. These risks are manifestly worth taking in situations where there is a medical need, but are generally understood to make normal birth safer for almost all women.

Some obstetricians claim that a caesarean can protect the pelvic floor, and reduce the risks of stress incontinence. The evidence for this is very poor, with one survey showing that caesarean section gave 10% of women some protection from some types of incontinence, and research by an Adelaide professor of obstetrics concluding that pregnancy, not birth, was the cause of incontinence. To reduce the risk of incontinence, he said, “Its better not to have a baby, and its better to be a man”.

The cost of all this surgical birth is a huge burden on the health system, with various sources putting the cost of a caesarean at 2 to 5 times a normal birth. With many private hospitals having 50% caesarean rates, and with about half the cost being paid by the taxpayer, there are big costs to an overstretched health care system.

Women’s Preference
Despite the hype, the claim that these extreme caesarean rates are being driven by women’s request is completely unsupported by evidence.

What evidence does exist indicates that something like 1% of women are choosing caesareans, and this appears to be in the absence of evidence-based information.

In Queensland Health’s most recent report, 1.3% of the state’s births in 2001 were caesareans due to “Unspecified psychosocial circumstances”, presumably including women’s preference.

A recent Griffith University survey of expectant Queensland women reported that under 1% of women preferred a caesarean, in the absence of a medical need or a previously traumatic birth.

In Britain, where similar publicity has surrounded women’s choice of caesarean, the National Health Service reports that just over 1% of births are caesareans solely by women’s request.

In the past, the risks from anaesthetic, infection, and other surgical complications were much greater, and doctors were more inclined to make the most of non-surgical approaches. Although caesareans still present significantly greater risks to mother and baby than normal birth, it is these days a relatively safe procedure, in terms of short-term physical health of mother and baby. The effects on longer term psychological health are rather harder to be confident about.

Some women will have personal reasons to choose a caesarean, and they deserve respect. “Too posh to push” is a critical label which trivialises the choice, as does the “modern emancipated women” title used in medical marketing. In the Griffith survey mentioned above, nearly all women who stated that they preferred a caesarean had experienced a previous traumatic birth, or believed that they had a medical need for the procedure. Given many women’s traumatising experience of birth in what can be like a combat zone, it is easy to imagine wanting to avoid a repeat performance.

Despite this, 1 or 2% of women choosing a caesarean doesn’t explain why nearly one third of births are done that way.

Other reasons have been boldly proposed by some more extreme obstetricians for rising caesarean rates. None of these stands scrutiny any more than “women’s request”.

Litigation
It is frequently claimed that doctors are choosing surgery more readily because of their fear of being sued for a bad outcome – once again blaming women. The fear appears to be real, but whether it is well based is another question.

It is worth pointing out that doctors will be judged against the standards of their peers in cases of negligence. If a case against a doctor is successful, it will be because another doctor, as expert witness, has argued that the defendant’s practice was not up to the professional standard. Thus, much responsibility for the situation lies with the medical culture itself.

Also, recent changes to state laws have made it very difficult to sue for poor birth outcomes, and federal funds are unavailable for large payouts. The difficulties of medical insurance companies have been sorted out, and doctors do have access to insurance which will cover them against legal action. Despite these changes, caesarean rates continue to rise.

Think of the ethical and legal implications of this claim: major surgery with serious consequences is being done on healthy pregnant women purely to reduce a small chance of insured practitioners being sued. If so, how long will this be accepted?

Maternal Age
The increasing age of mothers does have an effect on the ease of birth, but in the Netherlands, where maternal age is also increasing, the caesarean rate is 12% and birth outcomes are excellent. Clearly maternal age is not to blame.

Pelvises
The need for caesareans is often attributed to women’s defective or undersized pelvises, obstructing the passage of the baby’s head, medically titled “cephalopelvic disproportion”.

Australian Medical Association President Dr David Molloy recently claimed that the proportion of mothers with “difficult pelvises” was increasing because so many mothers had been born by caesarean themselves – the rescuing of babies from defective mothers causing a decline in genetic stock.

Around 1% of Queensland births are recorded as being caesareans due to “cephalopelvic disproportion” (CPD). It is very unlikely that more than half of this number actually are due to CPD, and of those pelvises that truly are small, only some will be due to the mother’s genes. So only a fraction of 1% of babies are being born from mothers with genetically undersized pelvises. The laws of genetics do not condemn babies to inherit their mothers pelvis – they are just as likely to have one of their great-grandmothers’ pelvises, which is 99% likely to be beautifully built for birth.

Therefore, simple mathematics means that only a fraction of one percent of women could be inheriting “difficult pelvises”, and the whole genetics argument is simply another way to blame women and their bodies for a cultural problem.

The Real Causes
A look at the evidence shows that we can’t blame women for the caesarean epidemic. If so, then what are they driving factors?

“Model of Care” is how we describe the philosophy and system of care provided by a health care system. It is clear that in Australia, it is our model of maternity care which is pushing women toward surgical birth. Some important elements are:

•    Private obstetricians are frequently heavily booked and overworked, and don’t have the time to wait all night for women to give birth normally.
•    Medicare and private insurance provide financial incentives for caesareans.
•    Medicare gives a monopoly in birth care to doctors, excluding midwives.
•    Taxpayer subsidies to private care are drawing women to private hospitals with extremely high caesarean rates.
•    Models of care designed to support normal birth are not generally available to women in the public or private systems.
•    State and Federal governments have ignored all these problems, and excluded women from policy development.

Real Choice
If, as the evidence shows, most women want a normal birth, then the solution to the caesarean epidemic must be to allow those women to choose a model of care which supports that choice.

Currently the only choices are obstetrician controlled care in a public hospital, or obstetrician controlled care in a private hospital. Queensland women cannot access the choice made by most New Zealand, British, and Dutch women: one-to-one care from a community-based midwife working collaboratively with doctors, obstetricians and hospitals.

Strong evidence shows that for a healthy woman in normal pregnancy, one-to-one midwifery care gives excellent outcomes for women and babies, at lower cost to the health system and with lower caesarean rates. This model has a consensus of support from Australia’s maternity consumer groups, midwifery groups, and nursing groups and unions. In other Australian states implementation has already begun, with support from medical advisory groups.

Time for Change
Some women prefer a caesarean. Their choice must be respected and it appears they have access to that choice. Other women just want to have a normal birth, but our current services are failing to support that preference, causing health funding to be drained by many unwanted, avoidable, and often harmful caesarean operations. It is time to let women into the driving seat of maternity care policy, and allow them to make their own choices in birth.

State branch contacts, for information about meetings, email groups, and how to be part of getting better choices for women is available from the website, or in Queensland email [email protected]