Back in 2007, I wrote about Western Australian birthing statistics, based on the 2005 statistics that had just been released at the time.
New data is out since then, for 2006 and 2007, in which the much-touted “epidemic” of old mothers and fat babies again fails to cause problems.
Quite the contrary, in fact! I’m pleased to report that my worries that a skyrocketing intervention rate could continue have failed to come to pass. Instead, with a lot of hard work from mother-baby advocates, the maternity care conversation in Western Australia in the past couple of years has become more focused on how intervention rates can be reined in, though there are plenty of dissenters. Public hospitals are edging toward encouraging or at least ‘allowing’ vaginal birth after C section, which has the potential for a huge impact on C section rates, with nearly half of C sections done simply because te woman had a previous C section.
There are lots of ifs and buts and caveats on this, but it seems that our healthcare system seems to be inching toward a better understanding that More Isn’t Better, and that we haven’t yet reached the mooted runaway point with obstetric interventions.
Let’s have a look at what’s happening to some of those key intervention and mortality figures in Western Australia.
Here are the data on Caesarean section rates in Western Australia for the past three years. The increase has stopped, and C sections in fact slightly down across the board, even in private hospitals. “Elective”* C sections before labour onset have reduced particularly.
Cesarean section rate:
2005: 33.9%
2006: 32.7%
2007: 32.7%Private hospital C section rate:
2005: 45.7%
2006: 44.1%
2007: 43.0%Public/Departmental hospital C section rate:
2005: 27.9%
2006: 25.4%
2007: 24.3%Teaching hospital C section rate:
2005: 31.1%
2006: 30.7%
2007: 33.0%Percentage of women having C section who never experienced labour:
2005: 65%
2006: 64.5%
2007: 61.8%
Perinatal mortality trends may disappoint the hardcore Vaginal Bypass and Dead Baby Card fans, as this decrease in C sections has coincided with a decrease in perinatal deaths:
Perinatal deaths:
2005: 10.1 per 1000
2006: 9.5 per 1000
2007: 8.3 per 1000
Episiotomy stats are still absurdly high. There is no evidence-based reason for this many episiotomies.
Episiotomy:
2005: 17.8%
2006: 17.4%
2007: 17.3%
Spontaneous labour is up, and induced labours and augmentations are down:
Percent of women who went into labour spontaneously:
2005: 49.4%
2006: 51.1%
2007: 52.3%Induced labours:
2005: 28.6%
2006: 27.8%
2007: 27.5%Augmented labours (of spontaneous labours):
2005: 49.4%
2006: 40.2%
2007: 41.4%
Lest my enthusiasm for the arrest of runaway interventions be overwhelmingly, let’s still remember that there’s a long, long way to go yet. Fully half of women birth surgically, with episiotomy or C section, and the number of women who experience major birthing intervention is still above 75%.
Women birthing with a surgical incision (abdominal or vaginal)
2005: 51.7%
2006: 50.1%
2007: 50%Labour without augmentation and with spontaneous vaginal birth:
2005: 22.7%
2006: 23.6%
2007: 23.5%
~~~
* In quotes because many people (mis)understand “elective” to mean “too posh to push”. Elective C sections are simply C sections planned in advance, and very, very few are due to maternal choice.
Related Posts:
- Western Australian birth statistics. by Lauredhel
- That Homebirth Study in South Australia by Lauredhel
- Why are caesarean section rates increasing so rapidly? by Lauredhel
- Hutton’s Ontario Homebirth/Hospital Birth Study by Lauredhel
- Reducing major surgery by 80%: why are surgeons not interested? by Lauredhel
* Quicklink to recent open threads
bluemilk: 
mindyhoyden: 
vivsmythe: 
CastIronBalcony: 
puzzlement: 
ChallyWrites: 
ilauredhel: 
Indeed, but thanks to you and other advocates all the same for beginning to turn the trend around. I look forward to seeing birthing practices with much lower rates of interventions (and for those women for whom intervention is necessary, evidence based assessment, informed discussions and holistic consideration of the mother’s wellbeing).
Are there breakdowns by type of hospital for the other interventions?
Rebekka: Good question. I can see a breakdown for assisted delivery (quite a lot lower in public hospitals), but not for other interventions. It’s important to remember also, when reading the stats, that private hospitals deal with a much wealthier and significantly healthier population, and turf very high risk births (very preterm, etc) off to public hospitals.
How very interesting. Thank you for sharing, breaking down and graphing. :-)
This is a really interesting breakdown, but one thing irritates me – the classification of an episiotomy as ‘surgical’ birth and the conflation of Caesarians with episiotomies. The two could not be further apart.
I had an episiotomy and it was one cut, with a pair of scissors, by a midwife, in a natural birthing centre during a natural birth. It was done because my skin steadfastly refused to tear ‘naturally’ to allow my nearly-ten-pound baby to pass through. My birth was no less natural or more ‘surgical’ than any other woman who had torn naturally.
To classify my natural birth experience which included an episiotomy in the same breath as a Caesarian is frankly a little insulting. :o/
Anji it’s pretty unusual for a perineum to “need” cutting. You’ll find a midwife like Gloria Lemay, for instance, may have done one or two in a 40 year career. The frequency with which it occurs in clinical settings makes it hard to see when one *could* be necessary. Good midwives go with “wait, wait, wait, wait, wait some more” with crowning babies who can crown for many hours and it’s totally normal. Hospitals don’t let babies crown for hours. They just don’t.
But a few other things in brief:
The venue/performer really doesn’t make the cut to a perineum more acceptable, does it?
How is an episiotomy “natural”?
And why is a caesarean something insulting?
There’s nothing even remotely “natural” about cutting a perineum with scissors, regardless of need. There’s nothing remotely “natural” about surgery of any kind. My caesarean wasn’t more “natural” because it came at the end of 30 hours of spontaneous labour and a transfer from a homebirth.
I think the consent of the mother makes a cut to the perineum more acceptable. I can understand that given the choice of crowning a 10 pound baby for hours or a cut and stitches that many women would choose the episiotomy. I think in a birth centre that the decision would more likely be left up to the mother. As far as interventions go I don’t think it rates very highly.
Mindy, it seems to me that what blessed is trying to draw out is whether calling something a surgical birth is the same thing as insulting that birth, per Anji’s: “to classify my natural birth experience which included an episiotomy in the same breath as a Caesarian is frankly a little insulting”. I don’t know what Anji intended, but it doesn’t seem to me as a reader to be a big leap from that to “ew, women who had Caesareans, what crappy birthers/mothers they must be.”
I gather the idea is not so much to allow people to stand in judgement of individual women: Becky had eclampsia and her emergency Caesarean was therefore sad but morally acceptable, Susie had a 5kg baby and her episiotomy was therefore sad but morally acceptable, but Jenny with her 4kg baby and healthy kidneys should morally have had a no intervention birth. That seems to be kind of where this conversation is sliding. (Rather like the temptation to get into “Becky had a double mastectomy and therefore it’s sad but OK for her to use formula” but “Susie had one bout of mastitis, she is morally required to continue breastfeeding” when the real question is why, given the evidence for the benefits of breast milk, there isn’t a milk bank for Becky to draw on and lots of care and support and consistent advice for Susie and let’s see where that gets breastfeeding rates to.)
Instead, the principle for me at least is a default birthing culture which fully integrates the growing understanding that routine interventions are at best useless and often in fact harmful. The numbers Lauredhel gives show essentially all of these interventions being regarded as routine by many, most or nearly all birth attendants. Instead they may be indicated for certain particular circumstances, which there are valid arguments about, but the temptation to get into those arguments perhaps misses the original point that few birth attendants currently regard them as responses to particular pregnancy and birthing circumstances and instead as regard them something that should be part of everyone’s birth, because, hey, won’t hurt anyone even if it wasn’t needed.
@ Mary – I can see what you are getting at.
I don’t think I can add anything more to the discussion by getting into my interpretations of what someone else said/was feeling/ did, so I’m going to shut up now.
Mindy, while I agree that the informed consent of the woman makes any intervention more acceptable, I’m puzzled why you would categorise having your vagina cut open as a “minor” intervention.
I think you’re probably right that most women would choose it in the circumstances you’re talking about, but I’m not sure it’s an informed choice. The evidence shows it’s better to tear (it’s likely to be more superficial, it heals better, and it results in less long-term damage), and hospitals are certainly hurrying things along rather than letting the physiological process unfold in its own time.
Episiotomy increases the risk of anal sphincter laceration, third-degree perineal injuries, urinary incontinence and sexual dysfunction, among other things. It might seem like a small thing, but it’s really not.
@ Rebekka – having had my belly sliced open twice colours my perceptions of these things. I agree that having an episiotomy is not necessarily a choice made in a calm and considered manner and that the complications can be many.
My main concern was that Anji didn’t go away feeling that silence on the thread indicated that the general consensus was that any intervention = a bad birth. Nor am I trying to imply that that was what Blessed meant, just that it struck me that it could have been read that way.
Mindy, I totally concur that intervention != bad birth. Intervention can be both necessary and life-saving.
But I also know that women can suffer PTSD after an intervention-filled birth, and that in the majority of cases, unfortunately, the intervention is neither necessary nor life-saving.
It’s certainly true that a caesarian is a “bigger” intervention than an episiotomy, but both are still a woman’s body being cut – a “surgical incision”, as the report puts it – and an episiotomy is, though smaller, in a more sensitive spot. I absolutely understand why the authors of the report have equated the two – and I support their doing so, as it helps to deconstruct the lie that a woman having her genitals sliced open is just a “minor”, “routine” thing and not a “serious” intervention.
I think the ‘silence’ (well, for me) had more to do with it being overnight than anything else :)
Mary has said more or less what I was going to say, however. I’ve tried to avoid invoking the naturalistic fallacy in this series of posts, but it’s bound to come up; I’ve also tried to avoid an individualistic approach, as I’m not in the business of passing judgement on every individual birth. A statistical approach is, I think, far more enlightening and useful for what I’m trying to achieve.
I don’t judge your birth, Anji, or slap any moral labels on it, any more than I slap moral labels on people who’ve had their gallstones removed or skin cancers cut out! I have no idea whether your episiotomy was necessary; that’s between you and your midwives.
I do think calling an episiotomy a surgical operation is a fairly straightforward sort of thing. It’s a significant incision, cutting through skin, vaginal tissue, subcutaneous tissue, and sphincter muscles, and needing multi-layered repair. It isn’t as major as C section, but it’s still an operation. The obstetric profession has worked very, very hard at calling it “just a little snip” and convincing us that’s it’s not really an “operation”, not really an “intervention”, just one of those routine little things mothers go through. I’m not buying what they’re selling.
Useful in certain constrained circumstances? Sure. Used far more often than it needs to be, and more often than is optimal? Absolutely.
ETA: I dragged out my Williams Obstetrics, 1985 edition, to see how OBs talk about it amongst themselves. The author addresses the terminology, stating that “perineotomy” is what is typically performed. He states:
“Except for cutting the umbilical cord, episiotomy is the most common operation in obstetrics.” [Things have changed since then, with C sections soaring to nearly double the episiotomy rate.]
He goes on to claim that episiotomies heal better and reduce vaginal prolapse, which are patently false claims.
[...] into the hands of the actualy people involved – pregnant women. As Lauredhel’s posts on WA statistics on birthing intervention and Canadian statistics on injuries associated with home, birthing centre and hospital births – the [...]