Why are caesarean section rates increasing so rapidly?


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I just placed this comment at Andrew Leigh’s blog, but I thought I would open up the floor here.

Commenter conrad asked about the rapid increase in cesarean section and birth intervention rates in Australia:

Just out of interest Lauredhel — why is there such an increase? I believe it is pretty much a worldwide phenomena, including places with the lowest death rates in the world (like Singapore & HK), where I believe it isn’t nearly as easy to sue your doctor, unlike Aus or the US, so the obvious reason (it happens to avoid litigation) is ruled out.

My off-the-top-of-the-head response went thus:

conrad: that is an enormous topic, and one that I don’t think it’s appropriate to address in detail in comments here. Very briefly, there is a confluence of factors (any one alone would be insufficient, and they are inter-related), including:

– the institution of medicine taking control of birthing and women’s bodies,

– technology that allows most women to come out alive from surgical delivery,

– a set of cultural beliefs around all vaginal birth being “messy” and “uncivilised” and “torture”,

– a set of cultural beliefs around surgery being “clean” and “quick” and “easy” and “painless”,

– legal issues (which are about what is likely to meet with acceptance in a court of law, not about what is actually safer),

– non-rational assessment of relative risks when the risks differ in nature,

– a multitude of false ideas about birthing mechanics, and now,

– an acceleration based on the unsupported idea that “once a caesarean, always a caesarean”.

And, I might add here, there are at least two reasons that are NOT why C section rates are increasing:

– women are “too posh to push” these days, they demand them

– C section is safer and less traumatic for mothers and babies

So, the floor is open. Why do you think birth intervention rates are rising so rapidly? And what can we as a society do about it?

A note on terminology: all of the following are birth interventions (the list is not exhaustive):

– cesarean section
– induction of labour
– augmentation of labour
– artificial rupture of the membranes
– vacuum delivery
– forceps delivery
– episiotomy
– epidural analgesia
– narcotic analgesia
– coached pushing
– continuous fetal heart rate monitoring
– restraint of any kind
– routine vaginal examinations
– withholding of food and/or fluids
– random people coming in and out of the room
– coercion of any kind
– encouragement to birth in a supine, lithotomy or sitting position
– the deliberate instilling of fear
– any statement about what the birth attendant will or will not “allow”

Categories: gender & feminism, medicine

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11 replies

  1. 1. Because it’s easier for doctors to do surgery than deal with the unknown. I’m not suggesting doctors are consciously slack here, just that human nature is to take the known risk rather than an unknown. I wonder how many of our doctors have even seen a birth without any of those interventions you’ve listed.
    2. We don’t trust midwives and their skills. Most women don’t need to see a doctor at all, we need them to be around ‘just in case’, and yet most women do see a doctor.
    Everyone I’ve known who had intervention in their birth, especially surgery, was told their baby could/would die without it. It takes a pretty strong woman to decline at that point. I think there’s some pretty rotten doctor-patient relationships in this country, and it’s about time doctors (not just obstetricians, all varieties of doctor) took responsibility for it.
    A midwife at the birth centre where I had my son does work in PNG for a few weeks every year. She is perfectly capable of assisting in the delivery of twins there naturally, and safely, but as soon as she returns to Australia she isn’t. Our whole system (funding, the design of hospitals, insurance) makes it impossible for women to give birth in the way they want, with the assistants they want. It’s bad for individual women, and it’s terrible public policy. It’s also much more expensive than it needs to be.

  2. I put up a big post on the myth of c-sections for maternal convenience a while back. It’s … let’s see … ah. Here:
    I very much liked the soundbite answer to the question of why c-section rates are rising that you provided in comments there.
    Brooklynite’s last blog post..Race, medicine, and the hidden history of the United States.

  3. I very much liked the soundbite answer to the question of why c-section rates are rising that you provided in comments there.

    Wow, you’ve got a memory like a … thing with a really, really good memory. Mind if I grab that comment over to here, too?

    My impression is that a lot of obstetricians really have bought into their own mixed-up medicolegal nightmare. They are completely convinced that C section is the default safe choice, the norm to which all other births must be compared, that they’re complication-free so long as the mother doesn’t peskily and wilfully go into labour first, and that whatever coercive techniques they use to secure an elective C section are strictly necessary for the delivery of a live child.
    There is even a school of thought amongst some OBs that “nothing good happens” after 38 weeks, and that all pregnant women at that time should be either summarily sectioned, or peremptorily induced (followed of course by section in a huge number of cases for inducing on an unripe cervix plus failure to wait).
    Reading the OB-GYN list is a salutary lesson in mass self-delusion.

  4. Not such a good memory — I just remembered that I’d written about the maternal convenience thing a while back, and flipped through the posts filed under my “childbirth” tag until I found it. I had a hunch you’d weighed in at the time, but didn’t remember what you’d said until I saw it again.
    Brooklynite’s last blog post..Race, medicine, and the hidden history of the United States.

  5. People interested in the topic might like to also check out the ensuing discussion in my personal blog, here.

  6. Hello, just wanted to weigh in.
    To me, every birth has an amazing amount of energy. Making yourself indispensable to the “safe passage” of this birth, puts you in the room.
    When usurping the power of a woman to birth naturally, the western medical model must be better than nature. Most of our culture would say that the “civilised world” is better than nature. I wonder how sustainable that thinking can remain.
    Perhaps in the end, it’s all about whom you trust, yourself? natural design? or the western medical model? Going into one of the most life changing experiences, we look to what we trust.
    When the western medical model presents itself as “THE Authority” of YOUR body, whether in a birthing situation or any other, threatening the possibility of death (culturally a very charged fear), its a mighty force to ignore.
    “It’s not just the making of babies, but the making of mothers that midwives see as the miracle of birth.”
    — Barbara Katz Rothman, Sociologist, Author of The Tentative Pregnancy, Genetic Maps and Human Imaginations and other books.
    from http://inamay.com/archive
    Herein lay the greatest tragedy of the rise in C-sections, women not trusting themselves and never knowing their own power to birth.
    Coming back to your question, WHY? because there is an entire industry, in fact MANY industries, dependent on the C-section.
    (I’ve not been reading your blog long so please forgive me if this is old news..)
    I had a home birth, water, near 16 years ago. For a while there, when I was listening to many womens stories, I held mine back, because my story was so beautiful, so powerful, and SO many women don’t have that story… But not NOW, for the hidden side effect, the story you tell your children of their birth, is rarely seen.
    Thanks, didn’t know I had quite so much to say…
    Katherine Cunningham’s last blog post..Spirals of thought and pleasure

  7. Because it’s schedulable. You know how men’s house chores tend to be the schedulable ones, like taking out the trash, and women’s tend to be the ones that just have to get done when needed/immediately? Well, I think the same thing goes for C-sections.
    They’ve done studies that show episiotomies increase on Friday afternoons. The theory goes that the doctors would rather cut than wait. So I’m betting it applies to C-sections too.
    Elaine Vigneault’s last blog post..Gay Marriage and Sperm Control

  8. Katherine, no worries at all mentioning the Business of Being Born – I’m hoping to post a review here once I get to see it.

    Perhaps in the end, it’s all about whom you trust, yourself? natural design? or the western medical model? Going into one of the most life changing experiences, we look to what we trust.

    I think it’s possible to have a synthesis: to trust natural design, and to have a backup plan. The ‘western medical model’ has the potential to embrace and include midwifery caseload/woman-centred care, homebirth, birth centre birth, non-interventionist birth, and it does in some places. In those places where it doesn’t, the practitioners are in fact NOT practising the “western medical model” in an intellectually honest and scientifically consistent way, since their practices are not evidence-based. See the post I just sent on the WHO’s idea of appropriate birth care.
    I was just thinking a few days ago that that trusting nature was exactly what I was doing, when I had a couple of family members tromping around up on the roof doing handyman stuff. (New pergola roof! Yay!) There was a non-zero risk of one of them falling off (either slipping, or experiencing a medical event and falling), and injuring themself in a life-threatening way. (They were not two perfectly young, fit, and perfectly medically healthy people.)
    But our basic expectation was that their bodies, balance organs, and judgement would likely keep working for the duration. Our precautions didn’t consist of having an ambulance parked outside the house; they consisted simply of having one responsible, competent adult not on the roof at the time, who could keep an eye on things, call for help and administer interim emergency care as needed.
    And that’s all most births in Australia need.
    Lauredhel’s last blog post..The WHO on Birth: the ?Fortaleza Declaration? and ?Safe Motherhood: Care in Normal Birth?

  9. I had an emergency caesarian. I still don’t know if it was ‘necessary’ – at the point of surgery it was, but I don’t know if the cascade began when I was induced several hours earlier due to a very low birthweight baby.
    I’d say two ‘valid’ reasons for the increase in caesars is the increasing number of women over 40 having their first baby and increasing number of conceptions via IVF (both of which applied to me.) IVF conceptions tend to result in difficulties at delivery due to things like low birthweight, placenta previa etc, and then there are the fertility problems which lead women to IVF which can also make vaginal delivery hard or impossible.
    susoz’s last blog post..reno rage

  10. Susoz, both those reasons for a slightly higher rate of c-sections in affluent countries seem quite likely. Unfortunately, those cases would hardly account for our drastically elevated c-section and other intervention rate.

  11. I think another factor is that we’ve lost hold of the reality that not every birth is going to result in a perfect, live baby.
    There’s an expectation now, which there used not to be, that if you get to the end of a pregnancy, then you get a normal, healthy baby. It’s like it’s a right. It’s probably partly because of prenatal testing, partly because babies and mothers dying is actually a lot more rare than it used to be (for various reasons, most of which have nothing to do with the medical model of childbirth) so most people haven’t had someone they know affected by a death during childbirth, and partly a sort of overall sense of entitlement that we deserve things.
    People used to understand that sometimes not everything goes right, that sometimes babies die, that sometimes they’re disabled. But I think a growing wish to ignore that reality is partially responsible for the c-section rate. Partly because doctors are not willing to take the ‘risk’ if they perceive there is one with a vaginal birth, and they think c-sections are less ‘risky’ (in the face of the available scientific evidence, mind you), and partly because women have been brainwashed into thinking, like doctors, that a c-section is the “safest”, that it guarantees them a healthy perfect child.
    Rebekka’s last blog post..Useless help desk monkeys

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