Birth has been a natural phenomenon for longer than humans have existed; as have complications resulting in maternal and neonatal loss.
Photo by Patricia Prudente on Unsplash
Humans have developed a remarkable amount of life saving technology in the past several hundred years- one being birth by abdominal surgery- also known as caesarean section. According to Lindmeier (2018), birth by abdominal surgery is the most common surgery performed worldwide. Caesareans have saved the lives of many, and are essential in cases of fetal distress or fetal malpresentation which cause vaginal birth to be unsafe or impossible.
However, according to Lindmeier (2018), many modern caesarean sections are performed with the absence of medical need. This absence creates serious risks to the health of mothers and their babies, such as disability and even death. It has been well known in the global health community for over three decades that when caesarean sections rise above 10% of documented births, there is no improvement in the mortality rate. Favaro (2018) states that the current rate of birth via caesarean surgery in Canada is one third of all births. Although caesarean surgery can be life saving, the overuse of this major procedure is a threat to maternal and neonatal health when performed without medical necessity.
As stated by Cassidy (2006), although caesarean surgery has been around for hundreds of years, it was primarily only performed when the head of the fetus was stuck in the pelvis; until a dramatic rise in the caesarean section’s popularity in the early 1990’s (2006, p. 107). Cassidy states that ‘’… [caesarean surgery], when performed under the proper conditions, is remarkably safe- even, occasionally, when performed under less than optimal conditions.’’ (2006, p.108). Nevertheless, with vaginal births having a mortality rate of 0.01% (2006, p.116), a caesarean surgery poses four times the risk of physiological birth when not medically necessary.
The rate of caesarean birth started to soar in most developed countries in the late 1980’s-early 1990’s, and has risen to one third of all births in Canada and the United States (Favaro, 2018). In certain countries, such as Brazil, the rate is even higher. As researched by Paula and Chauvet (2013) in the creation of their documentary The Birth Reborn, the national caesarean rate in Brazil is 53%, with certain private hospital rates sky-rocketing as high as 70-90%. ‘’Today, childbirth in Brazil has become a surgical procedure, instead of a physiological event.’’ (Paula & Chauvet, 2013, 12:02). The caesarean rate in Scotland was 24.7% (Butcher, G. 2010) and 43% in South Korea (Cassidy, 2006, p.125.). These rates are vastly higher than the 10-15% rate recommended by the International Health Community (Lindmeier, 2018), beyond which prove no evidence-based support of lowering rates of maternal or infant mortality. What, then, are the factors contributing to the rise in caesarean surgery?
Many caesareans today are planned in advance and are also known as elect caesareans. These caesareans are either chosen by the mother, or by their care provider due to various risk factors.
1) It's the Care Providers Call
According to Cassidy (2006), these risks can stem from a previously existing illness, a pregnancy-induced illness, a placental abnormality, or due to advanced maternal age. Those who delay pregnancy until their mid-late thirties or forties are believed to have an increased likelihood of needing the help of fertility treatments in order to obtain pregnancy, which can lead to more high-risk complications, such as the birth of multiples. Being labeled high-risk for any reason, whether it is due to being pregnant over the age of thirty-five or carrying twins, greatly increases the probability of having a caesarean (2006, p.118). The necessity of planned caesareans is debatable, depending on the reasons for the choice, the information provided by the care provider, and the comprehension and consent of the patient regarding the benefits and risks. In some countries, and in some hospitals, mothers aren't even given a choice, they are simply told that they will have their baby by caesarean section. The main issue is, caesareans are happening to those who do not want them, without medical necessity.
2) Its the Mothers Choice
Elect caesareans have climbed in popularity in the last twenty years and are especially common among childbearing celebrities (Cassidy, 2006, p. 123-124). This has coined the term ‘’too posh to push’’, indicating that caesareans are favored by people who ‘’want to preserve their narrow hips, believe sex will be better, and their babies intelligence won’t be impaired [from the pressure of being born through the birth canal].’’ (2006, p.125-126.). This mentality has branched out of Hollywood and into the modern home, making elect caesareans a trend that physicians are becoming accustomed to. One woman told her care provider that she wanted a vaginal birth, to which he replied, ‘’No Amanda, a natural birth? That doesn’t exist anymore.’’ (Paula & Chauvet, 2013, 17:40). This kind of manipulation from care-providers is not an isolated event and has been reported by many postpartum parents. The societal beliefs that physiological birth will ruin a birthing person’s body, and is pointless in comparison to a ‘’easy’’ major surgery, reinforces the idea that the female body is inadequate in terms of its abilities to safely birth a baby and its abilities to heal postpartum- leading people to believe that surgery is the better alternative, even with greater risks and longer healing periods.
It is important to note that for some people, for a variety of reasons, a caesarean section is the only way that the birthing person can feel comfortable and safe birthing their baby. Birthing people should be supported in their desires and wishes and educated about their options. The facts and issues being examined here are not only the causes of the rise in caesarean sections popularity, but the danger it can pose to those who do not want or need the surgery.
3) Emergency Caesarean
Other caesarean surgeries are not planned, and are referred to as an emergency or ‘’stat’’ caesarean. Cassidy (2006) explains that one of the most common reasons for doctors to perform these unplanned surgeries is due to the inaccuracy of electronic fetal monitoring (EFM). These machines often show ‘’non-reassuring’’ fetal heart tones, even though it is a known fact that these machines are very inaccurate; signalling that a baby is in distress when in fact the baby is in good health. 15% of all labouring people end up with an ‘’emergency’’ caesarean because of these unreliable signals (Cassidy, 2006, p.120-121). With the implementation of more reliable EFM technology, caesareans performed due to fetal distress would be limited to those who are in true danger, and prevent otherwise healthy mothers and babies from exposure to unnecessary risks.
Another cause of unplanned caesareans is called ‘’failure to progress’’, which according to Cassidy, is a ‘’catchall term’’ used if the baby’s head has not emerged through the pelvis within a specific amount of time. Doctors use this term to explain to their patients that the baby’s head is too big to fit through the pelvic opening, or the baby is in a difficult position, or cervical dilation isn’t happening as quick as they would like, or the client has been pushing for too long (2006, p. 120). According to Tiran (2012), Tocophobia, or fear of childbirth, is present in 10% of childbearing people. (2012, p.1). Dr. Sarah Buckley (2010) states that high levels of stress hormones inhibit uterine contractions and can stall or even stop labour. This is a part of the ‘’fight or flight’’ response, which activates the sympathetic nervous system in order to flee from danger and to keep the baby safe in the womb until the threat has ceased (Buckley, 2010, p.5). With the combined research of Cassidy, Tiran and Buckley, it is clear that stress and fear can contribute to ‘’failure to progress’’, and can result in caesarean births that may not have been necessary if the birthing person had the proper support to cope with their fears during labour.
4) Repeat Caesarean
According to Butcher (2010), if one has already had a caesarean, care providers are likely to convince their clients that a repeat caesarean is safer than a TOLAC (Trial of Labour After Caesarean), due to the increased risk of uterine rupture. (2010, p.1). Norton (2013) performed a study where 70% of those who had a repeat caesarean reported that they did not know that the risk of uterine rupture during a TOLAC was only 0.5%. Many US hospitals do not allow TOLAC, due to the fact that they cannot guarantee that staff will be available for an emergency caesarean surgery in the rare event of uterine rupture. (Norton, 2013, p.6). When implemented, TOLAC greatly reduces caesarean rates.
Risks of Caesarean Surgery
As stated by Simkin, Whalley, Keppler, Durham, & Bolding, (2010), risks of caesarean surgery include: a prolonged hospital stay, injury to the bowel, kidney or ureter, infertility, hysterectomy, increased blood loss, rehospitalization, blood clots, infection and postpartum depression-which for some, is caused by the feeling that their body failed to give birth physiologically. There are risks of scalpel injuries to the baby, along with breathing problems, delayed contact with their mother, and admittance to a Newborn Intensive Care Unit. Although it is rare, death is a risk for both the mother and baby. There are higher rates of complications with subsequent children, including placental abnormalities and a doubled risk of stillbirth (2010, p.310). With the overuse of this surgery being evident, ways of reducing excessive caesarean surgeries are being researched.
What needs to be done in order to stop unwanted and unneeded caesareans from happening?
“Information gathered in a standardized, uniform and reproducible way is critical for health care facilities as they seek to optimize the use of caesarean section and assess and improve the quality of care” (Temmerman, 2018). In addition, Tiran (2012) believes that counselling, alongside alternative therapies such as hypnosis, reflexology and hormone-balancing medications can greatly help those suffering from fear of childbirth, and can therefore decrease caesareans performed due to failure to progress. With a compassionate, educational, standardized classification system evaluating each expecting parent’s physical, mental and emotional health, caesareans due to care provider manipulation or lack of knowledge regarding risks, can be reduced. With a more reliable fetal monitoring system and the allowance of TOLAC, even more unnecessary surgeries can be diminished. Caesarean sections must remain a lifesaving alternative, used only when vaginal birth is dangerous or impossible. Caesarean surgery has saved the lives of many, but it is being performed on people who do not want or need it- which can cause disability and death. For the safety of future generations, standardized and compassionate maternity care must be implemented on a global level.
As a Doula and Childbirth Educator, I felt a great need to do this research for my clients, and will continue to do so in the years to come. The work I have done has only scratched the surface. There are copious amounts of information out there, and as always, educate yourself and make decisions that feel right for you. If preventing caesarean surgery is something that is important to you, I highly recommend this article, ''Prevention of the Primary Cesarean Section: Facts, Myths and Tips'' by Vijaya Krishnan.
Thank you for reading,
Sincerely
Jaz Wilson
References
Buckley, S. (2010). Ecstatic Birth: Natures Hormonal Blueprint for Labour. Sarah Buckley.com,
(1-18). Retrieved from: https://sarahbuckley.com/articles/
Butcher, G. (2010). Caesarean section... Just another way to have a baby?
Midwifery Matters, (126), 3–4. Retrieved from https://www.ctvnews.ca/health/while-canada-s-birth-rate-drops-c-section-rates-rise- report-1.3891951
Cassidy, T. (2006). Birth: The Surprising History of How we are Born (p. 103-130). (1st ed.).
New York, NY: Atlantic Monthly Press
Favaro, A. (2018). While Canada's birth rate drops, C-section rates rise: report. Ctvnews.ca, (1).
Retrieved from https://www.ctvnews.ca/health/while-canada-s-birth-rate-drops-c-section-rates-rise- report-1.3891951
Lindmeier, C. (2018). Caesarean sections should only be performed when medically
necessary. Who.int, (1). Retrieved from https://www.who.int/mediacentre/news/releases/2015/caesarean-sections/en/
Norton, A. (2012). Women Lack Info on Labor Versus Repeat Caesarean Surgery. Inside Childbirth Education,6. Retrieved from http://ezproxy.nic.bc.ca:2048/login?url=http://search.ebscohost.com.ezproxy.nic.bc.ca:2048/login.aspx?direct=true&db=awh&AN=91889145&site=ehost-live
Paula, E. (Producer), & Chauvet, E. (Director). (2013). The Birth Reborn/O Renascimento do Parto [Documentary]. Retrieved from https://www.netflix.com
Simkin, P., Whalley, J., Keppler, A., Durham, J., & Bolding, A (2010). Pregnancy, Childbirth, and the Newborn (4th ed.). Minnetonka, MN: Meadowbrook Press.
Tiran, D. (2012). Complementary Therapies can Help Discourage Women from Choosing Caesarean Section due to Fear of Childbirth. Positive Health, (194), 1. Retrieved from http://ezproxy.nic.bc.ca:2048/login?url=http://search.ebscohost.com.ezproxy.nic.bc.ca:2048/login.aspx?direct=true&db=awh&AN=75276142&site=ehost-live