Giving birth

Is the increased C-section rate women's fault?

What's driving the trend to surgical birth

By Holly Bennett
Is the increased C-section rate women's fault?

In 2005, we saw record-high C-section rates in both Canada (25 percent) and the US (29.1 percent), and a sharp increase over rates in the 1990s. Those who’ve been tracking birth trends weren’t surprised to see this.
Recent years have seen a steady erosion of vaginal birth, largely due to a series of studies that narrowed the criteria for a “safe” vaginal birth. Breech birth was the first to be ruled out. Then the opportunities for VBAC (vaginal birth after Caesarean) were reduced with a finding that induction of labour is risky for VBAC moms. (In fact, it turned out that only treatment with prostaglandins significantly increases the risk, but that important distinction was not widely reported.) Guidelines encouraging routine induction of overdue labour at 41 weeks further boosted the chance of Caesarean birth, since induction when the cervix is not ripe may fail, leading to surgical delivery. Next we heard that Caesarean delivery led to less postpartum incontinence. Women could protect their pelvic floor (and, by implication, their sex lives) by avoiding vaginal birth.

What didn’t get reported was that by six months postpartum, differences in incontinence rates disappear. Recent research showing that Caesarean delivery increases the risk of placental problems in subsequent births didn’t get much coverage either. And the long-established risks of C-section, from wound infection to increased postpartum pain, are rarely given more than a passing mention.

It all adds up to a sustained push in favour of Caesarean birth. I’m sure individual research teams did not intend this, but the cumulative impression is that vaginal birth is dangerous, unpredictable and disfiguring. Caesarean, by contrast, appears neat, quick and convenient.
Now that the stats — and financial costs — are out, health professionals are sounding the alarm. Unfortunately, some reports have pointed the finger squarely at…consumers. For example, an Associated Press article about Massachusett’s 31 percent C-section rate opened with, “Public health officials are puzzling over a medical mystery — why thousands of young, healthy women facing low-risk births are opting instead to deliver by Caesarean section.” Only in the back half of the story does one source suggest that, far from being a barrage of demands, consumer-requested sections only account for a small portion of the increase. In Canada, a recent Globe and Mail article laid the blame for our own increased rates on women who are “too posh to push,” while the National Post announced that “more women opting for the procedure have helped drive up the cost of childbirth.”

This kind of response is disingenuous at best: When doctors recommend surgical birth ever more frequently, whether because of truly compelling medical reasons, fear of malpractice lawsuits or research that demonstrates a slim safety advantage along one vector without weighing the entire balance of risk, it rings false to express such consternation at the logical outcome. And it is deeply unfair to lay the responsibility on the shoulders of pregnant women. If women read a barrage of news about the dangers of vaginal birth and hear little about its benefits or the dangers of Caesarean, it’s hardly surprising if some then decide to “let the doctor do it.”

This debate is not about women being “too posh to push.” It’s not even primarily about rigour in the interpretation of research or the complexities of informed consent, though these issues are important. At the core, this is the same debate we’ve been having since the invention of twilight sleep: How do we use the gift of medical technology to save lives and reduce suffering, while still valuing and protecting the powerful human ability to give birth? Until we are able to weigh all the factors in the risk-benefit equation, including such intangibles as emotional health and postpartum adjustment, the scales may continue to tip towards ever-higher rates of Caesarean and other interventions.

This article was originally published on Jul 19, 2006

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