Canada's C-section crisis: Why are rates so high?

It's major surgery that introduces real risks to mothers and babies– so what's being done to lower Canada's ever-rising C-section rates?

Photo: iStockphoto
Photo: iStockphoto

It’s amazing how your carefully thought-out birth plan can change in an instant. I still remember the day, very late in my first pregnancy, when the ultrasound technician announced that my son was breech with one foot down. Next thing I knew, I had a Caesarian section booked for Christmas Eve. The actual surgery was so fast and uneventful—my son and I were in our semi-private hospital room within a few hours—that I blithely opted for another C-section over a vaginal birth after Caesarian (VBAC) for my next baby two years later.

My positivity about C-sections stood in stark contrast to friends whose difficult emergency Caesarians had denied them much-longed-for vaginal births. I wasn’t aware then, though, that by choosing an unnecessary second C-section, I was putting myself and my daughter at a higher risk of injury. Thankfully we were both fine, but I admit it wasn’t a fully informed decision.

What I didn’t know then is that the average total Canadian C-section rate has rocketed from 19 percent in 1997 to 27 percent in 2013, with a wide range between provinces; compare Manitoba’s 22 percent rate to BC’s 33 percent, for instance. Meanwhile, individual hospital numbers climb as high as 47 percent. (Note that these figures combine first and subsequent births.) In the US, 33 percent of 2013 births occurred via Caesarian. Contrast this to the ideal 10 to 15 percent rate recommended by the World Health Organization, which states: “Although it can save lives, Caesarian section is often performed without medical need, putting women and their babies at risk of short- and long-term health problems.”

Like me, you may be surprised to hear these stats and shocked to discover that your likelihood of having a C-section may be determined more by where you deliver than what’s best for you and your baby. Understanding why C-sections have increased, the risks involved, when they are and aren’t necessary, and what some hospitals are doing to address avoidable Caesarians can help you explore all of your birth options. As George Arnold, chief of obstetrics and gynaecology at Markham Stouffville Hospital (MSH), says, “Women need to feel both empowered and comfortable to ask questions about the type of care they’ll receive and about an institution’s induction rates, Caesarian rates and the skill of the people taking care of them.”

Let’s start with the risks. A May 2015 report from the US Centers for Disease Control, which reviewed approximately 3.5 million births, concluded that women who have C-sections are more likely to experience blood transfusions, ruptured uteruses, unplanned hysterectomies and ICU admission.

“For years and years, maternal mortality in childbirth was going down, but now it’s going up for the first time, almost certainly in major part due to the increase and overuse of Caesarian section,” says Michael Klein, emeritus professor of family practice and pediatrics at the University of British Columbia, and a scientist at the BC Child and Family Research Institute in Vancouver. While it’s rare for women to die in childbirth, the increase from three to five deaths per 100,000 births marks a preventable public health challenge.

As for the babies delivered via C-section, they may be arriving prematurely, because of scheduling or gestational age miscalculations or, rarely (between one and two percent), be cut accidentally during the surgery. They’re also more likely to experience breathing difficulties due to prematurity, and have breastfeeding challenges if mom and baby are initially separated or mom’s milk is delayed due to surgery. Researchers are exploring whether babies born via Caesarian are more prone to asthma, eczema, diabetes, obesity or intestinal diseases later in life as well, perhaps because they’re not exposed to certain hormones during labour or immune-boosting bacteria during vaginal delivery. (To offset this, some doctors are studying “vaginal seeding,” where they swab a newborn’s mouth, eyes and skin with its mother’s vaginal fluid immediately after a C-section.)

Despite these risks, medically indicated Caesarian sections can literally be lifesavers for high-risk pregnancies, babies in distress or mothers with health conditions such as pre-eclampsia, diabetes and high blood pressure. Jennifer Whiteford, an Ottawa mother of two, has been there. She was at term and experiencing normal labour for a day before she went to the hospital for her first birth. She was admitted because the baby’s heartbeat wasn’t responding well to contractions. It stabilized for several hours, and then suddenly the fetal monitor showed no heartbeat at all. “Within five minutes, they had me on a stretcher, full emergency, Grey’s Anatomy style, for an emergency C-section,” she says. “It was terrifying, but my baby and I were just fine in the end.”

It’s not the medically necessary C-sections that are worrisome for researchers and health organizations—it’s the routine misuse of Caesarians for low-risk pregnancies that’s most concerning.

Though elective C-sections only account for three to four percent of Caesarians done nationally, says Arnold, many of them may be the result of misperceptions about birth. A 2017 study from the University of British Columbia found that providing women with information about childbirth earlier in life made them less likely to prefer Caesarian sections in healthy pregnancies.

Other contributors to the rising rates of C-sections include older or overweight mothers, bigger babies and an increase in twins and triplets (due, in part, to IVF), though not all of these scenarios necessarily require a surgical birth. For example, Caesarian is often the default recommendation for twin births, especially by younger doctors with little experience delivering twins vaginally; but a recent study of 106 centres in 25 countries by Sunnybrook Research Institute in Toronto concluded that delivering twins by planned vaginal birth is just as safe as delivering them by planned C-section.

Among other influences, improved surgical techniques, perceptions of safety and “physician practice patterns” have also boosted C-section numbers, notes a Journal of Obstetrics and Gynaecology Canada study. The habits and attitudes of doctors and hospital administrators play a huge role, confirms Klein. His 2011 survey of about 850 obstetricians (82 percent of them women) revealed that 20 percent felt that C-section is safer than a vaginal birth for mothers and babies. Interestingly, it was the youngest obstetricians (both men and women aged 40 or younger) who were more likely to choose C-section for themselves or their partners, citing concerns about bladder, rectal or sexual functioning. However, research indicates that pregnancy itself contributes to the pelvic-floor challenges that affect these functions and that the delivery method has little long-term impact.

First-time expectant moms may not be helping to reverse the trend toward C-sections. A UBC study of 1,318 low-risk women having their first baby determined that fewer than 30 percent went to prenatal classes, getting information from the web and books instead. And those with obstetricians were less knowledgeable about epidural analgesia, episiotomy and Caesarian section; while women with midwives were more informed. Many Canadian women have no idea about some of the risks of a variety of procedures, says Klein. As a result, they may mirror their doctors’ attitudes or go along with delivery recommendations without properly considering the alternatives.

The biggest reason C-section numbers are so high: 83 percent of Canadian women who deliver their first baby by C-section have subsequent babies the same way, whether or not it’s medically necessary. Doctors, especially those with less VBAC experience, have a strong tendency to prefer a second C-section over a VBAC, even though up to 75 percent of VBACs will be successful, says Klein. Meanwhile, the risks and the chance of complications rise with every successive C-section, often due to scarring or placenta challenges.

When provincial organizations and hospitals work to better monitor and educate themselves and their patients about the relative safety of vaginal birth, C-section rates and their related costs go down significantly. (The hospital cost for a Caesarian is about double that of a vaginal birth.) A comprehensive Quebec study found that hospitals taking part in a C-section review program, including audits and on-site training, had fewer Caesarians in low-risk pregnancies and fewer complications for newborns. Lead author Nils Chaillet, associate professor of obstetrics and gynaecology at the University of Sherbrooke, noted that measuring the effectiveness of various delivery methods highlights opportunities to reduce unnecessary procedures, benefiting women and children alike.

Studies like this and research initiatives by groups such as Alberta’s Perinatal Health Program and BORN—Ontario’s birth and pregnancy registry—are shining a revealing light on the factors behind C-section rates, while individual hospitals like MSH are mining their own data. Four years ago, faced with budget cuts and a C-section rate of 29 percent, Arnold and former colleague Joanne MacKenzie began considering possible efficiencies. “We thought if we can lower our Caesarian rate, for each section we could do two vaginal deliveries for the same amount,” he says. “So we could do the same number of deliveries without any cut to our budget and improve our quality of care in the process.”

Noting that induction (as opposed to spontaneous, natural labour) tends to increase the likelihood of needing a Caesarian, Arnold and his team lowered MSH’s C-section rate by halving the induction rate from 30 to 15 percent. They will still induce when it’s medically required, of course, but if both mom and baby are good according to ultrasound and other indicators, they won’t induce now until 10 days past the due date. The hospital also began sharing individual physicians’ C-section rates among the team, says Arnold, to allow OBs an opportunity to compare themselves to others with similar practices and then ask themselves, “Is there something in my practice that could be changed to lower my rate and maintain or improve the quality of my care?” Today, MSH’s C-section rate is down to 23 percent (from 29 percent). Similar processes are taking place at other Canadian centres, including Toronto East General and Children’s & Women’s Health Centre of British Columbia. Plus, research and guidelines on safely decreasing Caesarian sections from provincial bodies and the Society of Obstetricians & Gynaecologists of Canada are plentiful. Yet rates still vary widely across the country.

Education about VBAC has also been a focus—not enough women know it’s a viable option, and some doctors may not encourage discussion. MSH holds monthly classes offering objective information about VBAC—and the majority of those who attend end up choosing it, because they realize it’s safe and successful for about 75 percent of women nationally and 85 percent of MSH patients, says Arnold. Additionally, women who deliver via C-section are fully informed about the reasons for their surgery and are told why VBAC may be possible and beneficial the next time. Their first baby may have been breech, for instance, which happens about four percent of the time, says Arnold. “Those women are very good candidates, provided that their next baby is head down, to try vaginally.” Mothers booked for a repeat C-section who are healthy and dilating well will be told whether a safe vaginal birth is possible, in case they want to try. As a result of these efforts, VBAC rates at MSH sit at 29 percent, compared with about 17 percent nationally, with no increase in birth trauma for mothers or babies.

It was this kind of reassurance that convinced Whiteford to go for a successful VBAC with her second baby. “The nurse came to see me right after my first had been born, and said, ‘Don’t let them tell you that you have to have another Caesarian,’” she says. “It was the first I’d heard of there being any other possibility.” Speaking with an acquaintance who’d had a VBAC and finding a supportive physician and doula, who both outlined the risks and benefits, helped confirm her choice. “My doctor did a good job of not panicking us—letting us know that she was on our side and that VBAC was completely possible.”

Whether you’re pregnant with your first or third child, it’s crucial to talk to a range of doctors, experts and hospitals so you can choose the ones that best align with your delivery preferences. Every birth is unique, and circumstances may lead to a different delivery than you expected, but you won’t regret that research. And while it’s great to see individual hospitals and regions actively lowering their rates of C-sections in low-risk pregnancies, more needs to be done.

A kinder caesarean
Hospitals in the US have offered “gentle Caesarians”—which allow babies to be placed on and held by their mothers sooner than with typical surgical delivery—for several years. Now skin-to-skin Caesarians are being practised and studied at Sunnybrook Health Sciences Centre in Toronto. With this procedure, the newborn is placed on the mother’s tummy after birth and pushed up to lie on her chest for 10 to 20 minutes. (This means the umbilical cord doesn’t need to be clamped right away, either, which may be beneficial.) Skin-to-skin contact immediately after birth boosts babies’ health and also promotes bonding and breastfeeding, says Jon Barrett, Sunnybrook’s chief of Maternal-Fetal Medicine. The technique can only be used for certain deliveries, however, and requires extra medical staff as well as further study.

A version of this article appeared in our November 2015 issue with the headline “C is for Crisis,” pp. 74-8.

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