Is normal birth at risk?

With C-section rates at an all-time high and the list of contraindications for vaginal birth growing, critics worry we're headed back to the bad old days of birth as a medical procedure. What does it mean to you, the pregnant woman?

/p> Vicki Van Wagner jokes that one day she and her peers may perform the same function as ecotourism hostesses, escorting clients through a corner of the world that’s teetering on the brink of extinction. As a midwife, Van Wagner helps expectant mothers safely navigate “normal” birth by charting a course around unnecessary medical interventions, but today, births that steer clear of technology have become —statistically speaking — abnormal.

According to the latest figures from the Canadian Institute for Health Information, three of four Canadian women who gave birth in 2001/02 underwent some kind of medical procedure. Nearly half — 45.5 percent — used epidural anaesthesia, and the C-section rate hit an all-time high: 22.5 percent of hospital deliveries. The induction rate also climbed: One woman in five had labour artificially induced, versus one in eight a mere decade ago. While women once fought for the right to drug-free delivery, today’s headlines debate whether expectant mothers should have the right to request Caesarean for non-medical reasons.

Have Canadian women evolved in such a way that our bodies can’t push babies into the world without assistance? Or are we simply, as one Internet blog puts it, “too smart to suffer”? Are women making truly informed choices, or has our society sold us a bill of goods about the benefits of birth interventions? Today’s Parent Pregnancy & Birth asked several experts to consider what has changed Canada’s childbirth landscape — and what to keep in mind when you’re planning your baby’s birth.

Demographic Factors
Some experts blame the rising intervention rate on the fact that today’s expectant mother is older and fatter than earlier generations of women were when they started families. In 1991, only 34 percent of Canadian babies (excluding Ontario) were born to women older than 30, but that group grew to 42 percent of all newborns by 2000. And, according to population surveys, the average woman is also packing a few more pounds. Most experts agree that we do become more likely to encounter certain problems during pregnancy and birth as we age, and some studies suggest obese women tend to labour longer than their slimmer sisters.

However, physicians like Philip Hall don’t believe demographic factors alone can account for the dramatic upswing in interventions. “I think it’s a factor, but a minority element,” says the professor of obstetrics, gynaecology and reproductive sciences at the University of Manitoba and director of fetal assessment at St. Boniface Hospital in Winnipeg. Van Wagner echoes his assertion, noting the same move to older motherhood has occurred in Scandinavian countries that have nonetheless maintained low intervention rates.

But that doesn’t mean demographics aren’t affecting the C-section rate: according to Hall, some research indicates simply labelling a woman “high risk,” due to age or another factor, doubles her odds of surgical delivery, and there’s scant evidence these interventions improve the health of babies or mothers.

Our Changing Health Care System

Less experienced labour support
Health care cuts have forced many labour wards to make do with fewer nurses, who, due to the widespread use of epidurals, may have little experience helping women through labour without medication. “There are qualified, competent nurses who do not have enough experience looking after women who have not had an epidural,” notes Michael Klein, emeritus professor of family practice and paediatrics at the University of British Columbia in Vancouver. Nor does our system reimburse other health professionals — such as family physicians — for spending hours at the side of a labouring woman.

Why might that make a difference? One-on-one care — by a doula, midwife or nurse who’s experienced at providing support during labour — significantly reduces a woman’s odds of needing pain medication or encountering other interventions, including C-section, says Jan Christilaw, head of specialized women’s health at BC Women’s Health Centre and former president of the Society of Obstetricians and Gynaecologists of Canada (SOGC).

Hospital closures
Ivy Lynn Bourgeault, associate professor of health studies and sociology at McMaster University in Hamilton, notes health care restructuring has also caused many maternity units within small community hospitals to close their doors. Consequently, many women in rural areas are forced to travel long distances to give birth. Bourgeault observes that particularly in winter, these mothers may opt for induction rather than face the possibility of driving for hours in an emergency.

Fewer family doc deliveries
Exorbitant malpractice insurance for doctors doing obstetrics and a demanding, unpredictable lifestyle are driving family physicians out of the baby business: Between 1996 and 2000, the proportion of Canadian vaginal births attended by family doctors dropped from 44 percent to 39 percent. Midwifery programs aren’t currently producing enough graduates to take up the slack, so obstetricians are catching more of Canada’s babies. Since family doctors and midwives as a group may be less likely to use interventions than their specialist colleagues, this changing of the childbirth guard could be swelling the numbers of birth-related medical procedures.

Epidural “Epidemic”
Use of epidural analgesia has become increasingly common over the past 20 years, partly because many more centres now provide this service, observes David Young, professor and head of obstetrics and gynaecology at Dalhousie University and the IWK Health Centre in Halifax. “Certainly your epidural rate is low if you don’t offer it,” he observes.

Nobody’s going to argue that enduring hours of agony is preferable to pain relief. However, Klein argues that if epidurals are administered too early in labour, they can slow progress and significantly up the odds of further interventions.

The Research Issue
Over the past dozen years, several large-scale studies have dramatically changed the way many doctors approach situations such as pregnancies lasting longer than 40 weeks and breech birth. Today, many caregivers routinely induce labour at 41 weeks and recommend C-sections for breech babies, based on the belief that these practices reduce the already slender odds of stillbirth. Young hopes these higher intervention rates will instill confidence because “we’re making advances that are responding to evidence.”

The use of research to determine the benefits or risks of interventions is welcome progress. However, some physicians have begun questioning how some studies have been interpreted and applied in everyday practice. When a trial is published, charges Hall, many caregivers “don’t take the extra step of looking carefully to see if there’s more fertilizer than roses in it.”

For example, in an analysis of several studies (involving more than 3,000 women) comparing induction at 41 weeks to waiting for labour to start naturally, five of seven baby deaths in the “wait for labour” group (versus a single stillbirth in the induction group) were unrelated to pregnancy length alone. “So the evidence that it is ‘safer’ to induce at 41 weeks is not as strong as it appears at first glance.”

And while some study authors assert that inducing labour doesn’t increase the odds of C-section, scientists like Hall and Klein also find fault in the way the underlying figures have been analyzed. One trial, for example, categorized women according to whether researchers intended to kick-start their contractions. In other words, a woman slated for induction was lumped with that group even if she went into labour naturally before her induction date. Once the numbers are reshuffled to reflect whether women really were induced, says Hall, C-sections were less common among women whose labours started spontaneously.

This conclusion is borne out by statistics from BC Women’s Health Centre. “In our institution, a woman having her first birth who goes into spontaneous labour has an eight percent chance of Caesarean,” says Klein. “If she has an induction, it’s 44 percent.”

Social Attitudes
Media portrayals of vaginal birth are often hair-raising — after all, writers and producers choose plotlines for dramatic punch. “When you see obstetrics on television, it’s disaster TV,” observes Christilaw. These stories, and the growing list of indications for Caesarean, can send us the message that vaginal birth is dangerous.

“That’s a socially created fear that’s unconnected with reality,” stresses Barbara Katz Rothman, author of In Labour, and professor of sociology at City University of New York. She compares this gulf between perception and reality to the way many of us are more fearful of flying than driving, “even though intellectually, we understand it’s safer to fly.” In the same way, she argues, some women have a disproportionate fear of labour and vaginal birth, and lend far less weight to the risks of surgery.

Craving control
Why? Just as holding the steering wheel gives us the illusion of being in complete control while we’re driving, scheduling a C-section or an induction may make some women — particularly those who’ve waited until later in life to become pregnant — feel more in charge than waiting for contractions to start. “As we get older — I’m speaking as someone who’s older and slightly obsessive — we may feel the need to try and control those factors that are not really controllable,” observes Debbie Penava, assistant professor of obstetrics and gynaecology at the University of Western Ontario in London, and the chair of women’s health policy for the SOGC. We’re also far more frightened of the unknown than the familiar, and many of us have undergone some kind of minor surgery before becoming mothers, but never had an opportunity to witness a woman give birth.

Trust in technology
At the same time, magazines run stories about celebrities choosing to forgo labour, and reality shows like Extreme Makeover glamorize surgery as a quick fix, while glossing over the potential perils. Our love affair with technology may make C-section seem like a civilized, squeaky-clean alternative to a messy, mysterious (albeit miraculous) and sometimes unpredictable natural process.

Preference for predictability
Indeed, for some women, predictability is a selling point for induction or planned Caesarean. In fairness, sometimes the desire for an ironclad delivery date is more than a matter of mere convenience: For example, since our society offers little support for new parents, those needing help with household chores or child care in the first weeks may feel the need to coordinate Grandma’s plane reservations with the baby’s arrival.

Add to these influences the controversy over whether C-section can prevent urinary incontinence (experts are still duking it out over that question) and it’s easy to understand why some women might want to skip directly to the OR. However, you may pay a price for booking your baby’s birth-day: Women who undergo Caesareans can’t resume normal activities until weeks later than mothers who give birth vaginally, and C-section moms are more likely to experience serious infections and pain in the first weeks of motherhood.

And while a Canadian mother’s chance of dying during either type of delivery is very slim, recent figures suggest C-sections multiply the risk fourfold. Experts are still debating whether operative or vaginal birth is safer for babies in selected situations, but C-section does seem to increase a newborn’s chances of experiencing breathing problems in the first days of life and may increase the likelihood he’ll eventually develop food allergies. Growing evidence also suggests an operative birth increases the risk of stillbirth and other complications in subsequent pregnancies.

What Does This Mean to You?
Having four out of five of your friends undergo interventions during labour can seriously undermine your confidence that you can get through the experience without a technological assist. But if you do want to avoid unnecessary interventions, several strategies may improve your chances:

Get informed
If you’re reading this article, you’ve already taken the first step toward learning about the options open to you, then deciding what’s best for you and your baby. The next order of business? Gathering more information from resources such as the websites listed below. Klein suggests books by Sheila Kitzinger or Penny Simkin, whose writings are both realistic and reassuring.

Choose childbirth classes carefully A childbirth educator who deeply believes birth doesn’t have to be a medical event can bolster your own faith in the natural process, connect you with caregivers who have a similar outlook, and guide you through the maze of medical literature. To find such a person, you may have to look beyond the classes offered by your local hospital: Your local La Leche League group or midwifery practice may be able to suggest some candidates.

Consider counselling
Women who have survived sexual abuse or assault, or endured a traumatic pregnancy loss, may feel very anxious when contemplating labour, Penava acknowledges. If this is your situation, talking to a midwife, doula, doctor or psychologist may help you overcome your fears.

Seek support
Do consider hiring a doula — a person who’s been trained to provide hands-on support and cheer you on during labour. “The research is there,” says Kathleen Lindstrom, a Vancouver-based perinatal consultant and educator who teaches labour support skills across North America, that the presence of a doula reduces intervention rates and improves outcomes for babies. Individual studies suggest having a doula may reduce the odds of C-section and epidural use by as much as 50 percent. A doula can also help you rethink your attitudes about birth and focus on the positive. For example, a 24-hour labour breaks down to about 3½ hours of contractions!

Select low-tech caregivers
Your caregiver’s beliefs about the worth of different birth interventions and when best to use them can’t help but influence how he or she presents those options to you and your partner. Try to find a care provider who has a reputation for not jumping in with technology before it’s really needed: a midwife, family physician, labour and delivery nurse or friend who’s had the kind of birth you’re hoping for may be able to point you in the right direction.

Opt out of unnecessary induction
When your due date has come and gone, and you can’t sleep more than five minutes because Junior’s jostling your bladder, getting birth underway any way sounds like a great idea. But rushing into induction probably does increase the odds of other interventions — so you may want to wait it out as long as tests continue to confirm your baby is doing well.

Delay epidural
Try using non-drug methods (such as walking, changing position and relaxation) to ease contractions, at least, as many advocates believe, until your cervix has dilated four to five centimetres. If you do need an epidural, it’s less likely to slow down labour if you wait until you reach that milestone.

Maintain the machinery
Labour is just that — physical work. You don’t have to train like an Olympic athlete — but eating a balanced diet and building up your endurance with regular activity like a daily walk will ensure you’re in top condition for the big day.

Believe in your body
Your uterus is the strongest muscle in the human body, bar none. “We have to respect what our bodies are intended to do,” says Penava. After all, birth is a process that’s been honed by nature over thousands of years. And remember: Our standard of living, public health programs (such as fortifying flour with folic acid, a nutrient that sharply reduces the odds of certain birth defects), first-rate prenatal care, and the availability of technology when it’s truly needed have helped Canada achieve a safety record for new mothers and babies that’s the envy of most other countries in the world.

“Birth doesn’t have to be horrifying — for most women, it’s an empowering, beautiful thing,” Jan Christilaw emphasizes. “Birth can be a rewarding, fulfilling, amazing experience,” agrees Vicki Van Wagner. “It was one of the most challenging things I’ve ever done — but it was also one of the most inspiring.”

On the Other Hand…
Not all of the news about birth interventions is bad: Between 1991 and 2001, the rate of episiotomy (a cut that widens the entrance of the birth canal) fell more than 50 percent. Other hopeful signs:

• BC Women’s Hospital & Health Centre and Vancouver Coastal Health have launched a pilot program that teams midwives, family doctors, doulas and community health nurses: These professionals provide group pregnancy assessments and childbirth education sessions, which encourage expectant mothers to support one another.
• Medical and nursing students at the University of British Columbia now undergo labour support training alongside doulas and midwives.
• At an upcoming conference, caregivers will debate whether we currently rely too heavily on interventions.
• The Society of Obstetricians and Gynaecologists of Canada and the Canadian Association of Midwives have issued statements supporting the idea that vaginal birth is the safest option for the majority of women.
• In Ontario, a panel (of midwives, family doctors, obstetricians and a consumer) was recently struck to rethink the way the province’s maternity care is delivered.

Resources
Doulas of North America, DONA.org. Questions to ask a prospective labour support professional, a run-down of research on the benefits of doula support, a “find a doula” service (BC only) and lots of other birth-related information.

Maternity Centre Association, maternitywise.org. This US-based site features a wealth of readable resources, including the booklet What Every Pregnant Woman Needs to Know About Cesarean Section.