Editorial: The High Caesarean Rate

By Stephanie Ondrack

The World Health Organization states that the Caesarean rate should ideally hover around 10%. Anything lower means parents and babies who might benefit from Caesarean births are not getting enough access, and anything higher means too many surgeries are being performed without any improvement in maternal or newborn outcomes. The remaining 90% of the time, vaginal births are safer, healthier, and physiologically important for mothers and babies, whereas unwarranted caesareans unnecessarily increase risks for both, as well as for future pregnancies. 

Caesarean births are medically essential or beneficial approximately 10% of the time. Yet in many places, the Caesarean rate is well above that. Here in BC, it has settled around 30%, only moving slightly up or down from year to year. So what causes all these extra Caesareans? Why is our rate so high?

One factor is certainly our approach to VBAC, or Vaginal Birth After Caesarean. Every uterine scar caused by a Caesarean birth slightly increases the risk of uterine rupture in subsequent births, as well as increasing the risk of an improperly attached placenta over the scar tissue. But in many cases, a VBAC is still safer than a Caesarean. Even though BC Women’s hospital had a longstanding program to promote VBAC’s, and to educate families and care practitioners about assessing the relative safety, many people (doctors and families alike) seem to default to the incorrect assumption that a repeat Caesarean is always safer. Sometimes it is, but this is a case by case determination, and should not be a blanket approach.

Another factor is our loss of skills with breech birth. Breech presentations are a normal variation approximately 4% of the time, and many countries are perfectly comfortable and confident delivering the majority of breech babies vaginally. Again, BC Women’s hospital used to have a campaign to educate the staff and the public about the pros and cons of vaginal beech birth, but since most practitioners are no longer practiced with breech delivery, much of our available wisdom and skill has eroded. Care providers and families alike often mistakenly believe that Caesarean birth is always the safer option. The exact same tale can be told for twin birth.

Another factor is our medical expectations around labour progress. Many practitioners and hospitals still rely on the Friedman’s Curve even though numerous studies have found that it is inaccurate for the majority of women. Since Failure to Progress is a leading cause for unplanned Caesareans, our outdated adherence to the Friedman’s Curve and similar ways of setting expectations around average archaic measurements might be partly to blame. We tend to intervene when interventions might not be warranted.

Another factor that is more challenging to pinpoint is human fallibility and subconscious inclinations. Many hospitals have been shown to have their highest Caesarean rates on Friday afternoons and just before holidays, and specific doctors and hospitals have much higher or lower Caesarean rates than others. As well, studies have shown that when mothers are admitted to hospital at 6cm instead of 4cm, the Caesarean rate reduces considerably. Having a doula in attendance also measurably lowers the risk of Caesarean. Obviously, none of these factors is remotely medical: they all indicate that some of what guides our decision-making around medical interventions is based on more elusive biases or unconscious influences.

The media often points to mothers themselves as the culprit, the ‘too posh to push’ crowd demanding excessive surgeries. While this might be true occasionally, it is not what mothers report. Surveys of mothers, as well as studies, repeatedly find that most people try to avoid caesarean birth unless it will be safer for themselves or their baby. Here in Canada especially, where unwarranted surgeries are not covered by our medical system, the incidence is very rare indeed.

These are all among the contributing variables, of which there are many more, but the one that I think is the most pervasive is also the hardest to identify: birth culture. It is extremely difficult—almost impossible--to imagine what birth might look like outside of our cultural paradigm. Many people have noted that animal births proceed smoothly only when uninterrupted, undisturbed, or even unobserved. The vital role of high oxytocin levels in moving labour forward and triggering the foetal ejection reflex might be something that’s hard to adequately foster in a medical setting. Oxytocin is a shy hormone, and the minute any stress enters the atmosphere—in the form of time awareness, measurements, medical interventions, strangers, fears, or even just obvious observation—the gentle building of hormonal layers can be interrupted. Watched pot syndrome can ensue: failure to progress, synthetic pitocin, and a complete avalanche of the carefully choreographed hormones in the delicate house of hormonal cards. Iatrogenic interventions follow, further stalling, and a resulting caesarean due to failed labour. 

As this scenario unfolds step by step, it is hard to see our own role in it. At what point does cautious observation become disruption? It is hard to reconcile how the very tools we use to mitigate risk might unintentionally derail the physiological process itself, and lead to the very intervention we are seeking to avoid. 

Approximately 10% of the time, we need to embrace Caesarean Birth, normalize the experience, make it special and perfect for all families and babies who need it. We need to shift the culture around Belly Birth so that it is never perceived as a less valid birth, or a failed vaginal birth. It is simply the way some people need to give birth, and some babies need to be born. It can be miraculous and wonderful and transformative. We need to celebrate it as the success that it is. 

But this is easier to accomplish if our caesarean rate is low enough to leave no room for doubt that they are not being performed excessively, that when a belly birth is needed, it is truly needed. Which might mean asking ourselves some uncomfortable and possibly challenging questions about our birth practices and our birth culture. 

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