The SMH has a series this week going on caesareans – why they are on the increase in Australia, and increasing evidence of their long term riskiness. About 30% of births in Australia are now by c-section. It’s a good series, which points out that as well as appearing to have higher risks of themselves (this BMJ article shows an increased risk of respiratory distress in babies born by c-section and this one shows increased risks to the mothers from c-sections in normal (not breech or cephalic) delivery), c-sections increase the risks of serious complications in subsequent pregnancies.
The series mostly refrains from blaming mothers who are “too posh to push” – previous articles I’ve seen on this topic often simplistically suggest that the issue is that mothers demand c-sections. This opinion piece today is a relatively mild example – starting by talking about mothers demanding a c-section, rather than a natural birth.
In my, admittedly anecdotal, experience, the change in demand is much more nuanced. There are undoubtedly women who demand c-sections. But there are far more women, and medical professionals, who now have a different threshold for considering c-section. The changes are about how we (society at large) view risks, perceived and imagined, and our control over those risks.
The book Paradox of Choice, by Barry Schwartz describes how many people make choices to minimise their regrets, rather than maximise their chance of happiness. It seems to me that if you are on the slippery slope of things starting to go wrong with pregnancy and delivery, if you or your doctor chooses a c-section, you and the doctor can tell yourselves later that you have done everything you can to make things work. At that point, you are part of the universe of all possible women having a natural birth. You are part of a much smaller group which is now at an increased risk of your baby being injured, or something happening to your own body.
As my own doctor said when I asked him what the relative risks were of my various options, “I can tell you all the statistics, but you’ve got to remember that whatever happens, it’s going to be 100% for you”.
My own experience is somewhat illustrative. I’ve had two c-sections. The first was because I had high blood pressure, which was drifting upwards to dangerous levels, and even though I was one week overdue, my Bishop’s score was so low that an induction was highly likely to lead to a c-section anyway. I could have waited longer, but given that my high blood pressure persisted for a week after delivery, there was a reasonable chance that would have damaged my kidneys enough to permanently increase my blood pressure. Thirty years ago, I’d be surprised if I would have had a c-section. And maybe I would have been fine. But maybe Chatterboy or me would have been permanently damaged in some way by the experience. Statistically, I don’t know (and neither does anyone else) whether I should fit in the 50% of c-sections that are probably justified from the statistics, or the 50% that are doctors being overly interventionist.
My second c-section was made more likely by the first – having had one c-section means you can’t induce a subsequent birth (substantially increased risk of uterus rupture) and my blood pressure was high and creeping upwards, with ambiguous liver test results, so that I went for a c-section again. Again, I could have waited for natural labour, or my blood pressure to become unambiguously dangerous, but my doctor and I chose not to.
It’s clear from the literature that any intervention (pain relief, induction through any means, especially drugs) increases the chance of subsequent interventions. And that even after adjusting for the difference in women at Australian public and private hospitals, women in private hospitals generally end up with more interventions, including c-sections.
This article makes a similar point:
“People on higher incomes are more likely to use specialist services and when they do they are more likely to be charged higher fees,” Mr Van Gool said.
“However, if you are a public patient in an obstetric ward you might be primarily seen by midwives, whereas in the private sector you are cared for by the obstetrician – immediately you are dealing with a higher price.”
But there is also a cultural issue at play. Women who have private health insurance are very aware that they have paid for it. They would expect to be able to exercise more control over their experience. And a natural birth is inherently uncontrollable. Intervening by starting an induction, and having early pain relief will provide an illusion of control.
I don’t have any magic solutions, but I do think that our cultural attitudes to acceptable and unacceptable risks and how much control we want have changed substantially in the last 30 years ago, and that has been a big factor in the change in c-section rates. Understanding that will be an important part of making any changes.
I think you’re too generous in your assessment of the SMH’s ascribing of responsibility/guilt for the high and increasing caesarean rate. They may not have used the term “too posh to push” but I thought they totally conflated “elective” and “expectant-mother-driven”. Of course all my information is also anecdotal but I’ve never heard directly of anybody who had a caesar because she was the one to suggest it first to the doctor. Yes, elective surgery is technically the patient’s choice, but what are you to do if you are pregnant for the first or second (or even third) time and a doctor who has attended thousands of births is telling you the baby’s too big/wrongly positioned/your BP is too high/VBACs are higher risk? That whole “too posh to push” thing has the whiff of urban myth to me. But apart from that irritation, I have found the series interesting.
I think this is an incredibly reasonable and calm post on a topic which is usually treated with some media hysteria. I’ve been lucky enough to have had three natural births – I’m probably the type to err on the side of maximising my chance at happiness – but I do have friends who’ve had elective c-sections. Apart from those who’ve had them for health reasons (mother’s and baby’s), those who’ve elected do tend to be the kind of people who like to minimise their risk. The theory that it’s tied up with wanting more control helps me understand my friends’ decisions far better.
I know someone in London who had two totally elective caesarians – she was very scared of the idea of vaginal birth. She said she was treated badly by the nursing staff.
I had a caesarian that was an ‘emergency’ – it was similar to yours Jennifer in that I had high bp and the baby was very low weight – I was induced but then the baby became distressed. My ob (private ob but I was a public patient) decided on an ‘emergency’ caesar at 5pm on a Friday. Hmm. I still don’t know what to think of it all. Some would say that the main thing is that we both survived. I’m still not sure if that was in any doubt.
I don’t know any mothers (okay, maybe one) who’ve opted for the experience out of convenience. There are so many other factors at play – increased knowledge of the risks of birth promotes c-section, the increasing age of mothers who are therefore defined as over another risk threshold (as with supermum). Our first c-section was an emergency one and the second was an elective on the consultant’s advice. Our choice in the sense of “So, we’ll book you in for next week, shall we?” after listing a catalogue of risks and likely problems.
I do agree that control is part of it, which isn’t a good or bad – just a cultural thing. The medical discourse is so rigorously controlled at every stage, any sliver of control that the subject of all this can claw back must feel so valuable…
I think the big risk — baby dying — is SO big that the c-section risks — respiratory distress, possible future pregnancy complications — seem worth it by comparison. Especially when so many people have c-sections now, so the pool of repeat c-sections has also grown large. I’m sure there’s a tipping point issue at stake, too.
I’m not really qualified to discuss it, of course. We would have been allowed to trial vaginal delivery if we’d made it to 36 weeks and both baby A and baby B had been vertex. As it was, baby A was footling breech from very early on, and stayed that way, and I delivered at 32 weeks, 4 days anyway.
Almost every triplet mom I’ve ever encountered who made it to 36 weeks wanted a c-section anyway. The risks of doing both — vaginal delivery of A/B but c-section delivery of B/C after signs of distress via monitoring — are fairly large. And who wants to risk fetal death? That’s what’s at stake for most women I know.
Well, that and exhaustion/stalled labor, which takes us in the USA into questions about labor management, crisis-level nursing shortages, and a dearth of doulas. I wonder how much money could be saved over all if we spent more money on labor management, possibly staving off some percentage of c-sections.
There’s a reality show here called A Baby Show, and it’s breath-taking, how many women do most of their labor on their backs, hooked to monitors and IV drips, without the slightest attention paid to anything anyone knows about movement, shifting positions, showers, birth balls — anything that would make labor better (if we can use that term) and less likely to stall/exhaust the mother.