C- Section rates across Canada
Our idea and vision of normal birth has taken on many definitions and directions in the last 30 years. Maternity care now offers women more choices in how, and when, they would like to bring their baby into the world. But are these choices truly in the best interest of mom and baby or those directing care? Are these choices supported by medical evidence and best practice statements as provided by professional medical associations? Are women really making informed choices when it comes to childbirth or are they prompted by fear, shame, and a lack of confidence in how to birth? We are dealing with the most precious and delicate thing your family will ever create – a baby-and it is crucial for you to ask lots of questions of your care provider to get the information and answers needed to make the best choice for you and your baby.
You may think maternity care has made leaps and bounds over the last hundred years or so. It is true that many new diagnostic tools and medical interventions exist compared to when our mothers were in their childbearing years. But are these tools and interventions doing anything to change infant and maternal disease and death , that is, actually doing what they were invented to do? Social Policy in Ontario has an answer for you. No. Infant mortality is actually increasing. Once holding strong at 6th place in world rankings, Canada has now dropped from sixth to 24th place – just above Hungary and Poland (Globe & Mail, May 24, 2010). The entral Intelligence Agency has released statistics for 2012 for infant mortality and ranks Canada just after Cuba, way down in the rankings. Regardless of which source you want to use, the numbers are sad and disappointing, for a country that prides itself on seemingly great maternity care.
The Society of Obstetricians and Gynaecologists of Canada and its associated partners claim in a 2008 joint position statement that, “Caesarean section should be reserved for pregnancies in which there is a threat to the health of the mother and/or baby” and “a Caesarean section should not be offered to a pregnant woman when there is no obstetrical indication”. From both personal and professional experience I can confidently say this is not the case.
The World Health Organization (WHO) recommends a C-section rate between 5-15%. The national Canadian average for C-sections is 26.94%, close to double the upper limits of the WHO recommendations. The Canadian Institute for Health Information (CIHI) recently did a survey of GTA hospitals and their section rates and found some hospitals to have a 30-40% section rate. The U.S. is similar with a national average of 29.1%, which is over a quarter of all deliveries. This is a frightening statistic, and we need to ask some hard questions and demand truthful answers. How can we explain why 30-40% of births need major surgery?
Reasons for a C-section
Many women are not being educated in how labour begins and why its spontaneous onset is so important. A baby’s hormonal biochemistry actually initiates the process of birth, not the mothers body. The baby initiates birth because only it knows when it is fully ready to meet the world; and yes, a day or two early can make a difference for baby’s health and transition to the world. We need to respect the spontaneous initiation of labour as what follows is an extremely complicated and intricate cascade of chemicals and hormones, each level and stage of labour depending on the one preceding it. If you induce and medicate, or skip right to surgery, you have leapfrogged over mother nature’s way of providing pain management chemicals, adrenaline to complete the ‘marathon’ of birth, bonding hormones, and hormones to initiate the letdown of breast milk.
The most common reasons women cite for a C-section birth:
- Multiple babies (i.e. twins or triplets)
- Fetal heart rate dropped. As routine use of fetal electronic monitoring has increased so have the rates of C-sections. This does not mean it is the cause but there is a relationship to consider. Fetal heart monitors have a huge level of variability and inaccuracy. Fetal heart rate may respond to pain medications working to slow down the heart and breathing rate of the infant.
- Breech birth. A breech presenting baby can be birthed vaginally with the assistance of a qualified professional.
- Elective sections either because an OB/GYN will be on vacation or they want the convenience of knowing when to expect their baby. There are many risks, complications, and side effects (for both mom and baby) associated with abdominal surgery, and these must not be taken lightly.
Risks of C-section
We have become desensitized to the serious and real side effects and complications associated with a surgical abdominal birth. These risks apply to BOTH mom and baby. I think we have become anesthetized to the seriousness of C-sections for several reasons; 1) One out of three women have surgical births, so it’s becoming almost more common than a normal vaginal birth; 2) the ease and ‘neatness’ of C-sections as portrayed in movies, media, and baby shows; 3) its discussion and inclusion in standard prenatal visits with OB-GYNs, so that’s its almost an expected outcome.
Side effects and complications vary in seriousness, from infection to death. Maternal death associated with C-sections has decreased over time but death resulting from a C-section is still doubled (or more) after (elective) C-sections. You have twice the risk of dying as a result of a C-section as a vaginal delivery. Fetal death and dismemberment is also a factor as there are sharp objects cutting through the space in which the baby is living.
The list of side effects and complications for mom include:
- a higher risk of operative complications including infections at the incision site, in the uterus, and in other pelvic organs
- bleeding (more blood is lost in a caesarean delivery than with a normal vaginal delivery)
- organ injury
- adhesions (scar tissue) may form inside the pelvic region causing blockage and pain. Adhesions can also lead to future pregnancy complications such as placenta previa or placental abruption.
- blood clots
- psychological problems in the postpartum period including post-partum depression
- extended recovery time
- extended hospital stay (and increased exposure to germs and infection for you and baby)
- Adverse drug reactions to anaesthesia and/or pain medications
The list of side effects and complications for baby include:
- Fetal injury. On average, 1 or 2 babies per 100 will be cut during the surgery.
- Premature birth, if the gestational age was not calculated correctly
- Breathing problems (passage through the vaginal canal helps squeeze out excess fluid from the lungs which does not happen during a surgical birth)
- Low APGAR scores possibly resulting from anaesthesia and/or pain medications and the abruptness of being pulled from the uterus versus a transition period in the vaginal canal
In RARE cases a C-section is medically indicated and warranted to save the life of mother or baby, this cannot be disputed. However, with the increasing and soaring section rates, we are not seeing a judicious use of surgery for life saving reasons, but rather to avoid potential law suits should there be a negative outcome.
So for women considering an elective C-section (and some women have it planned and scheduled in their first trimester), please think long and hard about the risks you are taking at the expense of your unborn baby. Your baby is relying on you to make an informed, educated decision, so ask questions before you make the decision to go the surgical route.
One way to help decrease the increasing rates is to choose midwifery care. C-section rates are significantly lower under their care. On the table for Ontario is the development of free standing birth centres, a place where women not choosing to birth at home but would like the reassurance of a hospital-like atmosphere, can birth their babies; these centres also have much lower section rates. Health Minister Deb Matthews says, “That when we can move procedures out of hospitals, that’s better health care, better quality of care at a lower cost”.
Just because C-sections are common, does not mean they are always right or warranted. Make a birth plan during pregnancy and discuss this with your midwife, OB/GYN, or MD. Ask them what their C-section rates are and why. You have a right to know this information. A C-section is major surgery and comes with all the complications that surgery brings with it; except in this case you have two lives to consider and make choices for.
By: Dr Carly Wendler
Dr. Carly Wendler’s clinical expertise lies in maternal and pediatric medicine. She brings to her practice and educational workshops over 6 years of clinical experience, an evidenced-based approach, and a passion for helping families get and stay healthy. For more information on pregnancy, birth, post-partum, and infant health visit www.drcarlywendler.com.