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Facing the Caesarean epidemic: some issues for discussion

Around one in four babies in the UK is delivered by Caesarean section, and rates are increasing. Sheila Kitzinger looks at some of the reasons why women are being offered Caesareans, or electing themselves to have the procedure, and what this means for childbirth, now and in the future

Sheila Kitzinger
MBE M Litt (Oxon)
Social Anthropologist of birth
Honorary Professor
Thames Valley University

In the US, Caesarean rates have been rising each year since the 1990s. The latest statistics show that 31.8% of births are by Caesarean – this is a 50% increase since 1996 and more than twice the 15% recommended by the World Health Organization.1–3 Much of this surgery may be unnecessary and counterproductive.

The normal length of pregnancy in the USA has been eroded by planned Caesareans. The late preterm birth rate went up from 7.3% per live births in 1990 to 9.1% in 2005.2 It was previously thought that elective Caesareans were harmless for late preterm babies. In fact, research shows that they are at increased risk of morbidity and death compared with those born vaginally, often because of breathing problems.3 Their mothers are at increased risk, too, compared with vaginal birth, both when surgery is performed after labour has started – often with induction – and when it is done in the absence of any uterine activity.4

US birth intervention rates vary widely between different care providers and most of these are unrelated to women's health. They are the result of different styles of management and protocols. But patients can't find out what these are, in contrast to the UK, where Birth Choices (www.birthchoices.co.uk) indicates birth outcomes succinctly and clearly.  

The Coalition for Improving Maternity Services is calling for access to hospital data, which are almost nonexistent there.1 They say the need for transparency in maternity care has never been more urgent because active management style interventions, together with induction – which was never part of the original Dublin package – were routine practices in the USA several years before they became standard in the UK.5,6 They include clock-watched labour, artificial stimulation of the uterus, continuous electronic fetal monitoring, drugs for pain relief and assisted vaginal delivery. Active management has turned into aggressive management.

The goal behind active management was that Caesareans could be reduced if labour was strictly controlled, and if there was one-to-one personal nursing care (it may be significant that O'Driscoll wrote about "nurses" not "midwives"). But ways in which it has been interpreted by obstetricians worldwide have had the opposite effect. Kickstarted with induction, labour tends to be followed by one harmful intervention after another in the hope that the uterus is forced to become a smoothly operating machine. This is "just in case" obstetrics. We are witnessing the risks of risk management. Perinatal mortality and morbidity rates resist all efforts to reduce them. Women are damaged physically and psychologically.

A host of interventionist practices that are not evidence-based have replaced the personal support and protection from external interference that supports the hormonally driven, innate processes that have developed through human evolution to benefit childbearing women and their babies. In their report, Evidence Based Maternity Care, Carol Sakala and Maureen Corry summarise these.7-9

They include:

  • The mother's elevated levels of beta-endorphin, an endogenous opiate that relieves pain and facilitates an altered state of consciousness, similar to experiences of endurance athletes.
  • The mother's rhythmic involuntary expulsion efforts shortly before birth ("Ferguson's reflex").
  • The unmedicated and undisturbed infant's drive to crawl on its mother's chest, self-attach to the breast, and begin suckling shortly after birth.
  • The mother's surge of oxytocin at the time of birth, which stimulates loving feelings and inhibits haemorrhage by contracting the uterus.
  • The continuing oxytocic effects of breastfeeding.

A vital element in a midwife's work is to create a relaxed setting in which a woman can gain confidence in her body and avoid dangerous interventions.  As midwifery skills in creating an environment that supports spontaneous neurophysiological processes are neglected, theatre nurses are needed to take the place of midwives.

How should we be exploring these issues? How can we listen reflectively to women who see surgery as an answer to their fears and to professionals who see Caesareans as enabling them to maintain control?

All dogma is dangerous. Assumptions need to be questioned. Whereas too many women in technocratic Western cultures have Caesareans, too few women have access to them in Africa and other underdeveloped and impoverished countries where they desperately need them.

A Caesarean may be the consequence of unintended collusion between the patient and the obstetrician, or an effect of authority exercised by professional caregivers in an imposing institutional setting. In an editorial in the British Medical Journal, Steer suggested that, in future, women will choose to avoid the risks of vaginal birth and opt for Caesareans.10 Fear, rigidity of thinking and inadequate research evidence have powerful effects on practice. Blanket condemnation or blanket approval of Caesareans are both insensitive and crude. To work in harmony, it is vital for the midwife to understand what is in the mind of a pregnant woman and obstetric and midwife colleagues.

Topics for discussion and perhaps also one-to-one roleplay might include exploring the statements below and thinking about what is behind them.

Why some women seek Caesareans

  • "It's safer for the baby."
  • "I had a failed induction last time. I don't want to go through all that again."
  • "I don't want my partner to see me out of control. I want to keep a bit of mystery in our relationship."
  • "It is much more convenient. We can fix the day and the time in advance and there won't be any upset."
  • "I shan't feel any pain."
  • "The professionals will be in charge, so nothing can go wrong."
  • "My mum had a bad time, so I expect I will too."
  • "I want to take all the help that is offered."
  • "I was never a very physical person – no good at games - so I don't trust myself not to make a
  • cock-up of the birth."
  • "I was sexually abused as a child."
  • "I want to get it all over with as quickly as possible. Birth is disgusting."
  • "We are postfeminists now. I organise my life efficiently. Why not birth?"

Some overheard obstetric reasons for nonemergency Caesareans

  • "This is a very precious baby."
  • "I need more Caesareans to qualify."
  • "Her last delivery was precipitate."
  • "She is an elderly primigravida."
  • "It's a repeat Caesarean. Her last baby
  • was macrosomic."
  • "She is a private patient and I am going abroad at the 39th week of pregnancy."
  • "With an elective Caesarean I can be certain the neonatal team is onhand."
  • "She's a colleague of mine."
  • "She is at 40 weeks gestation and the head is high."
  • "The patient asked me. Don't women have the right to choose?"
  • "This is a high-risk pregnancy."
  • "Better to be safe than sorry."

Conclusion
If Caesarean rates are to be reduced we need to create an environment for all women in which they are free to act spontaneously and without fear. This means that women should be able to choose birth at home or in a midwifery unit. But above all we need to rediscover midwifery.

References
1. Coalition for Improving Maternity Services (CIMS). Need for Transparency Increases as Cesarean Section Rates Rise. Available from: http://www.motherfriendly.org/pdf/PR_20090319_Ceserean_Stats_Released.pdf
2. Martin JA, Hamilton BE, Sutton PD et al. Births: final data for 2005. Natl Vital Stat Rep 2007;56(6):1-103.
3. Villar J, Valladares E, Wojdyla D et al. Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. Lancet 2006;367:1819–29.
4. Malloy MH. Impact of cesarean section on intermediate and late preterm births: United States, 2000-2003. Birth 2009;36(1):26-33.
5. O'Driscoll K, Jackson RJA, Gallagher JT. Prevention of prolonged labour. BMJ 1969;2(5655):477–80.
6. O'Driscoll K, Meagher D, Robson M. Active Management of Labour. Dublin: Mosby; 2003.
7. Sakala C, Corry M. Evidence-Based Maternity Care: What It Is and What It Can Achieve. New York: Milbank Memorial Fund; 2008.
8. Buckley SJ. Undisturbed birth: nature's hormonal blueprint for safety, ease and ecstasy. MIDIRS Midwifery Digest 2004;14(2):203-9.
9. Winberg J. Mother and newborn baby: mutual regulation of physiology and behavior – a selective review. Dev Psychobiol 47(3):217-29.
10. Steer P. Caesarean section: an evolving procedure? Br J Obstet Gynaecol 1998;105(10):1052-5.