How we can curb rising C-section rates in Canada

Unnecessary surgeries pose risks, write Dr. Margaret Morris and Dr. George Carson.

Even during the pandemic, labour and delivery are the most frequent reasons for hospitalization in Canada, with more than 350,000 births per year. That's happy news. But of these births, nearly one-third are by caesarean section (C-section). That rate is far too high — and rising.

C-section is the surgical procedure to deliver a baby that involves an incision in the mother's abdomen and uterine wall, recommended when the baby's or mother's lives are at risk from a vaginal delivery. Nearly 105,000 C-sections take place each year, making it the most common hospital-based surgery in Canada.

The COVID-19 pandemic has underscored the importance of using our limited health-care resources wisely. Yet a significant proportion of C-sections are being done when they may not be necessary.

C-section rates have more than doubled in the past 25 years. Even accounting for some changes in the child-bearing population over this time, such as mothers having children later and higher rates of obesity and chronic diseases, this still shouldn't be driving such a sharp increase in the way babies are being born. So why is this happening?

When needed, the life-saving benefits of C-sections far exceed the risks for the pregnant woman and newborn. But each C-section is also a major operation. This surgery has significantly more risks than a vaginal birth — including higher rates of infection, hemorrhage and death for the mother. In some cases, there can also be immediate and long-term risks for the newborn.

As well, after a C-section, there is a scar on the uterus, which has implications for future pregnancies and labour. Recovery from a C-section can be painful — and usually includes a longer hospitalization and recovery period.

Unnecessary C-sections can harm patients. The two of us — one a past president of the Society of Obstetricians and Gynecologists of Canada (SOGC) and one the incoming president

Overuse of C-sections occurs when it appears that mothers are not progressing in early labour.

— are committed to raising awareness about the harms of C-sections that are not medically necessary.

As part of the Choosing Wisely Canada campaign, an organization dedicated to reducing unnecessary tests and treatments in health care, the SOGC recently released recommendations for all clinicians involved in birth, including obstetrician gynecologists, family physicians and midwives, and urges rethinking when C-sections are necessary.

Research suggests that a significant part of the overuse of C-sections occurs when it appears that mothers are not progressing in early labour. Labour has both a latent, or beginning, phase and an active phase. The transition from latent to active labour can take many hours. A latent phase of up to 20 hours is normal for a woman having her first labour.

For healthy women with a single pregnancy, the optimal management during this phase is to allow them time to progress while offering supportive care, including pain relief and rest. Most women can then enter active labour and proceed to vaginal delivery.

There are major differences in C-section rates among provinces, hospitals in the same city and even obstetricians. Research shows a major driver of this variation can simply be impatience. A C-section may often relate to providers' and/or patients' reluctance to wait for active labour.

Research also shows that sometimes an obstetrician's own practice styles, impatience, scheduling and/or system pressures may prompt an unnecessary C-section. This increases risks for the mother and newborn, and for all future pregnancies.

Our recommendation urges physicians to rethink their practice to curb rising C-section rates.

Now more than ever, it is important to use health-care resources wisely.

Dr. Margaret Morris is a professor in the department of obstetrics, gynecology and reproductive sciences at the University of Manitoba and president-designate of the Society of Obstetricians and Gynecologists of Canada. Dr. George Carson is a clinical professor of obstetrics and gynecology at the University of Saskatchewan and past president of the Society of Obstetricians and Gynecologists of Canada.