More women requesting caesarean birth
Doctors required to provide valid medical reason
Frozen from her rib cage to her toes, the 35-year-old woman felt a fleeting, uncomfortable sensation during her second caesarean delivery last year. Then the anesthesiologist adjusted the medication and 25 minutes after surgery began, her son was born. “It was pretty laidback,” she recalls.
The Toronto-area woman, who requested anonymity for privacy reasons, chose a planned surgical delivery because of overwhelming anxiety over a vaginal birth. She had nightmares of “tearing, forceps and episiotomies gone wrong,” she once shared on an online pregnancy forum where women swap names of doctors open to elective caesareans. “The planning of it, that was my biggest thing.”
She also “kind of pushed” for an earlier date because her in-laws were leaving for Florida the next day. “I had to get the baby out. If I had let nature take its course, they wouldn’t have been there, and it was important to me.”
Both her pregnancies were uncomplicated. There was no medical reason to warrant major surgery. But she is part of a growing trend: As Canada undergoes a historic shift in fertility patterns, with more women giving birth later and to fewer babies, more are requesting — or being prompted by their doctors to choose — delivery by caesarean.
It’s leading some to wonder whether the tide of Csections will ever be pushed back — and others to question whether it’s time to abandon arbitrary targets for caesareans altogether.
In 2014-15, 17.5 per cent of women under 35 delivered their first baby by C-section, compared with nearly 23 per cent of first-time mothers over 35, according to the Canadian Institute for Health Information. An earlier Ontario study found that for women over 40, nearly one in two (43 per cent) had a C-section.
While older mothers are more likely to have obesity, gestational diabetes and other conditions that increase the likelihood of a surgical birth, those complications alone don’t account for their disproportionately high rates of C-sections.
More is at play, doctors and women agree, from worries over lasting damage to the pelvic floor muscles and a phobic fear of vaginal delivery, to a phenomenon obstetricians have dubbed “precious baby” syndrome — the idea that this might be the only pregnancy the woman will likely ever have and nothing should be done to risk it.
“You’ve either tried a long time to get pregnant, or you’ve had IVF and finally you get pregnant and you say, ‘I can’t take any chances, I’m going to have a caesarean section,’ ” said Dr. Michael Klein, a professor emeritus at the University of British Columbia and senior scientist emeritus at the Child and Family Research Institute.
“It makes perfect sense — you’ve tried so hard for so long and you’ve got the idea this is your last chance. It’s not safer, but it’s believed to be safer.”
Klein says it’s difficult to argue against the science: In a study of breech pregnancies, Canadian researchers found healthy women with a healthy fetus who underwent a planned C-section had rare but higher risks of postpartum cardiac arrest, bacterial infections in their reproductive tract, blood clots and hysterectomy than the planned vaginal delivery group. More worrisome, maternal mortality is increasing for the first time in Canada, a phenomenon he partially links with unnecessary C-sections. As well, a 2006 study of more than six million births found neonatal mortality rates are higher among infants delivered by caesarean (1.77 per 1,000 live births) than those delivered vaginally (0.62 per 1,000 births).
Others say the risks of elective caesarean births are being exaggerated and the benefits of natural childbirth inflated. Many studies comparing C-sections to vaginal deliveries include not just planned but also emergency caesareans, which pose much higher risks. C-sections have led to slight decreases in stillbirths, they argue; fewer babies are also running into trouble due to lack of oxygen at birth.
Doctors don’t even have a clear benchmark: While the World Health Organization once long argued the “ideal” rate shouldn’t exceed 10 to 15 per cent of all births, many experts say that figure isn’t grounded in good science. The WHO now says doctors shouldn’t undertake C-sections “purely to meet a given target or rate, but rather focus on the needs of patients.”
In Britain, newly published guidelines support a woman’s right to a planned caesarean.
Pauline Hull, co-author with Calgary physician Magnus Murphy of Choosing Cesarean: A Natural Birth Plan, says the debate has taken on almost biblical overtones.
“If you think of the days before anesthesia, women were told ‘in sorrow thou shalt bring forth children,” said Hull, whose two children were delivered via caesarean.
“There was almost this religious idea that pain is part of your rite to passage to motherhood, and there is an element of that still remaining — the idea that all women should given birth vaginally unless they medically absolutely cannot.”
In Canada, a doctor is required to provide a valid medical reason for an elective C-section. “You have to put something in the surgical indication box,” Klein said. “You can’t just say, ‘ she wants one.’
Doctors have a “lower threshold” for C-sections in older women, according to the Society of Obstetricians and Gynaecologists of Canada, adding that “maternal requests” for caesareans are also more common among older women.
“Sometimes it’s the fear of the unknown of a vaginal birth, or the fear of damage to the perineum, or the fact that they’re older and they’re going to have only one child,” said Dr. Jon Barrett, chief of maternal-fetal medicine at Toronto’s Sunnybrook Health Sciences Centre.
Other times, it’s a matter of convenience and control. “Maybe as we get older, we just like things more scheduled and less uncertain,” Barrett said, adding that some women are “persistent.”
“And if they want it, in many cases, we’ll go ahead and do it.”
Klein’s own research shows 20 per cent of obstetricians believe — incorrectly, he says — caesareans are safer for mother and fetus.
“The new generation of (female obstetricians) are living it for themselves — an increasing proportion are choosing never to have a vaginal childbirth, so you can imagine what they’re telling their patients,” Klein said. “They’re afraid of pelvic floor dysfunction, urinary incontinence, sexual dysfunction.
“If you think childbirth is nothing more than an opportunity to pee in your pants, you’ll counsel your patients accordingly.”
Klein and other doctors say they’re seeing a clear fallout of too many C-sections, including a rise in placenta accreta, where the placenta attaches itself to an old C-section scar on the uterus.
C-sections also cost hospitals twice as much as vaginal births. But proponents of maternal choice caesareans argue the comparison doesn’t include the costs of surgery to repair damaged pelvic floors or other potential complications of vaginal births down the line.
Janice Williams moderates a closed Facebook page, Caesarean By Choice Awareness Network, for women “who choose or would choose caesarean without medical indication.” It has about 400 members.
Williams’ second child was born by caesarean. Her first planned C-section ended in a vaginal delivery with no pain medication after her scheduled surgery was unexpectedly “bumped” and no anesthesiologist was available at the Victoria hospital when she went into labour. Her daughter was born with the umbilical cord wrapped around her neck and required emergency resuscitation.
Williams says women are not choosing C-sections lightly or for reasons of convenience, and many women can’t find doctors “willing to respect their choice.”
Some of the strongest resistance to elective C-section comes from other women, she says. “It’s almost like female machismo. There’s this preconceived notion that ‘real’ women give birth the way nature intended,” she said.
Studies suggest, for older mothers, the risk of an emergency caesarean is as high as 50 per cent, she said. “So, if you’re making a birth plan that has one-in-two odds of winding up in an emergency situation, who are we to say that a woman is not wise to choose an elective caesarean?”
IT’S NOT SAFER, BUT IT’S BELIEVED TO BE SAFER.