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C-sections: Necessary, Unnecessary, Overdone?

C-sections: Necessary, Unnecessary, Overdone?

From my own upbringing I was taught that c-sections are simply an easier way to get that baby out. My mom had to have two emergency c-sections after having lost her first in natural birth. She had no choice. But after learning about her experience, during my first pregnancy I was bold enough to tell my midwife I’d love to schedule a c-section. That poor woman’s eyes almost popped out of her head. She continued to warn me against that decision and I’m glad I didn’t go through with it.

I’ve heard of child birth becoming something that over uses medicine in the process. It’s seen as a condition to be treated more than a natural process.

Women’s rights have been taken away in the process as we are no longer given clarity of our options during child birth. This can be a confusing matter to dig into. Especially concerning c-sections.

Maturing Mama is so happy to introduce our new author Alison. Proud mom and step-mom of two sons aged two and ten and a fifteen year old daughter. Alison has a background in Health Systems research— specifically around equitable access to high-quality prenatal care in Canada and the United States.

Here she is to tell us more about the facts concerning our options with c-sections as a method of giving birth:

Just like most things in life, medicine has many dichotomies. Things that some or most people perceive as good also being bad and vice versa. Arguably, c-sections have become one of those things. Don’t get me wrong, c-sections have saved many a life; both mom and baby. They are great when needed and used appropriately. When clinically indicated, c-sections are a means of reducing risk of death and morbidity for the birthing parent and their newborn.

However, the opposite is also true, when c-sections are used inappropriately they can result in great risk of death and morbidity (short term and long term) to both mom and baby. Some of the risks include breathing problems and surgical injury of the baby; infection, postpartum hemorrhage and increased risks during future pregnancies for the birthing parent.

For the past 36 years, the World Health Organization (WHO) as well as the global healthcare community at large, have considered the ideal rate for c-sections to be between 10-15%. The rationale for this being that c-section rates higher than 10% are not associated with reductions in maternal and newborn mortality rates.

A 2019 study by Gu et al. examining all in-hospital births in Canada (outside Quebec) showed that 29.1% of 286 201 women had c-sections. The study found that there were large variations in c-section rates across provinces and within different hospitals in the same province.

The reasons for c-section have historically been maternal and obstetrical complications, previous c-section, difficult or obstructed labor, fetal distress, breech presentation, and malpresentation of the baby at birth (Lin, 2004). These days however, these criteria have been expanded to include increasing maternal age and higher rates of hypertension, diabetes, obesity, and multiple gestation (Joseph, 2003).

There are many other reasons for the increase we are seeing in c-section rates that include patient preference and the perceived safety of c-sections. Many of them are confounded by socioeconomic factors and medical racism that results in people who are oppressed or racially marginalized experiencing care that differs greatly from the care received by white, cisgender, heteronormative, middle to high income women.

Vedam et al. found that 2 out of 5 women who had a c-section felt pressured to agree to surgery and that 1 in 2 women felt pressured to accept an induction. This would imply that perhaps c-sections and inductions are being used in situations where they are not medically indicated and as a result more women are experiencing births that are over medicalized which is reducing their sense of autonomy and empowerment during childbirth.

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A Canadian study looking at hospital births in five provinces (British Columbia, Alberta, Ontario, Nova Scotia, and Newfoundland and Labrador) for a four-year period found that women with at least one previous c-section who were at term with a single baby facing head down had the highest c-section rates as well as the highest absolute number of c-sections (Kelly, 2013). 

Other groups that accounted for the most c-sections were; women who have never given birth with a monofetal pregnancy at term in head down presentation, women who had an induction of labor or a c-section before labor, and lastly women with spontaneous onset labor (Kelly, 2013).

The data from this study would also suggest that birth is being over medicalized and more c-sections are taking place than may be medically necessary. Unfortunately, this is a trend that we are seeing globally, including in low resource settings.

A few solutions for this could include increased uptake of a midwifery model of care as well as increased vaginal birth after c-section and trial of vaginal birth after c-section. Midwives provide care for 11% of births in Canada presently (Association of Ontario Midwives). P

References

  1. Lin HC, Xirasagar S. Institutional factors in cesarean delivery rates: policy and research implications. Obstet Gynecol. 2004; 103 : 128-136
  2. Liu S., Liston RM, Joseph KS, Heaman M. R Sauve. Kramer MS. Maternal Health Study Group of the Canadian Perinatal Surveillance System. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. CMAJ. 2007; 176 : 455-460
  3. Joseph KS., Young DC., Dodds L., OConnell CM., Allen VM., Chandra S. Changes in maternal characteristics and obstetric practiceand recent increases in primary cesarean delivery. Obstet Gynecol.2003; 102: 791-800
  4. WHO Statement on caesarean section rates. https://apps.who.int/iris/bitstream/handle/10665/161442/WHO_RHR_15.02_eng.pdf?sequence=1
  5. Examining Cesarean Section Rates in Canada Using the Modified Robson Classification. Jing Gu, Sunita Karmakar-Hore, Mary-Ellen Hogan, PharmD, Graeme N. Smith, Arthur Zaltz,, Yana Gurevich. December 26, 2019 DOI:https://doi.org/10.1016/j.jogc.2019.09.009
  6. Vedam S, Stoll K, McRae D, Martin R, MacRae L, Korchinski M, Jolicoeur G, CCinBC Steering Council. The Changing Childbirth in BC Study: examining autonomy in Canadian maternity care. Patient Education and Counselling, 2018. https://doi.org/10.1016/j.pec.2018.10.023
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