In the last 25 years, the number of babies being delivered by caesarean section in Australia has steadily risen. The number has gone from less than 20 percent to more than 33 percent meaning that today, the delivery of more than one-third of Australian babies involves major surgery.
Now, there’s no shortage of articles to be found dissecting the ‘whys’ around this increase. And these ‘whys’ point mainly to the changing demographic of women giving birth. The consensus being that, as women get older and as the rates of obesity and assisted fertility increase, so too does the risk of pregnancies increase. This then necessitates an increase in the rate of caesarean section.
While the reasons above are all valid, they do not, however, account for the fact that the World Health Organisation (WHO) has indicated the ‘ideal’ rate for caesareans is 10-15% and Australia’s rate of caesarean is more than double this.
Typically, conversations around the rate of caesareans focus on ‘who is to blame’. Which quickly derails the ability of any such conversation to be useful.
That’s why I’d like to take the chance to reboot the conversation somewhat.
Rather than trying to pin blame for why our caesarean rate is so high, I’d like to offer a case for lowering the rate, along with some guidelines for how.
Before I continue, however, I need to make one thing clear (particularly to any expectant mothers who are reading). The intent of this article isn’t to suggest that vaginal delivery is the ‘right’ way to give birth.
Emergency caesarean sections are important life-saving interventions for both mother and child.
I also fully support any mother’s decision to have an elective caesarean provided she is fully informed about the risks vs benefits of that procedure. My main concern is that many mothers aren’t fully aware of those risks vs benefits and might appreciate the chance to make a more informed choice.
Why we should aim to lower the rate of caesareans in Australia
One big reason is the cost to our health system. It costs much more to deliver a child via surgical methods, and care for a mother who’s just undergone major surgery, when compared to a vaginal birth.
Related to this is the fact that time and resources dedicated to caring for a mother who’s undergone surgery steals time and resources from helping that new mother meet the needs of her new baby. It also impacts the ability of caregivers to help the new mother make the mental and physical adjustments required after birth.
Thirdly, there is a psychological cost. Many new mothers feel ‘robbed’ that they weren’t able to experience a ‘proper’ birth. It’s easy to be dismissive of this and think, ‘healthy mum, healthy baby – that’s all we care about here’. But doing this ignores the fact that a mother’s birth experience has a huge effect on her mental health in the early months of her baby’s birth.
Speaking of ‘healthy mum, healthy baby’. In 2018 WHO stated that:
When caesarean section rates rise towards 10 percent across a population, the number of maternal and newborn deaths decreases. When the rate goes above 10 percent there is no evidence that mortality rates improve.
So, while Australia is one of the safest countries in the world in which to give birth, and while this is something that we should be incredibly proud of, WHO’s research suggests that if we reduced our rate of caesareans, we’d still be able to maintain our enviable ‘healthy mum, healthy baby’ record.
How we can reduce the rate of caesareans in Australia
Before getting into the suggestions below, it’s important to note that I don’t advocate for a ‘blanket approach’ to lowering caesarean rates. It’s essential that any decisions made take into account a patient’s history, pregnancy and their individual views.
When looking at reducing caesarean section rates, it is not just one measure that will lead to a reduced rate. Rather, a ‘bundle’ of measures, all of which have been shown individually to have an impact, can be called on.
1. Better education around the risks vs benefits of caesareans
This would involve ensuring the antenatal education delivered to pregnant women focuses on how labour works (what’s normal/what to expect) and the importance of ‘active’ labour (including mobilisation and positioning). Better education and expectation management around labour will allow the woman to feel more empowered to advocate for herself during labour.
2. Embracing birth planning
It’s important to actively engage the patient in the development of a birth plan, one that focuses on ensuring they have appropriate support people. Those support people would know how to support them through the active management of the early stages of labour, with a focus on mobilisation and positioning.
3. Continuity of care
It has been shown that continuity of care is associated with lower intervention rates, lower caesarean section rates and improved maternal satisfaction with the birth. The development of a trusting relationship leads to a more informed and empowered patient.
4. Involve the patient in the decision-making process
While patients are currently involved in the decision-making process, it is important that they are an active participant. A well-informed patient, who is encouraged to ask questions and supported in their decision-making is essential. While leading to a lower intervention rate, it will also lead to higher patient satisfaction. Higher patient satisfaction is associated with both improved clinical quality outcomes and most importantly lower rates of psychological issues in the postnatal period.
5. Develop protocols, based on evidence-based medicine, regarding induction of labour and other interventions
By basing the reason for induction on medical need, rather than obstetrician or maternal choice, the incidence of failed induction of labour or failure to establish into labour will decrease. While it is important to respect maternal choice as a valid reason for induction, there are often social or other factors that impact on the decision to intervene and induce labour. (This is another area in which increased antenatal education will allow the mother to make a more informed choice.)
6. Roster obstetricians to a shift
Specialist level care is important for ensuring maternal and neonatal safety during the intrapartum period. However, allocating specialists to shifts rather than patients, allows for greater patience during the management of labour.
Importantly it also increases the quality of life for the obstetrician, ensuring that they are not tired and that their decision making is not affected by fatigue.
7. Support vaginal birth after caesarean section (VBAC)
It is important to educate patients about the risks and benefits of VBAC in subsequent pregnancies. This involves appropriate assessment, education and support for those wishing to undertake a VBAC. ‘Once a caesarean, always a caesarean’ should not be the default.
It’s one thing to make suggestions for how things could be better, it’s another to be an active part of the solution. That’s why, at One for Women, we have put in place a model that we believe will address many of these issues.
We passionately believe in the importance of education, continuity of care and importantly involvement of the patient in the decision-making process. We believe that this will lead to lower intervention rates, which in turn will lead to better patient birth experiences, which then ensures a successful start to often ignored, but incredibly important, fourth trimester.