We have the highest rate of births by caesarean in the world. Is it mothers or doctors leading the push?
Tuesday, July 7, 2015 - 19:30

Australia has one of the highest rates of caesarean births in the world, and some are concerned that mothers are being coerced.

The World Health Organisation recommends caesarean sections should only be performed when medically necessary. It has stated “there is no justification for any region to have higher caesarean rates than 10-15%”.

Out of 137 countries that report their rates, Australia’s is one of the highest, with 32 per cent of all births delivered through a caesarean section. In comparison, New Zealand’s rate is 20 per cent, the UK’s is 22 per cent, France’s is 18 per cent and Norway’s is 16 per cent.

Australia’s C-section rate has nearly doubled since 1991, where it was 18 per cent.

Dr Michael Permazel from the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, attributes this growth to the increase in age of mothers, and an increase in obesity, both of which are more likely to be associated with caesarean section.

“The most important thing which tends to be forgotten is that women are realizing that if the risk of something going wrong could be avoided by C-section, then they’re very keen on doing the best possible thing for their baby.”

Hannah Dahlen from the Australian College of Midwives, says that although those factors are contributing to the rate rise in part,  caesareans are not making changing maternal or infant mortality, and says the rate rise is unwarranted.

“There’s no doubt women are feeling bullied and coerced into caesareans. It can be very, very subtle, and it’s about not giving them the full information, and moving them towards a direction you want to take,” she said,

 “You can find a medical reason for anything,” said Dahlen. “Whether or not it’s a good medical reason is the question, and a lot of pseudo reasons are being used to argue women into C-sections.”

Private hospitals have a higher caesarean section rate than public hospitals. In 2011 43 per cent of women in private hospitals have birth by caesarean section compared with 30 per cent in public hospitals.

Dahlen points to the increased caseload of patients for a private OB/GYN, estimating that many have up to 300 patients per year, which is an incentive to manage through scheduled surgical births.

“There’s not a direct financial incentive,” she said, “but there’s an indirect one which enables you to have more women through your practice if you can schedule them within reasonable business hours.”

Permezel strenuously denies that obstetricians perform C-sections for personal convenience.

“A C-section involves a lot of work for the obstetrician, for the whole healthcare team in the hospital,” he argues. “Generally it’s a lot of care and time in the hospital afterwards for the mother. A vaginal birth can be the most straightforward thing for birth.”

“I just can’t see that there’s any reason why an obstetrician would prefer C-sections for their patients. The C-section is about advising on the safest mode for her and her baby.”

Jessica Klaver opted to have a caesarean birth at twelve weeks in order to maintain her vaginal integrity.

“At no point was I pressured by my doctor to do so. I had the freedom to change my mind up until the night before,” she said.

Briony Garlick had the opposite experience, having an unwanted caesarean despite being told she would be supported in a natural birth. She says that she was misled to believe that a natural birth was not an option because her baby’s head wasn’t positioned ideally.

“[The doctor] raised this with an attitude like, ‘the V-back isn’t an option now, we’re going to have to go with caesarean,’” said Garlick. “The reason for me consenting to the procedure was my own questioning of whether my body was able to give birth naturally.”

Garlick had her anatomy analysed after giving birth, which confirmed her suspicion that she would have been capable of a vaginal delivery.

“I left the hospital feeling desperately sad, like I’d failed again,” she said. “It wasn’t what I wanted.”

“I suffered from postnatal depression. Only recently am I starting to feel that that’s lifting.”

Dahlen believes there is a fundamental dissonance between the way OB/GYNs and midwives are trained to look at the birth process.

“The real reason I think is the obstetrician is trained for six years to be a surgeon,” she said. “It’s very hard for them to see that a woman is not a potential problem.”

Sarah Tapp was induced when she was three days past her due date, which she says led to a cascade of intervention resulting in an unnecessary caesarean section. She says that a service provider mentality of the private sector leads obstetricians to allow mothers to make choices that may not necessarily be in their best interests.

Her inducement was offered after she complained of increasingly tiredness and discomfort in late pregnancy, despite her dilation indicated she was not near delivery. She was not made aware than an inducement increased the chance of an emergency C-section.

“That is one of the things about private care, you’re paying for a service and a lot of obstetricians feel that their job is to facilitate what their women want,” she said. “Which is commendable in lots of ways. But maybe if he’s said, ‘your baby will come when your baby is ready, but if we induce you, you have a higher risk of having a caesarean.’”

“I will definitely take some of the blame myself in that I was desperate to end my pregnancy and have a baby in my hands,” she said. “But you also feel like there’s an obligation by your care providers to make sure that the decision that you’re making is informed.”

Tapp still feels traumatised by the birth seven years later. “It affects people much more strongly that we give credit for.”

Dahlen believes that the C-section rate of obstetricians should be made public to prospective patients in order for them to choose a doctor most aligned with their desires for the birth.

“Let’s get OB to declare their CS rates so women can truly be informed,” she said. “If you want a CS go to the one with 90%, if you don’t want a CS go find yourself a birth centre or midwife group practice where your chances of having a normal birth are really high.”

Permezel believes that could lead to obstetricians trying to keep their CS rate down and recommending against the procedure even when it is in the best interests of their patient.

“In terms of a policy to reduce C-section rates, I think that’s dangerous,” he said. “Individuals should be making the decisions around their choice of birth, based on good information. And the policy of reducing the C-section rate isn’t a good one.”

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