Too posh to push? Caesarean versus vaginal delivery

Pamela Wilson,
Tuesday, August 28, 2007
Image: Snapper Media
Not so long ago caesarean sections were something to avoid unless there was an emergency. These days many of us know women who elect to have a caesarean instead of a vaginal delivery. Current data from the Australian Bureau of Statistics (ABS) shows that 29 percent of women gave birth by caesarean in 2004, a substantial jump from 18 percent in 1991.

So, are we becoming too posh to push?

Midwife Hannah Dahlen doesn't believe so. While popular theory suggests that many mums-to-be independently choose caesareans for personal reasons like convenience and to protect their pelvic floor, the issue is actually far more complex. Ms Dahleen, secretary of the NSW Midwives Association, cites US research that showed that while about five percent of women reportedly chose a caesarean section, when they were later asked about their experience almost none had initially intended to opt for the surgery. "So, you have to consider how much do women actually choose and how much of that decision comes from other influences and women being talked into it," she says.

Ms Dahlen believes women are influenced by their fears and personal experiences, the experiences of women around them and by the views of their doctors and/or midwives. When some mothers hear "Your baby is big. I don't think you should go to term so let's induce you" they oblige readily and embark on a path that increases their chance of having a caesarean. "When you induce labour you start on a cascade of intervention," says Ms Dahlen. "Caesarean rates, epidurals, episiotomies, haemorrhage rates, they are all increased."

Profiles of mums-to-be
It is impossible to profile the group of women more likely to elect for a caesarean at the outset. However, research does show that those women with health insurance who are under the care of a private obstetrician are far more likely to have a caesarean than those in a public hospital setting.

Australian researchers reviewed 170,000 low-risk first-time mums and found that private patients had higher rates of caesarean before and during labour (16.4 percent) compared to public patients (10 percent). They were also more likely to have interventions such as forceps procedures, epidurals, episiotomies and inductions.

Dr Christine Tippett, President of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), says women fall into one of three groups when it comes to choice of delivery. There is a small number who want an elective caesarean, a larger group wanting a vaginal delivery and the largest group is in between who would prefer a vaginal delivery but don't have a set view.

Understanding the increasing rates of caesareans
Dr Tippett believes the reasons for increased caesarean rates are numerous. One reason is that if there is ever an adverse outcome in a vaginal delivery, the first question asked of the doctor is "Why wasn't a caesarean performed?"

"Doctors pay huge indemnity insurance — $80,000 to $100,000 per year to practise in private — which makes you realise you are in a higher-risk speciality … and you don't get sued for doing a caesarean section," says Dr Tippett. She says the other main driver is the wide community acceptance of caesareans. "Women given an indication that a vaginal delivery will be risky will opt for a caesarean section, but this is often done on the assumption a caesarean is without risk, yet clearly that is not the case."

Dr Tippett says the ability to plan, fear of childbirth and other health reasons like protecting the pelvic floor muscles also motivate some women into choosing a caesarean. The 2007 ABS study on social trends suggests other factors pushing up caesarean rates include advancing maternal age, multiple pregnancy, low birth weight, breech presentation and private accommodation status in hospital.

Whilst obstetricians are often said to perform caesareans too readily, Dr Tippett disagrees that this applies to the whole group. She says it's true that there may be a few obstetricians who do push for a caesarean too soon, but points out many midwives will push too hard for a vaginal delivery. No matter which method health professionals espouse to, however, they all have the mother's best interests at heart. Both Ms Dahlen and Dr Tippett believe that the best outcome for women comes from a team care approach when midwives and doctors work together and have good protocols and strong lines of communication.

To attempt to reduce the rise in caesarean births, the NSW government released policy directives earlier this year stipulating that a mother's request for a caesarean without medical reason was not enough for it to be given the tick. The directive says that when a caesarean is under consideration, the mother has to be informed of the benefits and risks of the surgery compared to a vaginal delivery.

Pros and cons
At the end of the day, there is no right or wrong way to deliver a baby. Ms Dahlen says that so long as women are well informed then the choice should be theirs and they should not be judged for the decision they make. "It's really important that women don't feel guilty … but they need to know all the options and they need to feel in control," she says. "So many women are not told of the ramifications and they then go down a pathway that is not what they wanted." And, as Ms Dahlen points out, women can have fantastic or horrendous experiences no matter which way their baby is delivered.

Australia is one of the safest places in the world to have a baby, but there are small risks with both caesareans and vaginal births. Naturally, there are also plenty of positives. Here we list just some points to consider:

  • Caesareans enable parents to plan the birth and other things such as childcare and work.
  • Caesareans can reduce the risk of injury to the pelvic muscles and tissues and the anal sphincters, but not eliminate them.
  • Caesareans eliminate the pain of labour; but the pain after lasts longer than with vaginal birth and recovery usually takes longer.
  • Babies born by caesarean have higher rates of admission to neonatal intensive care with breathing difficulties. This risk increases dramatically if caesarean is done before 39 weeks gestation.
  • Vaginal births carry a risk of episiotomy and this can be extremely painful.
  • Caesareans are very safe, but the risk of maternal death due to complications is much higher than with a vaginal delivery (less than one in 2,500 after a caesarean and less than one in 10,000 after a vaginal birth).
  • Risks are low, but caesareans carry a higher rate of injury to abdominal organs, infection, blood clotting and other complications.
  • A caesarean can impact on how you deliver subsequent babies.

There is just one certainty in childbirth — it will undoubtedly be one of the most important experiences of your life. So, it is worth arming yourself with all the facts and making an informed decision on how you would prefer your baby to enter the world.

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