Forget ‘too posh to push’ – doctors are behind the rise in c-sections

Only half of all Qld women who chose to give birth by caesarean made an informed decision. Sean Dreilinger

The proportion of Queensland women giving birth via caesarean section has increased by a staggering 74% in the past 20 years. This wouldn’t be of concern if more babies’ lives were saved as a result but the evidence suggests otherwise.

There’s a belief among some in the health industry and wider community that women who are “too posh to push” are driving the increase. But this myth has been consistently busted, most recently with a study from the University of Queensland’s Centre for Mothers & Babies (QCMB), which surveyed more than 22,000 Queensland mums about their maternity experience.

Of women who gave birth in Australian hospitals in 2009, around a third (32.6%) had a caesarean section delivery. The caesarean section rate of 42.5% for women in private hospitals was higher than for women in public hospitals (28.4%).

The overall caesarean section rate for women giving birth in Queensland hospitals (public or private) was 33.9%, which isn’t much higher than the national average. But Queensland tops the list for the highest rate of caesarean section deliveries in private hospitals, accounting for almost half of all births (47.9%), followed by Western Australia (41.8%) and Northern Territory (41.0%).

Rowan Simpson

Best start to life

We have long known the health ramifications of caesareans for the mother. Compared with women who give birth naturally, she is at greater risk of:

  • dying during childbirth
  • acquiring an infection
  • losing her uterus
  • having the placenta grow into the uterus or in front of the baby in future pregnancies
  • rupturing her uterus in future pregnancies and labours
  • having a stillborn baby in the pregnancy following a caesarean
  • needing to stay longer in hospital.

And we are increasingly beginning to realise the health harms of caesareans on the baby. A 2011 review published in Biological Reviews analysed all the literature to date and found growing evidence of a link between caesarean birth and future disease in the child, including type 1 diabetes, asthma, allergies, gastroenteritis, obesity and some cancers.

The authors conclude that “normal vaginal delivery is an important programming event with life long-health consequences.”

Not too posh

When it comes to caesarean sections, the increase seems largely driven by the recommendations of doctors, particularly in Queensland’s private hospitals.

Women aren’t given enough information about birthing options to make informed decisions. saarnott

Perhaps the biggest surprise in the QCMB study was that only half (52.4%) of all women birthing in public and private facilities reported making an informed decision to have a planned caesarean before going in to labour. Only one-fifth (19.9%) of women made an informed decision to have a caesarean section when the procedure was unplanned.

This isn’t just a local problem. During the United Kingdom’s 2001 National Sentinel Caesarean Section Audit, British women said they would prefer more information about the risks (48%) and benefits (43%) of caesarean section. Nearly all wanted a birth that was safest and least stressful for the baby. Women’s own safety and a quick recovery from the birth that wouldn’t impede on breastfeeding were also priorities.

In the United States, a 2006 nation-wide survey of mothers found that only one of the 1,314 respondents requested a planned caesarean section for her first pregnancy without a medical reason (0.08%). Yet more than 30% ended up with a caesarean. One quarter of survey participants who had a caesarean reported pressure from a health professional to make this choice.

Despite having one of the highest rates of caesarean sections in the developed world, the United States has one of the highest maternal and infant mortality rates. The authors of the study concluded that despite public perception, women weren’t free to choose how they gave birth.


Other factors?

When we’re not using the “too posh to push” or “asking for it” explanation for rising caesarean rates, health professionals resort to the “too old, too sick and too fat” mantra to explain away our responsibility for the rise. In other words, women are giving birth at older ages, they have more health complications and are increasingly overweight.

All of this is true on one level – women are older and more likely to be overweight and this all increases the chance of complications – but caesareans are rising among all groups, regardless of age, risk factors and weight.

In fact, there is a greater correlation between your postcode and private insurance status and the caesarean section rate than being older, overweight, sick or asking for it. And the healthiest, wealthiest women who are least likely to be obese, smoke or have poor health (women giving birth in private hospitals with private obstetricians) are nearly twice as likely to have a caesarean section.

When a healthy first-time mother in this country has less chance than not of having a normal birth, then something is seriously wrong.

It’s time to abandon the “too old, too fat, too sick and asking for it” mantra and stop blaming women for the high rates of caesarean births. Instead, we need to address the real problem: we health providers are too often scared, impatient and inadequately informed to give women a real choice.