What’s behind Canada’s rising C-section rate?
By Jenny Hall, posted on Thursday, October 1st, 2009
Professor Ellen Hodnett of the Lawence S. Bloombeg Faculty of Nursing shares her thoughts
Newborn at rest. Source: www.photoxpress.com Photo by Adam Borkowski
A report released last month by the Canadian Institute for Health Information found that the national Caesarean section (C-section) rate is on the rise—up to 26 per cent of babies born in hospitals in 2005, compared to 23 per cent five years earlier and 17 per cent in 1993.
We asked Professor Ellen Hodnett of the Lawence S. Bloombeg Faculty of Nursing for her thoughts on what’s behind this trend. Hodnett holds the Heather M. Reisman Chair in Perinatal Nursing Research.
Why is the C-section rate going up?
The first thing to note is that it’s been going up for a long time. When I was a manager of labour and delivery at a hospital in Toronto in the early 1970s, we thought anything above a five per cent Caesarean rate was high.
What’s so bad about C-sections?
They carry increased risk for the mother and the baby, and increased risk for the development of serious complications in subsequent pregnancies And a C-section is major surgery.
So what has happened since your days in labour and delivery in the 1970s to explain the dramatic increase?
Care during labour was very different in those days. The Caesarean rate has gone up very steadily since the introduction of a lot of technology during childbirth—routine electronic fetal monitoring (EFM) is an example.
With EFM, the woman labours in a bed. But a bed is a very poor place to labour. And the position that she is in, even if it’s sitting or semi-reclining, is not optimum for good labour progress, for descent of the fetal head.
There is a systematic review of randomized trials that shows that when routine EFM is used it increases the likelihood of a Caesarean, without important long-term improvements in the baby’s well-being.
So EFM is to blame?
Continuous EFM is just one element in a cascade of interventions. If you’re immobilized in a bed, there are limits in what you can do to cope with the pain of labour. So epidural analgesia is often the best option. However epidural analgesia increases the likelihood that you will need an IV containing artificial oxytocin, to enhance the quality of contractions. So you get this triple whammy of interventions which adds risk and decrease the likelihood of a spontaneous, normal birth.
So then a C-section is needed because labour isn’t progressing?
Yes. “Failure to progress” is the catch-all phrase for the biggest contributor to the rise in the primary (first-time) C-section rate.
How common are these three interventions?
We recently did a large trial that involved 5,002 women in hospitals in Canada and the US. These were healthy, normal first-time mothers in early labour. Sixty-two per cent had oxytocin started once active labour had begun. And a whopping 85 per cent had epidural analgesia.
And it’s not just the immobility that’s the problem. These technologies, by sending a powerful, perhaps subliminal, message that undermines women’s confidence in their own abilities to labour and give birth.
So it’s not a question of just focusing on C-sections, we need to look at the kinds of technological interventions that lead to them?
Exactly. We need to rethink how and where we care for healthy women in labour.
And I would argue that many of the Caesareans that are done today are necessary, necessary in the sense that by the time things have gotten that bad, they actually are needed. So it’s not a matter of pointing a finger and saying you shouldn’t have done this C-section. It’s about what leads up to them.
Then why use these technologies that are resulting in more C-sections if there isn’t evidence that they’re useful?
I don’t place the blame per se on any one any one group. We’re all part of the same culture, in which the messages are powerful. For example, it’s very difficult for me to watch TV programs that show birth stories. You see these women flat on their backs with little or no labour support and all this stuff being done to them and—surprise!—they run into problems and then have these dramatic rescue stories.
So TV doesn’t show what birth is really like?
I think these programs show what is typically happening, but not what ought to or could happen, under different circumstances.
We hear a lot about women who chose C-sections without a medical reason. Do these play a role in the rising rate?
No, less than one per cent of Caesareans are performed because of maternal request. It gets all the press—women demanding it, women who are “too posh to push” and all that nonsense. Women who request Caesareans are an interesting group to study—to find out why they fear labour—but they’re not making a significant contribution to the rising rate.
What about previous C-sections?
A big contributor to the rising rate is the repeat Caesarean. That’s why my focus has been primarily on promoting conditions that would decrease the likelihood of the first one, because then you’ll be stopping the need for the second one.
We’ve been talking about low-risk, normal births. Are there circumstances or conditions in which women would need to plan a C-section ahead of time?
Yes. If the baby is malpositioned, for example, is in the breech position, a planned C-section is advisable. A planned C-section is also advised for women carrying more than two babies, and in the case of any medical condition of mother or baby for which labour would be riskier than a C-section.
You did a study recently that looked at changing the environment that women labour in. Can you tell us about it?
There is increasing evidence that the environment sends powerful messages. We know from tons of studies that go back decades that high levels of anxiety and fear in women in early labour will stop labour. Whether we are consciously aware of it or not, to go into a setting where there’s all this technological stuff sends messages that you might need it and can be quite inhibiting.
I was part of a Canadian Institutes of Health Research-funded strategic research training program called “Healthcare Technology and Place.” Through it, I was exposed to research on hospital architecture. It’s an emerging science, but people have done some amazing things to change care settings around the world and looked at whether they have measurable benefits for the health of patients. Nobody had done this for labour before.
There’s a researcher who’s done a systematic review of the characteristics of health-inducing or what we would call “ambient” hospital settings—what the key characteristics of those settings are. Views of nature were a big part of it, as was privacy, a sense of control and freedom of mobility. We took those attributes and wondered how we could incorporate them into a hospital labour room.
So we removed the bed and put a double sized mattress on the floor with a lot of pillows so the woman and her partner and caregivers could use it. We turned the lights down low. We projected scenes of Hawaii and the Caribbean and northern California on the wall. We gave the woman a selection of iPods with music that was both calming and energizing.
They were simple modifications in the sense that they didn’t cost a lot of money but radical in the sense that this room did not look anything like the typical hospital labour room. Even in this study of only 62 women in two hospitals in Toronto, we had a 40 per cent decrease in the use of oxytocin, and yet their labours were, if anything, slightly shorter.
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