AIBU to think we shouldn’t worry about an increase in c-sections?

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I came across an instagram post earlier where someone had shared data indicating the UK’s c-section rates have increased significantly in the last five or so years. The commenters almost universally consider this to be ‘tragic’ and think it is ‘so so sad’ that some women are electing to deliver via section. There are also a whole bunch of commenters who think if only women were properly informed they would push for a natural birth even if drs are recommending inductions etc.

I accept the UK’s maternity system is under strain and needs improvement, but really isn’t the point that we have healthy mothers and babies not that women give birth via one method or another.

There are downsides of attempted vaginal births, because of course not all of them go to plan! There is an increased risk of severe birth trauma or hypoxic brain injury to baby vs choosing a c section. For women, tears and pelvic floor injury are very common. While C-sections come with their own risks, these are well known and often presented without acknowledgement that vaginal births have downsides too.

For the NHS I understand planned c sections are cheaper than other births, given so many of them end in emergency sections anyway and because of payouts when things go horribly wrong.

Are we not looking at this all wrong? The goal should be healthy mothers and babies irrespective of how those babies get out. Why are people so fixated on reducing the c section rate?

As someone who had an emergency c section after being pushed into an induction earlier than I wanted, I’m very interested in why there are these increases. While I may well have ended up with the c section anyway, I felt like my induction was too early and, when the baby clearly wasn’t ready to come despite multiple attempts over four days, I was unsurprised when they told me he was in distress and I needed a c section. It felt like a self-fulfilling prophecy and was exactly what I had feared.

I said throughout my care that I wanted to avoid a c section unless absolutely necessary and I wanted to avoid an induction unless absolutely necessary. Yet I was strongly encouraged to book an induction for my due date. The reason for this was because I was late thirties and had had an IVF conception; there were no issues identified with my actual pregnancy.

When I asked my midwife repeatedly to change the induction to later, she told me that the appointments were ‘hard to come by’ and I had better keep it. She did not tell me that I would get a later appointment if I wanted one so I thought I was at risk of having no appointment if I delayed.

When I complained about this the midwife denied it and I now have to decide if its worth taking the complaint to the ombudsman (I’ve already pushed back twice through the NHS complaints system and they’ve made a concession that the tone of their initial response was dismissive but have maintained that they believe they are right). Anyway, I understand the statistical risks which inductions are designed to mitigate but patients should always have choice, the quality of information provided needs to be much better, and I’m still not sure it’s always being got right.

Most women I know have delivered by c section. If I take one friendship group alone (eight of us) with 13 babies in the last 9 years, 8 of those have been emergency c sections and six of the eight of us have had sections. And that’s a group where the majority were having babies in their early to mid thirties. It’s even more common among my mum friends, lots of whom were older than that when giving birth.

I also think there were a lot of traumatic births in the past that it was more taboo to talk about. I suppose there was probably a sweet spot when we had healthier mothers and better maternity care where outcomes were better but I’m not sure it’s ever been a panacea.

@WhatWouldDianeLockhartDo I had a quick VB so no time for pain relief. The contractions & pushing at the end were intense & painful but the crazy thing was, once baby was out the pain just went away. I only had a few stitches so no discomfort sitting etc, the only soreness I really had was just like muscle tiredness as if you had had a really intense workout the day before. I was lucky.

I was reading that C section rates have doubled in the last decade …so I assumed that as doctors perform c sections and don’t generally get much involved with natural births, that they’d need more doctors right?

Did a bit of research and apparently the obstetric workforce has increased by 4% over that time.

100% more c-sections …. Delivered by an obstetric workforce that has increased by 4%?

And you’re ok with that?!!!

In what other industry would the output increase by 100% and the workforce grew by 4%? How is that even possible (without AI obviously!)

Mine certainly wasn’t maternal fitness (or lack of). Anecdotally my impression is that it’s at least partly a care issue.

My mum and her peers seem to have had far fewer c sections.

I had an emergency c-section and wouldn’t wish it on anyone. I took me a long time to get over the birth. Out of the 7 people in my NCT group, 5 had a traumatic birth. This is nearly 20 years ago, so it doesn’t look like there’s been much improvement.

I’d like to know how many of the c-sections in the report were emergency, or elected after a previous traumatic birth.

I totally agree, which is part of the reason why I’m bothered by the hand wringing re c section rates. I don’t think there’s anything wrong with a woman making an informed choice (and there’s a lot of patronising crap about educating women better if they review the info and choose a section).

I’m sorry about your traumatic experience. In your case, would you have preferred elective to start with or do you wish you had been allowed to continue to labour naturally?

I agree. 2 natural births without issue. My mum was the same. DH mum the same x4 and his sisters both had 7 positive natural births together between them. You really don’t know anyone who had a positive natural birth?

I think better maternal care throughout pregnancy would likely reduce CS rates. I still think women should be able to choose but care should be better.

2 naturals, 2 electives. Would have electives every time. Like others I only hear a positive birth story maybe 5 percent of the time. I was traumatised from my 2nd birth so much I decided not to have any more children. Only an accidently pregnancy I realised I had tokophobia I still had to fight for my elective. As they were trying to push for Induction which normally ends in emergency section anyway.

I think this is such an important point.

My mum would say she thought most people she knew had 'easy' vaginal births. Yet most of the women she's talking about also suffered through prolapses and incontinence and so on, because it was dismissed as just 'natural' and what you should expect. I know people her generation (70s) who honestly believe that they had no physical trauma during childbirth but that 'everyone' has to use incontinence pads afterwards in case they leak. Obviously not everyone thought that, but lots of people did.

Sadly I think it's also the case that people didn't talk so much about other negative outcomes. Not so very long ago (1990s) guidance for midwives if someone had a stillbirth was still to suggest the mother shouldn't think too much about it. I don't think there was such widespread awareness of how common it was. Stillbirth rates have reduced (though it's worrying that this may not be a very secure thing), but my impression is that a lot of sections happen because people are far, far less willing to take the risk than they used to be.

We already have done to an extent. Women who failed to deliver naturally historically would die.Now they don't which is obviously great but they go on to produce daughters who also struggle to give birth naturally due to inherited pelvic anatomy.

I see your grasp of science is as good as your spelling....

I think the 100% increase in c-sections over the last decade, carried out by an obstetric workforce that has only grown by 4% over that time, must be putting pressure on the system which is perversely making it less safe? A lot of staff are involved in a c-section… I only had two staff for each of my vaginal births.

If two thirds of maternity hospitals are judged unsafe by the CQC then it must be a system issue? The effect is to encourage even more c-sections.

Do they even have enough theatres to perform that many c-sections? Are midwife led birthing units now underused? It takes a long time to build new hospitals and theatres.

I’m not sure this is true. A c section is over very quickly so while you need a lot of staff, not for very long. Labour can last for days and so the total staff commitment for even 1-2 people attending the birth would probably be higher.

Also … why does it follow that the effect of inadequate maternity care leads to more sections?

Good point, per hour over the course of the whole labour it could be

However I would say I was only 1-1 during the active part of labour. Before then the midwives were working across multiple women. It was only 1-1 after a certain point. For me that was 60 minutes and 30 minutes 1-1 (I had a second junior midwife for my first)

Because women feel unsafe or concerned and are more likely to opt for a c-section? Women can choose to have c-sections now in England

I think the ideal is an uncomplicated vaginal birth because it’s the natural process and that comes with benefits that can’t be replicated. The baby gets the microbiome, the lungs are squeezed of the fluid, breast milk comes in, recovery is much faster etc

That said, there’s no guarantee that the birth will be uncomplicated so it’s always a bit of a gamble.

My friend is a trainee midwife and was telling me that they were learning about a trial in America where they essentially insert gauze into the vaginal canal of women having c sections and remove it to wrap about the baby after they are born. The point is to see if they can replicate the exposure a baby gets during a vaginal birth.

I’m not anti or pro c-sections or vaginal births. I don’t have a strong opinion or knowledge of maternity beyond my own and peers experience

But I am interested in systems and what are the factors that are causing maternity care to be so unsafe.

We clearly have something going on here that needs to be investigated and unpicked. Whereas all you hear about on the news is that staff and culture are the problem.

I’m sorry, but very few people choose to work in healthcare and set out to deliver poor care. Something has happened to cause some staff to lose their empathy.

Something has gone badly wrong with the SYSTEM. We need to understand what has happened and course correct.

Poor care and cultural issues are SYMPTOMS of the problem- they are never the causes.

edited to correct grammar errors!

C-sections also have risks, they are major abdominal surgery. And there is always a point where you are creating more risks than you are preventing.

A good general principle in medicine has traditionally been, only intervene in natural body processes when necessary, to avoid doing more harm than good. The riskier the intervention the more that holds.

What exactly that means is perhaps not a hard line, however, reasons like reducing costs, making more money for surgeons, freeing up beds, or decreasing liability, are generally considered to be bad reasons.

A significant jump in any kind of surgery is cause for concern.

Yes I agree it does seem there is a systemic problem.

What I struggle with is the idea that the high c section rate is the problem when actually surely it is at most a symptom, and at best just a reflection of informed maternal choices and medical decisions which save lives.

This is a falsehood.

The NICE guidelines also say this. It's very much not just me.

They say that basic cost alone should not be a reason to refuse an Elective because the downstream costs associated with a VB are not taken into consideration. It says that if you take into consideration the costs associated with urinary incontinence for attempted VB (which includes EMCS) and an ELCS alone then the cost of an ELCS is not much different because there are differing rates of incontinence (much higher in an attempted VB). It then goes on to say, that there's a level at which it becomes CHEAPER for if the ELCS rate is high enough. Why? It sounds perverse doesn't it. And then you think about it - ELCS are done between 9 and 5 Monday to Friday and babies coming out of fannies have a rather inconvenient habit of being much more likely to be born out of hours. Thus the staffing costs at a high enough ELCS rate become lower because you don't have to pay as much staff unsocial hours rates. This level of ELCS was not an outcome they felt desirable. China has gone down this route, in part because of staffing issues and desirability of an ELCS.

So if we talk about costs, you should be careful what you wish for and how you push it, because realistically if we were to go down this route, there'd be MORE ELCS not less.

Women who request an ELCS, by their very nature, are much more likely to suffer from anxiety related issues and anxiety related issues are strongly related to poorer outcomes with an attempted VB. A lot of these requests are actually mental health related and legitimately are therefore effectively medically indicated for mental health reasons. In theory women with particularly strong levels of anxiety, should be automatically be talked to about this and informed decisions made by all parties. (Inc doctors and midwives who don't always take this risk seriously enough).

I know the NICE guidelines on ELCS inside out. It pisses me off when someone comes along thinking they are clever saying ELCSs are a waste of money.

There are many legitimate arguments why the headline numbers for ELCS should not be looked at in isolation.

What is concerning is the increase of the EMCS over the same period as that's the most dangerous and expensive outcome. Neither of which are desirable considerations.

Totally agree c sections come with risks (these risks are made very clear, whereas ime midwives do not always outline the risks of a vaginal birth in the same way). Why do you consider an increase in surgery to be a cause for concern?