Cesarean Birth Statistics

[iknowitsmadbutiwantit]

Hi.
I am not currently pregnant (unfortunately)(dd and ds already), but my sister is and we have had some interesting conversations recently. One of these concerned the alarming figures I read somewhere that 1 in 4 women in America have cesareans. Imagine our suprise, when we checked out the national birth statistics in Great Britain! A 25% cesarean rate is not uncommon in this country either! My local hospital, Colchester General, has cesarean statistics of 25 - 28% depending on where you research. I personally know of someone who was told she would have to have a cesarean if the maternity ward was short staffed!
Do these figures worry anyone else? or is it just us? Id be interested to hear other peoples opinions. x

tittybangbang this is what we're after. It is assumed that C sections are A Bad Thing but nobody is saying why. You still haven't in your persuasive post. Once we get there we can start to look at it properly.

Nobody is saying 'sections are a bad thing', when they are used appropriately. When they are necessary they save the life of mother and baby, so are categorically A WONDERFUL THING.

But they are major surgery - and if not necessary then why would you want major surgery, with all its attendant risks.

Have a look at this - the NICE clinical guidelines on CS.

[[http://www.rcog.org.uk/files/rcog-corp/uploaded-files/NEBCSectionFull.pdf here]

(tabl 3.1a)

On page 22 they give a table setting out the comparative risks of vaginal and c/s. They make a point of saying that "Even though a vaginal birth is planned, a CS may become necessary for other reasons. The
planned vaginal birth group includes women who had either vaginal birth or ?emergency? CS.
Likewise the planned CS group includes women who had a vaginal birth or emergency CS."

In other words, a signficant number of women in the vaginal birth group would have had an emergency c/s (I should imagine about 10% - 14%, the national average). Probably a much smaller number of planned c/s mothers would have had a vaginal birth or an emergency c/s.

What you notice with the table is the massively increased risk of bladder injury, admittance to intensive care, thromboembolitic disease, hysterectomy, and most importantly - death, in the C/S group. Also increased seem to be stillbirth in subsequent pregnancies, as well as placenta praevia, uterine rupture, and not having further children. Sure - perineal pain and damage and uterine prolapse are higher after vb than c/s, but you'd expect that.

These risks of a really bad outcome with c/s are still low, and it wouldn't necessarily put someone off having one, if they had very strong emotional or health reasons for wanting to avoid a vaginal birth, but for those making decisions about health policy - well you couldn't ignore the fact that more women would die and end up infertile if c/s became massively more common in this country.

Sorry:

here

Wanted to add, that surgical techniques are very good now, and I should imagine it would be quite difficult to reduce morbidity and mortality associated with c/s, particularly with our growing rates of obesity, which make surgery much more complex and dangerous.

Reducing the injuries associated with v/b is much more possible. Decreasing women's need for epidural by offering more access to waterbirth would reduce rates of serious perineal trauma and instrumenal birth. Having better consultant cover, more midwives and encouraging women to have female birth partners would reduce rates of emergency c/s, which would in turn reduce overall morbidity hugely, as so much of the serious morbidity attributed to vaginal birth is linked to planned v/b ending in emergency c/s.

It's not that they are bad just that they should only be done when needed, does anyone think differently?

There does seem to be more research coming out that points to more problems with regards to allergies in children delivered by c-section v. naturally.

I'm not saying that I think every baby should be delivered by C Section. But there is an assumption that C Sections are bad, and the OP refers to being "appalled" by the C Section rate. Some of us were trying to get to the bottom of why that rate is what it is, and if it is really all that appalling.
Thank you tittybangbang for the link. I'll read it shortly. It's this sort of information that I've been asking for.
My argument (I think it was on page 1, crikey!) was that medical advancements like ultrasound meant that many babies could be delivered by C section that would have just died before, my own placenta previa being cited as an example. Even in the 70s scanning didn't happen, my mother had an X Ray to check my size late on in her pregnancy.
Someone else suggested continuous monitoring as a factor, I suggested that could actually be a good thing as the baby can be born before anything too horrific happens.

I have another suggestion - only a suggestion mind! Many many years ago at university I was reading a book on how babies learn to do various things, walk, talk etc. It touched on how human babies are born with much less ability than animals, e.g. they can't walk for a long time after they're born. The author suggested that was because our brains were more developed, leading to larger heads. If the gestation period were comparable to other animals, we'd never be able to deliver vaginally! Are we heading that way?

"Someone else suggested continuous monitoring as a factor, I suggested that could actually be a good thing as the baby can be born before anything too horrific happens".

They've tried this though - putting all women on CTG throughout labour, and not just women with health issues, or when labour wasn't progressing normally.

The net result was more emergency c/s and more babies in special care. It didn't make any positive impact on infant mortality at all, which is why they don't do it any more.

TBH - you can only come away feeling 'even handed' about c/s is if you compare it to a complicated vaginal birth which has resulted in serious birth injuries. I've had three difficult vaginal births, but only one which resulted in me needing antibiotics and three days of bed rest.

But most vaginal births are uncomplicated, untraumatic and result in a fit and well mother and baby. All C/S result in a physically scarred mother needing bed rest, antibiotics, heavy duty pain relief and medical attention.

I honestly just think we've become blind to the idea that a C/S is a serious operation. We're so blase about it.

I also think that most people spend very little time thinking about the psychology of labour and birth, and the affect of the hormonal cascade on the bonding process between mother and baby. The more you know about it, the more impossible it becomes to see mode of birth as an irrelevance.

It is worth looking at the table tittybangbang suggests - on page 22 of that NICE document.

The 'massively increased risk of bladder injury' she mentions is from a risk of 0.003% with VB up to 0.1% with planned CS.

She doesn't mention the reduced risk with a planned CS of maternal urinary incontinence at 3 months after birth - 4.5% compared to 7.3% with VB.

People can decide for themselves how important these differences are.

There is a very important disclaimer with the table, which is worth repeating - "Care needs to be taken in interpretation of data from observational studies as there is usually more than one explanation for any associations seen, and it is OFTEN NOT POSSIBLE TO DISENTANGLE THE EFFECT OF CS FROM THE REASONS FOR CS." [caps are mine].

Of course, the vast majority of planned CS's are carried out because there is a medical problem with the mother or baby - so in comparing planned CS's with VB's, you're already looking at comparisons between a group more likely to have problems, and one without.

It is worth also looking at table 3.1b (page 23). This compares the risk to babies of planned CS v VB. There is NO DIFFERENCE IN NEONATAL MORTALITY between planned CS and VB. The only difference they list is in increased respiratory morbidity (up from 0.5% with VB to 3.5% with planned CS).

Thats a really interesting point shaz10 - Ive often mused the same thing myself. Also as nutrition improves, babies get bigger all over (inc head circ) - but that doesnt necessarily mean the mother giving birth to that baby is bigger IYGWIM.

Also after reading some of the midwife archive discussion tittybangbang linked to it seems being a horsewoman might have contributed to me problem Ive ridden since I was 4 years old and apparently - to quote one of the midwives on that forum - it gives you a "perenium like leather" . This was never ever mentioned but I guess this theory is anecdotal rather than research proven or anything - add that to the list of reasons poppet45 quoted LOL

Barkfox, you are right with everything you say and I agree that people should look at the tables themselves to work out how they feel about the comparative risks.

Would want to say though re: neonatal morbidity, that the view that vaginal birth is more difficult, traumatic and dangerous for babies than a planned c/s is common currency in some places. I think it's good to see evidence here that this is not the case.

However, I don't personally feel that the 7 fold risk in babies experiencing respitory difficulty is an insignficant one. The trauma of being separated from a baby in SCBU - even if it's only a transitory separation, is something many women won't forget. Also have thought a lot about how this separation impacts on breastfeeding.

Personally I find a lot of this research quite frustrating, in the sense that the less tangible, but very important outcomes of birth are so rarely considered. I would love to see a comparison of two groups of low risk, healthy women: those having elective c/s on maternal request, with another group planning homebirths or births in MLU's - ie not obstetric births. Looking at rates of PND, breastfeeding and bonding among other things. It would be an absolute bugger of study to design and would have to involve large groups of women, but it would make fascinating reading!

titty, I totally agree that studies which compare 'like with like' a bit more (i.e 'healthy' CS v 'healthy' VB, however one defines that) would be SO much more informative than what we have to go on so far. Which always compare apples and oranges, really.

And absolutely, more holistic studies which address the less tangible but very important issues around birth/bonding/infancy etc would be invaluable.

Still on available info - someone a few pages back, and I forget who, I'm sorry, raised the question - if it's true that obstetricians are performing more CS's in order to avoid litigation, then what is it that is felt to be risky about VBs?

In this NICE document about intrapartum care - www.gserve.nice.org.uk/nicemedia/pdf/IntrapartumCareSeptember2007mainguideline.pdf, on pps 240 - 242, there is some (pretty limited) research discussion of the differences between different instrumental VBs (ventouse v forceps).

After that, there's some even more limited research discussion of outcomes comparing CS with instrumental VBs. I found this paragraph: -

"There is limited evidence on assisted vaginal birth on women?s and babies? outcomes, compared with CS. Limited evidence showed women with CS were more likely to lose more blood, and stay in hospital longer, while babies born with CS were more likely to be admitted to a neonatal
unit, but LESS LIKELY TO HAVE TRAUMA, compared with assisted vaginal birth." (caps are mine).

This is purely speculative, obviously, but I wonder if part of the rise in CS rates is because CS's are, or are perceived to be, less likely to physically damage a baby than an assisted instrumental vaginal birth, once things have got to the point of intervention. Even given the increased likelihood of admission to a neonatal unit. It just struck me as a key area of potential litigation. [even as I type that, I'm feeling frustrated that I can't tell what they mean by 'trauma' - i.e. short term or permanent damage.].

Just a thought.

Pinkmook, the think about being a horsewoman is not theoretical, afaik. It is real. I vaguely remember seeing it mentioned by you lower down this thread and meant to tell you.

Had you disclosed this information to a previous midwife antenatally, or even during labour, they should have taken this into serious consideration.

I can't remember the detailed reasons why it makes a big difference to labour but I am sure you can find out why. It has to do with the fact that your pelvic floor is going to be quite 'fit' from all that horseriding, i believe.

BTW, saying you have a perineum like leather is not a nice thing to say or hear.

the way I see it, C/S is not a bad thing. That is way too simplistic.

What is a bad thing can be the reasons women end up having one. I have said much the same earlier in this thread.

When women are left to labour alone, many times for long periods of time because midwives are looking after several women at the same time. During this time alone she can ponder all the horror stories society feeds us through television and through friends and family instead of getting positive support that this is normal, she is normal and with intermittent foetal monitoring, to be told her baby is doing well.

Layer upon that the fact that for many women it will be the first time they are experiencing childbirth.

Layer upon that the fact that having small families mean that we are many times never ever seen or accompanied another woman in labour before so we are full of the unknowns.

Layer upon that the fact that when we don't have a clue about what labour is about, that we are acculturated to quickly do what people in the medical profession tell us, that women in labour can be in a highly suggestible state of mind, we simply do what we are told. Example: "Lie here so I can strap this monitor onto your belly. It'll only be on for 20 mins. but you have to stay still or it won't work." Then 40 mins of agony later, she returns to tell you that your contractions are not regular and you are better off at home.

Layer upon that the hospital environment which is not conducive to labouring women.
Mammals labour best when they feel secure. Somewhere where the ancient animal brain tells us is safe to give birth. Not where this new human brain, capable rational thought and which tells us a hospital is a safe place, says is safe. The bright lights, complex and sudden noises, people, nay, strangers coming and going many times touching you in personal places without ever knowing them from adam, the lack of consistent, one to one support... These factors keep the animal brain in a labouring woman on guard, ready to fight or flight, rather than allowing her to relax and descend into a semi conscious state where she cannot defend herself which is necessary for her body to give birth. It is this animal brain which controls the birthing process. The animal in us give birth. Not this civilised human.

Mammals on the savanna tend to give birth at night because the darkness is protection. An elephant will give birth surrounded by her herd. Or they will give birth en masse because there is no way they can all be attacked in childbirth or just like the wildebeests do. Lions find a hiding place not just because the young are born helpless but because she will be unable to protect herself while giving birth. Domesticated horses won't give birth if they are being watched. Likewise, women delay labour till they feel safe.

A woman can be in established labour at home, transfer to hospital, the new environment 'puts her off' labouring, her contractions space out again, her cervix even starts to close up again. So she is examined and determined to be 'only' 2 or 3 cms and is sent home again.

When she is finally admitted, her partner may be sent home because it is after 10 pm which increases her sense of panic. Her animal brain has to work out how she will make herself secure before she can go back to labouring.

Meanwhile the emotional and physical exhaustion builds with each 'delay'. As she tires because her labour is stalling, then it is more likely to need an epidural, an assisted delivery which both can lead to birth injuries if she delivers vaginally or to a c/s.

A c/s may be an welcome relief to this struggle and seen as 'saving' the woman from an ordeal. Then instead of saying to the woman that her needs were not properly addressed while in labour, she is given useless platitudes like 'as long as you and your baby are fine' which naturally shuts her up from saying 'actually that was a horrific experience. why did it happen that way?'
And for someone to give her an honest, informative responses.

Disclaimer: this is all a hypothetical scenario so please don't respond with your personal anecdote. We all have 'em which doesn't mean it is useful evidence with which to address whole populations.

I think when the WHO says the C/S rates are too high they also are saying that lots of things can be changed antenatally and intrapartum which means that women will have smoother labours where a C/S is unnecessary.

The statement is that when a C/s rate is above 10% there are no longer any benefits in terms of mortality and morbidity. It is possibly saying that a lot more can be done culturally and medically in order to make the birthing process more woman and baby friendly.

Foxytocin - some really interesting information in your post and I can see why a VB may be preferable to a CS - IF - the environment/conditions you describe can be created. I dont know how we can get from where we are now to a scenario where women feel safe and secure in labour in the way you describe (without being at home which may not be an ideal scenario for many in its self).

And yes the "perenium like leather" comment did make me a bit when I read it!

Foxytocin - If I'd ever been asked to disclose this info (re: being a horsewoman) I would have gladly disclosed it - but I was never asked. I wonder why its not a standard part of the questions you are asked at booking in if its such an issue?

Anyhow too late for me now. All I know is I cant go through VB again I'm too scared of what will happen to the damage thats already there, and Im happy with the fact I will now have a CS

I think the growing popularity of Midwife led units points to the fact that it can be available for more women.

in an ideal situation, one midwife to one woman especially during labour and consistent, competent, empathetic support can allay the fears of many women once they get onto the labour ward. There is a lot of very good evidence which shows that 1 to 1 care addresses a lot of the problems that lead to assisted deliveries and / or emC/S. the human element of both midwife and the woman is a dynamic relationship and a woman's needs changes during the different phases of labour. How can a midwife monitoring several women at the same time properly address the needs of all of them all of the time? It leaves the woman and the midwife feeling disempowered in many instances and lead to poor outcomes and lack of career satisfaction.

It will be easy to say that the NHS can tackle it with money but money is a short cut for a lot of answers and sometimes, not the right ones.

why c/s rates are unacceptably high is a result of a complex set of circumstances which cannot be addressed simply. It takes having an open mind to want to discuss them without becoming defensive and trying to listen and wanting to learn from the voices of many.

here is a case of a highly successful midwife led unit in the UK, working in an area of a lot of socio-economic disadvantage. It seems like, to the cynic, that it was shut down because it was too much competition, too much by its success, criticism of the mainstream hospital under which it operated.

have a good look around the site to understand that it isn't just about those homebirthing, breastfeeding, radicals who want us to all go back to nature and force us to have births without pain relief.

I agree -midwife led units seem like the best option for many women and 1 to 1 care defintiely would be preferable.

I think its very hard for defensive attitudes NOT to appear when discussing a really emotive subject like this, that many of the people discussing will have really strong, negative memories attached to.

I try really hard but just the same as someone who has had a bad CS experience feels they know what is best for them, I feel sure of what is best for me in my situation and when the issue gets discussed, it feels like some groups of people want to "take away" my choice to make the best decision for me either literally, by removing it as an option or more subtly by making women feel as if they are (to quote poppet45) "too old, fat, in-love with their undercarriages, pain-averse or descended from inferior genes that should have been wiped out in previous childbirth"

I really welcome a discussion about it, but for me now, after years of having fertility treatment followed by IVF - I will never have the chance to have a baby again (we are too skint to pay for more IVF!) and do not want to risk repeating the terrible experience I had with my first vaginal birth (which led to the situation where my husband had a vasectomy - against my wishes -because he was messed up by what he saw, and messed up by the consequences for the next few years after that traumatic birth on our lives and relationship) then when we had finally "got over" (as much as we can anyway) the physical/emotional stuff we could not conceive due damage to him from the vasectomy and subsequent reversal (all of which we paid for our selves - including the vasectomy, reversal, fertility treatment, IVF)

So ramble over, I am just so so happy to be finally pregnant again after all that and so so happy that the consultant agreed with me that CS is my best option (despite the fact that many would not see it as a "medical need" necessarily - since I do not have placenta praeiva, breech presentation or any of the things which mean a definite CS).

That midwife unit you linked to looks amazing BTW

congratulations on your current pregnancy and good luck with your baby.

similarly, I was horribly traumatized by my first birthing experience. I could not countenance having sex, never mind ever conceiving another baby for many months after my first. It has been a long process to be the person who I am today and it took a lot of self informing and listening and questioning and reflection to put that experience into context and to move on to another pregnancy and birth.

Your conclusions work best for you and no one is trying to take that away or insinuate that you should not have that. It is normal to feel as if you have to defend your choice. Your choice is a product of your experience which exists within a cultural context of labour and birth in this society. To say we ought to lower c/s rates does not mean we take away elective sections from women or leave women in horrendous birthing conditions in the hope that she'll end up with a vaginal delivery sooner rather than later. It just isn't like that.

Whenever I read positive and uneventful birth stories I felt very sad and sometimes jealous because mine was 'horrendous'. And that was dh's one word description 3 years later.

When I met my consultant the first time he wouldn't have been surprised if I asked for a c/s or and it wouldn't have been difficult for him to authorise one, I am sure. But I am a stubborn one and became that annoying patient who wanted a home birth instead. . All I am saying is that equally, I and a lot of other mothers have had to fight,literally, for a perfectly reasonable choice and have had hcp's hoping we would just be quiet and follow guidelines do as they prefer.

Foxytocin - I think its excellent that you got what you wanted and were tenacious enough to do so.

I too couldnt countenance having another baby for around 3 years after (couldnt actually have intercourse for 2.5 years LOL!)and I can see from your posts you have done a lot of research and investigated the subject thouroughly, I have done similar. But I have to dsagree that "no one is trying to take that away or insinuate that you should not have that." (one poster on this thread said CS's for a woman in my position should not be an option)for the reasons discussed in this thread and others like it here. (not that I think that is your opinion as it clearly isnt)

I think I'm going to have to bow out of this discussion now (I probably should never have got involved with all the pregnancy hormones I have flying around ) as it just seems circular. I know CS's are not for everyone but the truth is there is an attitude that CS's are a bad thing (as evidenced by the OP of the thread stating that CS rate figures are "alarming".

Anyhoo! Off I pop to eat DS's easter eggs sneakily and enjoy the day. Good luck to everyone who is due to give birth however that may be. Happy Easter

If someone has insinuated that further down the thread then I should think that there is very little peer reviewed evidence which can back her up. Psychological trauma (if that is a part of your reason)is a perfectly valid reason to have a c/s. Would she say that to someone who for example had experienced sexual abuse that her vagina is in good condition for childbirth? I don't think so. So why should anyone on a message board have a valid reason to say that you cannot have one? they have never and will never walked in your shoes and you are the only person who can decide what is best for you supported by reliable information and hcps who are willing to treat you as an equal party in the decision making process.

Thanks foxytocin. FWIW Ive found the info you have given very useful/interesting even though I personally dont want a VB this time so thank you. Happy Easter

Happy Easter. you have brought a smile to my face. onwards and upwards. will look out for your birth announcement.

maybe with your third you will countenance one.

Apologies for not reading the whole thread, read the OP and some of the end of it...

I had a letter from a private GP and counsellor stating that I had been through psychological and sexual trauma, which was resulting in an extreme fear of childbirth. Both recommended I have a cs. Midwives said, no, we'll see how it goes and kept convincing me to "give it a try". They set up an appt with a consultant for me at local hospital. Consultant also said they wouldn't just schedule me a cs and we'd have to see how it went. I'm American, but haven't lived there for many years. One dr even said to me "a lot of American women surprise themselves. They think they want a cs but then give birth naturally with no problems". I spent 9 months being absolutely terrified. It was not because I'm american ffs.

Birth was horrible. End result was amazing, of course and I love my beautiful DS. But, 18 months on and I don't want to be pregnant again because of it. In fact, I have an irrational fear now of getting pregnant... which really affects other parts of my life quite a bit!!

For about 6 months after the birth I was petrified of having sex. When I finally tried to do it, I kept having flashbacks/images of the internal exams where they had my dh hold my arms down while they forced their hands inside me and I screamed at the top of my lungs for them to stop.

maybe I'll have this post deleted because I just poured out quite a bit there. But hearing people parrot on about how "alarming" and "horrible" cs are... blah blah blah.... it really makes me SO !

Starexpat that is a horrible way to treat a woman. The benefit of hindsight tells me that had you written a formal letter to the head of midwifery a. asking for a second opinion, b. asking for a different named midwife, c. ask them for a written explanation citing medical research why in your case psychogically damaged women ought not have an ELCS, d. copying it to AIMS and asking for their support

then they would have rolled over and done as you had requested and you'd have a very stress free rest of your pregnancy.

there are quite a few ways to disempower women in maternity care.

starExpat, that's an awful story, it makes me really furious and sad. You were treated callously and incompetently. I'm in a related 'boat' (history of sexual abuse leading to a few problems! including tokophobia, but am in the process of being given an elec CS, not refused one).

IME, people in general who don't have anything in their own experience to compare it to just don't 'get' it, and are very judgemental - and that can be hard, but it's different when it's the medical profession, who are supposed to look after your welfare. I'm very sorry you had that experience.