Many new mothers do not plan to give birth via c-section, yet around one in three women in Australia and the United States will give birth this way.
When medically necessary, c-sections can save lives. When conducted as an elective procedure, however, the risks outweigh the benefits. The World Health Organization (WHO) recommends a c-section rate of just 10-15%, which is much lower than 1 in 3 women!
If fewer women are planning a c-section, why are so many having them? Our birth culture and maternity care ‘system’ are not supportive of low-intervention vaginal births. Even when a mother prepares for a vaginal birth, she might be met with care that isn't supportive of her desired birth. Unfortunately, avoiding a c-section often becomes the responsibility of the birthing woman.
How Can We Increase The Number of Low Intervention Vaginal Births?
The WHO’s recommendation for c-section births is informed by evidence-based research, therefore we know it is possible to have more vaginal births. The American Congress of Obstetricians and Gynecologists (ACOG) recently published a study with recommendations to reduce the primary c-section rate.
Here are 9 changes we need to make to increase the rate of vaginal births:
#1: Low Risk Providers For Low Risk Mothers
Midwives provide wonderful care for low risk women. They are trained to support normal physiological birth. Midwifery care is linked to improved maternal and fetal health outcomes, including lower c-section rates. In some developed countries, midwifery care is the norm, while obstetricians are only needed for women experiencing complications. Many of these countries have higher rates of vaginal births when compared to Australia.
While midwives are trained to help facilitate normal physiological birth, obstetricians are more likely to be trained to manage labour. They are also trained surgeons. This training is excellent and needed when caring for a high risk mother, but is often unnecessary for low risk women. Therefore, some women may end up with procedures that they really didn't need.
How a professional is trained will influence their view of c-sections. When trying to increase vaginal births, it's important to make midwifery care the norm for low risk women.
#2: Continuous Labour Support – Use More Doulas!
Women who utilise doulas not only report more satisfaction with their labour and birth experience, they also increase their chances of a vaginal birth. The ACOG study linked above shows continuous labour support reduces c-sections, and other studies show trained doulas dramatically reduce c-section rates.
Having a doula present increases:
- The likelihood of spontaneous vaginal delivery
- Satisfaction with the birth experience (for both mother and partner)
- Rates of breastfeeding at 6 weeks postpartum
- The mother's self-esteem
It decreases the likelihood of:
- Utilizing medicinal pain relief, including an epidural
- Labour induction and augmentation with the synthetic oxytocin (which does not act the same way as natural oxytocin)
- Vacuum or forceps assisted birth
- C-section birth
The evidence speaks for itself. Continuous labour support from a doula can help increase our vaginal birth rates. We need doula care to become the norm, and we need team work between all care providers, so birth professionals can all play their role (or step aside) as needed.
#3: Encourage Movement
Before hospital birth became the norm, many women stayed active and moving during labour. Now it's not uncommon for women to go to the hospital early in labour and remain in bed.
Barring medical necessity, staying in bed is not an evidenced based practice. Moving during labour helps women cope with contractions, and facilitate baby's movement into the pelvis and through the birth canal. Coping with contractions, using gravity and facilitating easier movement for baby can help increase vaginal birth rates.
#4: Only Use Induction and Augmentation When Medically Necessary
Choosing baby's due date and speeding up labour can seem appealing, but they are not without risks. Mother and baby fare much better when labour begins and progresses naturally. If providers use only evidenced based practices when deciding to induce and augment labour, we could see an increase in vaginal births.
When medically indicated, it's wonderful that we have the ability to induce or augment labour, and improve outcomes in high risk situations. Unfortunately, the current rates of induction and augmentation do not reflect that they're being used only when medically indicated. The use of synthetic oxytocin, a common induction and augmentation drug, is not considered appropriate for elective inductions.
#5: Awareness and Availability of Birth Options
Many first time expectant mothers assume a hospital delivery with an obstetrician is their only or best option. However, many other options exist. Normalizing these other options can play a key role in increasing vaginal deliveries.
Delivering in the hospital with a certified nurse midwife (CNM) or a family physician, instead of an obstetrician, can increase the likelihood of a vaginal delivery. Like midwives, family physicians use less routine interventions and are not trained surgeons. Their approach to care during labor results in lower c-section rates, just 15.4%.
Planned out of hospital delivery with a skilled midwife is a safe option for low risk women. Some freestanding birth centers have a spontaneous vaginal birth rate of over 90%! A recent study confirmed the safety of midwife attended home births for low risk women and found a c-section rate of just 5.4%.
Obstetricians have a key role in maternity care. It is important that we have access to life saving interventions when medically necessary. Statistics, however, tell us that access to other birthing professionals and locations other than hospitals – even at home – can help increase vaginal deliveries.
#6: Encourage The Use of Natural Comfort Measures
While IV narcotics and epidurals provide pain relief, they also have side effects and limitations. Once medicinal pain relief is administered most women are required to stay in bed and have limited mobility. This removes or limits the ability to assist baby in its decent with mom's movement. Epidurals can also make it difficult for mom to feel the urge to push which can increase the risk of needing assisted delivery.
Labor is work though, and women need coping techniques and comfort measures. Encouraging and educating about natural comfort measures might increase vaginal delivery rates. Hydrotherapy, massage, self-hypnosis, the use of warm and cool compresses, aromatherapy, counter pressure, position changes and more can help moms cope with contractions while adding little to no risks.
#7: Keep Women Off Their Backs
For most of human history women did not give birth in the supine position. It wasn't until the 1700s that women began giving birth lying down. When a woman delivers on her back labour is often more difficult.
There are many benefits to giving birth in an upright position including:
- The assistance of gravity
- More efficient contractions
- Less pain
- More pelvic space for baby to make its way through
- Shorter labor
These benefits can help increase vaginal births. Giving birth in an upright position as the norm is an important step in reducing c-section births.
#8: Normalise VBAC (Vaginal Birth After C-Section)
One major contributing factor to the rise in c-sections was the belief that a repeat c-section birth is usually safer than a vaginal birth after a caesarean (VBAC). Current research tells us this is not the case.
While a VBAC has risks, a c-section birth is not without them. Women have been conditioned to fear a ‘uterine rupture' after a c-section, when the likelihood of this occurring is actually very low — and the chances of it being fatal is even lower. Yet women are not told about uterine rupture being a possibility while having an induction of labour. Why is this so?
Women should have access to evidenced based information regarding VBAC versus c-section. Many women believe a repeat c-section birth is their only option, or that choosing a VBAC is extremely dangerous. Some women are well informed and desire a VBAC, but are unable to find a provider willing to support her. Giving women access to VBAC information and supportive care can help drastically reduce c-section rates.
For more information, read our article: 4 VBAC Myths Busted.
#9: Build Everyone's Confidence in Normal Physiological Birth
Birth is a normal bodily process that often unfolds well with a healthy mother and baby as the result. This may be hard to believe with the current high level of interventions, but it's true. The US is a prefect example – they invest an absolute fortune into maternity health care (more specifically, technology), but have some of the highest newborn and maternal death rates in the world. We can do better and we can save more lives, with less.
If providers, expectant parents and society begin to view natural physiological birth as normal, we will begin to see more vaginal births. What we believe influences how we practice, the decisions we make and even how our own labours unfold.
When a provider is trained to view physiological birth as the norm, and necessary intervention as the exception, their care will better facilitate vaginal births. When expectant parents are educated about normal physiological birth, remain an active participant in their care, and make evidenced-based choices during childbirth, they are likely to have a healthier birth experience.
If society begins to view birth as normal, we will see positive birth in the media building our confidence. We will also have friends and relatives encouraging and building us up, rather than creating fear around natural birth.
Our current c-section rates are simply too high, meaning many mothers are having unnecessary major surgery.
By being informed and changing our perceptions about birth, we have the ability to change this trend. We are extremely fortunate to have medical support available at birth when we need it. But when used unnecessarily, medicalised birth interventions often cause more harm than good.