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With Australia's caesarean section rate exceeding 30 per cent of births-among the highest worldwide-many are left wondering what drives this sudden increase in surgical birth, and why it might matter.
The blithe response is that surgery is convenient and profitable for doctors, and in part this is true. In one study, Australian birth rates fell by four per cent during the week of an obstetric conference, with a correlative rise in births the week before - this meant the births of 116 babies were 'moved' to accommodate the doctors' schedules.
Numbers of babies born on weekends have declined by almost 18 per cent from 1969 to 2005. In the United States, caesarean surgery peak-hours are 4pm ('I want to be home for dinner') and 10pm ('I don't want to be up all night with this woman'). Doctors get paid more for labours with interventions, and they take less time, so as a business model, they're efficient.
An international study, How Should Doctors Be Paid?, concluded that, comparing vaginal and caesarean section delivery, the greater physician fee for the latter was likely to be significant in treatment choice and the experience in numerous countries has borne out this conclusion.
The high caesarean section rate is also a product of Australia's litigious personal injury environment. Obstetrics leads the field in medical negligence payouts, followed by anaesthesia. And obstetricians don't get sued for performing caesareans. There is an attitude that if the doctor performed a caesarean section, she did everything she could.
In New Zealand, where there is a publicly funded no-fault compensation scheme for personal injury, caesarean section rates are lower. (There is also a homebirth rate of about four per cent in NZ, where homebirth is publicly funded; in the Netherlands, 30-40 percent of women have homebirths and 13.6 percent have caesarean sections.)
Litigation risks to doctors produce physical risks to mothers and babies. A caesarean section rate of 30 per cent doesn't arrive out of the blue. It is often the result of other high rates of hospital intervention, such as inductions and administration of pain relieving drugs, which work against the body's natural instinct and ability to birth.
The textbook 'cascade of interventions' starts with an induction of labour (rarely warranted on any medical basis), which brings on contractions much faster and stronger than would naturally have occurred if labour had been commenced spontaneously. This intensity means a woman's normal endorphin response to pain can't operate quickly enough to allow her to cope and she is offered, and accepts, chemical pain-relief. This often slows labour, usually to the point where she is re-administered the same drugs that induced her in order to 'augment' the labour again.
Or the baby goes into distress as a result of the ****tail of drugs (perhaps passing meconium, the first 'poo' passed by a newborn and therefore guaranteeing itself a stay in the newborn infant care unit, missing out on critical contact with the mother) and a forceps or ventouse extraction, or a caesarean section, is advised. Hospital protocols allow a certain time for each stage of labour and don't hesitate to pressure or force women to comply with their timetable or suffer further intervention.
By contrast, if she were home birthing, the woman would wait for labour to start spontaneously, contractions would usually increase gradually, giving her body time to adjust, she'd be offered emotional support and the use of water or heat packs rather than chemical pain relief. In most cases, the baby would arrive in its own time, undrugged, often into a family member's hands and to a blissed-out mother. If the midwife-whose total focus is on one woman birthing-noticed problems, such as foetal distress, they'd transfer to hospital.
The hospital practices that create an environment of fear and intimidation are precisely inimical to natural birth. We are, after all, still mammals. And like our cousins in the wild, a shot of adrenalin produces the fight or flight response: it's not safe to birth here, turn off the birth and run. Birth is an intense physical process but it is also a profoundly emotional and mental one, dimensions that are utterly discounted in the medical model of birth.
Why should we care about Australia's rising caesarean rates? After all, the baby comes out one-way or another, doesn't it?
Babies born surgically are three times more likely to die than babies born vaginally, and that's excluding emergency caesarean sections. That's a compelling reason to worry about a third of our population being born surgically, but one that's often not discussed.
C-section babies also suffer more breathing difficulties and receive lower Apgar scores, a rating developed to give a newborn a number of out ten, indicating their 'condition'. They are much more likely to end up spending their crucial first days in intensive care, rather than bonding with their mothers. They are less likely to be breastfed at all and more likely to be switched to formula earlier. The incomparable health benefits of breastfeeding have been well documented-breastfeeding is probably the most important thing a mother can do for her child.
Women who have elective c-sections are at least twice more likely to die than those giving birth vaginally, twice more likely to be rehospitalised after birth, more likely to suffer post-natal depression, more likely to have subsequent miscarriages or ectopic pregnancies, take longer to become pregnant again and have a much higher risk of uterine rupture in subsequent labours.
But perhaps the most under-acknowledged way caesarean sections damage a mother is by robbing her of the most profound, fortifying and transformative experience she will ever have. A woman who has given birth naturally-which means more than just vaginally; it means that she hasn't been drugged and can feel the full soaring effect of the massive endorphin and oxytocin rush that comes with supported, natural, vaginal birth-knows herself to be a different woman than the one who felt the first niggles of a contraction a day or so earlier. Giving birth is a rite of passage, not an annoying interlude that can be inconsequentially skipped over in the rush to the prize.
In addition to the effects on mother and baby, there are severe consequences for the medical practitioners in terms of skill loss. Try finding a hospital that will 'let' you have your breech baby vaginally. For that matter, good luck finding a hospital that will support your desire to have a natural third stage (allowing the placenta to detach and be born without drugs speeding the process). The result is that hospital-based midwives and obstetricians don't know what natural birth looks like, sounds like, and moves like. They don't know its rhythms and progressions because the clock drives them and they're not familiar with the natural operation of hormonal stimuli throughout labour because it's taught in medical school.
Obstetricians learn about dangers and risks that affect tiny percentages of women, and how to manage them; then they apply them across the board, and in assuming a woman is high-risk and intervening 'just in case', they create myriad adverse outcomes-like a 30 per cent caesarean section rate and all that entails, or a culture in which women are afraid of birth and 'can't handle it' because they've been expectation-managed not to.
In Australia, caesarean sections are the most common reason for surgery on women, and all are at least partially publicly funded, through the public hospitals or through the 30 percent rebate on private health insurance. And yet, in Australia, a woman who wants a homebirth-which is less expensive, doesn't involve anaesthesia or other chemical pain relief, rarely results in caesarean section or forceps or ventouse extraction, doesn't consume hospital beds, produces a drastically lower rate of post-natal depression and consequent social problems and is safer for mother and baby-must find $5,000 for a midwife committed enough to practice without professional insurance.
The average cost to government of an occupied hospital bed is around $1,000 a night and women delivering babies are the single largest group occupying those beds. If the new federal government wants to free up some hospital beds, cut its caesarean section spending and improve birthing outcomes, it might start by redirecting its $85 million plan for post-natal depression into maternity care that will drastically reduce the incidence of depressed mothers, and provide Medicare coverage for registered independent midwives providing domiciliary homebirth services throughout Australia.
