C-section or vaginal birth? If you have the choice, what would it be? In recent years we have heard much about a considerable increase for c-sections by choice, rather due to medical advice. But is it possible to judge quickly what motivation drives women to more c-sections?
C-sections are risky, expensive and have been correlated to chronic diseases in the children. In contrast, c-sections can be scheduled and seems to be more convenient. But is this the case? In a Guardian post Hadley Freeman warns about the issue of quick judgement of women who decide to have a C-section, and writes:
Contrary to how it’s often depicted in the press, there is nothing of the “cheats option” to a c-section, unless you count being sliced in half as a walk in the park.
Unfortunately, there were 6.2 million unnecessary c-sections in 2010 (says the WHO). In total this is 14% of total global births, so almost exactly the ideal c-section rate (BMJ). So what is the problem? The country to country variation means that there are far too many c-sections happening in places where they maybe not needed and too few happening where they should be.
69 countries have C-section rates higher than 15%. It is however not clear why this is happening and there may be different reasons for different environments. The UK gives a surprising picture, if you take a closer look.
In the UK, it appears that there has been a drastic increase from 4% to 21% in only 30 years (BMJ, 2001). But when taking a closer look, it doesn't boil down to more mothers requesting c-section. In fact caesarean delivery on maternal request is relatively rare in the UK, only about 1 - 2 in 100 births (in the US it is similar with 3%). Does this mean that the medical system pushes for unnecessary C-sections?
But there are countries with much higher C-section maternal request rates, contributing much more to the number of c-sections not medically needed. In some middle income countries the rate is high and growing (20% of births in southeastern China in 2006) says it in a new analysis by the BMJ titled 'Emerging Global Public Health Concern'.
Why Are Unnecessary C-sections Being Called a Public Health Concern?
The new BMJ analysis looked at number of chronic diseases of children who were born via c-section, and found that there is a link between c-section and the risk for childhood chronic disease.
During an interview, the researcher admitted that they do not know for sure what the reasons are. Initial hypothesis point towards microbiota transfer through vaginal and fecal fluids during birth and variations in stress hormones.
C-section is risky for both the mother and child, has a longer recovery period and on top of that is almost twice as costly as natural birth. Jan Bludstein and Jianmeng Liu got interviewed by the BMJ this week about the risks of c-section.
Would You Like a C-section?
C-section should only be performed when medically necessary says a press release by the WHO. But we do women still do it?
Where C-sections are Needed?
Needed C-sections vs. Overall C-sections
Graph comparing countries with less than 15% of C-sections with the rate of "needed" or "medical necessary" C-sections (WHO, 2008, Data). The rate for needed C-sections is high in developing countries (including Nigeria, Ethiopia and Congo). According to the WHO, still around 800 women die from preventable causes related to pregnancy and childbirth, whereby almost all (99%) occur in developing countries. Thanks to a number of drastic improvements (such as the push for needed C-sections in these countries) the maternal mortality rate decreased sharply between 1990 and 2013.
Countries with Unnecessary C-sections and a C-sections rate > 15%
Graph comparing countries that have a C-section rate higher than 15% with the rate of unnecessary C-sections (WHO, 2008, Data). China and Brazil stand out.
Different countries have different cultures which could drive the rate up or down says Bludstein in the BMJ interview. Sweden for example has a relatively low c-section rate, possibly influenced by the heavy emphasis on midwives who do not practice c-sections, says Bludstein in the BMJ interview.
The US with a C-section rate of 30.3% and 10.8% of necessary c-sections presents an interesting picture. It is estimated that the US healthcare system costs 687 million USD annually. Consumer reports in the US found that for-profit hospitals tended to have higher C-section rates.
A US Hospital in Orange County, California successfully managed to reduce C-sections within three years
Does this mean that more women request C-sections? Not necessarily. In the article it says that almost two out of three women in the Listening to Mothers survey who had their first C-section said their doctor was the decision maker, and more than one-quarter who responded to the survey said they felt pressured to have the surgery.
China has a lower rate of C-sections (25.9%) but a much higher rate of unnecessary C-sections (31.8%). An article by the Monterey Herald mentioned the WHO analysis that included around 110,000 births across Asia, which found that the 27% of c-sections performed "was partially motivated by hospitals eager to make more money".
In a BMJ comment, Blustein says that for a variety of unrelated reasons up to 70% of women in affluent cities of Southeast China choose to deliver their one child via C-section.
What Are the Non-Medical Reasons for A Women to Request A C-section?
1. Is Intercourse Giving Women Pain After Vaginal Birth?
The Problem 87 Percent of Women Have with Sex After Birth http://t.co/9fnVcJ9Qep— What To Expect (@WhatToExpect) January 28, 2015
Content like this post found on a forum specifically for mothers could be off putting. The blogger talks about being ok but sex being painful three months after natural birth.
The doctor says I'm ok and gave me the go ahead for sex. It has been three months since my daughter was born and when we have sex it feels like someone is cutting me with a knife and it's extremely tender.
...writes a contributor in a forum that discusses mother's concerns.
NHS Choices recommends mothers to talk to a GP if sex continues to be painful months after giving birth. But women may feel uncomfortable about sacrificing pleasurable sex for natural birth. Perhaps these conversations need to be made more open and move out of informal blogs?
2. Time & Money?
You can schedule your kid's birthday when having a c-section. Although natural birth has a faster recovery time, it is less predictable. This unpredictability could be inconvenient for businesses and tight corporate schedules. C-Sections are also more expensive than natural births.
The medical professionals could gain more from c-sections, incentivising them to prematurely jump into the procedure. Unnecessary c-sections totalled to a whooping 2.32$ billion.
Demi Moore broke the ice by posing heavily pregnant for the cover of Vanity Fair in 1991. Where before pregnant woman hid, pregnant celeb pics become a must do.
But the post pregnancy body is still taboo and is massively underrepresented in media imagery of women. An art project, The Shape of Mother, is encouraging women to embrace the transition and take pride of the changes. It's still early days, and pressure on women to maintain their pre-motherhood shape and form is pushing some women for c-section despite the disadvantages.
4. Fear & Anxiety?
The Comic Relief skit with the Call the Midwife Crew shows how the culture of giving birth has changed. The tv series One Born a Minute uncovered some the the mystery shrouding pregnancy and child birth. But it is still presented as a scary event, hidden from the father. Could this intimidating story be putting women off giving birth naturally? A new series called The Dads looks at fatherhood - an often neglected part of childbirth.