July 7, 2006
IN doctors’ rooms around the country pregnant women are walking in and asking for their babies to be surgically removed. They’re not the majority, but evidence shows their numbers are increasing.
Some of them are paralysed by the fear of giving birth, others want to remain in control of where and when they have their baby, and still others think caesarean section is a less risky option than leaving delivery up to Mother Nature.
Add to these the women advised by their obstetricians to have a caesarean section before, or during, labour and you get a national caesarean rate of nearly 29 per cent.
Midwives have loudly criticised the rapid growth of surgical deliveries over the past decade, and now doctors are joining them.
More obstetricians are worried that the looming possibility of one in three babies checking in to the world via the spartan surrounds of an operating theatre is too high a number. And important new research published last month in the US journal Obstetrics & Gynecology (2006;107:1226-1232) gives us an idea as to why.
The study of more than 30,000 women showed the more caesareans they had, the greater the risk of complications including hysterectomy, bowel and bladder injury, admission to intensive care and blood transfusions. Risks for some complications more than doubled between the first and the third caesar.
Given that more than 80 per cent of Australian mothers who’ve had one caesar go on to have another, the US results are particularly relevant to us.
“In the desire to do good we have actually started to do some harm, and this paper illustrates that well,” says David Ellwood, professor of obstetrics and gynaecology at the Australian National University.
Ellwood says we need to think carefully about getting the balance right between what’s excessive and a safe level of intervention to avoid harm. “I really think at the moment we have swung too far the other way. We perhaps overestimate the size of the impact on outcomes for babies and underestimate the risks (to the mother).”
Senior vice-president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists Dr Chris Tippett agrees.
She says too many women are getting biased or selective information on the pros and cons of caesarean section, which is now seen by many doctors and their patients as the preferred option.
“Caesarean section is a significant intervention . . . there are concerns about whether or not we are leaving a legacy of problems.”
Until now, studies looking at the question of repeat caesarean risk have reported mixed results, but many doctors and midwives have long suspected the caesarean story is not a completely rosy one.
Experts say that while this study confirms what they’ve been thinking, it’s significant because of its sheer size and conclusive results, which can now be used to give women a better picture of what they’re up against.
It showed one in 155 women needed a hysterectomy after their first caesar, but that risk rises to nearly one in 40 for those having their fourth – figures Ellwood describes as “surprisingly high”.
Another major complication was placenta accreta, an abnormally firm attachment of the placenta to the wall of the uterus, which hampers control of bleeding after the baby is born. In many cases of placenta accreta, severe bleeding leads to the need for a blood transfusion or hysterectomy.
According to the study the risk of placenta accreta more than doubled for those women having their third caesar (one in 175) compared with those having their first (one in 413).
By the fourth caesar, the risk was one in 46.
Tippett says she now sees a case of placenta accreta every three to four weeks, a huge jump from when she started her obstetrics training in the early 80s.
“This study is good evidence – it says to women that caesarean section is generally a safe procedure, but if you are planning on having a family of three to four children, think very carefully before you go down the caesarean section pathway.”
Ellwood thinks we’ve lost sight of the bigger picture.
“It is the third caesarean where you start to see this increased risk, and in numerical terms it is going to be a relatively small proportion of the population. But the scale of the morbidity in placenta accreta and hysterectomy is enormous and the only way we are going to address it is by an overall reduction in the caesarean rate.”
Some might argue that most women just have one or two children these days, so the risk of three, four, five and six caesareans isn’t something we need concern ourselves with. But Ellwood is seeing a shift.
He says while government policies to encourage women to start families are having an effect, there’s another increasingly frequent story: the impact of the divorce rate.
He is treating more women entering their second marriage, and while they may have originally intended on one or two children, they often change their mind and plan more when there’s a new partner on the scene.
Ellwood says there needs to be more effort put into encouraging women who have a first caesar to try vaginal delivery next time, particularly if they plan on having more than two children.
Clinical director of women’s services at Melbourne’s Royal Women’s Hospital Professor Jeremy Oats says his hospital actively supports this policy, but attitudes vary.
He says a major study published in the New England Journal of Medicine two years ago (2004;351:2581-2589) linking a trial of labour after a prior caesarean to greater risks for mothers and babies had a huge impact, particularly in the US.
The absolute risks, however, were small: 0.46 in every 1000 births was associated with an adverse outcome such as rupture of the uterus, which in some cases led to birth asphyxia (where the baby does not receive enough oxygen). And problems were more likely if the labour was induced.
Oats says there shouldn’t be any reason for concern provided the labour is carefully monitored. “It comes back to the obstetrician and the maternity team to work with the woman and give her confidence and support in her decision.”
Robin Austin says she could have done with that kind of support when she decided to have her second and third children naturally and at home after having a caesarean when her first labour failed to progress.
“What I came up against was other people’s fear,” says Austin, 38. “No one was talking to me about other choices and I found that distressing because I felt I had been butchered.”
She describes the distress of coming home from hospital the first time with an infected wound and unable to pick up her screaming baby because of the impact of major surgery.
“The whole process was traumatic and we thought it should not be like this. Whatever happened to women just having babies – where is that? It is almost like it is a medical condition that needs to be fixed, rather than a process that needs to be gone through.”
Austin, who now has her hands full with Toby, 2, Lucy, 13 months, and one-month-old Isabella, says she felt a sense of loss after the birth of her son. “I missed his birth and so did his father. It is gone and it is something that will never come back.”
Tippett also wonders whether rising caesar rates are denying women an important life experience. She spends up to an hour with every new patient explaining why surgery is not the easy option.
“There are many women coming in and requesting elective caesarean section and that did not happen 10 years ago,” she says. “We very rarely do a primary elective caesarean – it is our policy not to – but there are other doctors who rarely do vaginal deliveries.”
So are women or their doctors driving the upward trend in caesareans?
Senior obstetrician at Sydney’s Royal Prince Alfred Hospital Tony Frumar believes it’s a little of both.
He says there’s every chance more women would be talked out of the procedure if medico-legal concerns were not an issue for doctors: “If you steer someone away from a caesarean section and have a problem you leave yourself open to action.”
He says most women can be discouraged from elective caesareans by the end of their pregnancy, but there are those that are so “freaked out” by the pain of childbirth that not to do the procedure could have its own psychological consequences.
Australian College of Midwives spokesperson Shannon Morris says the convenience factor for obstetricians can’t be discounted as a driver of the caesarean rate.
She says this was acknowledged privately recently by a senior obstetrician.
“There’s a new generation of obstetricians who don’t want to put in the hours who say ‘This will be safe and I can do it on this day at this time and still be home to pick up my kids from school’.”
Morris also raises concerns about the number of induced labours (where a mother is given hormones to kick-start contractions). She says incorrect due dates are causing supposedly overdue women to be induced before their babies are ready. And induction of labour dramatically increases your chances of needing an emergency caesarean section.
Oats agrees energy needs to be devoted to addressing this. But he also raises the possibility that nature, as well as societal attitudes, might be having an impact on the caesar rate.
“There’s an argument that with better nutrition babies are getting bigger and there is a genetic gap between that and the increase in maternal pelvis size.”
While Morris says caesars are a fabulous intervention that have saved many lives, they’ve become as routine as getting your tonsils out.
Ellwood agrees obstetricians must step up to the challenge.
“It is quite unreal to think women when making choices about what to do in this pregnancy will think long term about what might be happening 10 years on. It is a responsibility that we as obstetricians have to point that out to them and not be involved in unnecessary caesareans.”
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