Updated: Dec 2, 2022
In Canada (and I suspect other countries as well), cesarean section is the number one reason for surgery, and birth is the number one reason for hospitalization. The cesarean section rate has been a rising trend in many countries all over the world, and in almost everything I have read or seen about this issue, the blame is almost always placed on the person giving birth.
So I decided to look into this some more, to satisfy my curiosity and research some of my suspicions. I will be using some statistics for the Province of British Columbia (BC) in Canada, simply because that is where we are based, and these statistics are easily accessible. Before we dive in, there are some things that are good to know. The statistics are done by fiscal year, which for them ends in March, and so for each year of data, you will actually see two calendar years on the label. In the latest reported statistics, the total number of births was 43,053, and the provincial cesarean rate was 36.6%, which is higher than the national average for Canada.
You can see these statistics for yourself on the Perinatal Services BC website.
In June of 2019, shortly after some new statistics had just been published, Global news published a story about it. In the story they interviewed an obstetrician who said that a lower cesarean rate was unrealistic because of higher instances of Gestational Diabetes (GDM) and High Blood Pressure and because people are waiting until they are older to have children. These reasons are commonly given, as well as higher BMI rates and because people are simply just choosing a cesarean when there isn’t a medical reason for one.
Let’s take a closer look at these reasons and see if they are valid or not.
For gestational diabetes, I didn’t include statistics for pre-existing diabetes, which only accounts for about 0.7% of all births. When I looked at the statistics for GDM, I did find a rising trend, 14.8% in 2019/20, up from 6% in 2000/01. At first glance, that looks like a big increase, but the numbers are deceiving. In 2014 there was a wide movement to switch from only screening those people who had risk factors for GDM, to a universal screening approach, which screened everyone for GDM. This meant that there were less missed cases of GDM. So that statistic of 6%, and any statistics from before 2014 are artificially low. They don’t report on the rate of testing for GDM and so the results of this data are inconclusive. Click here for more information about GDM testing.
When I looked at instances of High Blood Pressure, I included any hypertension, pre-existing as well as gestational. The rate of hypertension is about 6%-7% and that statistic has not changed much at all in the past 17 years. So claiming there are more instances of hypertension is not substantiated.
Next let’s look at age trends. The average age at the time of birth from 2000/01 to 2011/12 was 30 years. It stayed the same, and yet, in that same time period the cesarean rate went from 24% to 31%, a 7% increase. There is no apparent correlation between the two. In 2019/20, which are the most up to date statistics, the average age is now 32 years, and the rate for cesarean sections is 36%. That’s a 12% increase overall.
Now, don’t even get me started on all the issues with the Body Mass Index. That is a topic for another day, but it is used as a tool in the medical system, and it is a statistic that is collected and reported on and so I took a look at it. The best data starts in 2008/09, and at that time, BMI data had only been recorded for 64.6% of the birthing population. That number rises to 80.6% in 2019/20. As the amount of data collected increases I found a rising trend in three categories including Normal Weight, Overweight, and Obese. I could analyze these numbers a bit more but with so much data still missing and with the trend rising in multiple categories, including the normal one, I find this data also inconclusive.
Lastly, the claim that people are simply choosing cesareans. Not only is this incorrect, but it is a harmful and misleading claim. Personally, when I was going through my first pregnancy, I read through the literature from my health authority, and there was a very strong implication that the cesarean rate was high because people were electing for cesareans. It also implied that I had to simply not choose a cesarean in order to not have one. Not the case. In my naivety, and with a lack of resources available to me in the early months of the pandemic, I trusted my health authority. At the time I did not know how to look up the statistics and had no idea what they were for emergency cesareans, or that the cesarean rate for first time moms at my local hospital was 42.7%! I highly doubt that almost half of new moms in my area are choosing a cesarean over a vaginal birth.
So next I looked at the statistics for Elective Primary Cesareans, and this one took some math because the data given is not straight forward. I found that elective primary cesareans only account for about 3%-4% of all births, and these statistics group both those with and without a medical reason together. So the people simply just choosing a cesarean because they want one is an even smaller number than this. And just a little side note, some people actually want a cesarean because they had a previous traumatic labour or vaginal birth. The latest estimates of birth trauma is 45% of all births every year. That works out to almost 20,000 people last year in BC alone! That is also another topic for another day.
I will get into repeat cesareans in a minute, but first let’s talk about why I believe the cesarean rates are rising.
The first reason is that it is always easier to blame someone else, than to take an introspective look into your own contributions to a problem. If health care professionals and health authorities analyzed their own contribution to the rising cesarean rate, they would have to also take responsibility for it as well. There are implications to this that even I don’t know the consequences of, but I’m sure that they are well aware and think about them all the time.
But wait, there is an exception to this, meet Richmond Hospital. Their cesarean rate for first time birthers, which was previously one of the highest in the country, is now one of the lowest at only 20.6%! I’m guessing you are wondering how that happened. The change happened when their current head of obstetrics took over, and she says that changing the culture of maternity care was a key factor. You can read more about this story here.
My second reason is the rising induction rates. The rate has risen from 20.4% in 2008/09 to 27.7% in 2019/20. There has also been a trend in the method of induction from using Artificial Rupture of Membranes (ARM/AROM) and Prostaglandin, to going straight to using Oxytocin. Oxytocin is a common thing to use, but is much more aggressive and associated with more risks, one being an increased risk of cesarean section. The risks associated with induction are also often not fully explained to the birther before the procedure is started.
My next reason is increased use of the External Fetal Monitor (EFM) during labour. Using only the EFM to monitor labour has gone up from 22% in 2007/08 to 33% in 2019/20. It has been long established that EFMs don’t actually improve birth outcomes, and they are also associated with higher rates of intervention and cesarean. If you would like to learn more about fetal monitoring you can find more information here.
And lastly, there is not enough support for Vaginal Birth After Cesarean (VBAC), also called Trial of Labour After Cesarean (TOLAC). Elective repeat cesareans currently account for 26.1% of all cesareans in BC. Out of all the people who have had a previous cesarean, 77.4% have been identified as VBAC eligible, but only 30.5% attempted a TOLAC. The success rate for a TOLAC was 69.5%, and with VBAC having less risk associated with it than a repeat cesarean, it seems like a no brainer. But the reasons why a TOLAC is declined more often than attempted is complex.
Just like the high cesarean rate, the low VBAC attempt rate is often blamed on the person who is electing for the repeat cesarean. In general, people tend to trust their doctor when it comes to medical advice. If their doctor is not VBAC supportive, they are highly unlikely to try. Risks of TOLAC are often over exaggerated, while the risks of a repeat cesarean are rarely mentioned. Some care providers initially claim to be TOLAC supportive but then at the last minute, try to use coercion tactics to talk a person into a repeat cesarean. It happens so often, there is even a name for it, it’s called “Bait and Switch”. And some care providers use the outdated VBAC calculator, which is highly prejudiced and racist in nature and always underestimates eligibility and success rates. If someone does manage to find a care provider who is indeed VBAC supportive, they still have to navigate the culture of fear surrounding VBAC. Often partners, family and friends are scared and will attempt to talk the person into choosing the repeat cesarean. If you are interested to learn more about the actual VBAC facts click here.
And here is a bonus reason, given by the current president, and a former president of the Society of Obstetricians and Gynecologists of Canada (SOGC). The reason they give is impatience. Known more commonly in the birthing world as “Failure to Wait”, a play on words of “Failure to Progress,” which is often the reason given for performing a cesarean section.
And there was a study conducted by the SOGC that found large variations in cesarean rates across provinces and hospitals. And the two largest groups affecting the cesarean rate were people who had a previous cesarean and people who had an induced labour.
There is very little evidence to support the common reasons that care providers and health authorities give for rising cesarean rates. There is a rising trend of induction and use of EFM, both of which have been established as being associated with higher cesarean rates. For years now there has been a call to lower cesarean rates by changing hospital culture and approach towards labour management.
These changes aren’t going to happen on their own. Hospitals and care providers are going to continue using the same excuses, news outlets are going to continue to report these excuses, and the general public is going to continue to believe them. We won’t see change until we hold them accountable and demand better.