Rising Tide of Caesarean Sections?

Why is a Caesarean section rate of 30% now considered normal? And is this reasonable?

The average Caeserean section rate in Australia is somewhere between 30 and 40%. In the 1960s the rate was close to 5%. So why has this significant increase, and does it has it resulted in improved outcomes in childbirth?

My intention is not to discuss in detail the benefits or otherwise of Caesarean section, but to try and explain why that increase has occurred. From a babys' point of view, the available evidence suggests that there is no further improvement in perinatal mortality with an increasing rate of Caesarean of over about 20%. So the idea that an ever increasing c/s rate will continue to improve perinatal outcomes is probably not true. But that's not to say that there are not significant potential benefits both for the mother and the baby of Caesarean section when it is deemed necessary, as there are.

There are a number of reasons usually offered for the increasing Caesarean section rate. The worry of medico-legal ligation, the increasing age of mothers, and the increasing BMI, maternal request, social pressures, concern regarding pelvic floor dysfunction and incontinence are just a few. All these are legitimate factors, each contributing to the overall sum of the increase.

But I believe there is another, more generic, underlying mechanism that is important. Atul Gawande, an American surgeon and writer, interviewed a retired obstetrician who had started practice in the 1960's, and worked through to the 80's and early 90's. His Caesarean section rate was of the order of 5% at the start of his career, and increased to around 20-25% by the time of laid down his forceps and scalpel. He was not unusual; he had kept up with the contemporary practice of the time.

The question that Dr Gawande was interested in was, why did contemporary practice change?

Training in medicine has often been compared with that of the airline industry. It's not altogether analogous but there are certain similarities, and valuable lessons have been learnt from pilots' training. What pilots training tries to achieve, as much as is possible, is to ensure that the same reproducible outcome results from any given situation.

There are a number of 'manoeuvres' used in obstetrics. These are skills that obstetricians learn for use in more difficult situations in childbirth; that might be used in breech presentations, rotational forceps, shoulder dystocia and others. They require more training, and more practice, both of which have diminished for one reason or another over the decades. These can sometimes be thought to constitute the "art" of obstetrics. The thing about art, is that some people can draw, and some can't! Usually the outcome will be good, and an operation, i.e. a Caesarean section, averted. But for a small proportion of mums or baby's', the outcome will be significantly worse.

Caesarean section on the other hand is a relatively straight forward procedure, with much less individual variation in overall performance and outcome. A Caesarean section can rescue many of the difficult obstetric situations that that might otherwise require some of these special manoeuvres.

Over the past few decades we have striven to improve and standardise obstetric outcomes as much as possible. Many of the more difficult obstetric situations that we encounter, for which we might need to employ one of these special manoeuvres, can often be resolved by recourse to Caesarean section. Our pursuit for more improved and standardised outcomes has led to an inevitable increase in Caesarean rate. For many this will result in a better outcome for both mother and baby, but a smaller number will have had a Caesarean section that some might argue could have been avoided.

As a profession, throughout most of the western ('developed') world we, as obstetricians, have slowly but inexorably moved away from the more artistic, 'skilled' type of practice, to the less adventurous, more predictable Caesarean section. Our outcomes, both for mother and baby, have never been better, and indeed, we in Australia are fortunate to have some of the lowest perinatal and maternal mortality and morbidity figures in the world. That has come, to some extent, with an increase in the Caesarean section rate.


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