Preparing for birth requires open and transparent conversations around the current state of our maternal health system.

Birthing people are walking into the current system blind to what is actually happening in today’s operating rooms. Nurses, doctors, and midwives also know that something doesn’t add up when it comes to the high rate of women who are not birthing vaginally. There is something about the policies and procedures in place that prevents these individuals from speaking up. The following collection of data will shed a little light on what is happening behind those OR doors.

Why Is This Data  Important

The World Health Organization states that the cesarean rates should not exceed 10 -15% of total births in developed and developing countries. This holds importance because:

• Babies born via cesarean section do not have access to the same microbiome that they would if they have passed through the birth canal, picking up important bacteria from the walls of the vagina that has lifelong effects on the baby’s gut health. The number of genes in one person’s microbiome is 200X the number of genes in the entire human genome. Our neurological capability begins with the connection to the microbiome, in turn impacting mental health and well-being.

• Birthing people are entering parenthood traumatised while also healing physically, emotionally, mentally, or spiritually. As a society, we expect them to heal from major abdominal surgery and care for a new baby at the same time. This includes navigating feeding/ breastfeeding/ formula feeding, lack of sleep, caring for themselves,and tuning into the cues of a newborn.

• Severe complications can arise for cesarean births and for every subsequent pregnancy and birth. Examples include infection, blood loss, injury to the baby or other organs, emergency hysterectomies, placenta accreta and abruption, further surgeries.

• There can be a significant risk of Placenta Accreta, in which the placenta can grow outside the uterus along the scar line in subsequent pregnancies. This can be higher than the risk of uterine rupture for those planning a Vaginal Birth After a Cesarean (VBAC

Current Cesarean Rates in British Columbia 

I requested the Cesarean versus Vaginal Birth daily statistics for June - October 2020 in seven hospitals. 

• BC Women’s Hospital (BCWH)

• Burnaby General Hospital (BGH)

• Lion’s Gate Hospital (LGH)

• Royal Columbian Hospital (RCH)

• Surrey Memorial Hospital (SRY)

• Chilliwack General Hospital (CGH)

• Abbotsford Regional Hospital (ARH)

All of the above-listed  hospitals responded, with the exception of BCWH, which omitted the information needed to make an accurate comparison, so for now, they have not been included in these findings. BCWH may be added at a later date when the appeal process from the Freedom of Information Act is complete. 

Currently, the average cesarean birth rate among these remaining six hospitals is 43 percent.  Burnaby General Hospital has slightly more cesareans at 48 percent and Surrey Memorial has slightly less at 41 percent,  however, all local hospitals are significantly higher at about three times the WHO recommended percentage.

There is no statistical difference in the month of birth.   

The study findings for the five month period of cesarean rates are:

• BCWH- N/A 

• BGH - 48%

• LGH - 41%

• RCH - 43%

• SRY - 41%

• CGH - 42%

• ARH - 45%

What Does the Future of Cesarean Rates Look Like?

Consider that the World Health Organization states “when caesarean section rates rise towards 10% across a population, the number of maternal and newborn deaths decreases. When the rate goes above 10% there is no evidence that mortality rates improve.” 

British Columbia consistently runs higher than the Canadian average of a 29.1 percent cesarean rate, according to Optimal Birth BC.   In 1999, the BC cesarean rate was about 23% and in 2010 it rose to 31.8% . The local hospitals I surveyed  have almost doubled that BC average in approximately  20 years.   Compared to the most recent Canadian average, these local hospitals are significantly higher. 

Based on my research, the future of cesarean rates is grim.  Continuing on this trajectory could leave more than half of all babies being born via cesarean in the province.   Increased use of cesarean without medical indication can have short and long term effects on otherwise healthy mothers and babies.  Babies can have altered immune development, increased chance of allergies and obesity, asthma, and a reduction of healthy microbiome in the gut.  Under question in my research is the long term impacts on cognitive development, gut health, and the emotional and mental health of all involved parties (babies, mothers, families, partners).    For mothers, there is an increase of stillbirth and miscarriage, placenta previa, placenta accreta (the placenta starts to grow outside of the uterus)  and placental abruption in subsequent pregnancies.   Short term, there can be struggles with bonding, holding baby, surgical healing,  and breastfeeding.

 What is less studied is the impacts on emotional health, relationships, finances, intimacy, confidence and choices in conceiving future children.

What These Results Don’t Provide

In this simple evaluation, these results don’t provide a full picture of what is happening in hospitals.  We don’t know how many of these births were planned, and how many were classified as an emergency.  An emergency cesarean is classified as any surgical birth that was not preplanned.

This could bring up more questions though.  Questions like:

• Is there a time of day in which cesarean surgery is at an increase?

• Is there an increase in cesareans leading up to a holiday weekend?

• Is there a demographic in which cesarean birth is more likely to happen (i.e. immigrants, people of colour or a certain sexual identity, people of an advanced maternal age)?

• What are the medically indicated reasons? How does that vary from what patients understand is the reason? For example, obesity, a large baby, advanced maternal age, prolonged births, failure to progress, baby in distress.

• Are informed consent conversations happening that include long term impacts on becoming pregnant and birthing again,  and on the baby’s life?

• How many people are happy with the experience and how many have trauma, or both?

• Who were these cesareans  being performed on (i.e. Multiparous, Nulliparous, Vertex/Breech Babies, Repeat births, Inductions)?

• Who were the primary care providers (Registered Midwife, General Practitioner, Obstetrician, no prenatal care)?

Conclusion

The current rate of cesarean sections in the Lower Mainland and Fraser Valley are substantially higher than the WHO recommendation.  It is also higher than current rates across Canada.  This surgery saves lives and does make a difference to those who truly need it.  We also need to review the current policies and procedures that are leading to these high rates.

 If you are concerned about the current situation and are pregnant, there are actions you can take that may make a difference for you, and other families. 

1. Ask your care provider what they are doing to reduce the amount of cesarean births. 

2. Write to your local hospital and ask them what they are doing to reduce the amount of surgical births.

3. Write to your health authority and tell them the impacts this situation has on you.  Ask them what they are doing to support people who have had an emergency cesarean.  What is happening to those people after they are sent home, and what support is being given to address the many impacts on families? 

4. Share this knowledge with others,  speak up, and use your voice to share with friends and family. 

If you are working within the system and want to reduce the amount of cesarean births here are a few ideas. 

1. Ask questions to midwives about physiological birth. 

2. Report to your college and the college of others that work within the system.

3. File a complaint with  your health authority.

4. Speak to your supervisor.

5. Have informed consent conversations that also address emotional and mental impacts (before birth in some cases).  

6. Report abuse, coercion and bullying within the system.

7. Research home birth or make a plan to attend an undisturbed homebirth.

References  
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31930-5/fulltext

https://evidence.nihr.ac.uk/alert/balance-of-long-term-benefits-and-risks-of-caesarean-delivery-explained/

Image Designed by Nicole Orsi Barioni