Efforts to reduce C-section rates ignore quality of life outcomes women value

quality of life word under torn black sugar paper

Earlier this month I wrote about The Lancet series on reducing C-section rates that used a benchmark rate of 10-15%. This despite the fact that the World Health Organization, which made it up, acknowledges there is NO EVIDENCE to support the safety of a 10-15% rate and considerable evidence that the minimum safe C-section rate is 19%.

A recent editorial in PLoS Medicine challenges the 10-15% rate on additional grounds: it ignores the outcomes that women value most.

The authors discuss a new paper from China:

Women value improved long term safety for their babies over increased short term risks to themselves.

Recent high cesarean section (CS) rates around the world have sparked intense interest in the underlying drivers, partly to inform efforts to reduce CS rates. This week in PLOS Medicine, Long and colleagues report on these trends from multiple perspectives in mainland China, Taiwan, and Hong Kong … These settings—with respective CS rates of 34.9%, 27.4%, and 35%—reside near the top of the CS birth rate tables …

The prospectively registered study stands out among related work because of the meticulous efforts made to understand and contextualise how nonclinical considerations lead to plans for CS births. In addition to detailing why many CS plans are made, the authors also report a recent shift towards placing greater value on vaginal birth in studies from mainland China. The latter observation supports previously reported impressions that removal of China’s one-child policy, in addition to multiple strategies to reduce CS rates, has led to an increase in vaginal births in women who previously gave birth by CS.

Women see C-section as a safer option particularly in light of China’s previous one child policy:

Multiple women described CS as the ‘safe’ choice for birth; quotes detailed CS as a means to avoid ‘any risk’ to their baby, whether ‘immediate complications’ or ‘longer-term child-development’ issues.

Despite the World Health Organization’s insistence that vaginal birth is safer than C-section, data out of China indicates the opposite:

Utilising the combination of large population databases of birth-related events and a high CS-on-maternal-request (CDMR) rate, researchers reported outcomes of over 66,000 first births in Shanghai between 2007 and 2013. Reduced offspring birth trauma, neonatal infection, meconium aspiration syndrome, and hypoxic ischaemic encephalopathy followed CDMR, with no difference in risk of serious maternal complications when compared with a plan for vaginal birth… Overall, these findings suggests that, where women are certain of their plan to have only one child, those with similar characteristics in equivalent healthcare settings may be justified in choosing CS on safety grounds.

In other words, women value improved long term safety for their babies over increased short term risks to themselves. Of course C-section also has long term risks for the mother such as increased uterine rupture and placenta accreta in future pregnancies. But vaginal birth has long term risks to continence and sexual function that are much more common than long term risks of C-section.

Efforts to reduce C-section rates ignore women’s preferences:

The agenda to lower CS rates appears to be driven by WHO’s position statement, which cites a lack of evidence for reduction in maternal and infant mortality at the population level for CS rates above 10%–15%. However, the WHO statement does not reflect the quality-of-life outcomes that appear to be important to women … Long and colleagues’ findings demonstrate that women and clinicians in these settings who plan CS may be voting with their feet to optimise both perceived safety and quality-of-life outcomes. In the United Kingdom and Singapore, where recent person-centred legal developments mean that informed consent to give birth requires that women are informed of (1) risks she considers to be important and (2) reasonable available options, decisions for CS based upon quality-of-life outcomes appear legitimate yet highlight the gulf between WHO priorities (saving lives) and those of women and clinicians making individual birth plans…

The WHO may claim that its priority is saving lives, but to my knowledge there is NO EVIDENCE that reducing C-section rates saves lives. It is theoretically possible, of course, but we should not be setting practice guidelines on theory that isn’t confirmed by scientific study.

The authors conclude:

China is in a strong position to use its high CDMR rates and its population-based birth registries to support studies of birth outcomes beyond mortality and to engage with women to identify outcomes that are important to them. Such a truly woman-centred approach would facilitate birth choices being made in the full knowledge of the balance of risks and benefits.

In contrast, aggressive efforts to reduce C-section rates are the opposite of a woman-centered approach that facilitates birth choices made with thorough information about risks AND benefits and taking into account quality of life outcomes that women value.

  • Amy

    Honestly, I was disappointed when my placenta previa resolved, because it meant I no longer got to have a scheduled c -section. In hindsight, my disappointment was not misplaced: I would gladly trade my third degree tear and months of PTSD-like symptoms (from my prolonged pushing and exhaustion) for a c-section.

    • Azuran

      I get it. I was also disappointed when I learned that by baby was head down. Having a breech baby would have meant a c-section.
      I still ended up having a c-section after hours of labour because by baby was just too large and all I accomplished during my 3 hours of pushing was repeatedly ramming her face in my pubic bone.
      By the time she was born, I was just so exhausted I didn’t even have the energy to feel anything about her birth. When they brought her to me (after I spent like 3 hours basically unconscious from exhaustion) I couldn’t even care, it was ‘meh’, I couldn’t feel any joy about it.

      When I’ll be having my second, if my ob so much as propose I try a VBAC I’m going to shut that idea down instantly.

    • They wouldn’t do maternal request?

  • FormerPhysicist

    This idea that you can’t have more than one c/s is insidious. (1) I’ll take the health of the current one over a nebulous tbd pregnancy that may never happen. (2) I had 3 c/s, and it wasn’t any uterine scarring that determined I shouldn’t have another child. That was bad PE and PPPE, and also being overwhelmed by three kids.

    • Anna

      True, but my plan was 3 kids. It ended up taking 5 pregnancies to get there, and now I’m pregnant accidentally with baby no. 5. 2 c-secs so not at huge risk and given my age, propensity to make great concrete headed babies and my fairly crap track record on vaginal a c-sec is the safer option. Had the first 4 babies been c-secs though to get my desired 3 – Id be fairly nervous about a 5th c-sec. When I had my first at 27 I probably would have said 2 kids.

      • The technology has improved greatly. Many women have no problem with more than 3 C/Ss.

        Some years ago I encountered a rabbi’s wife who suffered a uterine rupture — during her 8th pregnancy, after 7 perfectly normal vaginal deliveries. Anatomical and physiological factors influence both “normal” and C/S births.

        • Merrie

          My husband’s grandmother had 5 c-sections! Her doctors advised her to stop at 3 and advised her more strongly to stop at 4. But she made it out in one piece and lived into her 90s.

          • Cartman36

            she sounds like a boss. 🙂

          • Merrie

            She was Catholic. They raised 5 kids in a 2 bedroom house. They converted a breezeway into a pseudo third bedroom. My mother-in-law (she was kid #3) told us about how thrilling it was to get the breezeway ALL TO HERSELF after her two older sisters had gone off to college.

  • Cartman36

    This is exactly what Joan Wolf talks about in her “Is Breast Best” book. The WHO doesn’t care if the benefit to the baby is theoretical and as long as the risks are borne by the mother alone, then no benefit is too small (or entirely theoretical) and no risk is too great to expect the mother to bear it for her baby.

    • lawyer jane

      Wow, that’s a blunt but accurate way to put it. My theory is that public health-types know (consciously or not) that mothers are among the sector that they can most motivate, and place the most burden on without objection. The notion of giving advice to mothers and judging mothers is so ingrained, that it seems logical and natural to simply ignore burdens and risks on the mother. We’re used to thinking about women and mothers carrying the burden for everything. I also believe that public health professionals also derive a sort of satisfaction in knowing that they can place their exhortations on a group that’s likely to respond to them (mothers) when they feel so helpless to make changes in other areas (capitalism, colonialism, poverty ….)

      • Cartman36

        Why spend money, time, and resources trying to find comprehensive, multipronged solutions to complex social problems like poverty, terrible public schools, obesity, drug abuse, etc when we can just tell women that if they have their babies vaginally and breastfeed until puberty their babies will be successful, have higher IQs, be thin, and overall have better outcomes. The government and public health authorities get the smug satisfaction of promoting healthy babies without doing any work.

        • Anna

          And this!

      • Anna

        This so much! I think one of the reasons Japan has such excellent health outcomes, particularly in maternity is the highly compliant population.

    • Madtowngirl

      It’s very interesting that while placing great risks on the mother alone, the WHO seems to ignore the fact that vaginal birth (and exclusive breastfeeding) can be pretty damn risky for the baby.

      • Cartman36

        I agree. I hope that the WHO will soften their stance on both VB and EBF soon but I doubt it. I think part of it is, they don’t want to make different recommendations for different countries based on wealth. It could be a PR nightmare to say rich countries should encourage maternal request c-sections and that formula is just as good as breast milk while telling poor countries to do something different because they don’t have the resources to support safe c-sections or easy access formula.

  • lawyer jane

    “In other words, women value improved long term safety for their babies over increased short term risks to themselves”

    thisthisthis!!! I was gobsmacked when my midwife seemed to be surprised that I valued the health of my baby over avoiding a c-section. To her credit, she remembered that conversation and acted accordingly during delivery, but I was so confused that I even had to say that when we first discussed it at a prenatal appointment.

  • The Bofa on the Sofa

    I think the study reflects the fact that, as c-sections become safer and better done, they are more likely to be viable alternatives.

    The spinal block makes it so they are awake and can participate, and the extra day on average in the hospital is not a huge problem for them (in fact, many women like the extra day in the hospital with good nursery assistance – what they don’t like is being stuck in the hospital forced to care for their baby by themselves; that could just as well be done at home). And multiple c-sections can occur, although if you want huge families, yeah, you have are restricted. But it’s better than it was when my sister was having kids 40 years ago, and even she had 3 c-sections.

    Over the years, c-sections have just become safer and more convenient. It’s not surprising they are more popular.