Too many women are being pressured into having harmful vaginal births due to policies seeking to reduce caesarean delivery rates, a University of Sydney expert says.
The claim by Professor Peter Dietz is backed by a broad range of studies in the medical literature, but despite clear evidence of harm from the underuse of caesarean procedures, Professor Dietz says policymakers are “obsessed” with using rates of caesarean deliveries as the sole indicator of the quality of obstetric services.
“Policymakers are trying to cut caesarean birth rates because maternity services account for an ever-increasing share of hospital and health budgets,” says Dietz, who is a urogynaecologist at Nepean Hospital in Sydney’s west.
Policymakers are trying to cut caesarean birth rates because maternity services account for an ever-increasing share of hospital and health budgets
“There’s a common perception among health policymakers and administrators that obstetricians are to blame for rising caesarean delivery rates in both western and developing countries.
“This is concerning because caesarean section rates are largely determined by changing demographics, with women being much older and more obese at the time of a first birth compared to ten or 20 years ago. It's therefore not surprising that low rates of caesarean deliveries are associated with more adverse outcomes for mothers and babies.
“Recent recommendations generated by professional bodies in Australia and the US have advocated that clinicians should change practice to reduce the rate of caesarean delivery and increase the likelihood of vaginal deliveries,” says Dietz.
In 2010 NSW Health issued a mandatory policy directive expecting more than 80 per cent of women to give birth vaginally in all publicly funded maternity services by 2015.
Endorsed by the NSW Maternal and Perinatal Health Priority Taskforce, the policy requires chief executives and boards of NSW health services to take “actions to increase the vaginal birth rate and decrease the caesarean section operation rate”.
Professor Dietz considers the target “ludicrously unrealistic and in fact dangerous”.
Elective caesareans have risen steadily in New South Wales, climbing from 13 per cent to almost 20 per cent over the past 15 years.
And despite the NSW Health directive, caesarean rates in New South Wales have continued to rise. From 2010 to 2015, caesarean deliveries increased from 30.4 per cent to 32.2 per cent from, a figure that includes elective and emergency caesareans. While emergency caesareans have remained steady, elective caesareans rose from 17.7 per cent to 19.8 per cent during this period.
During the same period (2010-15) normal vaginal deliveries involving no intervention have fallen from 57.7 per cent to 56 per cent, while forceps deliveries have risen marginally from 4.0 to 4.7 per cent.
Nationally, the latest figures reveal that nearly one in three women (32.3 per cent) had a caesarean delivery in 2011. In the ten years to 2011, caesarean delivery rates trended higher, rising from 27 per cent nationally in 2002 to a peak of 32.3 per cent in 2011. Similar upward trends in caesarean delivery rates have been evident in the UK, Canada and the US, where they have become the commonest of all surgical procedures.
Increasing vaginal births among women who have previously had a caesarean delivery (known as VBAC) and promoting vaginal delivery among women bearing their first child are among the few options for lowering caesarean delivery rates.
However, there is good evidence that the risks associated with VBAC are higher for mothers and babies compared to elective caesarean delivery.
Professor Dietz says vaginal birth trauma can damage the pelvic floor muscle and anal sphincter, leading to pelvic organ prolapse and fecal incontinence.
"I can no longer run long distances and I'm unable to participate in races like the City to Surf, which I did pre-baby.
“In fact, 20 to 30 per cent of first time mothers experience trauma to their pelvic muscles and external anal sphincter muscles during a vaginal birth. Consequently 20 per cent of Australian women need surgery for this later in their lives,” he said.
“Major pelvic floor trauma suffered during vaginal childbirth seems to be a marker for psychological trauma, including post-traumatic stress disorder resulting from difficult deliveries. Many doctors and midwives are unaware of this.”
First time mother and registered nurse Anne sustained severe damage from her vaginal birth that five years later she suffers frequent passing of urine, prolapses and a dragging feeling in her pelvis.
"I can no longer run long distances and I'm unable to participate in races like the City to Surf, which I did pre-baby. I continue to struggle interpersonally. I'm now single and the thought of having to tell a prospective partner of my condition is difficult," she says.
Twenty to 30 per cent of first time mothers experience trauma to their pelvic muscles and external anal sphincter muscles during a vaginal birth
Rising rates of forceps deliveries are also causing harm. While forceps deliveries have been declining for decades across the world – replaced largely by the vacuum extraction method – forceps rates have doubled in England since 2004 and the trend is also evident in Australia.
Forceps can be traumatic to infants and cause pelvic floor trauma in women. They are a major risk factor for anal sphincter and pelvic floor tears and consequent prolapse of the uterus and bladder. Anal sphincter tears are the leading preventable risk factor for anal incontinence among women.
“One has to ask what has prompted clinicians to develop such a single-minded focus on avoiding caesarean deliveries,” says Professor Dietz.
“On the one hand, economic factors and concern about increasing numbers of difficult and potentially dangerous repeat caesarean deliveries are clearly justified. On the other hand, it seems preposterous to judge the quality of maternity care on the basis of a single indicator when this is clearly impossible to do, even with sophisticated analyses of maternal and perinatal morbidity.
“Other influences are at work too – sometimes through ill-advised public pressure, sometimes through government officials and administrators, but sometimes through poorly designed professional guidelines.”
For example, the American College of Obstetricians and Gynecologists recently published a Committee Opinion that explicitly dismisses obstetric trauma as a performance indicator of obstetric services. The justification for ACOG’s stance was that a focus on maternal trauma would likely lead to further increases in the rate of caesarean deliveries.
“An obsession with caesarean delivery rates, regardless of whether it is motivated by rational concerns or ideology, clearly has the potential to do harm,” says Dietz. “Guidelines and policy directives are not an excuse to ignore one’s clinical judgment, ethical precepts, or research findings.
“Women who see clinicians for obstetric care deserve to be treated like adults. They have a right to up-to-date, unbiased, and accurate information. This includes information on the risks of natural birth, including maternal obstetric trauma.
“If a mother or child is at heightened risk from vaginal delivery, doctors should volunteer the pros and cons of that option compared to a caesarean,” he says. “By comparison, the interests of government officials and administrators in lowering rates of caesarean deliveries are quite irrelevant from medical, ethical, and legal perspectives.”
During the birth, I believe my trust was broken. It seems delivery suite guidelines were heavily focused on the natural delivery of my baby at the expense of my health and safety.
A 30 year old Sydney woman who sustained a stage two rectocele prolapse during the vaginal delivery of her 4.4kg baby girl in 2015 describes her experience as “traumatic, terrifying and painful.”
"I was pushing for over two hours before my daughter was born. My physiotherapist believes it was likely that during this stage I suffered pelvic floor injury. She suspects I have an avulsion injury, which is when the pelvic muscle has been torn off the pelvic bone.
"At no stage during my antenatal clinic visits was I made aware that natural labour carried a risk of major pelvic floor injury to mothers,” she says.
“I had never heard of a rectocele prolapse until I was about to suffer from one. I believe my ignorance contributed to the shock and emotional pain I suffered in the immediate aftermath of this injury
“During the birth, I believe my trust was broken. It seems delivery suite guidelines were heavily focused on the natural delivery of my baby at the expense of my health and safety. Both of us were put at risk by this unrealistic desire to achieve a natural birth.
“The effects of this major injury to my mental health have been profound and life changing. Since my traumatic birth experience I’ve suffered depressed mood, anxiety and symptoms on the spectrum of Post Traumatic Stress Disorder.
“Throughout my stay in hospital, midwives said they were pleased to see such a large baby had been delivered naturally and without pain relief. This told me there was a problem or ‘us v them’ culture between midwives and obstetricians and it made me feel awful.
“My birth was traumatic, terrifying and painful, and I felt ashamed I didn’t agree with the midwives that the birth was a resounding victory for proponents of natural births. Now I know the midwives were wrong – it was not a resounding victory. The birth caused me huge physical and mental injuries that I still face.”