Caesarean Section

Sex and Gender-based Analysis of this topic

Definition
A Caesarean Section birth (C-Section) is a delivery involving the surgical incision of the abdomen and uterine walls [1]. C-Sections are usually performed when vaginal delivery could potentially risk the mother’s or infant’s life. C-Section deliveries have become more common even in cases where natural childbirth is possible. C-Section rate is the percentage of C-Section deliveries compared to the total number of deliveries in a given place and time [2]. The Canadian C-Section rate is approximately 26%, which is an increase of 45% since 1998 and most likely due to a rise in both elective and emergent C-Section births [1, 3]. Canada’s C-Section rate exceeds the World Health Organization’s recommended rate of 10%-15% [4]. The rapid increase in C-Section rates in Canada is a source of concern, as C-Section delivery is associated with increased risks for adverse outcomes for both the mother and the infant [1, 5, 6].
 
 
Sex Issues
C-Sections can be life-saving for both mothers and infants. Indications for medically necessary C-sections include: pre-eclampsia, dystocia (non-progressive labour), fetal distress, breech presentation, active genital herpes, multiple births, extremely large baby, and previous C-section birth [7,8]. C-Sections are a major surgery and deliveries can increase the risk of negative perinatal outcomes for the mother, such as risk of infection, cardiac arrest, major puerperal infection, anesthetic complications, pelvic floor complications, venous thromboembolism, hemorrhage, psychological trauma, and maternal death [1,2,3,5]. Women who have undergone C-Section procedures are also more likely to:  need further surgery; be re-admitted to the hospital; be admitted to intensive care units; and have increased hospital stay lengths. C-Section deliveries can also increase the risk of subsequent ectopic pregnancy, spontaneous abortion, placenta previa, infertility, and stillbirth [1]. Infants born by C-Section are more likely to: experience respiratory distress; be premature; and show higher incidence of both admittance to intensive care units and infant mortality [1, 5, 9].

 
 
Gender Issues

Recent shifts in medical and social trends can help explain the increasing demand for C-Section deliveries. Birth in Canada is becoming increasingly medicalized, with a rise in medical and surgical interventions, including C-sections. Current shortages of family physicians, nurses, and midwives trained in low-risk births mean that the majority of births in Canada are attended by obstetricians who are more likely to suggest medical and surgical interventions [3]. For example, in 2000/2001, about 75% of all Canadian births involved some medical or surgical intervention [10].  Many common obstetrical interventions, such as epidurals and inductions create a “cascade effect”, requiring further medical interventions, which may culminate in a C-section [11].  Recent changes in obstetric practices include the increased use of electronic fetal monitoring, caesarean delivery in the case of breech positioning, epidural anesthesia, and a reduction in the use of midpelvic forceps [12] and these changes are cited as leading to the increases in C-sections in the past 15 years [12]. Risk assessment for C-section has changed, leading to a number of different protocols that may guide physicians [8, 13, 14]. There is evidence that C-sections may reduce the risk of mother-to-child transmission of HIV [15].

A low rate of vaginal birth after caesarean (VBAC) may also contribute to the rising caesarean rate. In the 1980s, research evidence verified the safety of VBAC for women with previous transverse, low-segment incisions, and where there were no other contraindications [16]. VBAC rates have declined since then, falling from 35% to 20% in Canada between 1997 and 2005 [17]. The Society of Obstetricians and Gynecologists of Canada recommends VBACs as beneficial for mothers and babies, with benefits over a repeat C-Section, stating that most women with previous C-sections can deliver by VBAC safely [18].  There is a risk of uterine rupture, but those risks have been reduced since low-segment incisions became the norm. Nevertheless, fewer women are delivering by VBAC and this bears some investigation.

As more women delay childbirth to first get established in the workforce, there is an increase in risk factors that can lead to C-sections, including increased maternal age and increased utilization of assisted reproductive technologies including multiple births. There are discussions in the research literature about how much the rise in C-section rates is also driven by demand from women or their physicians. Although there is a perception that many women are requesting C-sections, recent evidence suggests this is not the case. Women may be more likely to agree to a C-section if their own physician will be present at the birth [19]. This suggests that women are not, or do not anticipate, benefiting from other supports in labour and feel it is most important to have “their” doctor with them, no matter what. One author sees this as a “wake up call” to the inattention to women’s needs [20].

There is evidence, however, that there have been changes in recent decades to physicians’ own understanding of birth and this may also influence their preference for C-sections for themselves and for their patients [20]. Recent studies suggest that women and their providers prefer medicalized births, due to a fear of potential risks and increased comfort with technology [20].

 
 
Diversity

The rate of C-Section varies across the country with the lowest rate of 8% in Nunavut compared to 33% in PEI, which is the highest provincial C-Section rate in Canada [21,22]. BC has the second highest rate in Canada at 30% [21].  In BC (2005), Vancouver Island Health Authority had the highest C-Section rate of 32% and Northern Health Authority had the lowest rate of 26% [1]. Access to C-Section procedures is limited in rural, remote areas, including Aboriginal communities, due to a lack of facilities, equipment, and skilled personnel [22].

The rate of C-Section increases with age. In 2005, the BC C-Section rate among mothers aged 20-29 was 26% compared to 36% in mothers aged 35-39 [23]. Canadian hospital data from 2002/2003 shows that women in low-income areas were significantly more likely to undergo C-Section births than women living in high-income areas [24]. This could be related to lack of pre-natal care, poor nutrition, and poorer health in general [25]. A Manitoba study found considerable variation in rates across the province, but that rates in Winnipeg tertiary hospitals were within the Canadian average [25]. Diabetes and gestational diabetes in women are found to be consistently associated with both emergency and planned C-sections in Manitoba [25].  Women who are overweight and obese are also more likely to deliver by C-section [25].

 
 
Critique
Canadian C-Section rates do not control for differences in population characteristics , such as maternal age, parity, or other C-Section risk factors [21]and these variables may vary across provinces/territories and health care settings. Caution should be used when comparing hospital-specific data, as different institutions may have disproportionate numbers of high- or low-risk clients, depending on available services [2]. Canadian C-Section data do not distinguish between elective and medically necessary C-Section [24] which is a distinction needed to appropriately monitor current C-Section trends and provide recommendations to reduce presently high C-Section rates. A Manitoba study, however, was able to distinguish indicators and risks associated with planned and emergency C-sections in the province [25], which can allow for more targeted monitoring.
 
 
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