by Margaret Morris and George Carson
Even during the pandemic, labour and delivery are the most frequent reasons for hospitalization in Canada, with over 350,000 births per year. That’s happy news. But of these births, nearly one third are by caesarian section (C-sections). That rate is far too high – and rising.
C-section is the surgical procedure to deliver a baby that involves an incision in the mother’s abdomen and uterine wall, recommended when the baby’s or mother’s lives are at risk from a vaginal delivery. Nearly 105,000 C-sections take place each year, making it the most common hospital-based surgery in Canada.
The COVID-19 pandemic has underscored the importance of using our limited health care resources wisely. Yet we know that a significant proportion of C-sections are being done when they may not be necessary.
C-section rates have more than doubled in the past 25 years. Even accounting for some changes in the child-bearing population over this time such as mothers having children later and higher rates of obesity and chronic diseases, we know that this still shouldn’t be driving such a sharp increase in the way babies are being born.
So why is this happening?
C-sections can be life saving for both mothers and newborns when they are medically necessary. When needed, the benefits far exceed the risks for the pregnant woman and the newborn. But each C-section is also a major operation. This surgery has significantly more risks than a vaginal birth – including higher rates of infection, hemorrhage and death for the mother. In some cases, there can also be immediate and long-term risks for the newborn.
As well, after a C-section, there is a scar on the uterus, which has implications for any future pregnancies and labour. Recovery from a C-section, as any woman who has had one can tell you, can be painful — and it usually includes a longer hospitalization and recovery period than vaginal birth.
Unnecessary C-sections can harm patients. As a past and the incoming President of the Society of Obstetricians and Gynecologists of Canada (SOGC), we are committed to raising awareness about the harms of C-sections that are not medically necessary, among our colleagues across Canada and among expecting mothers.
As part of the Choosing Wisely Canada campaign, which is an organization dedicated to reducing unnecessary tests and treatments in health care, the SOGC recently released recommendations for all clinicians involved in birth, including obstetrician gynecologists, family physicians and midwives, and urge rethinking when C-sections are necessary.
Research suggests that a significant part of the over-use of C-sections often occurs when it appears that mothers are not progressing in early labour. Labour has both a latent or beginning phase, followed by an active phase. The transition from latent to active labour can take time; in some cases, many hours. A latent phase of up to 20 hours is normal for a woman having her first labour.
For healthy women with a single pregnancy, the optimal management during this phase is to allow them time to progress while offering supportive care including pain relief and rest. Most women can then enter active labour and most proceed to vaginal delivery.
Across Canada there are major differences in C-section rates among provinces, among hospitals in the same city and even between individual obstetricians. We know from research that a major driver of this variation can simply be impatience. Deciding to do a C- section may often relate to providers’ and/or patients’ reluctance to wait for active labour.
Our recommendation urges physicians to rethink their practice for the latent phase of labour and wait and see if a patient can safely deliver vaginally to curb rising C-section rates.
Now more than ever, it is important to use health care resources wisely. Thinking twice before undertaking the most common surgical procedure for the most common reason for hospitalization in this country – labour and delivery – is a great place to begin.
Dr. Margaret Morris is Professor in the Department of Obstetrics, Gynecology and Reproductive Sciences at the University of Manitoba and the President-designate of the Society of Obstetricians and Gynecologists of Canada.
Dr. George Carson is Clinical Professor Obstetrics & Gynecology, University of Saskatchewan and past president of the Society of Obstetricians and Gynecologists of Canada.
The views in this commentary do not reflect the views of the SOGC.
by Margaret Morris and George Carson