Caesarean rate not just a result of ageing, overweight mums

Our attitude to women and the models of care and environments in which they give birth continues to change.
Our attitude to women and the models of care and environments in which they give birth continues to change. Photo: Max Mason Hubers

For a man who has spent his whole life researching the pelvic floor, Dr Peter Dietz's comments that women are endangering their health in a quest for natural birth to avoid caesarean sections comes as no surprise.

There is no doubt that pelvic floor injuries are a threat to the health of child-bearing women. It's imperative that we continue research in this area, and work to make birth safer. But women need comprehensive information that goes beyond the pelvic floor when considering the pros and cons of vaginal birth versus caesarean section.

I was part of the multi-disciplinary committee in 2010 that worked on the 'Towards Normal Birth' policy that Dr Dietz criticises. The policy was based on sound scientific evidence, and is in line with international recommendations from groups such as the World Health Organization.

More importantly, it was in response to intense consumer lobbying over the high rates of caesarean section in NSW and the resulting trauma (physical and emotional) for women.

Dr Dietz argues the rising caesarean section rate is linked to older and overweight women giving birth. This is, in part, true. It does not, however, account for the fact that we see significantly lower rates of caesarean sections in Scandinavia and the Netherlands, where women have the same demographic profile.

We published a paper last year repeating a study undertaken a decade earlier, which showed that with the same matched low-risk (no medical complications, under 35 years of age) population of women in NSW, there had been a 5 per cent rise in caesarean sections in the public sector, and 10 per cent rise in the private sector.

The ''oldest'' women giving birth in NSW do so in birth centres and at home, and have the highest rates of normal vaginal birth.

Studies show that women who give birth in private hospitals are much less likely to be overweight than those birthing in the public section, yet they have nearly twice the caesarean section rate.

So the question that must be asked is this: is the problem more about our attitude to women and the models of care and environments in which they give birth, rather than changing demographics and medical risks?

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The rising caesarean section rate is therefore not as ''inevitable as the weather'', as Dr Dietz argues.

Dr Dietz states that reducing epidural pain relief is ''reprehensible and anti-Hippocratic''. There is no intent to deny a woman an epidural if she wants one; we need to ensure they're not used unnecessarily. Women who have epidurals during labour have higher rates of instrumental birth (forceps and vacuum), which Dr Dietz quite rightly points out is a major cause of pelvic floor problems.

But continuity of midwifery care, for example, leads to a reduced need for epidural and higher satisfaction with birth, along with many other advantages. Immersion in water reduces the need for epidural and increases women's sense of control, so access to this is supported under the 'Towards Normal Birth' policy.

Dr Dietz's statement that ''human childbirth is a fundamental biomechanical mismatch: the opening is way too small and the passenger is way too big'' provides a real insight into why the caesarean section rate may be so high in this country.

If health professionals truly believe this, then what chance do women have to feel confident in their bodies and their capacity to give birth?

Hannah Dahlen is a professor of midwifery at the University of Western Sydney.

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