Which first-time mums are more at risk of caesarean?
There is growing concern about the number of unnecessary caesareans, and the rate of these is especially high in first-time mums.
That concern is the reason behind doing the research that I’m writing about today. But it’s important to be clear at the outset that this isn’t about criticising caesarean or those who want, need or prefer it.
Caesarean birth (CB) can be lifesaving in a few cases and some women request it. But many people would prefer to avoid having surgery unless it is genuinely warranted. Lots of women seek to do things that will help them avoid a caesarean if possible. So researchers around the world are doing research to find out what factors lead to increased caesarean rates and what we can do to bring these down.
There’s another important thing to understand about this topic as well. As I discuss in my book, In Your Own Time, caesarean isn’t an outcome that happens naturally to some women and not to others. Surgery happens as the result of someone (usually a doctor) making a decision to offer surgery to someone else (usually a woman). She then needs to decide whether or not to have it. So it’s a human decision. It’s important to remember that, and I’ll come back to it later.
So this group of researchers, who are based in Ireland, collected data from just over 3000 first-time mums who completed surveys, both during and after pregnancy. They also (with permission of course) gathered more data from the women’s hospital notes.
The point was to see who ended up with a caesarean and what factors were associated with having a caesarean. They looked at both pre-pregnancy factors, like age, BMI and treatment for infertility. They also considered pregnancy-related factors, for instance the type of caregiver each woman had. Other pregnancy-related factors include whether someone has one or multiple babies, a spontaneous or induced onset of labour and whether they opted for pain relief.
The overall aim is simple. If we know who is most at risk of caesarean, then maybe we can do things to help prevent it.
Here’s a summary of the key findings:
“The risk of having a planned CB significantly increased for women who were aged ≥40 years, had treatment for infertility, were in semiprivate and private care, and had multiple gestation and breech or other malpresentation, after adjusting for the prepregnancy and pregnancy factors.” (Panda et al 2022).
The higher caesarean rates in these groups aren’t necessarily because these women can’t give birth vaginally. Some may have problems and need help, yes. But some of those caesareans may be happening because of doctors’ or others’ perceptions of risk, rather than on the basis of genuine medical need.
Some of this isn’t new. We already know, for instance, that having private obstetric care means you’re more likely to end up with a caesarean. But it’s important to keep talking about these things, because not enough people know about it yet.
Inductions and epidurals
Even more telling are the results for women who had induction of labour and/or an epidural.
“Women aged ≥40 years, being overweight and obese/very obese prepregnancy, with preexisting hypertension or asthma, in private care, with multiple gestation and breech or other malpresentations, and who had IOL and epidural with or without the use of IV oxytocin in labor had a significantly increased risk of birthing by an unplanned CB, after controlling for prepregnancy and pregnancy factors.” (Panda et al 2022).
So having an induction or an epidural increased these women’s chance of having a caesarean. And the researchers found that having both of those things increased it even more.
“An unplanned CB occurred for 22.43% (n = 377/1681) of women who did not have induction of labor (IOL) or who had IOL with no epidural, but the risk was about twice as high for women who had IOL and epidural.” (Panda et al 2022).
Putting it into perspective
Now, am I criticising those who choose induction and/or epidural?
Especially when we know that induced labour is more difficult to cope with than when labour starts on its own.
This is about going into your pregnancy and birth journey with information and knowing the consequences of various options so that you can make the decisions that are right for you. (“What’s Right For Me?” is literally the title of one of my books.)
Going back to the risks of risk management
The researchers who carried out this study point out that there are often several reasons for recommending caesarean. They discuss, “the challenge of reversing the increasing CB rate if maternal age, overweight/obesity, infertility treatment, multiple pregnancy, and preexisting hypertension in Ireland continue to increase.” (Panda et al 2022).
But that’s not only a problem because those things are intrinsically riskier in themselves. It’s true that some of them are to some extent, but not always. There often isn’t evidence that intervention reduces risk, and there’s something deeper going on as well. That is, the way in which being deemed to be ‘at risk’ in itself can lead to being treated differently, and to being offered more intervention.
Yes, there are is a controversial study which claimed to show that induction is less likely to lead to caesarean. But that has been shown to be flawed and limited.
Many other studies and real-life data clearly show that intervention, particularly induction of labour, clearly increases the risk of caesarean.
The real issue
The real issue is that there’s a bigger picture here.
It’s not necessarily about you. Women’s bodies aren’t routinely failing, and many of these caesareans wouldn’t be necessary if it wasn’t for the way women and families are being treated. Often, there isn’t evidence to support intervening and yet, as this study shows, there is growing evidence that intervention leads to further intervention. This is something else that I wrote about in my book, In Your Own Time: how western medicine controls the start of labour and why this needs to stop. More people need to understand this as well. Then they can make the decisions that are right for them.
It’s important not to blame women, or suggest that high intervention rates are all about how big or old we are when we get pregnant. The high induction and caesarean rates we face at the moment reflect our cultural beliefs about birth, and the way we see, speak about and treat women and their bodies.
We need deeper understanding, better education and more respect.
I’ve written lots on induction of labour, including two bestselling books, so here are some resources if you’d like to look further at induction of labour.
Factors associated with cesarean birth in nulliparous women: A multicenter prospective cohort study. Birth, online ahead of publication: 10.1111/birt.12654, ,
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