When Monica Rooney of Toronto was placed in the caesarean group for a clinical study on twin births, she was relieved. She feared ending up in the same situation a friend of hers experienced: birthing the first of her twins vaginally, then requiring a C-section for the second.
And though it meant Rooney required another caesarean when she needed labour induced for her second set of twins, she is happy her choice to go with a C-section was respected in both instances.
“I was fine with my decisions,” Rooney tells Yahoo Canada News. “The doctor did leave it up to me for the second. I tried to go into labour, but I didn’t push back when I didn’t by 38 weeks. The risk of death [with twins] increases by quite a bit after 37 weeks.”
Whether it’s by choice, circumstance or some combination of the two, more Canadian women are having caesarean births. Caesarean rates in first births for women under 35 were 17. 5 per cent of births in 2014-15, according to the Canadian Institute for Health Information. For those 35 and older, the rate was 22.9 per cent.
“The overall percentage of women who are actually purely asking for maternal request C-sections, in the sense of absolutely no medical indication, is a small per cent but it is growing,” Dr. Magnus Murphy, a professor in the department of obstetrics and gynecology at the University of Calgary, tells Yahoo Canada News.
Doctors must provide a valid medical reason for an elective C-section, so tracking those C-sections that are truly elective is difficult to do in Canada. But there are several reasons why a woman might choose an elective caesarean, Dr. Murphy says: fears of a difficult labour, concerns about post-delivery problems such as damage to the pelvic floor, trauma from a past delivery that resulted in complications or injury. And the definition of “elective” varies considerably from doctor to doctor.
Rising caesarian rates
There are several factors contributing to increased overall rates of C-sections in Canada. In some cases a caesarean section is an emergency need; for others, some women have conditions or factors that make a vaginal birth risky.
Some research on maternal age could explain the rise in C-sections. A Pew Research study that looked at data from 1926-2011 showed that, in 2011, 52 per cent of all Canadian births were to women 30 and older. In 1981, it was 24 per cent for the same age cohort.
Older women are more likely to have risks of certain complications, like gestational diabetes, which are then more likely to lead to a C-section. One 2014 study of 160,000 women found that women older than 40 were three times more likely than those aged 20 to 24 to require an emergency C-section, for example.
In addition, the incidence of multiple births has increased over the past 40 years, according to the Society of Obstetricians and Gynaecologists of Canada. And about half of twins and nearly all triplets are delivered via C-section, according to Multiple Births Canada.
But none of this means that caesareans are always the best choice in any of these situations, says Dr. Murphy, who co-wrote Choosing Cesarean: A Natural Birth Plan with Pauline McDonagh Hull. And in some cases, women who would normally be scheduled for a caesarean are going in a different direction.
Even as C-section rates are rising overall, for example, some women want to attempt a VBAC, or vaginal birth after caesarean. The rates of repeat caesarean section are rising after decreasing between the 1980s and mid-1990s, according to research by the Association of Ontario Midwives, but attitudes can vary considerably from one practitioner to another.
After having a scheduled C-section with triplets in 2009, Danielle Young of Airdrie, Alta., had a VBAC last year.
“I am so glad I didn’t have another C-section,” Young tells Yahoo Canada News. “My doctor told me it was up to me what I wanted to do.”
Whether a woman prefers a vaginal birth or caesarean, that element of choice is something physicians should support based on the medical evidence available for each patient, Dr. Murphy says.
“I am not a proponent that every woman should have a caesarean section,” he says. “I am a very strong proponent for the right of every woman to make a decision.”
The Society of Obstetricians and Gynaecologists of Canada’s policy statement on natural birth, released in December 2008, states that women and families should be able to make informed choices and that all candidates for “normal” birth should be able to pursue it. It also states “caesarean section should be reserved for pregnancies in which there is a threat to the health of the mother and/or baby.”
Caesarean sections are major abdominal surgery and do hold risks, including infection, reactions to anesthesia, injuries related to surgery and complications in later pregnancies. Vaginal delivery has risks as well, including hemorrhage, perineal tearing, infection and pelvic floor injuries.
And for some women, childbirth can be traumatizing. A 2006 study found that birth-related post-traumatic stress disorder, which could occur in up to 2 per cent of women after childbirth, can have long-lasting effects.
But ultimately, most births — caesarean or vaginal — end safely for mother and baby. And C-sections do hold some appeal for women who are hoping to avoid an outcome they see as more undesirable than a scheduled caesarean: an emergency one after hours of labour that ultimately doesn’t end in a vaginal birth.
Kelly of Ottawa, who requested her surname be withheld due to the controversy of the topic, ended up having an emergency C-section after a long and difficult labour with her first child. When making a decision about the birth of her second child, she was conflicted.
"I really liked my OB, but I wish I’d felt more support to have a VBAC,” she tells Yahoo Canada News. “At the same time, I understand she’s seen some VBACs go really wrong, and that has to inform your perspective too. Some doctors are simply more conservative than others.”
Looking back at a vaginal delivery that went well is very different than looking ahead to one that could proceed normally but does involve some measure of risk, Dr. Murphy says.
“There’s no doubt that an elective caesarean is safer for the baby than going through a difficult delivery and ending up with an emergency caesarean,” he says.
Describing her difficult first labour as “traumatizing,” Kelly ultimately decided to schedule a C-section for her second birth. But it’s important to acknowledge that no one birth plan is right for all women, she says, and that the decisions about delivery are individual and personal.
Dr. Murphy says, “In every other healthcare realm, it is society’s understanding that people have authority and the right to make decisions regarding their own lives, their own bodies, the risks that they accept and don’t accept.”