SOON MORE FIRST-TIME mothers will be induced or delivered by planned caesarean section “than will present in spontaneous labour”.
That is according to Mary Brosnan, Director of Midwifery and Nursing at the National Maternity Hospital. She reflected on increasing interventions during labour and birth in a recent edition of the Irish Nurses and Midwives Association (INMO) magazine.
In addition to increasing maternal age and risks, she noted that “maternal request” was the documented reason for over half of planned caesarean sections in Holles Street last year.
Having a previous C-section was the most frequent reason listed for these procedures, according to the hospital’s annual report.
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“There’s a whole variety of reasons” that women may want this option, according to Dr Peter Boylan, retired obstetrician and former master of the National Maternity Hospital. These include concern over potential loss of bladder control or having “a terrible experience on her first birth”.
“The correct thing to do is to sit down and explore what the reasons are.”
The rate of both C-sections and inductions has increased year-on-year in Ireland over the past 15 years.
From calculations based on Maternity Safety Statement data for each hospital for 2022, Noteworthy estimates that a further increase occurred last year, with overall rates of inductions and C-section both rising one to two percentage points.
Latest confirmed statistics found over 35% of women were induced and over 36% had caesarean births in 2021.
This is high compared to many of our neighbours, in particular the Nordic countries where C-section rates are in the high teens.
A consultant obstetrician put this down to Irish pregnant women being “fat, old and short”, when he was interviewed by Sunita Panda, midwife and researcher from Trinity College Dublin (TCD) as part of her research.
Panda disagreed with this assessment. She travelled to Sweden to examine their low caesarean birth rate – just 18.6% in 2021.
“They do have women with high BMI” as well as women with “advanced maternal age”. She said that the key is how Ireland manages the pathway of maternity care.
Instead of an intense level of management that leads to more interventions, Panda said that a Swedish high risk woman is “treated like any other woman” and “given more time to go into spontaneous labour”.
Back in Ireland, a majority of women are now having medical interventions during birth. Since 2021, over half of all deliveries are done operatively – either through C-section or by using instruments such as forceps or vacuum extraction.
Noteworthy asked the HSE what is being done to address increasing interventions. A spokesperson said that “increases in the numbers of C-sections and inductions have been observed both nationally and internationally”. They continued:
“Research indicates that some of this is attributable to sociodemographic changes and increased complexity such as advancing maternal age, rising BMI etc.”
Increasing use of inductions
The increasing use of inductions to begin labour is one of the main reasons that C-sections are on the rise, according to all clinicians we interviewed.
“Practice has moved that way,” according to Greene. “Some of it directed by research.”
Most inductions are done because women are going over their due date, Boylan told Noteworthy.
Inductions are often advised when a pregnancy continues beyond 41 weeks. That is because rates of stillbirth and neonatal death increase, according to NICE guidelines on induction of labour.
About 31 more babies are expected to die per 10,000 whose mothers gave birth at 42 weeks, compared to at 41 weeks.
However, inductions can also start a cascade of medical interventions, including an increased likelihood of C-sections for women and neonatal intensive care unit (NICU) admission for babies.
“So there are valid reasons for induction, and then there’s what’s known as a social induction,” Boylan said. “That might be because either the woman wants to have the baby delivered or the doctor does.”
The same is true for elective C-sections. The increase in women opting for planned caesarean births is “a reflection of the increasing autonomy of women and involvement in their care”, according to the retired obstetrician.
Repeat C-sections a ‘key driver’
Women having a repeat elective caesarean birth was the “key driver of progressively increasing overall” C-section rates, according to the Rotunda’s 2022 annual report released earlier this week.
The hospital’s overall rate increased from 37% to 39% in just one year.
To address this, the report stated that the Rotunda “continues to encourage appropriately selected women” to attempt labour after a prior C-section. “The appointment of a dedicated Advanced Midwifery Practitioner” in this area is also hoped to “yield positive results” in 2023.
It stated that the continued increase in repeat C-sections “will also likely lead to an increase in diagnosis of Placenta Accreta Spectrum (PAS)”. This is when the placenta is fully or partially attached to the wall of the womb.
In 2022, the hospital reported the highest number of caesarean hysterectomies in the past five years, with 80% performed due to PAS.
Induction and C-section rates vary between hospitals in Ireland. Data on these is collected on a monthly basis through Maternity Safety Statements. This preliminary data indicates that C-section rates vary from 29% to 43% and rates of induction vary from 28% to 44% across the 19 maternity units.
- View the full table of last year’s preliminary induction, C-section and instrumental delivery rates at each maternity unit here>>
The HSE states that these are not intended to “be used as a comparator with other units”, with tertiary and referral maternity centres caring for “a higher complexity of mothers and babies”.
“Rates are monitored on an ongoing basis and reviewed” with maternity networks and hospital groups, a HSE spokesperson told Noteworthy.
Women’s choice or clinician’s influence?
There is huge concern, particularly among midwives we spoke to, about the increasing medicalisation of what many feel is a natural process. There is also debate over whether C-sections due to ‘maternal request’ are because of a women’s choice or clinician influence.
Ireland along with Poland were the only countries not to submit data on planned – also called elective – caesarean sections in the latest European report on the issue. This information is not published as part of the annual Irish Maternity Indicator System or the monthly maternity safety statements.
In addition, all outcomes for all women – public and private – are presented together in Irish reports, explained Panda. Her research, alongside many other studies, found that more elective and emergency caesarean sections occur in private care.
She has studied the rise of elective C-sections. “There are really complex discussions” about whether this is actually a woman’s request or is it a clinician’s conversation with a woman which results in a maternal request, according to the researcher.
“Women openly admitted” to Panda that they just “went with the professional recommendation to be induced or have a planned caesarean birth” and had “little role in the decision-making”.
As part of our BIRTH PLACE investigation, we reported earlier this week that half of the over 20 women we interviewed felt pressured into inductions or other interventions, with what they felt was no clinical indication. Some said they were threatened or coerced.
Every clinician that Panda interviewed told her that fear influenced their decisions to recommend interventions – fear of adverse outcomes, fear of litigation or fear from a previous negative experience.
Brosnan also raised this. She said that she is “constantly reflecting on the balance between choice and safety”.
In the INMO magazine, she wrote of wanting to promote normal birth but also protect the midwifery team “from exposure to excessive risk due to a poor perinatal outcome, which also would result in potentially career-ending litigation”.
“If we’re all honest about it, the single biggest factor that has increased the intervention rate is probably our litigation environment,” Professor Richard Greene told Noteworthy.
Greene, director of the National Perinatal Epidemiology Centre (NPEC) and professor of obstetrics at UCC, said that if the outcome is a C-section, “nobody is going to have you up for that”. But if you don’t do it and there’s a problem with the baby, litigation is more likely, he added.
This could be addressed by having better State support for disabled or injured children, rather than families needing to go to court.
“Families have said to me that [the court] is a cruel way to deal with families with bad outcomes”.
Why does the Irish health service offer so little choice for expectant mothers?
By Maria Delaney of Noteworthy
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