According to a Perinatal Services BC report, in the first quarter of 2013 almost 1 in 3 (31.7%) women in BC gave birth by cesarean section, and 1 in 5 women (20.1%) were induced. These are the highest rates of cesarean and induced deliveries ever recorded in BC and it forces me to reflect on how things have changed over the past 26 years.
I just re-read the Statistics Canada paper (1996) "Declining Cesarean Rates: A Continuing Trend?" and felt a twinge of nostalgia. Take a look at the study. The cesarean rate in BC during my first year as a doula (1987) was 21.9%, and a few years later in 1992 and 1993 the rate was declining! At that time, there was hope that the overall cesarean rate would continue to drop, with the goal of reaching the World Health Organization's recommended "medically warranted" cesarean rate of 10-15%. One local study (Janssen, Klein and Soolsma, 2001) found that Burnaby Hospital had a cesarean rate of 10.3% in 1995, which was appreciably less than the BC Women's Hospital rate of 22.9% (less than half an hour's drive away). They concluded that "Differences in use of epidural analgesia may contribute to differences in institutional rates of cesarean delivery. Use of epidural analgesia may be related to use of ambulation, consistency of caregiver during labor, availability of epidural, and suggestion for its use by caregivers." What does this mean for birthing women? It means, as more recent studies suggest, that inductions and epidurals – technology that have become more and more common throughout my years of doula practice – are influencing the rising cesarean rate.
But why are inductions and epidurals more common now than two decades ago? What has shifted in the past 26 years in the general population? I'm currently working on compiling and analyzing the statistics for my first 1000 clients and it looks as though their intervention rates have been consistent over time. Just to give you a snapshot of recent births, of my 18 clients in the first quarter of 2013, the cesarean rate was 5.5% (1), the induction rate was 11.1% (2), and the rate of epidural use was 22% (4). Here’s what happened:
- The lone client who gave birth by cesarean was over 40 and had been induced at 40 weeks. (Have you heard of the 40 at 40 trend? What are your thoughts?)
- The second induced client had prolonged ruptured membranes and gave birth without any other interventions - almost birthing her baby in the bathroom!
- Two of the four epidurals were planned in advance, due to non-pregnancy-related medical conditions.
- Among other clients who used analgesia, one woman was given a shot of morphine and gravol (and gave birth without complications or any other medications) and two women used nitrous oxide gas after reaching 8cm dilation (and while remaining mobile).
Without an induction or epidural, how did 78% (14/18) of my clients manage the power of their labour? Are my stats low because my clients are highly motivated to avoid interventions? Do they all deliver at home or with midwifery care? Do they avoid cultural messages that describe birth as risky and dangerous?
Maybe the women in 2013 are totally different than in the 1980s. Twenty-six years ago, the average age of birthing women was much lower than today. So are the high cesarean, epidural, and induction rates in BC related to the increase in older first-time mothers? That could be true. But, the majority of my clients are well over age 30, with 22% over age 40. So that idea doesn't explain the low intervention rates among my clients (though I’m going to explore the influence of age and other potential sociodemographic confounders in my case series analysis).
And, yes, my clients would all love to avoid a cesarean. But, those who are planning a home birth are the first to acknowledge that they don't know what their body or their baby will need on the "birth day." My client can be motivated and keep calm, but if her baby is in face presentation or if her placenta is lying over the cervix, there’s no choice in the matter. Her only option is a cesarean. The baby and body like to play the wild card.
And while many of my clients plan a home delivery with midwives, I work equally as often with clients cared for by physicians. We can try to make the hospital environment as homelike and undisturbed as possible, but when there is only one available birthing room and 5 women in the assessment room, and all the nitrous oxide tanks in the hospital are empty... you will be disturbed, your labour will be disturbed, and your probability of having a cesarean will increase. (Yes, that scene was played out the other day at BC Women's.) Each statistic has a real woman's story within it.
All my clients hear friends and family who say, "Get an epidural!" at some point during pregnancy. They have all heard other women recount horror stories (why must we do that???) And many have daily phone calls from those near and dear to them who inadvertently undermine their confidence. "Why would you think YOU could birth without drugs? I didn't. Just book your cesarean!" Women’s motivation can be severely impacted by the daily onslaught of negative images.
But in trying to understand why my clients’ intervention rates are so low, there's one piece of the statistical puzzle that really strikes me - The average dilation upon admittance at hospital for the epidural and no-epidural groups. The two women who had unplanned epidurals arrived at hospital at an average of 3.5cm. Those 14 who didn't have epidurals comprised of 7 successful homebirths (71% were having their first baby), and 7 hospital births (average arrival dilation upon arrival was 7cm). Does arriving at the hospital later in labour make a difference?
Now, I can't conclude that arrival at hospital at 7cm will never result in the need for an epidural or a cesarean. But, it certainly increases your chances of having a smooth, intervention free birth if you arrive at hospital in active labour. Every client and their partner who birthed without an epidural or cesarean said that, if I hadn't been with them at home, they would have driven to the hospital hours and hours earlier. Many women said their advanced dilation gave them incredible confidence - "I couldn't believe I was 9cm when I arrived! When I heard that number, I knew I could do it!"
So, my thought is that, taken together, these approaches account for my low epidural, induction, and cesarean rates: a positive attitude, low stress, low disturbance levels, late arrival at the hospital (as long as the woman is in contact with her caregiver, who is supportive of the plan), the presence of an experienced and calm doula (that's me), and low-tech options – movement (walking, dancing, swaying, spiraling, lunging), position changes, water (shower, tub), sound (singing, toning, talking, music) as well as continuous physical and emotional support (from me and their partner and team). All of my clients who had spontaneous labours, and used these tools, went on to have spontaneous "slow and simple" vaginal births.