Pulling back the curtain on Canada’s rising C-section rate

Caesarian sections (C-sections) are among the most common surgical procedures performed on women of child-bearing age. Canada’s C-section rate has increased dramatically in the past two decades.

The national C-section rate  has increased from 17% of all births in 1995 to nearly 27% in  2010. In Ontario, nearly 29% of births in 2011/12 were by C-section, with a similar rate in Alberta of 28% in 2009.

While C-sections are often the best approach to ensuring good outcomes for both mother and baby in high-risk pregnancies or complicated deliveries, rates are rising among women with low-risk pregnancies.

Sharply rising rates have led to debates about when this surgery is appropriate – and when it is not. This article highlights some of the drivers of rising C-section rates, as well as examples of where targeted approaches are attempting to reduce C-sections among low-risk pregnancies.

Ann Sprague, acting director of BORN – Ontario’s birth and pregnancy registry – says that while “everyone is interested in reducing C-section rates, you can’t tackle it all at once.” She highlights that “there are many things that drive C-section rates, including induction practices, changing demographics of child-bearing women, and general obstetric complications.” She suggests “if you look at small pieces of it you will make progress.”

Changing demographics and costs associated with C-sections

Changing demographics of Canadian women have implications for childbirth. The most significant factors are delaying child-bearing until a later age, as well as increased body mass and more pregnant women with chronic diseases. Women with one or more of these characteristics are statistically more likely to have a higher-risk pregnancy and more complications during labour, and are more likely to have a C-section.

There has also been a rise in birth weights in the past few decades. Bigger babies can mean more difficult deliveries for women.

In addition, there has been “an explosion” in the number of multiple pregnancies in Canada – driven by trends of delayed child-bearing and increased use of fertility treatments. Multiple pregnancies are more likely to be delivered by C-section, and once women have delivered by C-section, they are more likely to do so for subsequent pregnancies.

C-sections are more costly than vaginal births, because they require more resources like operating room space, anesthesiologists and  nursing care, as well as a longer hospital stay. A 2006 Canadian Institute of Health Information report estimated that a C-section costs $4,600, compared with $2,800 for a vaginal birth.

Lisa Graves, Chief of Family and Community Medicine at St. Michael’s Hospital, describes C-sections as “an important tool in maternal care, that when appropriately received and timed, saves lives of women and children who in an earlier era may not have survived.” However, she says it is important to “look at C-sections as a tool – like any action that we as physicians do it has good reasons to be used and poor reasons to be used.”

For a brief description of what a C-section is, and an overview of some of the debates related to variations in clinical practice, click here.

Targeted approaches to improve clinical decision making around quality measures

Given the complexity of the factors driving increased C-section rates, experts agree that the approaches taken to address this need to be targeted and driven by data on where these increased rates are being seen.

Sprague says that BORN Registry data is provided back to hospitals and clinicians “so that they have the information they need to make good decisions.” BORN has developed a ‘clinical dashboard’ of six measurements of quality.

The use of these data to tackle variations in C-section rates that may not be related to clinical or patient level factors has been one area highlighted by experts as promising.

Jennifer Blake, CEO of the Society of Obstetricians and Gynaecologists of Canada, points out that there is a “a lot of variation among hospitals and regions, and we need to understand what factors are driving these practices.”

One of the BORN Dashboard measures is the rate of repeat, planned C-sections in low risk women prior to 39 weeks gestation when there are no medical or obstetrical complications.  Sprague notes that this indicator was chosen because “there is good evidence that suggests that you shouldn’t do a C-section before 39 weeks” in these low risk women. A full term pregnancy is considered to be between 39 and 40 weeks and six days from the date of a woman’s last menstrual period. The practice is sometimes attributed to scheduling challenges for operating room booking, but evidence points to improved outcomes for mothers and babies if C-sections are scheduled after 39 weeks. Sprague says that simply auditing and reporting this quality measure to hospital administrators and clinicians has been associated with a reduction from 53% in 2012 to 40% currently.

Another quality measure on the BORN dashboard is the rate of labour induction prior to 41 weeks of gestation, which can also increase the chance of cesarean section.

Carol Cameron, a midwife and former head of the birth unit at Markham Stouffville Hospital used these data to support changing scheduling practices at Markham Stouffville Hospital, including not booking requests for inductions without a medical reason prior to 41 weeks. She says “data is king for changing practice and providers really respond to it.” Research has found that this change, and other targeted changes, has led to a 4% decrease in C-sections at the hospital in two years.

Similar initiatives are underway in Alberta. Alberta’s Perinatal Health Program provides hospitals with reports measuring their performance on selected indicators of maternity care, including C-section rates. These rates are categorized by the Robson criteria, which is a way of breaking down C-section rates by the characteristics of a pregnancy.

Nancy Aelicks, a nurse and information coordinator with the perinatal program says that this helps give providers context for the information and “see which Robson groups are making the biggest contribution to C-section rates.”

The application of the Robson criteria and recently published studies comparing C-section rates across Canadian provinces and regions are part of efforts to get a clearer picture of the complex trends driving C-section rates upwards.

Blake suggests more work is needed to understanding this complex interplay of factors – she says “we are only beginning to develop our understanding.”

Blake highlights clinical decision making and individual level ‘human factors’ – including patient and provider points of view as important contributors. “Someone is going to make a decision in the middle of the night that is based on their assessment of all these factors,” she says.

Debates and divergent viewpoints on birth: is it “a disaster waiting to happen?”

Debates around C-sections can be contentious and are often related to differing perceptions of risk, and what constitutes ‘normal’ birth.

Cameron says “if you happen to be someone who believes that birth is a disaster waiting to happen, you are going to tend to jump in quicker.”

Canadian studies comparing rates of interventions (like induction) during labour between midwives and doctors have found fewer interventions among women attending a midwife.  However, it should be noted that midwives only provide care to low-risk women with uncomplicated pregnancies. Doctor-attended births in these studies (while adjusted somewhat for patient characteristics) included more high-risk women who may require interventions to ensure safe childbirth.

Cameron also says that “ the midwifery perspective comes from a place of respecting and honouring normal birth – and wanting to support that process – however, this core belief can cut across disciplines and professional groups.”

Another important perspective beyond providers is that of women themselves. Experts suggest that women’s perceptions of birth, including fears of pain or being ‘out of control’, are an important factor informing choices, and increasing C-section rates.

“The perception that pain cannot be controlled in childbirth is wrong and that’s not the way that obstetricians, family doctors or midwives conduct birth,” says Graves.

Blake highlights that ultimately “our patients should feel completely comfortable with how they are approaching their experience with childbirth.”

A 2006 survey of pregnant women in Kingston, Ontario asked about their views on “elective primary C-sections”; that is, C-sections done without an obstetrical indication. Results suggest that a significant number believed that informed choice extended to C-sections, and all women should be provided with the option to choose a C-section.

However, data suggest that C-sections “by request” are a relatively small driver of C-section rates. A 2010 BC study found that these accounted for only about 2% of overall C-sections.

Blake says “you can’t fault women – and I think that we need to understand what the issues are, and the extent to which it is our responsibility (as providers) to address them.”

What does this mean for patients, and providers?

‘Michelle’ is a busy obstetrician at a Canadian hospital with a large maternity care service that delivers over 4,000 babies each year. Reflecting on the numbers of C-sections being done at her hospital, over 1 in 4 births, she acknowledges sometimes challenging conversations with patients about their childbirth expectations, concerns and choices.

“To a lot of people, women and family-centred care means natural, vaginal birth, but if we’re talking about informed consent and shared decision making, my patients occasionally express a clear preference for increased interventions during delivery, including C-sections.” She explains “because events during birth can sometimes be unpredictable, some women wish to assume more control over that process. If I feel that I’ve had a thorough discussion with patients about risks and benefits – it is ultimately their decision.”

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  1. Bob

    If women choose to have an elective Csection why not let them pay for it and save public resources?

    • Rosie

      A C-section is major surgery. Women do not choose this option lightly. If it is the best option for the mother and baby/babies, then it is worth every dollar and all health care resource time.

      • Fai

        Women DO choose c-sections lightly, and sometimes for ridiculous reasons. As the article states, statistics for low-risk women who elect to have c-sections before 39 weeks are being examined because there is clear medical evidence suggesting it’s better not to. So why are women making this decision, when it’s clear their babies would be better off coming out later? Because they’re selfish. They want to avoid pain, or having a loose vagina. They think their tummy will be less flabby. It’s the easy way out.

        • sarah

          This is a ridiculous uninformed comment, and not based on the evidence. The percentage of women choosing elective C-sections in canada is less than 2% and of those, you do not know their reasons. You cannot make assumptions as there is no data suggesting that it’s to make “their tummy less flabby” or similar reasons you have given. You should base your comments on the statistical medical evidence, and not your perceptions or opinions.

        • Alisha

          I did not choose my C-section lightly. 18 hours of labour. My son was stressed and my contractions stopped. I was told by the doctor I was not progressing, and the medication to make the contractions start again was dropping my sons heart rate dangerously low.

          Saying it is being chosen lightly by a lot of women is B.S. I Cried when I found out I had to have a C-section. Because i DID NOT want one.

          2nd Pregnancy. The doctor has been discussing my options with me at length. He said there is a very high chance of having all the same problems or more, since I had to have a C-section the first time, and the current complications I have been having with this pregnancy so far. So looking at the pros and cons of doing a VBAC vs. a C-Section have been heavily weighed.

          Its not a “light” decision for a lot of women. So don’t be an @$$ and assume it is.

          FYI Doctors offer C-section for Breach babies instead of attempting to turn them (which can be extremely painful for mom). Maybe they shouldn’t offer C-sections for Breach until the option of turning them has been done, and didn’t work.

          But who are we to judge especially when we do not have a medical background.

    • Diana

      Bob, clearly you have not given birth vaginally….And see the super informed comments of others to understand the issues with the cost calculation.

  2. Andrea

    NICE looked at the cost of cs delivery, and unlike the estimate provided in the article, included costs that incur after the 6 week postpartum period. These costs include health care provider visits for prolapse, incontinence and sexual dysfunction as well as down stream surgical costs to correct pelvic floor dysfunction. The difference was less than 100 pounds. Cs only look cheaper if you ignore the longer term implications of vaginal delivery – particularly difficult and instrumental vaginal deliveries.

    The falling rate of forcep deliveries seems to be a driver on te increased cs rate over the last few decades. And there is nothing wrong with that – once counselled most women seem to prefer a cs over forceps.

    I would like to see quality indicators in maternity care focus on outcomes rather than processes. I believe a cs is a process not an outcome although it hasn’t been traditionally looked at that way. Let’s measure things like obstetrical injuries, hemorrhage, transfusion, postpartum infections, PPD, maternal satisfaction, intrapartum fetal death, obstetrical brachial plexus injury, HIE, etc and start to look at pelvic floor issues and then relate that to the processes of cs and vaginal birth rather than being myopically focused on the cs rate.

    Maternity care outcomes are not limited to the six week post partum period!

  3. Janice Williams

    We need to get past the place where the rate of Cesareans is driving policy and practice as it is having disturbing ramifications for the health and well-being of both women and their children – particularly those who after being informed of the risks and benefits of Cesarean would choose it.

    1. On the cost of Cesarean deliveries – the numbers quoted here are misleading as to the actual cost differences between Cesarean and vaginal birth. First the Cesarean numbers are a composite of both planned Cesarean and unplanned urgent and emergent Cesareans. It is known that unplanned urgent and emergent Cesareans have higher rates of risk, and as a result higher costs. Further, most unplanned urgent or emergent Cesareans are the result of planned vaginal deliveries where the trial of labour must be abandoned. However, instead of attributing those costs to the “vaginal deliveries” they have been lumped in with the Cesarean deliveries. Secondly, as noted by another commenter below – costs that accrue after 6 weeks post partum are not attributed to the mode of birth. Need reconstructive surgery for pelvic organ prolapse – NOT COUNTED. Need counselling because you’ve been traumatized by the birth – NOT COUNTED. Need physiotherapy – again NOT COUNTED. Costs attributed to HIE or brachial plexus – NOT COUNTED. If the cost issue were more closely and accurately examined – the conclusions drawn might be dramatically different.

    2. On the use of induction prior to 41 weeks, there has been some evidence that waiting until “late post-dates” actually increases the rates of Cesareans needed and that judicial use of indictions prior to 41 weeks might reduce the risk of Cesarean.

    3. There is a discrepancy between the numbers of women who would choose Cesarean, and the number who are ultimately able to gain access to it. This should be seen as an unmet health need. I currently moderate a facebook group – “The Cesarean by Choice Awareness Network” – a group of women and write a blog – Awaiting Juno. Having personally experienced a denial of Cesarean Choice with my first pregnancy, and having heard the experiences of others – I am disturbed at how many women want to exercise their informed choice but have difficulties finding providers and facilities that respect that choice. Women with soft indications – like repeat cesarean, women who do not want to attempt a Vaginal Birth After Cesarean, are starting to fear that because of the pressure to reduce Cesarean rates, they will be forced to endure labours and deliveries against their informed wishes. This is a violation of their patient rights.

    We need to get past the place where maternity care is about “Respecting and honouring “Normal Birth”” – to a place where maternity care is about Respecting and honouring women, their bodies and their babies. We need to worry more about rates of birth trauma, and less about rates of Cesarean.

  4. Penny Christensen

    You can’t say that CS is more costly than vaginal births and be credible. You need to compare unlabored planned cesareans with planned vaginal births. Those are the only two choices a woman has. A planned vaginal birth can end as a spontaneous vaginal birth (with or without serious injuries to mother and child), inductions/augmentations, instrumental deliveries with forceps or vacuum extractor and acute cesareans. If you considered all the short term AND long term costs and maternal and neonatal physical and psychological morbidities, including the need for subsequent gynecological surgery (both right after a vaginal birth and throughout a mother’s lifetime), the cost for an unlabored planned cesarean would be lower than those of a planned vaginal birth.
    It is also a false hood to say that ‘everyone is interested in reducing the cesarean rate’. I most certainly am not. Cesarean rates are not an indicator of quality obstetrical care. Reducing the rate of acute cesareans is a noble goal but reducing the rate of planned unlabored cesareans by informed women who want to avoid the many and serious risks of a planned vaginal birth is an insane violation of maternal autonomy and rational thought.

    • Pauline Hull

      The name of the above website alone is unhelpful – pushing for the best choice – given that for many women, a caesarean birth plan is the best choice (whether because of medical /obstetric reasons or because this is their preferred delivery method).

      Also, the risks cited on this website (including maternal mortality, infection, hemorrhage, maternal or fetal injury, increased recovery time postpartum and difficulty breastfeeding) are NOT actually GREATER with a planned caesarean birth versus a planned vaginal birth, and yet this is what is inferred.

      The website also cites a caesarean rate of 28 percent in Ontario in 2010/11, which is nearly double the 15 percent target recommended by the World Health Organization, and yet in 2009, the WHO admitted that it has never had (and still does not have) any empirical evidence for recommending this rate. It said an optimum rate is unknown. Why do websites still persist in quoting this 15 percent rate in 2014? is there genuinely a suggestion that a 15 percent rate could deliver safe and satisfactory outcomes for women in Canada – in the current maternal landscape of older, heavier mothers and bigger babies at term?

      Perhaps if psychological wellbeing and the short and long term physical health repercussions related to birth injuries (of both babies and of mothers) are ignored, this rate is achievable, but I would argue that these outcomes SHOULD be measured, and not ignored.

      • Farley Nettenbourt

        Some women just don’t want to incur the risk of having their vaginas ripped up into their anuses, their babies’ heads stuck in their cervices, their uteri uncontrollably bleeding, etc.

        Unlike a vaginal birth, a C-section is more predictable. For that predictability, the cost is higher.

  5. Pauline Hull

    It’s great that the obstetrician ‘Michelle’ felt brave enough to be interviewed for this article at all, but the fact that medical professionals very often prefer to remain anonymous (or simply avoid sticking their head above the parapet altogether when voicing an opinion of support for maternal request caesareans) speaks volumes about the controversial barriers that need to be broken down before an open and honest debate on the subject of caesarean rates can occur.

    The fact that overall caesarean rates remain an accepted measure of quality of care and good outcomes in 2014 is shocking.

  6. Karen Born

    More than one commentator has correctly pointed out that when comparing the costs of C-sections and vaginal births, it is important to compare women who have a similar risk of complications, and to include relevant costs after the initial hospitalization (such as the treatment of complications). The cost data that we included in this article only took initial hospital costs into account. This data comes from a 2006 Canadian Institute of Health Information Report which can be found at this link

    Thank you to Andrea who pointed out a review commissioned by the National Institute for Health and Clinical Excellence (NICE) published in 2011 which looks at the costs in a broader way. It compared the cost of a planned vaginal birth and a planned C-section, taking into account the costs of subsequent complications to the mother and child. However, the review did find that a planned vaginal birth cost 888 UK Pounds less than a planned C-section. A link to the NICE review is here

    • Janice Williams

      With respect to your costs conclusions – NICE reported in the Health Economics section of its caesarean guideline that the difference in cost between a planned caesarean and a planned vaginal delivery is reduced from £710 to just £84 when the cost of treating postpartum urinary incontinence is included in cost comparisons. It’s simply not factually correct to state that planned caesareans are categorically more expensive or burdensome for the NHS than a trial of labour.

  7. Danielle

    I am a 38 week pregnant first time mom. I am 20 and have never had any surgery before. My baby is complete breech and I have a small abdomen. I measure only 35-36 weeks pregnant from pelvic bone to the top of my uturus and they say that my baby is a healthy weight and is of 38 weeks gestational age according to measurements. They say that my overall weight and fat percentage in my body is low. I am a healthy weight and eat right, I just seem to be super lean and no extra fat. So, they say that ECV (trying to turn the baby head down) would most likely be too invasive, complex, risky and most likely unsuccessful. I am sad to have to have a cesarean but, I know it would be less risky given the information on how my body wouldn’t be able to cope with a vaginal delivery. My abdomen is so tight they have trouble locating the top of my uturus. I wouldn’t have opted for a cesarean. I am very nervous. It is in 9 days from today. I see that cesareans are necessary in some cases. I also do not understand why mothers would want a cesarean. I have come to accept mine though and I do believe the mother should have some say in the matter but at the same time, I don’t think it is a good idea to just “let” moms choose a cesarean when there’s no need for it. There are many risks associated with cesarean delivery. I just hope mine runs smoothly. My poor squished little baby boy…!

    • Danielle again

      They wouldn’t be able to safely deliver the baby they say. He’s too big. I’m too small. He’s complete breech. Plus I live in a smaller city. I think my cesarean is unavoidable. It’s in nine days and I signed the paperwork. Wish me luck.

  8. Jennifer

    I’m 23 weeks pregnant now with my first child and because I have a number of risks it has been suggested to me from the beginning that I should have a c-section. I’m almost-40, I’m overweight, I have asthma, anemia, am still suffering through hyperemesis gravedarium, I had a LEEP procedure for cervical cancer over a decade ago that may have created scar tissue that will interfere with a natural birth, and I have lived through a childhood of sexual abuse as well as a gang rape a few years ago that is still fresh in my mind. For all of these reasons every medical professional I’ve talked to thinks a c-section is the best, if not only, option for me. However, because I have had poor medical care many times in the past I am really unsure if I should trust this opinion. I also have no confidence that things will turn out alright if I do take it – given prior poor care as well as conflicting opinions on c-section safety. I’m glad I have the choice. I just wish there was a clear indication of which was the safer option. I’m not looking for the easiest option, I understand my life is not only my own for the time being and I’m happy to make whatever sacrifices need to be made. I just want clarity and competent care and I don’t trust that I can find either. It’s not a nice place to be in.

  9. Aaron

    Why do ob push for c sec do they get paid more for them

  10. Barbara

    It is crazy the amount that c sections have gone up. Morphin is giving to labouring women in Kelowna all the time which is mistake number 1 as it slows down contractions. So sad it is even offered as it crosses barrier to the baby as well.

  11. Sirena

    My problem is with all the test they make you do when your pregnant. “Wtf anal swabs?”. Doctors and nurses are always bringing up the fact that something could and will go wrong. I live in Consort AB and when i was pregnant with my 2nd child the doctor in Provost wanted to induce me 3 weeks early for his convience. All i wanted was a natural labour..i had to fight for one and even after i got one, a needle was shoved in my leg and then my plasenta was ripped from my vag. It was a horrible experience. Ive always been a low risk but it doesnt stop them from constantly preping me on the idea of a its a really good possibility. Now im pregnant with my 3rd and im planning a home birth(free birth) to avoid unnecessary medical intervention. Womens bodies are ment to bare children. I trust my body & I trust God. I dont trust Doctors, nurses or hospitals. You walk in and theres signs every where about viruses, dont touch nothing, infection rates are high, always preping for the bad, wanting to keep you hooked up to machines, labling babies 3 times so theres a less chance of mess ups & they want to control your body..if you resist then your a problem and its not a friendly place. I dont know how man kind has ever servived before all this nonsense. Lol.

    • Rachael

      Yup! Exactly why I did a home birth for my first. I feel like interventions happen so often in the hospital with perfectly regular labours and deliveries. Makes no sense! I trusted my body, and I trusted God to get me through and with the help of my amazing midwives I was able to have the water birth I desired and I believe that is the reason my daughter is so calm. Because it was amazing!

  12. Rachael

    In non life threatening cases, It is better for both mother and baby to be birthed naturally and I feel like in a lot of cases they jump the gun, start pitocin, which stresses baby and then it ultimately leads to c section. The cases are higher in the states because they want to make money and get women in and out as quickly as possible. Makes me sad! I guess I just don’t understand why medical intervention is happening in 1 out of 4 births. That is a lot when our bodies are designed to do this. As a young woman who had a completely natural, home birth, I guess I cannot understand as I trusted my body to do what it needed to do and it did.. Just makes no sense!

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